Embolisation of uterine arteries or laparascopic uterine artery ligation as possible treatment of uterine leiomyoma
© Springer-Verlag Berlin / Heidelberg 2004
Published: 29 April 2004
Many women with symptomatic uterine leiomyomata wish to preserve their uterus. Novel organ- and fertility-preserving treatment options such as embolisation of uterine arteries or laparascopic uterine artery ligation have frequently been discussed as viable alternatives to myomectomy. This article strives to bring together the conclusions of major studies on novel organ-preserving treatment alternatives for uterine myoma.
Minimally invasive organ-preserving laparascopic myomectomy remains the best treatment option for patients with symptomatic fibroids who wish to retain their uterus. However, in certain cases other options such as embolisation or laparascopic ligation of uterine arteries can serve as viable alternatives
A failure rate of up to 39% and complications such as reduced fertility because of ovarian failure after transcatheter embolisation of uterine arteries might restrict the use of this method.
For postmenopausal women, transcatheter embolisation of uterine arteries is a possible treatment alternative. Laparascopic ligation of uterine arteries and anastomotic sites of uterine arteries with ovarian arteries might also be viable for young women who desire to preserve future fertility. Further data and studies on the long-term follow-up after ligation are yet to come.
A great number of leiomyomata can already be detected in women of childbearing age. Since the use of ultrasound has been established, the rate of detection has risen, and at the moment leiomyoma can be found in around 20 to 40% of women of childbearing age. It has been generally agreed upon that myoma in pre- and postmenopausal women should only be treated if they are symptomatic or fast growing. It has to be addressed on a case-by-case basis whether young women with myoma who desire to become pregnant will benefit from surgery before trying to conceive [4, 5]. When deciding if surgical myomectomy is necessary, symptoms such as recurring miscarriages as well as other myoma related complications in pregnancies should be taken into account. This article will concentrate on the advantages and disadvantages of the present minimally invasive organ-preserving treatment options for pre- and postmenopausal women with symptomatic fibroids.
Surgical treatment of uterine myoma
In the case of intra- or transmural myoma, however, treatment is clearly more demanding. Here, it is the size of the myoma that determines the treatment option. If myoma are small and solitary, they are normally asymptomatic and dissection therefore may not be necessary. Patients with bigger myoma should undergo surgery for two reasons. First, whilst myoma are benign for the major part, in rare cases rapidly growing myoma are malignant . Second, even solitary myoma can cause symptoms such as menorrhagia, hyper- or dysmenorrhoea or pelvic pain, once they have reached a certain size. Depending on the degree of experience of the surgeon, laparascopic organ-preserving myomectomy is a viable option for many women with solitary leiomyoma.
Nonetheless, in cases of multiple myoma, where preservation of the uterus is the aim, in general, laparatomy is necessary. When choosing organ-preserving myomectomy, patients should be counselled as to possible risks, such as the possibility that clinically occult/not visible myoma at the point of surgery might require future surgical intervention. In addition, due to transmural opening of the uterus, which is frequently necessary, uterine dehiscence might be a serious complication during a following pregnancy. Therefore, after transmural myomectomy, patients should be informed that future births will require primary cesarean section.
In postmenopausal patients or patients who do not desire future fecundity, hysterectomy may be offered as the definitive treatment for symptomatic fibroids . In most cases, minimally invasive surgery by laparascopically assisted hysterectomy is also possible.
However, for various reasons many women wish to avoid hysterectomy and ask for alternative solutions. In this article we have attempted to answer the question about which organ-preserving treatment options are available to these patients.
Treatment of leiomyoma by restriction of blood circulation
Embolotherapy was first performed by radiologists in 1995, using 500–900-micron particles injected bilaterally into the uterine arteries to the point of complete occlusion of the uterine arteries or the occlusion of the vessels feeding the myoma.
Since the publication of descriptions of the principles of interventional embolotherapy  and the efficacy of this treatment, there have been several case reports of typical complications [1, 3, 13, 25, 27, 29, 35, 36, 37, 38, 50]. Thereafter, studies with greater numbers of patients describing the whole range of complications were published.
