aparoscopic Surgery and Perioperative Nursing by murplelake78

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									                                                                                                            Capital C L I N I C


     aparoscopic Surgery and Perioperative Nursing
L      By Mr Adrian Lower FRCOG, Consultant Gynaecologist, Harley Street


 Laparoscopic myomectomy as performed by the team at
 The London Clinic Minimally Invasive Therapy Unit under the
 direction of Mr Adrian Lower is offering more patients the choice of
 conservative surgery, for this most common gynaecological condition
 in what is almost a day case procedure.

Introduction                           Appropriate treatment

Uterine fibroids occur in up to 50%    Intramural fibroids present something of a
of women and although they only        problem to most gynaecologists. Many are
                                       reluctant to perform a laparotomy for what          Adrian involved in a laproscopic
cause symptoms in around a                                                                            procedure
quarter of cases they remain the       may seem to be rather small fibroids of 3 or
                                       4 cm in diameter because of the perceived      assistant plays a vital part in the procedure
most common cause of                                                                  by holding the video camera, maintaining
                                       risks and prolonged recovery time. Open
hysterectomy before the                myomectomy is a notoriously bloody             control of instruments which may be
menopause. We know from recent         procedure and is recognised to be one of       retracting bowel or the ovaries and
research that fibroids substantially   the most adhesiogenic of gynaecological        Fallopian tubes, some develop a high level
reduce the chance of conception,       procedures and, where the goal is              of hand-eye coordination and will assist in
especially those which are             enhanced fertility, post-surgical peritubal    cutting of sutures and irrigation of the
submucous or intramural in site        adhesions may negate any benefit derived       operative field.
(Figure 1). Clearly hysterectomy is    from myomectomy. Laparoscopic
not acceptable to women who wish       myomectomy is a potential solution,
to conceive, and also has a fairly     however, few gynaecologists have the
high complication rate, which          necessary training to perform this
                                       procedure. Consequently many women
many women whose family is
                                       may not be receiving appropriate treatment.
already complete wish to avoid.
Others wish to retain their uterus
                                       The Procedure
                                       Laparoscopic myomectomy is performed
                                       under video-laparoscopic control using a                   Pedunculated fibroid
                                       small 10mm umbilical incision and two
                                       accessory ports of 5 mm and one of 10
                                       mm. These small incisions have a much
                                       lower rate of wound infection, less
                                       postoperative pain and allow much earlier
                                       mobilisation and a faster return to work. Mr
                                       Lower’s team have been using this
                                       technique for more than five years and have
                                       performed well over a hundred procedures
                                       without a single blood transfusion. The
                                       main obstacle to widespread uptake of the
         Description to go here        procedure is the need to suture the uterine
                                       defect after removal of the fibroid. Most
                                       surgeons do not achieve this level of hand-          Intermural posterior wall fibroid
for a variety of reasons including     eye coordination until they have been                        before surgery
concerns regarding sexuality and       performing laparoscopic surgery for many
the quality of their orgasm. A         years. The difficulty lies in performing
number of options have been            complex movements in a confined space
developed by minimal access            using both the dominant and non-dominant
                                       hand on a two dimensional video monitor.
surgeons, which have a lower
complication rate and may              A well equipped theatre and highly
enhance fertility. Submucous           professional support staff are essential to
fibroids are best dealt with by        success. The advantage of laparoscopic
hysteroscopic resection using a        surgery is that the whole theatre team can
diathermy armed resection loop.        observe the procedure and anticipate
Alternatively a new bipolar            equipment which may be required. In open
diathermy instrument called            surgery especially in the pelvis only the
                                       scrub nurse has any idea of what is going            After laproscopic suturing of the
Versapoint may be used to                                                                           myometril defect
vaporise smaller fibroids.             on. Some members of the nursing team
                                       have trained as first assistants. The first

