Dr. Walker's Russian Fibroids Embolization Website

fibroids

Welcome to the Uterine Fibroids Specialist Website.

This website presents information on fibroids and current methods of uterine fibroids treatment particularly UFE Uterine Fibroid Embolisation. (embolization). Also called UAE - uterine artery embolisation.

It presents data related to the treatment of uterine fibroids by Dr. W. Walker carrying out a procedure known as uterine fibroid embolisation (embolization). The data have been collated from the Royal Surrey County Hospital and The London Clinic trial.

Dr. Walker has carried out over 2,300 fibroid embolisations as part of the trial and his results and publications are presented including a synopsis of the World Experience of UFE and other related matters.

Dr. Walker works in central London and Guildford and his office can be contacted by telephoning 07795 643019.

To the best of our knowledge the information contained in this website is factual and correct.

 

An introduction to Uterine Fibroids as benign tumours

About Fibroids

Uterine fibroids are benign growths of the uterine muscle occurring in 30-40% of women. The aetiology of fibroids remains the subject of research but genetics is an important factor the condition being more common in Afro Caribbean women.

The tumours are sensitive mainly to oestrogen and progesterone. Most fibroids do not cause any problems and do not require treatment. Some fibroids, however, can cause heavy periods which can lead to anaemia and debilitation, or if the fibroids grow large they can lead to 'compression syndrome' in which adjacent organs may be compressed such as the bladder leading to frequency of urination, the bowel leading to constipation and bloating. Fibroids may press on nerves causing backache and sciatica and can cause cosmetic unsightliness by bulging the abdomen.

 


 

The usual treatment for fibroids is hysterectomy which is carried out in approximately 30,000 women a year in the UK and 180,000 in the US.

The Treatment of Uterine Fibroids by Uterine Artery Embolisation

Uterine Artery Embolisation

Uterine fibroid embolisation (embolization) for fibroids is no longer a new procedure. It was first carried out in France in a small number of cases in the early 1990s. Since then there have been numerous publications on the technique (2,5,9,10,11,12,15,18,20,21,22,23,24,25,26,42,43,44). The procedure which is non surgical involves the occlusion of blood vessels supplying uterine fibroids and certainly over 100,000 and probably several hundreds of thousands of fibroid embolisations have been carried out worldwide.

Procedure

Fibroid embolisation is carried out by an Interventional Radiologist and is technically demanding, requiring significant experience in the technique.

Under local anaesthesia and intravenous sedation a tiny catheter is inserted under local anaesthetic into an artery in the right groin. Under X-ray control a micro catheter is introduced selectively into each of the two arteries that supply the uterus. The micro catheter is passed approximately half way down the artery and then fine particles of a solid substance called PVA (Poly Vinyl Alcohol) are injected through the catheter into the uterine artery. The particles are carried to the leash of vessels supplying the fibroids. These vessels become silted up thereby depriving the fibroid of blood which dies and shrinks. PVA is an inert harmless material which has been used to occlude vessels in other parts of the body for decades (29).

Following the procedure the patient usually experiences pain over the next 12 to 24 hours. The pain varies from mild to severe and is controlled by intravenous and oral analgesics. Occasionally over the next 1-2 weeks the patient may experience cramps and occasionally some bleeding and often run a mild intermittent temperature in the first week. Patients spend 2 days in hospital and are usually advised to take 2 weeks off work. In our series the average time to patients feeling completely 'normal' was 2.2 weeks. During the procedure intravenous sedation is administered as required.

The complete process of fibroid shrinkage or in a small percentage of cases expulsion takes about 6 to 9 months; however most patients notice a considerable improvement in their symptoms within 3 months (expulsion usually occurs early in the first 6-8 weeks).

Alternatives

Hysterectomy

The commonest surgical treatment for fibroids is hysterectomy. Approximately 30,000 hysterectomies are carried out for fibroids in the UK alone and 180,000 in the USA, Wallach EE(30). Over the years before other treatments became available a large number of women obtained considerable benefit from hysterectomy. It is however a major surgical operation usually requiring approximately 5-7 days in hospital and 2-3 months convalescence. Hysterectomy for fibroids carries a serious complication rate of 4-6% and a mortality of 1:1,000–1,500(27,34). Serious complications of hysterectomy include bladder, bowel and ureteric damage, infection, haemorrhage, wound dehiscence and chronic problems such as bowel dysfunction and bowel obstruction and vaginal prolapse(27,35). Most serious complications of hysterectomy require further major surgery.

Treatments Other Than Hysterectomy or UFE

The medical alternative to hysterectomy is drug treatment with GNRH analogues such as Zoladex and Synarel but such drugs can only be used temporarily, are only effective on <50% of women and may have unpleasant side effects. On stopping treatment the fibroids grow back quickly.

