Patient Information

Uterine Fibroid Embolisation

Fibroids are very common non-cancerous growth in the uterus. They may cause heavy periods and painful periods, as well as bulk related symptoms such as urinary frequency and abdominal distention.

A non-surgical alternative Brief
Patient Information By Dr Eisen Liang

What are fibroids and what are the symptoms?

Fibroids are very common non-cancerous growth in the uterus. They may cause heavy periods and painful periods, as well as bulk related symptoms such as urinary frequency and abdominal distention.

What are the treatment options?

1. Uterine fibroid embolisation?

Uterine fibroid embolisation (UFE) is also known as uterine artery embolisation (UAE). Tiny particles are injected to block the flow of the arteries supplying the uterus, starving the fibroids, leading to shrinkage and alleviation of symptoms. This is a procedure performed under sedation and local anaesthetic by an interventional radiologist. A tiny nick is made at the groin and a catheter (small tube 1- 2 mm diameter) is inserted and advanced into arteries of the uterus under X-ray guidance.

What are the advantages of UFE over surgery?

UFE is a minimally invasive non-surgical procedure. The symptoms are effectively treated without surgically removing the uterus or fibroids. The risk of blood transfusion, wound infection/ breakdown and other surgical risk are eliminated and there is no need for general anaesthetics. The hospital stay is much shorter (1-2 days vs. 5-7days). Time to return to normal activities is much faster (1week vs. 4-5weeks).

How effective is UFE?

Overseas and local studies have confirmed the safety and effectiveness of UFE. UFE is as effective as hysterectomy in alleviating fibroid symptoms and improving women’s quality of life.

How do I recover from UFE? Is UFE painful?

After the procedure, you might experience pelvic pain, nausea, fatigue and fever. You will be kept in hospital for 1-2 nights to ensure that your symptoms are adequately controlled with medications. Most symptoms gradually resolve within 4 to 5 days. You should anticipate returning to work and normal activities 7 days after the procedure. Condoleezza Rice had UFE on Friday afternoon and went back to White House on Monday morning.

What are the potential complications after UFE?

Procedural related complications such as injury to artery are very rare (<1%). Delayed complications, such as shedding of dead fibroid fragments causing blockage and infection of the uterus, occur in < 3%. In case you develop pain, fever and smelly vaginal discharge, you will need to be assessed and treated in a hospital emergency department. Most fragments can pass by themselves. Rarely the cervix needs to be dilated by gynaecologist to remove the fragment causing the blockage.

May I lose my period?

Theoretically some particles might find their way to the ovaries due to shared blood supply. However, studies have shown that UFE does not affect ovarian function in younger women. The chance of permanent period loss is less than 3% if you were younger than 40 and more than 40% if you were older than 50. This is probably related to natural onset of menopause as we age.

Is UFE still experimental?

No. UFE has been performed since 1995. Overseas and local studies have proven that UFE is safe and effective in treating fibroid symptoms. UFE was approved by Medicare in 2006. It is recognized as an effective treatment option by Colleges of O&G in UK, USA and Australia New Zealand.

Am I a candidate for UFE?

If you were troubled by fibroid related symptoms, UFE might be an option, especially if you wish to preserve your uterus, avoid major surgery and desire a quicker recovery.

IRSA Credentialing Guidelines

IRSA Guidelines for Credentialing for Interventional Radiology

Introduction

Traditionally, interventional radiology has been regarded as an integral part of radiological practice, with any doctor gaining the F.R.A.N.Z.C.R. or equivalent qualification considered competent to practice the full gamut of interventional procedures. The last 10 years have seen an almost exponential increase in the number and complexity of minimal invasive therapeutic or biopsy procedures that require radiological guidance. All trainee registrars have considerable exposure to interventional radiology in addition to College requirements for angiography, nephrostomy, abscess drainage and biopsy.
However while they may have performed many complex procedures as first operator, there is no doubt that additional training is required for those wishing to perform the more complex interventional procedures.
The radiology community is ready and able to train medical graduates who are willing to make a 5-year commitment to learning the skills required. However we refuse outright to offer superficial or limited training to those who wish to indulge in invasive radiology procedures. Unless one understands all aspects of radiologic practice, it is not acceptable or responsible to try and perform one small aspect of it in a vacuum.

Credentialing

Credentialing is the process by which physicians are determined by hospitals to be competent and are permitted to perform procedures. The granting of credentials is designed to protect patients from persons with superficial training in imaging and maintain quality of care. Patients are not in a position to know which physicians are best qualified to perform which procedures. Patients place their trust in the hospital to screen physicians based on training and competency, not on their ability to refer patients to the hospital.

Training

The primary requisite for an interventional or endovascular radiologist is that they must be fully trained in all aspects of imaging.

Specialist interventional radiologists will require additional training in this sub-specialty. This will consist of one year of approved full-time instruction in interventional radiology at an approved site. Logbook documentation of which procedures have been performed is required. The documentation must allow for independent verification of the work done and indicate for which procedures the trainee was the primary operator. The Interventional Society of Australia (I.R.S.A.) and the Royal Australian and New Zealand College of Radiologists (R.A.N.Z.C.R) has draft documents indicating accreditation requirements for training in interventional radiology.

