- Review Article
- Open Access
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.
- Uterine Artery
- Uterine Artery Embolisation
- Anastomotic Site
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.
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.
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.
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.
- Al-Fozan H, Tulandi T(2002) Factors affecting early surgical intervention after uterine artery embolization. Obstet Gynecol Surv 57:810–815Google Scholar
- Andersen PE, Lund N, Justesen P, Munk T, Elle B, Floridon C (2001) Uterine artery embolization of symptomatic uterine fibroids. Initial success and short-term results. Acta Radiol 42:234–238Google Scholar
- Amato P, Roberts AC (2001) Transient ovarian failure: A complication of uterine artery embolization. Fertil Steril 75:438–439Google Scholar
- Aydeniz B, Wallwiener D, Kocer C, Grischke EM, Diel IJ, Sohn C, Bastert G (1998) Der Stellenwert myombedingter Komplikationen in der Schwangerschaft (n=474). Z Geburts Neonatol 202:154–158Google Scholar
- Aydeniz B, Grischke EM, Kurek R, Bastert G, Wallwiener D (1999) Change of the spectrum of uterus preserving myoma surgery. Gynecol Endocrinol [Suppl 1] 13:54Google Scholar
- Aydeniz B, Schauf B, Kurek R, Schiebeler A, Riedinger K, Tepper-Wessels K, Messrogli H, Bastert G, Wallwiener D (2002) Die operative Laparoskopie: Weiterentwicklung und Komplikationsraten. Geburtsh Frauenheilk 62:269–273Google Scholar
- Aydeniz B, Gruber IV, Schauf B, Meyer A, Wallwiener D (2002) A multicenter survey of complications associated with 21,676 operative hysteroscopies. Eur J Obstetr Gynecol Reproduc Biol 104:160–164Google Scholar
- Aydeniz B, Schauf B, Wallwiener D (2002) Wie sicher ist die operative Hysteroskopie? Geburtsh Frauenheilk 62:799–801Google Scholar
- Broder MS, Goodwin S, Chen G, Tang LJ, Costantino MM, Nguyen MH, Yegul TN, Erberich :(2002) Comparison of long-term outcomes of myomectomy and uterine artery embolization. Obstet Gynecol 100:864–868Google Scholar
- Brunereau L, Herbreteau D, Gallas S (2001) Uterine artery embolization in the primary treatment of uterine leiomyomas: technical features and prospective follow-up with clinical and sonographic examinations in 58 patients. Amer J Roentgenol 175:1267–1272Google Scholar
- Chen YJ, Wang PH, Yuan CC, Yang MJ, Yen YK, Liu WM (2002) Successful pregnancy in a woman with symptomatic fibroids who underwent laparoscopic bipolar coagulation of uterine vessels. Fertil Steril 77:838–840Google Scholar
- Friese K (2002) Perkutane Transkatheterembolisation von Uterusmyomen. Dt Ärzteblatt 99:1826–1827Google Scholar
- Goodwin S, McLucas B, Lee M et al (1999) Uterine artery embolization for the treatment of uterine leimoyomata: midterm results. J Vasc Interv Radiol:1159–1165Google Scholar
- Günther RW, Siggelkow W, Vorwerk D, Neulen J, Rath W (2002) Behandlung von Uterusmyomen durch perkutane Transkatheterembolisation. Dt Ärzteblatt 99:1828–1835Google Scholar
- Gynecologic Endoscopic Surgery. Herendael B, Wallwiener D, Rimbach S (eds), Schattauer, Stuttgart, New YorkGoogle Scholar
- Huang LY, Cheng YF, Huang CC, Chang SY, Kung FT (2003) Incomplete vaginal expulsion of pyoadenomyoma with sepsis and focal bladder necrosis after uterine artery embolization for symptomatic adenomyosis: case report. Hum Reprod 18:167–171Google Scholar