The usual surgical alternative to hysterectomy is abdominal myomectomy. In the latter procedure the surgeon attempts to cut out the fibroids leaving the normal part of the womb intact. Myomectomy has been used widely for decades but it is a difficult operation with a significant complication rate. In addition, importantly, there is a high recurrence rate of >70% (6) that occurs in patients with multiple fibroids. A high percentage of patients having myomectomies will require re-operation for recurrence usually hysterectomy. Complications include bowel perforation, damage to the urinary tract, adhesion formation, infection and haemorrhage. You should ask your gynaecologist whether he or she feels that abdominal myomectomy would be of benefit in your particular case and likely to succeed.

Laparoscopic (keyhole surgery) myomectomy is an effective, much less invasive, procedure but there are major limitations on the size and number of fibroids that can be treated. Again this surgery has a higher complication rate than UAE including damage to adjacent organs which may involve a further major operation.

Other recent techniques are MRI guided laser ablation and MRI guided focussed ultrasound. Essentially both of these techniques cause a burn within the fibroid which then changes to scar tissue. Only a few fibroids can be treated at particular sites and the procedure takes around 2-3 hours. It often only destroys part of the fibroid or fibroids. Only short term results are available. These would be expected to demonstrate initial improvement but the concern is that this will not be sustained as the residual fibroid tissue re-grows. Embolisation has the advantage of completely destroying all fibroids no matter how numerous at one session lasting between 45 minutes and one hour. Post-procedure pain and discharge are probably greater than with MRI ablation but this is probably because in the latter procedure not all the fibroid tissue is killed.

An article in the American Journal of Roentgenology ‘MRI guidance of Focused Ultrasound Therapy of Uterine Fibroids: Early Results’ 2004;183:1713-1719 showed a mean reduction in fibroid volume at 6 months of only 13.5% which would normally be regarded as treatment failure. Average for UAE is 60%. But more importantly in UAE in the overwhelmimg majority all of the fibroids are killed and cannot regrow

Fibroids treatment UFE World Experience

World Experience of Uterine Artery Embolisation

So far the world experience of uterine fibroid embolisation for fibroids would indicate a success rate of over 90%. Until recently we only had short and medium term follow up but now long term follow up data is available(2,5). UFE is now widely established particularly in the US and latterly Condoleezza Rice's UFE was widely reported in the US press. Hundreds of thousands of patients have had UFE worldwide. The procedure kills all the fibroids at one session with a very low recurrence rate i.e. the cure is permanent in the overwhelming majority of cases. The two major complications of the procedure are infection leading to hysterectomy and this has an incidence of <0.5% and ovarian failure (ie a premature menopause). Again, the incidence of this complication is extremely low (less than 1% of patients under the age of 45) and when it does occur does not appear to affect satisfaction rates.

A survey by the Society of Cardiovascular & Interventional Radiology in the United States in 1999 of 10,500 procedures revealed less than 1% of serious complications requiring emergency surgery after embolisation and one death i.e. a mortality rate of one in 10,000(37). From this data and numerous other papers (see table below) in this contect it would appear that fibroid embolisation has a much lower complication rate than hysterectomy which has a serious complication rate of 4-6% and a mortality rate for hysterectomy for fibroids of one in 1,000 - 1,500(27,34).

Kundu et al(4) compared 312 patients undergoing surgery (total abdominal hysterectomy, myomectomy, vaginal hysterectomy, laparoscopic assisted vaginal hysterectomy) for fibroids with 65 women undergoing UFE. In the surgery group there were 20 cases of major complication and one death. There were no major complications in the UFE group. Also 3 patients suffered pulmonary embolism in the surgery group and 27 cases of infection related to surgery but none in the UFE group.

Table of fibroid embolisation -v- myomectomy & hysterectomy

Author (year)Study designProcedures (No of
pts at procedure
Months of follow-up
(No of patients)
Broder et al (2002)RetrospUAE 59
AM 38
46 (N=51)
49 (N=30)
Edwards et al (2007)RCTUAE 106
Surg 51
12 (N=95)
12 (N=45)
Goodwin et al (2006)RetrospUAE 149
AM 60
6 (N=121)
6 (N=45)
Hehenkamp et al (2005)RCTUAE 88
H 89
1.5 (N=81)
1.5 (N=81)
Pinto et al (2003)RCTUAE 38
AH 19
6 (N=36)
6 (N=37)
Ravazi et al (2002)RetrospUAE 67
AM 44
14 (N=62)
15 (N=40)
Spies et al (2004)RetrospUAE 102
H 50
12 (N=76)
12 (N=30)
Volers et al (2007)RCTUAE 88
H 89
24 (N=81)
24 (N=73)

