FIBROID EMBOLIZATION

. . . preparation and procedure

The Fibroid Embolization Center
at the Northern Westchester Hospital, (888) 666-2002
(Ask for information, or to speak with the Program Coordinator, Adelaide Klivans.)
 

 

 

Preparation for UAE

We receive many questions from patients asking about what must be done to get ready for a UAE procedure. Others are interested in insurance issues; while still others inquire about post procedure recovery, or when normal activities can be resumed.

To answer this, we decided to put our entire Preparation Instructions, and Post-Operative Orders on our WebSite. What follows is a generalized set of rules that will be modified depending upon the medical or gynecologic issues of a particular case.

  • For those coming to our Institution for their procedure - these will be useful to print out completely.
  • For those going elsewhere, please understand that different IRs will have different preferences.

    There is - in all fairness - a number of ways to manage issues of pre and post procedure, all of which are very consistent with proper medical care. The important thing is to follow the instructions of the IR doing the procedure. For these are instructions coordinated with their technique and their institution that they know work well in that setting.

Pre-Admission Packet
For those who plan to be seen at our facility
  1. Print this current page as it includes both pre-operative and post-operative instructions.
  2. Click here for our Packet for pre-UAE records preparation.

Having said all that - let's look at what is involved in . .  .
Preparing for a UAE procedure

  • Record Review: It is important for the Interventional Radiologist to review all pertinent prior tests, procedures and surgical treatments already done. If patient is from outside of the area, full copies of all prior evaluations should be obtained.
  • Suitable Candidates include: (1) patient over age 18, (2) documented fibroids which are symptomatic enough to justify surgery, (3) exclusion of pelvic infection, and (4) assurance that neither pregnancy nor malignancy is present.
  • MRI evaluation: We will perform an MRI (if not already done) to evaluate the fibroids and rule out the possibility of an ovarian origin. It also establishes a baseline on which to evaluate the degree of post-embolization change. We do not routinely require prior laparoscopy or hysteroscopy.
  • Medical Evaluation: To be certain that the patient has no medical conditions that would contraindicate the procedure.
  • Gynecologist: If the patient's gynecologist is local, he or she will be kept informed of dates and times of procedures. If the patient's gynecologist is outside of the area, we will recommend members of our department of OB/GYN who are knowledgeable about the procedure. In this way were complications to occur, there would be a gynecologist already familiar with the patient's condition, and available at all times for any problems or questions. The patient's OB/GYN - even if out-of-town - will still be kept informed of the procedure and outcome.

 

 

 
 

Before the Procedure

  • Stop all Aspirin and Vitamin E for 5 days before the procedure.
  • Please have nothing to eat or drink after midnight of the night before UAE.
  • You should take any medications you usually take the morning of surgery, but use only a very small amount of water to swallow them.
  • Shave the right groin and pubic area the night before coming to hospital.
  • Come to the Northern Westchester Hospital approximately 2 hours before the procedure.
    (this is to allow the Ambulatory Surgical Nurses time to prepare all admission paperwork, administer medications, etc.)

Last minute steps before the UAE procedure include . . .

  • Routine bloods will be performed to test for anemia, kidney function and the blood chemicals that support clotting.
  • An Intra-venous is begun, and Antibiotics given prophylactically. (Ancef or Clindamycin - if Penicillin allergic.) The purpose of this step is to lower the possibility of infection as a result of the procedure.The IV will remain overnight.
  • An indwelling Foley catheter will be inserted (in the urinary bladder) so that a distended bladder will not complicate visualization or distort the anatomy. It remains in place overnight.
  • The Anesthesiologist will induce an Epidural Block (similar to that used in labor) to keep the patient pain free both during and after the procedure.

    Pain relief - which continues even after the epidural is discontinued - results from a small dose of morphine injected into the Epidural Catheter just before it is withdrawn. This Morphine creates an additional pain free period of 12 - 18 hours during which the patient can comfortably converse with friends or family. After 12 hours, much of the discomfort of the procedure subsides, and what remains can be controlled by pills alone.

The Steps of the actual UAE procedure include . . .

