The Lublin Protocol of the Uterine Arteries Embolization in the Treatment of Symptomatic Uterine Fibroids
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The Lublin Protocol of the Uterine Arteries Embolization in the Treatment of Symptomatic Uterine Fibroids Piotr Szkodziak*,1, Krzysztof Pyra*,2, Filip Szkodziak1, Jarosław Krzyżanowski1, Piotr Czuczwar1, Sławomir 1 2 1 Woźniak , Tomasz Jargiełło , Tomasz Paszkowski 1 3rd Chair and Department of Gynecology, Medical University of Lublin 2 Department of Interventional Radiology and Neuroradiology, Medical University of Lublin * These authors contributed equally Corresponding Author Abstract Piotr Szkodziak [email protected] Uterine fibroids are benign tumors originating from smooth muscle tissue, constituting uterine muscle stroma. Uterine fibroids are the most common benign tumors found Citation in women. In 20%–50% of women, fibroids are asymptomatic and do not require any Szkodziak, P., Pyra, K., Szkodziak, F., treatment. The main symptoms of uterine fibroids are profuse menstrual bleeding, Krzyżanowski, J., Czuczwar, P., Woźniak, S., Jargiełło, T., abnormal uterine bleeding, and pressure symptoms. Pressure symptoms can cause Paszkowski, T. The Lublin Protocol of pelvic pain syndrome, urination disorders, and constipation. the Uterine Arteries Embolization in the Treatment of Symptomatic Uterine Fibroids. J. Vis. Exp. (163), e61530, The treatment methods that are currently used include surgical treatment, doi:10.3791/61530 (2020). pharmacological therapy, and minimally invasive procedures. The most commonly applied minimally invasive method is the embolization of uterine arteries. This Date Published procedure is currently a widely accepted method of treatment for symptomatic uterine September 15, 2020 fibroids and has been recognized as such by the National Institute for Health and DOI Clinical Excellence in the guidelines for heavy menstrual bleeding. 10.3791/61530 This is a complicated procedure and requires close cooperation between gynecologists and interventional radiologists. We present a protocol applicable to URL uterine artery embolization in the treatment of symptomatic uterine fibroids. The jove.com/video/61530 protocol is divided into five section. The first two section are intended for gynecologists and interventional radiologists, explaining how to qualify and prepare a patient for embolization in a step-by-step manner. Section three, which is directed at interventional radiologists, explains how embolization should be done. Section four is directed at gynecologists or hospital ward doctors who look after the patients after embolization. This section of the protocol offers a method for treating post- embolization pain using the Patient Controlled Analgesia (PCA) pump. Section five completes the procedure with an assessment of the effects and late complications of uterine artery embolization. Copyright © 2020 JoVE Creative Commons Attribution-NonCommercial-NoDerivs 3.0 Unported jove.com September 2020 • 163 • e61530 • Page 1 of 44 License All five section create a uniform protocol directed at clinicians, experts, and researchers new to the field. Introduction Uterine fibroids are benign tumors originating from smooth in London. Available epidemiological data do not accurately muscle tissue, constituting uterine muscle stroma. They specify the incidence of uterine fibroids, as their large are monoclonal tumors, consisting of a large amount proportion remain undiagnosed. It is estimated that uterine of extracellular substance containing collagen, fibronectin, fibroids occur in 5.4% to 77% of all patients. Their prevalence and proteoglycans. The fibroids are surrounded by a is higher in the United States than in Europe, the probable thin pseudocapsule made of compressed muscle fibers, cause being racial differences8. collagen fibers, neurofibers, and blood vessels1,2. The Among women in the childbearing age, approximately 30% of pathophysiology of myomas is not entirely understood but myomas may give clinical symptoms in the form of abnormal seems to rely mainly on monoclonal proliferation caused uterine bleeding, resulting in inadequate blood supply in by selective and tissue-specific epigenetic changes3. No patients9. In most cases, patients have more than one single gene was found to cause uterine fibroids. However, myoma, which are spherical lesions located in the uterus. the presence of rare uterine fibroid syndromes, such as Their dimensions and location may vary. In 90% of the cases, multiple cutaneous and uterine leiomyomatosis, has been they are located in the body of the uterus. Their diameter can attributed to a gene that codes for fumarate hydratase, a be from several millimeters to 20 cm10. mitochondrial enzyme involved in the Krebs cycle4. The presence of chromosome 7 deletions and translocations in The FIGO (Fédération Internationale de Gynécologie et chromosomes 7, 12, and 14, which occur in 50% of fibroids, d’Obstétrique) classification divides them into groups from seems to be secondary rather than primary5,6,7. 