In brief the following requirements must be met:

  1. Sufficient workload to provide the necessary hands-on experience for each trainee. As a guide a caseload of 20 procedures per week per trainee is considered a minimum.
  2. Access to the other imaging modalities essential to proper performance of interventional radiology, namely CT, Ultrasound and M.R.I. The supervisor must be able to demonstrate competence in these modalities or be accredited by the R.A.N.Z.C.R.
  3. In-room supervision by an individual accredited for this purpose by IRSA /RANZCR.
  4. Proof of an existing and active Quality Assurance or EQUiP program.
  5. Written record of the fluoroscopy time for each procedure.
  6. Adherence to the established principles preventing self-referral for radiology procedures.
  7. Consistent billing and facility fees for all groups using equipment owned by third parties.

It has been determined by I.R.S.A. that there are two tiers of interventional radiology.

TIER A
Basic diagnostic angiography and interventional techniques – angiography, nephrostomy, abscess drainage and biopsy. This is in keeping with the training requirements of the R.A.N.Z.C.R. and any individual with R.A.N.Z.C.R. or equivalent qualifications may perform these procedures.

TIER B

  1. All neuro-interventional procedures intracranial and extracranial
  2. All vascular interventional procedures other than basic diagnostic angiography, i.e. stents, angioplasty, thrombolysis, thrombectomy, atherectomy, embolisation, retrieval of foreign bodies and laser and mechanical angioplasty
  3. Venous and arterio-venous graft interventions other than basic diagnostic venography or fistulography, i.e. thrombolysis, angioplasty, stents, atherectomy, pulmonary embolectomy/thrombolysis and caval filter insertion
  4. Biliary intervention including T.I.P.S.
  5. Thoracic intervention, i.e. embolisation of AVMs, bronchial stents, occlusion of broncho-pleural fistulae and bronchial artery embolisation Gastro-intestinal intervention, i.e. oesophageal and duodenal stents, percutaneous gastrostomy, gastrointestinal vascular procedures other than diagnostic angiography, i.e. embolisation, chemo-embolisation and transplant intervention.
  6. Urological intervention, i.e. renal artery embolisation, angioplasty or stenting, percutaneous nephrolithotomy
  7. Gynaecological – fallopian tube recanalisation, embolisation of fibroids, temporary aortic occlusion
  8. Orthopaedic – percutaneous vertebroplasty, percutaneous discectomy

In view of the small number of formal training sites so far established, accreditation for these procedures should be based on proof of a certain number of procedures performed as follows:

Minimum Training

The American Heart Association and S.C.V.I,R. have similar requirements for the performance of percutaneous angioplasty. Based on these figures and Australian experience, the following minimum training is proposed:

(i) Performance of 300 peripheral angiograms under accredited supervision

(ii) Performance of 50 peripheral/renal angioplasties with 25 as primary operator, with at least 10 using an antegrade femoral approach

(iii) Performance of 30 vascular stents (15 as primary operator)

(iv) Performance of 20 cases of peripheral vascular thrombolysis (10 as primary operator)

(v) Performance of 10 cases of peripheral catheter guided thrombus aspiration (5 as primary operator)

(vi) Ultrasound guided vessel puncture (20 cases as primary operator)

(vii) Completion of an approved course in radiation biology and protection equivalent to that provided to F.R.A.N.Z.C.R. candidates

These procedures should have been performed in an IRSA/ RANZCR accredited site open to peer review and audit with indications, primary success and complications documented. Combined procedures are to be counted as one procedure with the exception of ultrasound guided punctures (Angiogram + angioplasty + stent + aspiration + thrombolysis = one procedure)

Proof of Quality

IRSA in conjunction with the RANZCR has produced minimum standards of practice for interventional radiology (Appendix 1). These include threshold for complication rates and expectations of success of the procedures performed. The indicators are based on an “intention to treat”.

Appropriate clinical indicators | 95%
Failure to obtain percutaneous access (required open procedure) | <1%
Success of diagnostic accuracy | 95%
Success in crossing stenosis | 95%
Success in crossing occlusion <6cm | 85%
Success in renal stent placement | 80%
Puncture site haematoma (requiring transfusion, surgery or delayed discharge) | <3%
Contrast extravasation | <1%
Distal embolisation | <0.5%
Dissection / occlusion of vessels | <2%
All neurologic deficits | <4%
Permanent neurologic deficit | <1%
Radiation dose to patient and staff “ALARA” | 100%

On Call and cover for annual leave

Credentialing must allow for continuity of service to cover leave and provide a 24-hour on-call service. Any additional accredited interventionist would need to take a full share of the after-hours procedures including all angiography procedures.

Equipment

Equipment standards are outlined in IRSA Standards documented on page 10. Over 75% of the procedures required for training must be performed in a dedicated angiography suite. Mobile image intensifiers are not considered in the interests of the patient or the operator.