Preamble
Uterine artery embolisation (UAE) is an organ-conserving, established, safe and effective
procedure in
the physicianʼs toolbox for treating complaints due to myoma.
The aim of UAE is rather to reduce or eliminate complaints due to a myoma and not
to remove the myoma. At
the same time a reduction of the size of the myoma can be achieved.
There is agreement between the specialties gynaecology and interventional radiology
that an indication
for the required therapy in cases of uterus myomatosus is only given after expert
examination by and
consultation with a gynaecologist. A complete and comprehensive consultation on treatment
options for
symptomatic uterus myomatosus explicitly includes, besides the drug and surgical treatment
options, also
UAE. The decision for or against a therapeutic option should be made in consideration
of the individual
patientʼs wishes and with a full knowledge of other strategies, their chances of success,
their
limitations as well as their typical side effects and possible complications (informed
consent).
In Germany, Austria and Switzerland, uterine artery embolisation provides a treatment
option for
complaints due to myomas that enables a further individualisation of the therapy for
uterus
myomatosus.
Aim of the Consensus Meeting
Aim of the Consensus Meeting
The intention of the consensus meeting was to make an up-to-date evaluation of UAE.
The participants of
the radiology-gynaecology expert meeting have, on the basis of a renewed assessment
of the available
literature, published international guidelines as well as their own experience and
extensive
discussions, reached a consensus between the two involved specialties. The group of
experts was fully
aware that the possibilities and limitations of a radiological therapy option would
have to be discussed
with experts from the field of gynaecology who do not perform such procedures themselves
but who have
extensive experience in the diagnosis and treatment of diseases of the female genital
organs.
The expert group comprising 14 radiologists and 8 gynaecologists that came together
on January 19, 2013
in Berlin for the 4th radiology–gynaecology consensus also included radiologists and
gynaecologists from
Switzerland and Austria. After extensive and, in part, controversial discussion the
group formulated in
consensus the following recommendations. The consensus paper was supported by the
gynaecologists and
radiologists listed at the end of the present contribution. This paper reflects the
current state of
knowledge.
Structural Prerequisites and Quality Assurance in the Performance of UAE
Structural Prerequisites and Quality Assurance in the Performance of UAE
UAE should only be carried out in hospitals in which specialists in the fields of
gynaecology and
radiology are present who have the necessary experience in its performance, where
an adequate and
structured pain therapy after the operation and expertise in the management of side
effects as well as
of conservative and surgical therapy for myoma are available.
In particular, due to the postoperative necessity for pain therapy UAE should only
be performed in
hospitals on an inpatient basis.
Prior to introduction of UAE in a hospital, theoretical and practical training in
a centre with extensive
experience in the performance of UAE as well as participation in courses on the theory
and practice of
UAE are strongly recommended. Beside the legally required documentation, for quality
assurance the
determined characteristic numbers for radiation exposure (dose area product, exposure
time) should also
be checked every three months under consideration of the average values given for
UAE in the
literature.
Participation in a suitable quality assurance programme of the professional societies
is also
recommended.
Examinations Necessary Prior to UAE
Examinations Necessary Prior to UAE
Fundamental for therapeutic decision making is a gynaecological examination including
vaginal and/or
abdominal ultrasound (depending on the size of the uterus myomatosus) by a specialist.
If the ultrasound
diagnostics do not provide an unambiguous result then there is a generous indication
for an MRI
study.
Prior to the embolisation of any myoma, the indications for hysteroscopy and fractionated
abrasion should
be checked. Also in the past year at the most there should have been an unremarkable
cytological smear
test of the cervix uteri.
Besides a test for pregnancy, the following laboratory results must be available:
creatinine, coagulation
status, thyroid values (in cases with positive thyroid history), blood count and CRP.
An active
inflammation must be excluded by case history and clinically.
Indications for UAE
Indication for a uterine artery embolisation is a symptomatic uterus myomatosus. UAE
represents an
alternative to surgical and drug procedures as well as to myoma treatment with focussed
ultrasound that
is independent of the size and number of myomas or previous operations. Foundations
for the therapeutic
decision making are the objective of the treatment and the individual patientʼs wishes.
Criteria for Success of UAE
Criteria for Success of UAE
The main issues for therapeutic success after UAE are an improvement or complete elimination
of the
complaints (due to myoma) stated by the patient and to a lesser extent a reduction
in volume of the
dominating myoma or, respectively, the entire uterus after the treatment.
Contraindications for UAE
Contraindications for UAE
Technical
Relative
Anatomic
Relative
-
Isolated, submucosal myomas of types 0 and I according to ESGE, that are suitable
for
hysteroscopic removal
-
Isolated subserosal pedunculated myomas
-
(Co-)supply of the myoma(s) via an ovarian artery; here the benefits and risks of
an
additive embolisation of the respective ovarian artery must be considered
Clinical
Absolute
Relative
-
Documented allergic reaction to iodine-containing contrast media
-
Postmenopausal patients
-
Allergic to local anaesthetics
-
Latent hyperthyroidism
-
Renal insufficiency (creatinine value > 1.5)
-
Indwelling IUD
-
Family planning not yet completed
-
Immunosuppression
UAE in Patients with a Desire to Have Children
UAE in Patients with a Desire to Have Children
When the wish to have children is not yet fulfilled UAE must be considered as a last
resort treatment.