- Hurst BS, Stackhouse DJ, Matthews ML, Marshburn PB (2000) Uterine artery embolization for symptomatic uterine myomas. Fertil Steril 74:855–869Google Scholar
- Hutchins F, Worthington-Kirsch RL, Berkowitz R (1999) Selective uterine artery embolization as primary treatment for leiomoyomata uteri. J Am Assoc Gynecol Laparosc 6:279–284Google Scholar
- Köchli OR, Wallwiener D, Brandner P, Bratschi HU, Bronz L, Burmucic R, Eberhard M, Gallinat A, Hohl MK, Hucke J, Keckstein J, Kolmorgen K, Müller DJ, Nagele F, Neis KJ, Römer T, Schmidt EH, Tercanli S, Lindemann HJ (2000) Consensus of diagnostic and operative hysterectomy. In: Hysteroscopy. State of the art. Gynecol Obstet [Suppl] vol 20. Karger, Basel, pp 182–187Google Scholar
- Krämer B, Wallwiener D, Hönig A, Solomayer E-F (2003) Malignitätsverdacht bei riesigem Uterusmyom. Geburtsh Frauenheilk 63:160–162Google Scholar
- Lefebvre G, Vilos G, Allaire C, Jeffrey J, Arneja J, Birch C, Fortier M, Wagner MS (2003) The management of uterine leiomyomas. J Obstet Gynaecol Can 25:396–418Google Scholar
- Liu WM (2000) Laparoscopic bipolar coagulation of uterine vessels to treat symptomatic leiomyomas. J Am Assoc Gynecol Laparosc 7:125–129Google Scholar
- Liu WM, Ng HT, Wu YC (2001) Laparoscopic bipolar coagulation of uterine vessels: a new method for treating symptomatic fibroids. Fertil Steril 75:417–422Google Scholar
- Myers ER (2002) Uterine artery embolization: What more do we need to know? Obstet Gynecol 100:847–848Google Scholar
- Nikolic B, Spies JB, Abbara S (1999) Ovarian artery supply of the uterine fibroids as a cause of treatment failure after uterine artery embolization: a case report. J Vasc Interv Radiol 10:1167–1170Google Scholar
- Park KH, Kim JY, Shin JS, Kwon JY, Koo JS, Jeong KA, Cho NH, Bai SW, Lee BS (2003) Treatment outcomes of uterine artery embolization and laparoscopic uterine artery ligation for uterine myoma. Yonsei Med J 44:694–702Google Scholar
- Payne JF, Robboy SJ, Haney AF (2002) Embolic microspheres within ovarian arterial vasculature after uterine artery embolization. Obstet Gynecol 100:883–886Google Scholar
- Pelage JP, Le Dref O, Soyer P, Kardache M, Dahan H, Abitbol M, Merland JJ, Ravina JH, Rymer R (2000) Fibroid-related menorrhagia: treatment with superselective embolization of the uterine arteries and midterm follow-up. Radiology 215:428–431Google Scholar
- Pollard RR, Goldberg JM (2001) Prolapsed cervical myoma after uterine artery embolization. A case report. J Reprod Med 46:499–500Google Scholar
- Ravina JH, Herbreteau D, Cirura-Vigneron N (1995) Arterial embolisation to treat uterine myomata. Lancet 346:671–672Google Scholar
- Ravina JH, Vigneron NC, Aymard A, Le-Dref O, Merland JJ (2000) Pregnancy after embolization of uterine myoma: report of 12 cases. Fertil Steril 73:1241–1243Google Scholar
- Ravina JH, Aymard A, Ciraru-Vigneron N, Ledreff O, Merland JJ (2000) Arterial embolization of uterine myoma: results apropos of 286 cases. J Gynecol Obstet Biol Reprod 29:272–275Google Scholar
- Siggelkow W, Günther R, Neulen R, Rath W (2002) Die perkutane Katheterembolisation—eine innovative Behandlungsalternative bei Uterusmyomen? Geburtsh Frauenheilk 62:131–138Google Scholar
