Preoperative Uterine Artery Embolization Research Articles

Robotic-Assisted Laparoscopic Treatment of Residual Ectopic Pregnancy in a Previous Cesarean Section Scar: A Case Report

Study ObjectiveTo describe a technique of robotic-assisted laparoscopy of residual cesarean scar pregnancy (CSP) and uterine defect repair. DesignVideo case report, with step-by-step explanation of the procedure (Canadian Task Force classification III) SettingCSP may be treated by different approaches including surgery and methotrexate. Successful methotrexate treatments avoid an emergency surgical treatment. In these cases a residual CSP often remains and should be removed in women who desire to conceive. CSP is often associated with a cesarean section scar defect called an isthmocele. In case of isthmocele with important defect and desire for pregnancy, laparoscopic repair may be proposed. Diagnosis and treatment of isthmocele is usually performed in a second time after a successful treatment of CSP. In this case, a surgical treatment including the removal of the residual CSP and treatment of the isthmocele may be proposed. InterventionIn this video we describe a technique for the surgical removal of residual CSP and isthmocele treatment by robotic-assisted laparoscopy. A 32-year-old patient developed a CSP treated by 2 in situ injections of methotrexate. A magnetic resonance imaging study performed 1 month after the last methotrexate injection revealed a persistent 4-cm residual CSP, associated with an isthmocele. Preoperative uterine artery embolization was performed to reduce intraoperative bleeding. After localization of the residual CSP on the left side, a temporary left uterine occlusion was performed. Residual CSP was totally removed. The residual defect and isthmocele were closed using delayed absorbable suture. ConclusionRobotic-assisted laparoscopic removal of residual CSP and isthmocele treatment is a feasible and safe procedure. This procedure may be proposed in patients presenting with this condition after a methotrexate treatment of CSP.

A Retrospective Study on Preoperative Uterine Artery Embolization Prior to Hysterectomy [25E

INTRODUCTION: To determine whether preoperative uterine artery embolization (UAE) decreases blood loss during abdominal hysterectomy for fibroid uterus. METHODS: Patients who underwent same day UAE and abdominal hysterectomy at a single institution were identified based on ICD-9 codes. Data collected included blood loss, operating room time, hospital length of stay, and complication rates. This data was then compared with historical data from a study on patients with fibroid uteri >1000 g who just underwent hysterectomy. RESULTS: During 2006–2014, a total of 59 women underwent preoperative UAE prior to hysterectomy for fibroid uterus. Historical data included 47 women as controls. The average uterine size was comparable between cases and controls (1537±1285 g vs. 1658±793.5 g). The estimated blood loss was significantly reduced in the preoperative UAE group when compared to controls, 360.6±288.2 mL versus 555.8±386.5 mL (P=.004) respectively. Furthermore, women who had preoperative UAE had lower complication rates (21.7%) when compared to controls (61.7%), P<.001. Cases had higher length of stay 3.7±1.1 days and OR time 217.8±56.9 min when compared to controls 2.9±0.8 days and 124±30.6 min (P<.001). CONCLUSION: Preoperative uterine artery embolization decreases blood loss and complication rates for women undergoing abdominal hysterectomy for fibroid uterus.

Revisiting Imaging and Pathology of Malignant Appearing Uterine Smooth Muscle Tumors: A Mistaken Identity of Leiomyosarcoma on MRI

Uterine leiomyoma is a relatively common condition occurring in a majority of African American and Caucasian women by age 50. Magnetic resonance imaging of the pelvis with contrast is the modality of choice when evaluating uterine tumors. We report a case of a patient with a four-day history of intra-menstrual vaginal bleeding who underwent magnetic resonance imaging of the pelvis that suggested the tumor was a leiomyosarcoma, the malignant counterpart of leiomyoma. Therefore, the patient underwent pre-operative uterine artery embolization to decrease blood loss with exploratory laparotomy, resection of pelvic mass and dilation and curettage. Pathologic evaluation of the mass returned a diagnosis of leiomyoma. Magnetic resonance imaging evaluation of leiomyomata remains difficult. Further development of imaging parameters could improve diagnosis of benign uterine fibroids.