  1. After an appropriate sterilizing prep and draping of the groin area, the Radiologist makes a tiny incision in the skin and enters an artery on the right with a needle through which a small catheter can enter the vessel. The needle is withdrawn during the rest of the procedure.
  2. The Radiologist, by looking through a Fluoroscope, can see the pelvic vessels as if they were a road map. The catheter is moved along the femoral artery, manipulated first into the iliac artery and then into the uterine artery on the left side.
  3. When the blood supply of the fibroid is visualized, Polyvinyl Alcohol (consisting of particles the size of tiny grains of sand) is injected until the blood flow in the fibroid vessels can be seen to stop.
  4. The Catheter is withdrawn and re-manipulated down the road map of the pelvic blood vessels to the right uterine artery, where the injection process is repeated.
  5. When the Radiologist is certain the blood supply to both sides is stopped, the catheter is withdrawn, pressure applied to the outside of the femoral vessel, and the procedure is over. At our institution, the average actual procedure time is 1 hour, though this can vary more/less depending upon the ease or the complexity of an individual case.

 

 

 

 

The Post Operative Time

  • Duration of time in the Ambulatory Unit
    Our patients can remain in the hospital up to 23 hours to be certain they are comfortable and free of complications. Though some can go home earlier, we believe in making use of the maximum time allowed for an Ambulatory Care Stay if this seems appropriate for comfort and care.
  • Medications recommended at home
    • Ibuprofen (Motrin, Advil) 600 mg should be taken 4 times a day for 10 days. We believe that this is a very important step in post UAE care, not only for pain relief, but to decrease the amount of swelling and tissue reaction.
      • Take this medication with food or an antacid. It has a tendency to irritate the stomach.
      • Notice the strength of the preparation you purchased. Commonly Ibuprofen (over-the-counter) comes in 200 mg capsules or tablets. Obviously 3 will be needed to reach the recommended 600 mg per dose amount.
      • Take the last dose of the day just before going to sleep.
      • Decrease the dosage to 200 mg 2 times a day on day #11 and #12. Repeat this daily as needed for any cramping or other pain.
    • Percocet taken 1 tablet every 4-6 hours, but only as needed (in addition to Ibuprofen). Chemically, Percocet is a combination of Oxycodone 5 mg (a chemical relative of Codeine), and Acetaminophen 325 mg (the active ingredient in Tylenol.) This is a prescription drug for which you will need a prescription before leaving the hospital. Though it is a very effective pain reliever, like most narcotics it should not be taken over long periods of time. Commonly no longer than 3 days is recommended.

      To read an explanation of the amount of PAIN following a UAE procedure click HERE to read an article about it.
    • Surfak Liqui-Gel (240 mg docusate calcium) is a stool softener, and should be used once a day especially while the patient is taking Percocet. This avoids a common side effect of pain medications, i.e., constipation. Other reasons for increased constipation after UAE is related to a combination of decreased physical activity and short term alteration of usual diet. Lower the dose if stools do the reverse and become too soft.

      An alternative medicine is Colace (100 mg capsules of docusate sodium) also sold generically in many pharmacies.       Take 200 mg (2 capsules) at bedtime each night for 3 days, and then if needed - continue for a week using 100 mgm each night at bedtime.
  • Recommendations after returning home
    • Increase your fluids for the first week to approximately one quart a day. This is roughly the amount of a Large bottle of Coke. Water, juice or other liquids are all acceptable to satisfy the requirement.
    • During the days after the procedure
      • Avoid Tub Baths or Hot Tubs for 3 days. Showers or sponge baths are all right at any time.
      • We do not recommend driving your automobile in the first 3 days after the procedure.
      • Do not take Aspirin or products containing aspirin or Vitamin E for 5 days after the procedure. (The Ibuprofen mentioned above does not have the same effect as aspirin on blood clotting and is all right to use.)
    • During the weeks after the procedure
      • For the first week avoid any strenuous activity, lifting or moving heavy objects. Do not climb stairs when it could be avoided. Do not stand in place for long periods of time (such as during cooking). Do not assume a squatting position.
      • For the first month after the procedure eliminate heavy exercise routines or athletic interests.
      • Sexual relations should be avoided for approximately 1 month. For additional comments on this please click HERE.
      • For 3 months do not use tampons - substitute pads for sanitary purposes.
  • Followup Examinations
    • The patient should plan to see her Gynecologist in approximately 2 weeks. Obviously this should occur sooner, if there are symptoms which seem unusual, or if there is fever or increasing pain.
    • A followup MRI should be done in 6 months after the procedure. The purpose is to document exactly what change in fibroid size has occurred.