Possible risks include above all a potential reduction of the ovarian reserves, an
increased risk of
abortions, placentation disorders and heavier postnatal bleeding.
For patients with an unfulfilled desire for children and a symptomatic uterus myomatosus,
the role of UAE
as treatment option has not been sufficiently clarified in the available literature.
Before hysterectomy is considered for a patient with fulfilled family planning and
a pronounced uterus
myomatosus the possibility of a UAE should be taken into account.
The Special Case of Preoperative Myoma Embolisation (PUAE)
The Special Case of Preoperative Myoma Embolisation (PUAE)
PUAE, i.e., embolisation as a direct preparation for surgical myoma enucleation, can
be considered and
offered to individual patients who have a strong wish to retain their uterus and for
whom even
preoperatively an elevated bleeding risk can be assumed and/or for whom the risk of
an eventually
necessary hysterectomy is considered to be high for “technical reasons” (e.g., very
large myoma and/or
multiple myomas, myomas that would be difficult to remove and myomas in unfavourable
positions).
Radiation Protection
Radiation protection in UAE is especially important. If at all possible pulsed fluoroscopy
should be
employed. Serial angiographies and oblique projections should be reduced to a minimum.
As a rule an
acquisition frequency of 1 image/s is sufficient. The average value for the dose area
product under
normal conditions should be less than 50 Gy × cm2 for pulsed systems. The average
exposure time for UAE should amount to less than 20 min. The exposure to radiation
here corresponds
to that of about 2 to 3 CT scans of the abdomen.
Side Effects ([Table 1])
Table 1 Relevant side effects and complications of UAE (in %) (sources: [1], [2]).
|
Amenorrhoea
|
3.9–4.3
|
|
Pain
|
3.6
|
|
Discharge
|
3.4
|
|
Angiography-related complications (e.g., inguinal haematoma)
|
2.9
|
|
Vaginal outflow of myoma material
|
1.5–4.7
|
|
Hot flushes
|
1.4
|
|
Endometritis/myometritis
|
1.4
|
|
Postembolisation syndrome
|
0.2–2.9
|
|
Deep vein thrombosis/pulmonary embolus
|
0.2
|
Uterine discharges in the first weeks after UAE can be normal. In the case of conspicuous
vaginal
discharges diagnosis of and therapy for infections should be carried out. Menorrhagias,
cramping pain in
the lower abdomen or discharge of tissue particles can occur, especially with submucosally
displaced
myomas. Depending on the clinical symptomatics and the findings of imaging diagnostics
a hysteroscopic
myoma resection or a vaginal myoma ablation as for a myoma in statu nascendi may be
indicated.
Hysterectomy is a priori not indicated. In cases of doubt the centre that performed
the UAE should be
consulted.
Follow-Up Examination after UAE
Follow-Up Examination after UAE
A follow-up examination by a specialist is recommended at about 6 months after UAE.
Imaging procedures
(e.g., ultrasound in combination with Doppler ultrasound, MRI) are helpful. In the
absence of
therapeutic success (no improvement of symptoms and/or growth progression of the myoma)
or conspicuous
imaging findings (increase in size of the myoma[s] or uterus and/or lack of devascularisation
of the
myoma[s]) further clarification is necessary.
Perspectives
It is planned in 2015 under consideration of the data that will then available and
the gained experience
to again reconsider and revise these recommendations on uterine artery embolisation
for complaints
caused by myomas.
Participants of the Consensus Meeting
Participants of the Consensus Meeting
PD Dr. med. Ralf Adamus/Nürnberg
Dr. med. Michael Bartsch/Hamburg
Dr. med. Tobias Belting/München
Prof. Dr. med. Christoph A. Binkert/Winterthur (CH)
Dr. Andreas Hatopp/Stuttgart
Dr. med. Thomas Hess/Winterthur (CH)
Prof. Dr. med. Augustinus L. Jakob/Zürich (CH)
Dr. med. Elke Krystek/Heidelberg
PD Dr. med. Peter Landwehr/Hannover
PD Dr. med. Boris Radeleff/Heidelberg
Dr. med. Göntje Peters/Kiel
Prof. Dr. med. Thomas Pfammatter/Zürich (CH)
Prof. Dr. Dr. Thomas Rabe/Heidelberg
Dr. med. Gernot Rott/Duisburg
Dr. med. Renana Schinker/Hamburg
Dr. med. Wolfram Seifert/Gehrden
PD Dr. med. Wulf Siggelkow/Hannover
Prim. Univ.-Prof. Dr. Siegfried Thurnher/Wien (AT)
Prof. Dr. med. Dierk Vorwerk/Ingolstadt
Prim. PD Dr. Peter Waldenberger/Linz (AT)
Participating Professional Societies and Working Committees
Participating Professional Societies and Working Committees
AGE, Arbeitsgemeinschaft Gynäkologische Endoskopie
DeGIR, Deutsche Gesellschaft für Interventionelle Radiologie
DGGEF, Arbeitsgemeinschaft Gynäkologische Endokrinologie und Fortpflanzungsmedizin
e. V.
DGGG, Deutsche Gesellschaft für Gynäkologie und Geburtshilfe
DRG, Deutsche Röntgengesellschaft
ÖGIR, Österreichische Gesellschaft für Interventionelle Radiologie
SSCVIR, Swiss Society of Cardiovascular and Interventional Radiology