Uterine Fibroids treatment at The Royal Surrey and The London Clinic, Harley Street

Dr Walker's Series

Dr Woodruff J Walker, Consultant Interventional Radiologist at the Royal Surrey County Hospital and The London Clinic, has so far carried out fibroid embolisation (UFE) on over 2,300 patients over 13 years. This has received considerable national coverage (see About Dr Walker, Publications and TV and Newspaper Coverage) In 1996 Dr Walker commenced an ethically approved trial of fibroid embolisation at the Royal Surrey County Hospital which later included patients from The London Clinic. The results of the trial have been reported in previous publications.

Mid Term Results

In 2002 we published an analysis of our first 400 patients(9) and a further series in 2002(10). The results of this series indicated a very high success rate of almost 90% with a low incidence of complications i.e. less than 1% incidence of infective complications requiring hysterectomy, a 6% incidence of failure or recurrence, a less than 2% (4 patients) incidence of amenorrhoea (no periods) under the age of 45, and a 6% incidence of troublesome vaginal discharge, usually curable by hysteroscopic procedure(8). Satisfaction rates for the procedure (i.e. where patients stated on follow up that they were satisfied with the procedure and would recommend it), were over 90%. Fibroid shrinkages were over 60%. Interestingly, as techniques improved, since the early series we have had no incidences of infection leading to hysterectomy in over 1,700 cases and the success rates are around 95%.

Patient Satisfaction with UFE

We asked patients whether or not the quality of their lives had changed for the better since UFE, whether they would still choose to have the procedure again and whether or not they would recommend to others and finally we asked for the patient to give an overall level of satisfaction with the procedure.

 

Our results showed that over 88% of women would recommend and choose UFE as a form of treatment.

Over 84% of women reported improvement in Quality of Life post UFE.

The overall level of satisfaction with the procedure was over 88%.

Long Term Paper Results

In 2006 we published our long term results(2). A total of 258 women were identified as being between 5 and 7 years post UFE and suitable for long-term follow up. 172 completed questionnaires were analysed. 75% of women had either a return to normal or an improvement in menstrual flow compared with how they were prior to UFE. More than 80% of fibroid related symptoms were resolved or improved. 88% of women were satisfied with the outcome of the procedure at 5-7 years and would choose UFE again or recommend it to others. The findings showed that UFE is of benefit to women wishing to avoid hysterectomy and it carries a low risk of complications and its benefit is sustained - more detailed results of long term data below and under Long Term Results paper.

Complications

We have performed fibroid embolisation in over 2,300 patients. Since the early phase of the trial our complication rate has fallen and the technique has undergone changes. The two most significant complications of fibroid embolisation are premature menopause and infection leading to hysterectomy. We had 5 infections leading to hysterectomy in our first 500+ patients. None of these were acute emergencies or required intensive care unit admission. Since then in over 1,700 patients we have had no hysterectomies due to infection. With regard to amenorrhoea i.e. premature menopause, this has occurred in 5 patients of 773 under 45 years of age i.e. 0.6%. 4 of these, however, again were in our first 400 patients when the technique we were using differed from our current protocol. In addition 2 of the patients had predisposing factors for ovarian failure. Of the 5 patients 4 of them have stated that despite the amenorrhoea they were satisfied with the procedure and would have preferred UFE to hysterectomy. These patients have all done very well. A small minority of fibroids are expelled spontaneously from the uterus through the vagina and occasionally these fibroids become impacted and have to be removed by putting a small 'telescope' through the cervix into the cavity of the uterus and resecting the fibroids. This almost invariably leads to an excellent result with a virtually normal uterus. In the 1,500 patients, 13 required hysteroscopic resection of impacted fibroids following embolisation.

Current Situation

The results above are from the early part of our series (last patient approximately 2001). Over the following 12 years the technique has been refined and results further improved. Success rates are now in the mid 90% and complications even rarer.