Laparoscopic Myomectomy for Large Fibroids with Synchronized use of Uterine Artery Embolization

Objective: To determine the feasibility and efficacy of the laparoscopic myomectomy for large fibroids (>10 cm) with use of synchronous uterine artery embolization. Design: A prospective observational case series of laparoscopic myomectomy performed for single and multiple uterine fibroids. Setting: A tertiary referral center for gynecological oncology and minimal access surgery. Population: A 15 premenopausal women with large fibroids who wished to conserve their uterus from March 2005 to August 2011. Materials and methods: Laparoscopic myomectomy was performed using harmonic scalpel with synchronized preoperative uterine artery embolization (UAE) following multidisciplinary team discussion. Tissue retrieval was performed by morcellation. Main outcome measures: Early discharge and reduced intraoperative blood loss. Results: Of all 15 cases, mean number of fibroids removed was 2 (range: 1-4) and mean mass of tissue excised was 450 gm (range: 320-1540). The mean diameter of the fibroids removed was 13 cm (range: 10-20 cm). Mean estimated blood loss was 156 ml (range: 25-1,000 ml) and the mean operating time was 113 minutes (17-200 minutes). All cases were successfully completed laparoscopically with no conversions to open surgery. One patient who had a 13 cm broad ligament fibroid required a 2 unit blood transfusion intraoperatively and another patient developed a single port-site infection 2 weeks following the procedure. Histology confirmed benign leiomyomas in all cases. Conclusion: Laparoscopic myomectomy with use of synchronized UAE using harmonic scalpel is feasible and efficient procedure for single or multiple large fibroids within an experienced multidisciplinary setting.

Uterine artery embolization immediately preceding laparoscopic myomectomy

Objective To determine whether performing uterine artery embolization (UAE) immediately before laparoscopic myomectomy can facilitate a minimally invasive surgical approach for larger uterine fibroids. Methods In a retrospective case–control study, laparoscopic myomectomy with and without preoperative UAE was examined. Data were analyzed from 26 laparoscopic myomectomies performed by a single surgeon at Northwestern University Feinberg School of Medicine between 2004 and 2010. Controls were matched for age, calendar year, surgeon, and number of fibroids removed. Surgical outcomes included preoperative clinical uterine size, operative time, operative blood loss, and postoperative myoma specimen weight. Data were analyzed via 2-tailed Student t test. Results Twelve women underwent laparoscopic myomectomy within 169 ± 16 minutes (mean ± SEM) of preoperative UAE. Fourteen control patients underwent laparoscopic myomectomy alone. The UAE group had a greater mean preoperative clinical uterine size (19.7 versus 12.4 weeks, P < 0.001) and a greater mean myoma specimen weight measured postoperatively (595.3 versus 153.6 grams, P < 0.05). There were no significant differences in operative time or blood loss, and there were no intra-operative complications. Conclusion UAE performed immediately before laparoscopic myomectomy facilitated minimally invasive surgery for larger uteri and larger uterine myomas, with no differences in operative time or blood loss.