Major studies on transcatheter embolisation of uterine leiomyoma
Number of patients
Improvement of initial symptoms
Side effects, complications
Worthington-Kirsch et al. (1998) 
Bleeding disorder (100%), pelvic pain (58%), anaemia (41%)
Improvement of bleeding disorder and anaemia (88%), of pelvic pain (94%), average volume reduction of myoma (46%)
Postembolisation syndrome (24 patients); nausea/vomiting (22 patients); pelvic pain (20 patients)
Hutchins et al. (1999) 
Menorrhagia, pelvic pain
Average volume reduction of the uterus (48%), improvement of menorrhagia, pelvic pain in 92% after 12 months, hysterectomy in six cases, in five cases myomectomy
No severe complications
Goodwin et al. (1999) 
Bleeding disorder, pelvic pain
Average volume reduction of uterus and myoma for 42.8 and 48.8%; improvement of clinical symptoms in 81%
Postembolisationsyndrome in six cases; one case of amenorrhoea; one case of protracted infection with subsequent hysterectomy
Vashisht et al. (2000) 
Menorrhagia (66%), abdominal tension (33%)
Improvement of bleeding disorders in 9/13 cases, improvement of abdominal tension in 2/7 cases, 1 pregnancy
One case of lethal overwhelming septicimia
Ravina et al. (2000) 
Bleeding disorders, pelvic pressure
Reduction of myoma volume of 60%, significant improvement of uterine bleeding in 80%, 18 pregnancies
No severe complications
Pelage et al. (2000) 
Uterine bleeding, pelvic pain
Improvement of menorrhagia in 90%, three pregnancies
Septical necrosis of myoma requiring hysterectomy in one patient; permanent amenorrhoea in four patients
Siskin et al. (2000) 
Bleeding disorder, anaemia, abdominal tension
Average reduction of uterine volume of 47.5%, general improvement of symptoms in 88% of patients
Pelvic pain, nausea/vomiting
Brunereau et al. (2001) 
Bleeding disorder, pressure, pelvic pain
After 1 year 2/27 patients with no change, 3/27 improvement, 22/27 reduction of uterine size in 26% and of myoma in 51% without symptoms
In three cases fever, headaches, nausea/vomiting
Andersen et al. (2001) 
In two cases no change, reduced uterine bleeding in 21 patients (96%), reduction of bleeding in 21 patients (70%), less pelvic pain in 18 patients (61%), less pelvic pressure, reduction of uterine volume of 68%, one pregnancy
Endometritis in one patient, allergies in four patients, haematoma due to vascular puncture in two patients
In November 2002, Walker et al. published the largest study in this field assessing 400 patients who had undergone embolotherapy . Here, patients showed a great degree of satisfaction after embolisation of the uterine arteries. In 84% of patients, uterine bleeding could be reduced, and in 79% there were fewer perimenstrual symptoms. Furthermore, 12% of the women achieved successful pregnancy after embolotherapy. The rate of peri- or postoperative complications was 8.5%. Beside minor side effects such as minor infection, severe complications such as pulmonary embolism, arterial or venous thrombosis or embolism of other organs such as the ovaries have been reported because of aberrant/dispersed microspheres. Severe complications as mentioned above have occurred in only 0.5 to 2% of the cases.
At the same time, Broder published results of a study comparing the long-term outcomes of 51 patients after embolotherapy with 38 patients with abdominal myomectomy 5 years after their procedures . Thirty-nine percent of embolisation patients had to have further invasive treatment because of reoccurrence of fibroid-related symptoms, whereas only 3% of myomectomy patients required surgical intervention in the intervening years.
Publications of Friese  or Günther  from 2002 assess the efficacy of transcatheter embolotherapy and complications common with this treatment. Most of the severe complications were likely to be caused by the dispersal of microns leading to occlusion of other vascular systems. Other complications were caused by uterine and vascular puncture itself. The most frequent complication, described in around 80% of patients after uterine artery embolisation, is pelvic pain involving significant analgesia requirement and longer inpatient stay. Other typical side effects mentioned are headaches and nausea. In addition to these transient and minor problems, some rare but severe complications have been reported. In 2–5% of the cases, for example, septic necrosis or protracted infections required emergency hysterectomy. Twenty-one of these patients died of overwhelming septicimia although they had full treatment . What is more, some cases of postoperative ovarian failure, amenorrhoea or endometrial atrophy have been reported that resulted in reduced fertility.