References:

1. Walker WJ, Bratby . Magnetic Resonance Imaging (MRI) Analysis of Fibroid Location in Women Achieving Pregnancy After Uterine Artery Embolisation. Cardiovascular interventional Radiology - August 2007

2. Walker WJ, Barton-Smith P. Long-term follow up of uterine artery embolisation - an effective alternative in the treatment of fibroids. British Journal of Obstetrics and Gynaecology 2006;113:464-468
 
3. Walker WJ, McDowell SJ. Pregnancy after uterine artery embolisation for leiomyomata: at series of 56 completed pregnancies. American Journal of Gynecology & Obstetrics November 2006 195(5) 1266-71

4. Kundu S, Gadani S, Clements R, Asisa J, Wilcock G, Barnwell D Comparison of surgical periprocedural Morbidity/Mortality & Length of Stay with UAE for Symptomatic Uterine Fibroids. Presented SIR Canada 2006
 
5. Spies JB, Bruno J, Czyda-Pommersheim F, Magee ST, Ascher S, Jha RC. Long-Term outcome of Uterine Artery Embolisation of Leiomyomata. Obstetrics and Gynaecology 2005;106:933-9.
 
6. Hanafi M. Predictors of leiomyomas recurrence after myomectomy. Obstetrics and Gynaecology 2005 Apr;105(4):877-81
 
7. Carpenter T, WJ Walker. Pregnancy following uterine artery embolisation for symptomatic fibroids: a series of 26 completed pregnancies. British Journal of Obstetrics and Gynaecology, 112, pp321-325 March 2005.

8. Walker WJ, Carpenter T, Kent ASH Persistent vaginal discharge after uterine artery embolisation for fibroid tumours: cause of the condition, magnetic resonance imaging appearance, and surgical treatment. American Journal of Obstetrics and Gynecology, Volume 190, Issue 5, May 2004, Pages 1230-1233
 
9.Walker WJ, Pelage JP. Uterine artery embolisation for symptomatic fibroids. Clinical results in 400 women with imaging follow up. British Journal of Obstetrics and Gynaecology. Nov 2002; 109: 1262-1272

10. Watson GMT, Walker WJ. Uterine Artery Embolisation for the treatment of symptomatic fibroids in 114 women: reduction of size of size of the fibroids and women’s views of the success of the treatment. British Journal of Obstetrics & Gynaecology 2002 Feb;109(2);129-35

11. Walker WJ, Pelage JP, Sutton C. Fibroid embolisation [review]. Clinical Radiology 2002 57(5); 325-31

12. Walker WJ. Bilateral Uterine Artery Embolisation for Fibroids - A Three and a Half Year Experience of over 300 Cases and Comparison with Data from other Centres. The Yearbook of Obstetrics & Gynaecology, Sturdee D, Oláh K, Keans D (Eds) RCOG Press 2001; Vol.9: 209-15

13. Walker WJ. Limitations of Fibroid Embolisation. Controversies in Obstetrics, Gynaecology & Infertility. Ben-Rafael Z, Shohan Z, Frydman R, Monduzzi Editore 2001: 427-33

14. Pelage JP, Le Dref O, Soyer P, et al. Fibroid related menorrhagia: treatment with super selective embolization of the uterine arteries and mid-term follow up. Radiology 2000,215 (2) 428-31
 
15. Walker WJ. Fibroid Embolisation. Gynaecological Endoscopy. 2000; 9: 343-344

16. Jones K, Walker WJ, Sutton C. Sequestration and Extrusion of Intramural Fibroids following Uterine Artery Embolisation. Gynaecological Endoscopy 2000; 9: 309-13
 
17. Jones K, Walker WJ. Access Procedures to Treat Menorrhagia in one patient. Gynaecological Endoscopy 2000; 9: 323-5
 
18.Walker WJ. Bilateral uterine Artery Embolization for Fibroids. Menorrhagia. Sheth C, Sutton C (Eds). Isis Medical Media, Oxford. April 1999: 185-93

19. Goodwin SG, McLucas B, Lee M, et al. Uterine artery embolization for the treatment of uterine leiomyomata: midterm results. Journal of Vascular and Interventional Radiology. 1999; 10: 1159-65
 
20. Spies JB, Scialli AR, Jha RC, et al. Initial results from uterine fibroid embolization for symptomatic leiomyomata Journal of Vascular and Interventional Radiology. 1999:10: 1149-57
 
21. Hutchins J FL, Worthington-Kirsch RL, Berkowitz RP. Selective uterine artery embolization as primary treatment for symptomatic leiomyomata uteri. Journal of the American Association of Gynecological Laparoscopists 1999; 6: 279-84
 
22. Walker W, Green A, Sutton C. Bilateral uterine artery embolisation for myomata: results, complications and failures. Journal of Minimally Invasive Therapy1999; Vol 8 (6): 449-54
 
23. Walker WJ. Bilateral Uterine Artery Embolization for Fibroids. Menorrhagia. Sheth C, Sutton C (eds). Isis Medical Media, Oxford. April 1999: 185-93
 
24. Walker WJ. Arterial embolisation in obstetrics and gynaecology with particular reference to uterine fibroids. Advances in Obstetrics and Gynaecology. 1999;16:2-8
 
25. Worthington-Kirsch RL, Walker WJ, Adler L and Hutchins Jr FL. Anatomic variation in the uterine arteries: a cause of failure of uterine artery embolisation for the management of symptomatic myomata. Journal of Minimally Invasive Therapy, December 1999, Vol 8 (6): 397-402
 
26. Goodwin SC, (UCLA) USA, Walker WJ (RSCH) UK. Uterine Artery Embolisation for the treatment of fibroids. Current Opinion in Obstetrics and Gynaecology 1998;10: 315-2 5.
 