- Siskin GP, Tublin ME, Stainken BF, Dowling K, Dolen EG (2001) Uterine artery embolization for the treatment of adenomyosis: clinical response and evaluation with MR imaging. Amer J Roentgenol 177:297–302Google Scholar
- Spies JB, Spector A, Roth AR, Baker CM, Mauro L, Murphy-Skrynarz K (2002) Complications after uterine artery embolization for leiomyomas. Obstet Gynecol 100:873–880Google Scholar
- Stringer NH, Grant T, Park J (2000) Ovarian failure after uterine embolization for treatment of myomas. J Am Assoc Gynecol Laparosc 7:395–400Google Scholar
- Stringer NH, DeWhite A, Park J, Ghodsizadeh A, Edwards M, Kumari NV, Stringer EA (2001) Laparoscopic myomectomy after failure of uterine artery embolization. J Am Assoc Gynecol Laparosc 8:583–586Google Scholar
- Tropeano G (2003) Permanent amenorrhea associated with endometrial atrophy after uterine artery embolization for symptomatic uterine fibroids. Fertil Steril 79:132–135Google Scholar
- Vashisht A, Studd J, Carey A, Burn P (1999) Fatal septicaemia after fibroid embolisation. Lancet 354:307–308Google Scholar
- Vashist A, Studd JWW, Carey AH, McCall J, Burn PR, Healy JC, Smith JR (2000) Fibroid embolization: a technique not without significant complication. Brit J Obstet Gynaecol 107:1166–1170Google Scholar
- Walker WJ, Pelage JP (2002) Uterine artery embolisation for symptomatic fibroids: clinical results in 400 woman with imaging follow up. BJOG 109:1262–1272Google Scholar
- Wallwiener D, Pollmann D, Rimbach S, Stolz W, Sohn C, Bastert G (1993) Operative Hysteroskopie in der Fertilitätschirurgie. Gynäkol Prax 17:109–122Google Scholar
- Wallwiener D, Rimbach S, Pollmann D, Bastert G (1993) Organ preserving surgery and GNRH. Arch Gynecol Obstet 254:333–334Google Scholar
- Wallwiener D, Aydeniz B, Rimbach S, Rabe T, Diel J, Bastert G (1994) Myomtherapie. Minimal invasive Operationstechniken und GnRH-Analoga-Applikation. In: Schweppe KW, Bastert G, Alt D, Klosterhalfen (eds) GnRH-Agonisten in der Behandlung von Endometriose und Uterus myomatosus. Zuckschwerdt, pp 61–66Google Scholar
- Wallwiener D, Rimbach S, Kaufmann M, Aydeniz B, Sohn C, Bastert G, Conradi R (1994) Hysteroskopische Endometriumablation zur Vermeidung einer Hysterektomie bei “High-Risk”-Patientinnen. Geburtsh Frauenheilk 9:498–501Google Scholar
- Wallwiener D, Maleika A, Rimbach S, Pollmann D, Bastert G (1995) Differentialdiagnostische Aspekte der Laparoskopie aus gynäkologischer Sicht: In: Pier A, Schippers E (1995) Minimal Invasive Chirurgie. Grundlagen, Technik, Ergebnisse, Trends. Thieme, pp 139–142Google Scholar
- Wallwiener D, Aydeniz B, Rimbach S, Diel IJ, Grischke EM, Rabe T, Bastert G (1996) Der Wandel des Spektrums uteruserhaltender Myomoperationen unter Einbeziehung von Endoskopie und dualer Myomtherapie. Gynäkol Geburtsh Rundsch 36:118–132Google Scholar
- Wang CJ, Yen CF, Lee CL, Soong YK (2002) Laparoscopic uterine artery ligation treatment of symptomatic adenomyosis. J Am Assoc Gynecol Laparosc 9:293–296Google Scholar
- Worthington-Kirsch RL, Popky GL, Hutchins FL (1998) Uterine arterial embolisation for the management of leiomyomas: quality-of-life assessment and clinical response. Radiology 208:625–629Google Scholar
- Yeagley TJ, Goldberg J, Klein TA, Bonn J (2002) Labial necrosis after uterine artery embolization for leiomyomata. Obstet Gynecol 100:881–882Google Scholar