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  Operative technique                              diameter with a rotating cylindrical knife       Complications
                                                   blade inside which removes the fibroid
  The operation is performed using a 4 portal      tissue cutting it into long sausages of tissue   The complication rate following
  approach. One 10mm port at the                   – challenging for the histopathologist. The      laparoscopic myomectomy has been
  umbilicus, one 5 mm port positioned in           presence of a razor sharp rotating blade a       shown to be lower than open surgery in
  each iliac fossa and a 12mm port in the          few millimetres from the bowel also helps to     terms of the need for blood transfusion,
  midline 5 to 10 cm above the symphysis           focus the attention of the operating             infection and wound infection according to
  pubis. Pitressin is injected to the uterine      surgeon. It is essential that the blade is       a recent Italian study. Some authorities
  cornua to induce vasospasm and decrease          kept well in view throughout the procedure.      have expressed concern that the repair of
  bleeding. It also causes some peripheral                                                          the myometrium may be less strong than
  vasoconstriction which can be alarming for       Some form of adhesion prophylaxis is             after open surgery and so there may be a
  the anaesthetist as the pulse oximeter often     required to prevent adhesions forming at         higher rate of uterine rupture in subsequent
  stops functioning. Using diathermy armed         the site of the suture line. Currently a         pregnancies. The limited evidence available
  scissors the serosa is incised over the          solution of 4% Icodextrin is left in the         on this aspect is conflicting. Further
  fibroid and the fibroid is stripped away from    peritoneal cavity as a hydroflotant to           studies are required. For the time-being we
  the myometrium in much the same way as           separate the tissues during the early phase      recommend a formal trial of scar, as we
  it is at open surgery. The defect is then        of repair and adhesion formation. The            would following an open myomectomy, with
  repaired in two layers using vicryl to           efficacy of this product is currently under      intrauterine pressure monitoring in a
  obliterate the cavity left by the fibroid in a   prospective evaluation in a pan-European         specialist obstetric unit or an elective
  broad haemostatic suture followed by             study.                                           Caesarean section.
  monocryl – a monofilament absorbable             Post operative recovery is rapid. Most
  suture – to approximate the serosa.              patients leaving hospital less than 24 hours
                                                   after surgery. The majority will be back at
  The fibroid is removed from the peritoneal       work in two weeks, although it is important
  cavity using a morcellator introduced            that patients realise that they have had
  through the 12 mm suprapubic trocar site.        major surgery and should allow adequate
  The morcellator is a long tube of 12 mm in       time for rest and recuperation.


         aparoscopic Surgery and Perioperative Nursing
  L        By Stuart Pestana Perioperative Registered Nurse

  The role of the Perioperative Nurse within       prior to the scheduled surgery. During
  the theatre environment has been                 surgery the nursing teams work together
  constantly evolving and expanding, with          with the surgeon and anesthetists to
  forever increasing demands to gain               maintain optimal safety for our patients.
  knowledge of the latest surgical techniques      Each nurse team member has specific
  and to improve the efficiency of our working     responsibilities. The scrub nurse works
  environment. The primary focus however,          together with the surgeon and the
  of the perioperative nusing team, is to          surgeon’s assistant providing the correct
  ensure absolute safety of our patients. This     surgical instruments and materials
  safety is only possible through extensive        necessary to perform a specific surgical
  education and training specific to the           procedure within the sterile field. This nurse
  surgical procedures together with the            may also assist in laparoscopic camera
  combined experience of the nursing team          operation as necessary. Circulating nurses
  involved.                                        are also vital members of the team, as the
                                                   scrub nurse liaises with and relies on the
  Because laparoscopic surgery has become          circulating nurses to connect equipment
  increasingly complex, perioperative nurses       such as camera systems and also to
  have been required to develop a greater          provide any additional instruments and           Unique Skills
  understanding of the equipment,                  materials required during the surgery. The
  instruments and surgical techniques used         circulating nurses will also complete            With the continuing advancements in
  by laparoscopic surgeons. With this              documentation related to the surgery.            laparoscopic surgical techniques and the
  knowledge it is possible to adequately                                                            introduction of new equipment,
  prepare the operating theatre environment        Although the perioperative nurses do not         Perioperative nurses require constant
  to a level that is conducive to safe surgery.    perform any surgery themselves, they are         thorough training to maintain their skills to
                                                                                                    current levels. Because many operating
                                                   required to possess knowledge that
                                                                                                    theatre departments experience a turnover
  For laparoscopic surgery, the perioperative      enables them to comprehend surgical              of nursing staff members, a continuing
  nursing team generally consists of a scrub       procedures. Laparoscopic surgery is unique       orientation and education programme is
  nurse and up to two circulating nurses with      in comparison to open surgery because the        necessary to maintain high standards of
  one member designated as nurse team              nursing team shares the same direct view         patient care in the operating theatre.
  leader. Prior to surgery this team will          of the surgical site as the surgeon. Together
  prepare the operating theatre with               with knowledge of the surgical procedure,        The perioperative nurses form an integral
  equipment, instruments and consumables           this direct view enables the nurses to           part of the theatre team including surgeons,
  essential for the surgical procedures.           anticipate the needs of the surgical team        assistants, anesthetists, OPD’s and porters.
  Maintenance of equipment and organization        and to plan their requirements without           Together with our unique skills combined,
                                                                                                    we are able to provide patients optimal care
  of surgical instruments for sterilization are    unnecessary delay.
                                                                                                    within the operating theatre environment.
  significant considerations at least one day

