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 (UAE) on over 1500 patients over 8 years. This has received considerable national coverage see Publicity section about Dr Walker and C.V. 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. The results of this series indicated a very high success rate of 86% 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 (34). Satisfaction rates for the procedure (i.e. where patients stated on follow up that they were satisfied with the procedure and would recommend it), for the procedure were over 90%. Fibroid shrinkages were over 60%.

Long Term Results

In 2006 we published our long term results. A total of 258 women were identified as being between 5 and 7 years post UAE and suitable for long-term follow up. One hundred seventy-two completed questionnaires were analysed. 75% of women still had either a return to normal or an improvement in menstrual flow compared with how they were prior to UAE. 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 UAE again or recommend it to others. The findings showed that UAE 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:

Patient Satisfaction with UAE

We asked patients whether or not the quality of their lives had changed for the better since UAE, 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 86% of women would recommend and choose UAE as a form of treatment.

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

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

Complications

We have performed fibroid embolisation in over 1500 patients. Since the early phase of the trail our complication rate has fallen and the technique has undergone some changes. The two most significant complications of fibroid embolisation are pre-mature menopause and infection leading to hysterectomy. Out of 1500 patients we have had 5 patients who have required hysterectomy for infection which is a rate of 0.3%. None of these have been emergencies or have required intensive care unit admission. All of them were in the first 500 patients. With regard to amenorrhoea ie pre-mature menopause this has occurred in 5 patients of 773 under 45 years of age 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 pre-disposing 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 UAE to hysterectomy. In the 1500 patients, 13 required hysteroscopic resection of impacted fibroids following embolisation. 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.

Pregnancy Data

The trial at the Royal Surrey County Hospital and London Clinic represents the largest world series of pregnancies following Uterine Artery Embolisation (UAE). It is important to remember the population group in our trial is atypical i.e. older and with other additional risk factors compared with the general obstetric population.

In the series of 1500 patients we have had 87 pregnancies and the results of these pregnancies are summaries in Table 1. Updated August 2007

Table 1

Miscarriage and complication rates: The spontaneous miscarriage rate and other complications outlined in Table 1 are no higher than in the general obstetric population.

In our trial of 1500 women (8%) 120 women were trying at some stage to become pregnant. (53%) went on to become pregnant. Of this sub-group (21%) had been offered hysterectomy as only form of treatment.

Thus our research shows that it is scientifically invalid as is often stated by various bodies and in areas of the literature to claim that no patient wishing to become pregnant should have fibroid embolisation. It should be noted that a number of our patients who had had failed myomectomies had successful pregnancies following UAE and some patients who had UAE required myomectomy.

Our results in 56 pregnancies published July 2006 in the American Journal of Obstetrics and Gynecology can be read under 'The Paper'

References:

1. Ravina JH, Bouret JM, Fried D, et al. Advantage of pre-operative embolization uterine fibroids (In French. Contraception Fertilite Sexualite 1995; 23: 45-4

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. Walker WJ.Bilateral Uterine Artery Embolization for Fibroids. Menorrhagia. Sheth C, SuttonC (eds). Isis Medical Media, Oxford. April 1999: 185-93

10. WalkerWJ. Limitations of Fibroid Embolisation. Controversies in Obstetrics, Gynaecology&Infertility. Ben-Rafael Z, Shohan Z, Frydman R, MonduzziEditore 2001: 427-33

11. Watson GMT, Walker WJ. Uterine ArteryEmbolisation for the Management of Symptomatic Fibroids: Correlation of MRImaging Appearances with Patient Satisfaction in over 100 cases. British Journal of Obstetrics and Gynaecology(in press)

12. Walker WJ, Pelage JP, Sutton C. Fibroid embolisation [review]. Clinical Radiology(in press)

13. Walker WJ. Fibroid Embolisation. Gynaecological Endoscopy. 2000; 9: 343-344

14. Dover RW, Sutton CJG, Walker WJ. Arterialembolisation for uterine fibroids. The results of the largest UK series.British Journal of Obstetrics andGynaecology.1998; 105: 52

15. Walker WJ. Arterial embolisation in obstetrics and gynaecology with particular reference to uterine fibroids. Advances in Obstetrics and Gynaecology. 1999;16:2-8

16. Worthington-Kirsch RL, Walker WJ, Adler L and Hutchins Jr FL. Anatomic variation in the uterine arteries: a cause of failureof uterine artery embolisation for the management of symptomatic myomata. Journal of Minimally Invasive Therapy, December 1999, Vol 8 (6): 397-402

17. Jones K, Walker WJ, Sutton C. Sequestration and Extrusion of Intramural Fibroids following Uterine Artery Embolisation. Gynaecological Endoscopy2000; 9: 309-13

18. Jones K, Walker WJ. Access Procedures to Treat Menorrhagia in one patient. Gynaecological Endoscopy2000; 9: 323-5

19. Barr JD, Lemley TJ, Petrochko CN. Polyvinyl Alcohol Foam Particle Sizes and Concentrations Injectable ThroughMicrocatheters.JVIR1998;9:113-118

20. Anderson JH, Wallace S, Gianturco C. Transcatheter intravascular coil occlusion of experimental arteriovenous fistulas AJR Am J Roentgenol1977;129(5):795-8

21. Anderson JH, Wallace S, Gianturco C, GersonLP. "Mini" Gianturco stainless steel coils for transcatheter vascular occlusion.Radiology1979, 132 (2):301-3

22. Schuur KH, Bouma J. Palliative embolization in gynaecological patients. Eur J Radiol1983;3(1):9-11

23. Wallach EE. Myomectomy. In Thompson JD, Rock JA eds. Te Linde's Operative Gynaecology,7th ed, Philadelphia, USA: Lippincott, 1992: 647-62

24. Wingo PA, HuezoCM, Rubin GL,et al. The mortality risk associated with hysterectomy. American Journal of Obstetrics and Gynecology1986; 152:803-8

25. Takamizawa S, Minakami H, Usui Ret al.Risk of complications and uterine malignancies in women undergoing hysterectomy for presumed benign leiomyomas. Gynecol Obstet Invest1999; 48: 193-6

26. Hill DJ, Complications of hysterectomy. Balliere's Clinical Obstetric andGynaecology1997;11:181-195

27 Vashisht A, Studd J, Carey A, Burns P. Fatal septicaemia after fibroid embolisation. LancetJuly 24 1999; 354:1730

28.Uterine artery embolization survey results: 10, 500 procedures performed world-wide. Society of Cardiovascular and Interventional Radiology, October 1999

29.Walker WJ, Pelage JP. Uterine artery embolisation for symptomatic fibroids. Clinical results in400 women with imaging follow up. British Journal of Obstetrics and Gynaecology. Nov 2002; 109: 1262 -1272.

30. Hanafi M. Predictors of leiomyomas recurrence after myomectomy. Obstetrics and Gynecology 2005 Apr;105(4):877-81

31. 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

32. Spies JB, Bruno J, Czyda-Pommersheim F, Magee ST, Ascher S, Jha RC. Long-Term outcome of Uterine Artery Embolisaton of Leiomyomata. Obstetrics and Gynecology 2005;106:933-9.

33. Kundu S, Gadani S, Clements R, Asisa J, Wilcock G, Barnwell D Comparison of surgical periprocedure Morbidity/Mortality &Length of Stay with UAE for Symptomatic Uterine Fibroids. Presented SIR Canada 2006

34. Walker WJ, Carpenter T, Kent ASHPersistent vaginal discharge after uterine artery embolisation for fibroid tumors: 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