27. Takamizawa S, Minakami H, Usui Ret al.Risk of complications and uterine malignancies in women undergoing hysterectomy for presumed benign leiomyomas. Gynecol Obstet Invest 1999; 48: 193-6
 
28. Dover RW, Sutton CJG, Walker WJ. Arterial embolisation for uterine fibroids. The results of the largest UK series. British Journal of Obstetrics andGynaecology.1998; 105: 52
 
29. Barr JD, Lemley TJ, Petrochko CN. Polyvinyl Alcohol Foam Particle Sizes and Concentrations Injectable ThroughMicrocatheters.JVIR1998;9:113-118
 
30. Wallach EE. Myomectomy. In Thompson JD, Rock JA eds. Te Linde's Operative Gynaecology,7th ed, Philadelphia, USA: Lippincott, 1992: 647-62
 
31. Schuur KH, Bouma J. Palliative embolization in gynaecological patients. Eur J Radiol1983;3(1):9-11
 
32. Anderson JH, Wallace S, Gianturco C, GersonLP. "Mini" Gianturco stainless steel coils for transcatheter vascular occlusion.Radiology1979, 132 (2):301-3
 
33. Anderson JH, Wallace S, Gianturco C. Transcatheter intravascular coil occlusion of experimental arteriovenous fistulas AJR Am J Roentgenol1977;129(5):795-8
 
34. Wingo PA, HuezoCM, Rubin GL, et al. The mortality risk associated with hysterectomy. American Journal of Obstetrics and Gynecology1986; 152:803-8
 
35. Hill DJ, Complications of hysterectomy. Bellaire’s Clinical Obstetric and Gynaecology 1997;11:181-195
 
36. Vashisht A, Studd J, Carey A, Burns P. Fatal septicaemia after fibroid embolisation. Lancet July 24 1999; 354:1730
 
37. Uterine artery embolization survey results: 10, 500 procedures performed world-wide. Society of Cardiovascular and Interventional Radiology, October 1999
 
38. Mara M, Maskova J, Fucikova Z, Kuzel D, Belsan T, Sosna O. Midterm clinical and first reproductive results of a randomized controlled trial comparing uterine fibroid embolization and myomectomy. Cardiovasc Intervent Radiol 2008;31:73-85
 
39. Firouznia K, Ghanaati H, Sanaati M, Jalali AH, Shakiba M. Pregnancy after uterine artery fibroid embolisation for symptomatic fibroids: A series of 15 pregnancies. AJR 2009;192:1-5
 
40. Pisco JM, Duarte M, Bilhim T, Cirurgiano F, Oliveira A. Pregnancy after uterine fibroid embolisation. Fertility & Sterility 2011 Mar 1;95(3)
 
41. McLucas B. Pregnancy following uterine fibroid embolisation: An update. Minimally invasive Therapy Allied Tecnology 2013 Feb; 22(1)39-44
 
42. Hirst A, Dutton S, Wu O, Briggs A, Edwards C, Waldenmaier L, Maresh M, Nicholson A, McPherson K. A multi-centre retrospective cohort study comparing the efficacy, safety and cost-effectiveness of hysterectomy and uterine artery embolisation for the treatment of symptomatic uterine fibroids. The HOPEFUL study. Health Technol Assess 2008 Mar;12(5):1-248,iii
 
43. Hehenkamp WJ, Volkers NA, Donderwinkel PF, de Blok S, Birnie E, Ankum WM, Reekers JA. Uterine artery embolisation versus hysterectomy in the treatment of symptomatic uterine fibroids (EMMY trial): peri- and postprocedural results from a randomised control trial. Am J Obstet Gynecol 2005 Nov;193(5):1618-29
 
44. The REST Investigators. Uterine-Artery embolisation versus surgery for symptomatic uterine fibroids. N Eng J Med 2007:356:360-370

 

© 2006. Dr. W.J. Walker. All rights reserved. The Department of Radiology Located at: The Royal Surrey County Hospital, Egerton Road, Guildford, Surrey, GU2 5XX, U.K.