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                terine Artery Embolisation for the treatment of
       U        fibroids - a patient experience
       By Ginette Camps-Walsh, Chairman CIM Medical Group

       The latest research shows                            DVT and death rate from hysterectomy is       and embolisation. He couldn't tell me
                                                            relatively high, it is a very invasive        what effect hysterectomy would have on
       that over 70% of white and                           operation with a very long recovery time      my sex life and said he wouldn't know
       80% of black women have                              and also causes sexual dysfunction. I         until he opened me up whether he would
       fibroids. Despite this I                             had worked very hard to become a              need to remove my cervix or not. Much
       knew nothing about them                              director of a healthcare company and          to his surprise I opted for embolisation.
                                                            could not afford months off work.
       until my own diagnosis.                                                                            Most gynaecologists do not tell women
                                                            I had run a medical company specialising      about UAE, and some women have to
       I had an increasingly large stomach, so
                                                            in radiology and had seen embolisation        be very assertive to be referred for UAE.
       large that I couldn't bend over easily and
                                                            used to treat an aneurysm in the brain. I
       sitting down was uncomfortable. My
        periods were very painful and quite
                                                            knew the same technique could be used         Four large fibroids
                                                            to treat inoperable cancers. My GP was
           heavy, lasting 14 days, but I put this
                                                            surprised when I asked if fibroids could      Dr Nigel Cowan, the interventional
              down to one of the joys of growing
                                                            be embolised. She advised that a Dr           radiologist, gave me an MRI scan. It
                older. I also had urinary urgency
                                                            Cowan in Oxford might be offering this        showed that I had four very large
                  and occasional sciatica. On
                     holiday three years ago, my                                                          fibroids, three of which were over 10cm.
                                                            I went home and did extensive research        None were pedunculated subserosal
                      husband, rubbing suntan
                                                            on the Internet, looking at clinical papers   types, for which embolisation was then
                         lotion into my stomach,
                                                            and web sites on fibroid treatments.          contraindicated. I agreed to go ahead.
                           said 'this isn't fat’ it's all
                                                            Uterine artery embolisation [UAE] had         Dr Cowan gave me a very
I feel                      hard and you've got a
                              large lump down your
                                                            started in France in the late 1980s.          comprehensive presentation on the
                                                            Patients had been embolised prior to          treatment of fibroids, a detailed
                               right hand side'. Then
                                                            hysterectomy to reduce haemorrhaging.
like                            I sought medical
                                 help.
                                                            Many then refused the surgery, as their
                                                                                                          explanation of UAE and also briefed me
                                                                                                          thoroughly on the possible complications
                                                            symptoms had disappeared. A similar           and side effects. The fibroids would
                                                            technique has also been used at least a
a much                           I immediately
                                  thought of ovarian
                                                            decade before this for treating
                                                                                                          shrink by 60% and I hoped this would be
                                                                                                          enough. [Research now shows that
                                                            postpartum haemorrhage. Nature’s              fibroids continue to shrink after a year
                                  cancer and went
younger                           to my GP in a
                                                            version of UAE ‘red degeneration’ occurs
                                                            mainly in pregnancy.
                                                                                                          and some disappear all together.]
                                  panic. As soon as
                                  she examined me                                                         Home by next morning