Endoscopic Treatment of Ectopic Pregnancy in a Cesarean Scar

Study Objective To describe our experience with endoscopic removal of cesarean scar pregnancy. Design Retrospective study (Canadian Task Force classification II-3). Setting Tertiary-care university hospital. Patients Twenty-one patients with cesarean scar pregnancy. Interventions All the patients underwent removal of pregnancy mass at hysteroscopy or combined with laparoscopy. Nine patients received a methotrexate injection before the operation, and 13 underwent uterine artery embolization before surgery. Measurements and Main Results Clinical data, serum β-human chorionic gonadotropin concentration, findings of ultrasound or magnetic resonance imaging examinations, therapeutic options, operative time, operative blood loss, and duration of hospitalization time were recorded. The mean serum β-human chorionic gonadotropin concentration at diagnosis was 53 350.4 IU/ L. Seventeen patients underwent hysteroscopy, which failed in 2, and the other 4 patients underwent hysteroscopy combined with laparoscopy. Mean operative time was 51.4 minutes, and mean blood loss was estimated at 48.1 mL. A gestational mass can be removed at hysteroscopy, with rapid recovery and a high success rate. If a cesarean scar pregnancy mass grows toward the bladder and abdominal cavity, hysteroscopy combined with laparoscopy is more appropriate. Preoperative uterine artery embolization can decrease blood loss substantially during the operation. No patients underwent hysterectomy. Conclusions Endoscopy seems to be the optimal surgical management in patients with a cesarean scar pregnancy and who desire to preserve the uterus and fertility. However, further study is warranted.

Interest of uterine artery embolization with gelatin sponge particles prior to myomectomy for large and/or multiple fibroids

Purpose To evaluate the efficacy of pre-myomectomy uterine artery embolization with gelatin sponge particles to reduce operative blood loss and facilitate removal of fibroids. Materials and methods This retrospective study included 33 women (mean age, 36 years; range, 24–45 years), of whom at least 18 wished to preserve fertility. They presented with at least one large myoma (mean diameter, 90 mm; range, 50–150 mm) and had undergone preoperative uterine artery embolization with resorbable gelatin sponge by unilateral femoral approach between December 2001 and November 2008. Clinical, radiological and surgical data were available for all patients. Mean haemoglobin levels before and after surgery were compared with Student's t-test. Results No complication or technical failure of embolization occurred. The myomectomies were performed during laparotomy (25 cases) or laparoscopy (8 cases). Dissection of fibroids was easier (mean, 3 per patient; range, 1–11), with a mean operating time of 108 ± 50 min (range, 30–260 min). Bloodless surgery was the rule with a mean estimated peroperative blood loss of 147 ± 249 mL (range, 0–800 mL). Mean pre-(12.9 ± 1.3 g/dL) and post-therapeutic (11.4 ± 1.2 g/dL) haemoglobin levels were not statistically different ( p > 0.05). There was no need for blood transfusion. None of the patients required hysterectomy. The mean duration of hospital stay was 7.5 ± 1.3 days (range, 3–12 days). Conclusion Preoperative uterine artery embolization is effective in reducing intraoperative blood loss and improves the chances of performing conservative surgery. It should be considered a useful adjunct to myomectomy in women at high hemorrhagic risk or who refuse blood transfusion.

Computed tomographic angiography in diagnosis and management of placental polyp with neovascularization

To evaluate the neovascularization in placental polyp tissue by computed tomographic angiography and to determine the need for uterine artery embolization before hysteroscopic resection. Seventeen consecutive women with suspected placental polyp were enrolled in this retrospective study. Neovascularization in placental polyp tissue was assessed by computed tomographic angiography. Cases with neovascularization were treated by hysteroscopic resection with preoperative uterine artery embolization, while cases without neovascularization were treated by hysteroscopic resection alone. Of 17 patients with suspected placental polyp after abortion or parturition, nine patients were diagnosed to have placental polyp with prominent neovascularization by computed tomographic angiography, and were treated by uterine artery embolization followed by hysteroscopic resection. Two patients subsequently conceived after conservative management. After precise evaluation of neovascularization by computed tomographic angiography, hysteroscopic resection with preoperative uterine artery embolization is an effective minimally invasive procedure to conservatively treat placental polyp with prominent neovascularization.

Successful management of interstitial pregnancy with fetal cardiac activity by laparoscopic-assisted cornual resection with preoperative transcatheter uterine artery embolization

Interstitial pregnancy is a rare but dangerous form of ectopic pregnancy. Although various forms of minimally invasive management for this disorder have been previously reported, optimal treatment regimen has not been yet unknown due to its rarity. A 29-year-old married woman with no previous disease history was referred under suspicion of ectopic pregnancy. Serum hCG value was 95,365 mIU/mL. On ultrasonographic examination, gestational sac with a viable embryo was identified in the left cornual region. Three-dimensional computed tomographic angiography showed prominent vascular mass in the left cornual region. Preoperative transcatheter uterine artery embolization followed by laparoscopic-assisted cornual resection with local methotrexate injection was successfully performed. Laparoscopic-assisted cornual resection with preoperative transcatheter uterine artery embolization for interstitial pregnancy with prominent vascular flow is a safe and reliable minimally invasive procedure for woman wishing fertility preservation.