      If we will be doing your MRI, our MRI department can be reached at
      (888) 666-2002. Just explain that this is a followup MRI after a UAE in our department.
  • Interpreting Symptoms which may occur after the procedure
    • Fever:



      This can be the so-called "Post-Embolization Syndrome" but it is difficult for the patient to tell it from an infection which needs antibiotic treatment. Any persistent fever should be evaluated promptly by the patient's Gynecologist before making any assumptions about the "Syndrome."

      As discussed earlier, "PES" occurs in a minority (20%) of all cases. It can occur soon after the procedure (though usually if it does not happen in 36 hours, it probably will not occur). Less commonly it can occur as late as 10 days afterwards.

      When it occurs, the fever can go as high as 102 degrees F. It will run its course in 7-10 days. If infection is ruled out, sitting it out with Motrin for 10 days (which decreases this sort of response), is the treatment of choice. The explanation for "PES" is that it is a pyrogenic reaction (fever producing) of the body caused by breakdown products from the fibroid. It is more common when very large fibroid masses are embolized.

      We believe that this is the origin of the "Night Sweats" which some patients report. As long as the sweats gradually improve, the patient should do well. Only if these symptoms persist or increase is there the possibility that this was a uterus that was unable to survive the embolization process. The world's literature suggests that such a complication is less than 1%.       (See below under Serious Complications.)
    • Vaginal Discharge: This may start shortly after the procedure and have an unusual grayish or brown color without other symptoms. Occasionally even tissue can be seen. This is nothing to worry about, and merely indicates the elimination of breakdown products from degenerating fibroids.

    • Heavy Periods: For a few cycles after embolization, there may be a temporary increase in menstrual flow. This will not be permanent, and will subside without further treatment.
    • Loss of Periods (amenorrhea): This has been reported in about 1% of all cases. It is of note, that it most commonly occurs in patients near the menopause.

 

 

 


 

Can there ever be more serious complications from this procedure?

In the experience of most Interventional Radiologists, serious complications are rare.

  • Allergies to Drugs/Solutions
    The medications used during Embolization Procedures are not noted for any usually high incidence of allergic reactions. But as in any procedure, there is the occasional patient who can have a reaction to any medication used. Generally this can be avoided by a careful history of the patient's allergies, but it is always possible that new allergies can occur. The incidence of very serious allergy appears to be 0.006%.
  • The need for Hysterectomy because of complications from the procedure

    According to a study released in 9/99 for FDA review, the Society of Interventional Radiologists found that as of that date, approximately 4000 embolizations have been performed in the United States alone. Of these, 25 resulted in the need for hysterectomy - an incidence of 0.63% In an earlier study of 693 cases (7/98), 7 were reported to require hysterectomy as a result of the procedure - an incidence of 0.2%. Some studies have recorded higher numbers of 1%, while others say "the incidence is less than 10%". (updated 10/21/99)

    In comparison, the incidence of Hysterectomy being required during surgical myomectomy in some series is even higher.

    Though we have not experienced such a complication, still the uncommon case of severe Endometritis occurring 2-3 weeks after the embolization and requiring hysterectomy - is recorded in the world's literature. As the number of procedures done increase daily, even better information on the actual incidence will be forthcoming.

Advantages of the Procedure

It is clear that no one treatment "fits all." There are issues in all cases which make each case unique, and which must be considered in the decision for or against UAE. However, in our experience, these are the advantages that UAE offers when the option is being considered by the patient and her Gynecologist.

    1. Virtually no adhesion formation has been found.
    2. Treats all fibroids simultaneously.
    3. There has been no observed recurrent growth of treated fibroids in the past 9 years. (2/13/01)
    4. If the presenting complaint was excess vaginal bleeding, 87-90% of cases experience resolution within 24 hours.
    5. Emotionally, financially and physically - embolization can have an overall advantage over other procedures for the patient as the uterus is not removed.

 

      
 

 

 
 

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© 1998 Carlos Forcade, MD
(888) 666-2002