0–8 depending on the proximity of the endometrium (lower the number, closer will be the endometrium) (Figure 1)11. The regulators of the growth of uterine fibroids are In about 50%–75% of the cases, fibroids are asymptomatic. steroid hormones produced by ovaries (estrogens and The most common symptoms of uterine fibroids are profuse progesterone), growth factors, angiogenesis, and apoptosis. menstrual bleeding, abnormal uterine bleeding, and pressure Risk factors for the development of uterine fibroids have symptoms. Myomas are associated with about 10% of also been identified, including age, early menarche, African- the cases of infertility, and in 1%–3% they are the only American race, heredity, nulliparity, obesity, polycystic ovary cause12. Asymptomatic uterine fibroids usually undergo only syndrome, diabetes, hypertension, vitamin D deficiency, use a regular medical control, whereas symptomatic fibroids are of soybean milk, alcohol, and caffeine consumption8. an indication for treatment13. Uterine fibroids are the most common benign tumors of The treatment methods for uterine fibroids that are currently reproductive organs in women. These tumors were first used include surgical treatment, pharmacological therapy, described in 1793 by Matthew Baillie at St George's Hospital Copyright © 2020 JoVE Creative Commons Attribution-NonCommercial-NoDerivs 3.0 Unported jove.com September 2020 • 163 • e61530 • Page 2 of 44 License and minimally invasive procedures13,14,15,16,17,18. D may slow down or prevent the growth of fibroids and the Surgical treatment includes myomectomy (abdominal and onset of symptoms23. hysteroscopic) and hysterectomy. Both myomectomy and New methods using 2-methoxyestradiol combined with hysterectomy have a positive impact on the quality of life19. nanoparticles are also under development24. Minimally Hysterectomy is associated with irreversible loss of fertility; invasive methods used in the treatment of fibroids include thus, many women seek other treatment options20. uterine artery embolization (UAE), magnetic resonance- Abdominal myomectomy allows for the preservation of guided focused ultrasound surgery (MRgFUS), laparoscopic fertility. Depending on the size and number of fibroids, uterine artery occlusion (LUAO), and radiofrequency as well as the experience of the surgeon, this procedure myolysis14,25. Ultrasound-guided High-Intensity Focused can be performed via laparotomy or laparoscopy. Although Ultrasound (US-HIFU) is a new, still experimental, minimally hemorrhages are less common than in hysterectomy, overall invasive method26,27. morbidity is similar. Hysteroscopic myomectomy is a safer, Methods of therapeutic vascular occlusion and blocking less invasive method than abdominal myomectomy and the blood supply to the uterus were mentioned over 120 allows the treatment of submucous fibroids (FIGO 0). years ago. In 1894, Kelly presented the ligation of internal Subsequent hysteroscopic procedures may be necessary to iliac arteries during an oncological hysterectomy to control completely remove larger type-2 fibroids21. intractable pelvic bleeding, which at that time was a common Levonorgestrel releasing intrauterine devices are an effective complication after the surgical procedure28. Then, Sack treatment for heavy menstrual bleeding, but they do not (1973) described the effective use of the same technique reduce the size of the fibroids. Their use is limited in in the treatment of massive postpartum hemorrhage after patients with the deformed uterine cavity. GnRH analogues forceps delivery. In both cases, hemostasis was achieved are mainly used as a pre-operative agent to reduce the size without hysterectomy29. In 1979, Heaston et al. and of fibroids and perioperative blood loss. They also reduce Brown et al., independently described embolization of the the percentage of vertical incisions during hysterectomy and pelvic arteries using absorbable gelatin sponges to control myomectomy while increasing the possibility of a vaginal postpartum hemorrhage30,31. procedure20. UAE was first used as a treatment method for symptomatic In the short term, selective progesterone receptor modulators uterine fibroids in 1991 in France32. It was initially used to reduce the myoma volume and induce amenorrhea. reduce blood loss after myomectomy. In 1995, Ravina et al. However, the long-term efficacy and safety require further proposed this procedure as the primary treatment method for research. Along with aromatase inhibitors, there may be other symptomatic uterine fibroids33. In the United States, uterine options for pre-operative treatment of anemia and reduction