Embolisation artérielle utérine par matériel résorbable avant myomectomie

Fibroids are a frequent cause of gynecology referral. Myomectomy is a conservative treatment alternative. The main risk from this procedure is hemorrhage. The main objective of this study was to demonstrate the efficacy of preoperative uterine artery embolization with resorbable agents to reduce blood losses and facilitate myomectomy. Secondary objectives were to evaluate morbidity and subsequent fertility. Retrospective study of 21 patients with preoperative uterine artery embolization prior to myomectomy at the University Medical Center of Dijon over a 3 year period. Myomectomy after uterine artery embolization with resorbable agents was associated with only minimal blood loss. Mean preoperative and postoperative hemoglobin levels were comparable (p<0.0001). Uterine suturing was technically simpler. The number of resected fibroids (p=0.2824) and the presence of preoperative anemia (p=0.474) had no statistically significant impact on the duration of hospital stay. Uterine synechiae occurred in three patients after the procedure, and were easily treated. Two patients had normal subsequent pregnancies. Preoperative uterine artery embolization with resorbable agents was effective in reducing surgical blood losses. This technique reduces the number of hysterectomies and hemorrhagic complications (hematoma, infection, weaker scar tissue). It should be considered in patients wishing uterine preservation when the hemorrhagic risk is high. Its use in patients seeking subsequent pregnancy should be further assessed with larger series.

Preoperative Uterine Artery Embolization (PUAE) Before Uterine Fibroid Myomectomy

To evaluate the potential of uterine artery embolization to minimize blood loss and facilitate easier removal of fibroids during subsequent myomectomy. This retrospective study included 22 patients (median age 37 years), of whom at least 15 wished to preserve their fertility. They presented with at least one fibroid (mean diameter 85.6 mm) and had undergone preoperative uterine artery embolization (PUAE) with resorbable gelatin sponge. No complication or technical failure of embolization was identified. Myomectomies were performed during laparoscopy (12 cases) and laparotomy (9 cases). One hysterectomy was performed. The following were noted: easier dissection of fibroids (mean 5.6 per patient, range 1-30); mean intervention time 113 min (range 25-210 min); almost bloodless surgery, with a mean peroperative blood loss of 90 ml (range 0-806 ml); mean hemoglobin pretherapeutically 12.3 g/dl (range 5.9-15.2 g/dl) and post-therapeutically 10.3 g/dl (range 5.6-13.3 g/dl), with no blood transfusion needed. Patients were discharged on day 4 on average and the mean sick leave was 1 month. Preoperative embolization is associated with minimal intraoperative blood loss. It does not increase the complication rate or impair operative dissection, and improves the chances of performing conservative surgery.

Preoperative Uterine Artery Embolization in Cervical Pregnancy

Cervical pregnancy often results in massive hemorrhage following curettage. Performance of uterine artery embolization before curettage is reported in three consecutive cases of cervical pregnancy. All patients had a successful outcome without significant hemorrhage.

Preoperative angiographic uterine artery embolization in the management of cervical pregnancy

The diagnosis of a cervical ectopic pregnancy is often made intraoperatively in the presence of extensive hemorrhage during attempted evacuation. In some cases, hysterectomy has been the necessary treatment to control bleeding. We report two cases of cervical pregnancy detected by ultrasound. Before pregnancy termination, the uterine arteries were successfully embolized using angiographic techniques. As a result, surgical evacuation was performed with minimal hemorrhage; hysterectomy was not required and the patients' potential fertility was retained.