In around 6% of patients, fibroid size could not be reduced despite correct embolisation. During long-term observation, 39% of patients required further intervention because fibroids were growing again . One of the main reasons for frequent treatment failure might be anastomoses of uterine arteries with ovarian arteries, which cannot be occluded by bilateral embolisation of the uterine arteries .
In 2003 Sena-Martins et al. published similar results of a study evaluating the effects of treatment by embolization of the uterine artery in 32 women with symptomatic fibroids. He reports of a significant reduction in uterine and dominant myoma volume as well as decreased menstrual volume (90%) and shortened menstrual duration (81%). Adverse effects such as pain immediately after embolotherapy were described in 100% of patients. 34% of patients suffered from fatigue. There was one case of surgical myomectomy because of myoma degeneration.
Ravina et al. most recently performed UAE on 454 patients with menorrhagia or bulk-related symptoms due to myoma. Follow-up examination showed a reduction in fibroid size in 55% of patients at six months and 70% after one year. 27 Women became pregnant. However, principal complications were amenorrhoea and fibroid sloughs.
As to the efficacy of uterine artery embolization for symptomatic adenomyosis there is still controversy. Cases of pyoadenoma with sepsis and focal bladder necrosis after embolotheraby for adenomyosis have been reported.
Laparascopic restriciton of blood circulation
A new alternative approach leading to effective restriction of blood circulation in leiomyoma is bilateral laparascopic ligation of both uterine arteries and anastomotic sites of uterine arteries with ovarian arteries [22, 23]. One of the major advantages of this method is that complications due to dispersal of occluding particles into other parts of the body can be avoided. Clipping or bipolar coagulation of uterine arteries and anastomotic sites can be performed under sight control. Further advantages of a laparascopic approach are that other causes of clinical symptoms such as pelvic pain may be diagnosed and treated simultaneously. Moreover, although malignancy of myoma is rare, in some cases malignancy has been overlooked in the course of embolotherapy . During laparascopy, on the contrary, misdiagnosing can easily be avoided by taking biopsies if there are doubts about the dignity of fibroids.
February 2001 saw the publication of a prospective study on 87 patients who underwent laparascopic bipolar coagulation of uterine vessels and anastomotic sites with the ovarian vascular system . The results showed a low rate of intraoperative complications as well as symptomatic improvement in 90% of patients. Reductions of around 76% in the dominant fibroid size and 4% in the uterine volume were sonographically demonstrated.
Embolisation of uterine arteries vs. laparascopic clipping. Results of a study by Olaf Istre for the European Society of Gynaecological Endoscopy assessing 49 premenopausal patients with symptomatic myoma. → less postoperative pain after clipping
Reduction of volume
33% after 3 months, 30% after 6 months
30% after 3 months, 39% after 6 months
Requirement of analgesia
Further invasive treatment required
Problems of embolisation and laparascopic ligation of uterine arteries
Necrosis of myoma and its consquences
·Prolonged inpatient stay for high-dose analgesia
·Non-selctive embolisation and uncontrolled occlusion of ovarian or tubarian anastomoses
·High rates of further invasive treatment
·High rate of complications
·No long-term follow-up of endocrine consequences available at present
·Ovarian failure and unwanted loss of fertility
·Underdiagnosis of malignancy (rate of sarcoma 0.5%)
·Low level of evidence, low number of cases
·Only few studies on long-term outcome, but low rates of complications and easily accessible during staging laparascopy
Minimally invasive organ-preserving laparascopic myomectomy remains the best treatment option for patients with symptomatic fibroids who wish to retain their uterus. However, in certain cases other options such as embolisation or laparascopic ligation of uterine arteries might serve as viable alternatives. For postmenopausal women, transcatheter embolisation of uterine arteries is a possible treatment alternative. Laparascopic ligation of uterine arteries and anastomotic sites of uterine arteries with ovarian arteries might also be viable for young women who desire to preserve future fertility.
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