and                               she leapt out of
                                                            The procedure is carried out by an
                                                            interventional radiologist in an              I'd been in angiographic suites many
                                 the room and
                                                            angiography suite. No general                 times to see treatments on others, so the
                                 arranged an
healthier                       immediate
                                                            anaesthetic is required. It normally takes
                                                            60-90 minutes and requires a 1-night
                                                                                                          whole experience was a bit surreal. I
                               ultrasound scan.                                                           was conscious and fascinated with what
                                                            hospital stay, with return to work in 2-5     was going on and a bit frustrated that
                              The NHS worked
woman                        superbly for me; I just
                                                            weeks. Large fibroids of at least 24 cm
                                                            have been successfully embolised.
                                                                                                          lying flat I couldn't see much. With
                           walked straight across                                                         diazepam and diamorphine, I felt no pain
                                                            Fertility is maintained and a number of       when the angiographic catheter was
                          the grass from the GP
                                                            women have had successful pregnancies         inserted, just a warm flowing sensation
                         surgery to the John
                                                            after embolisation.                           when the contract medium was injected.
                       Radcliffe hospital and had
                    an immediate ultrasound                                                               I needed three times the normal dose of
                                                            The treatment is effective in 93-97% of       embolic particles, because the fibroids
                  scan. I was told, to my huge
                                                            patients. A few patients (0.25-7%) will go    were so large. Immediately the second
               relief, that I had many large
                                                            on to have hysterectomy because of            side was embolised I felt cramping pain,
            fibroids and an enlarged kidney, not
                                                            infection (1%) or insufficient reduction in   which grew worse. I spent a rough night
          cancer.
                                                            fibroid size. 5-7% of patients expel          with large doses of diamorphine, which
                                                            fibroids. Mortality is approximately 6-10     was gradually tailed off to paracetamol
       Hysterectomy no option for                           times lower than with hysterectomy.           by morning. I showered, dressed and
       me                                                   Morbidity is much lower too – no surgical     went home the next morning feeling
                                                            trauma to adjacent organs, early              bloated. I was given some NSAIDs and
       My GP said I would probably need a                   menopause necessitating HRT, urinary          analgesics, although my pain had
       hysterectomy and some GnRH                           incontinence, sexual dysfunction or           completely gone by the next day.
       antagonists as a pre-treatment, because              depression.
       the fibroids were so large. I told her I
                                                                                                          Recovery from embolisation is very
       would not be happy to have drug                      The gynaecologist said my uterus was          variable. I learned later that one woman
       treatment, since this could affect the               the size of a 34-week pregnancy and I         went to a party the day after. I had a bit
       intellect and short-term memory and I felt           had at least two large fibroids. The          of a tough time, not helped at all by
       hysterectomy was dangerous.                          treatment options were - hysterectomy,        getting a bad viral infection with a cough.
                                                            myomectomy (although he wasn't keen           This is not a good idea coupled with the
       From previous research, I knew that the              on doing that unless I wanted children)       inflammatory response from the
                                                                                                                                                        15
Capital C L I N I C

     embolisation - my temperature fluctuated      squash again. I feel like a much younger
     for some weeks.                               and healthier woman and have no scar                  UFE - MY FIBROIDS
                                                   or adverse side effects. I couldn’t
     I returned to work in 5 weeks, much later     recommend UAE highly enough.
     than the normal 2 weeks or the tough          Over 30,000 hysterectomies are
     Americans in a few days.                      performed every year for the treatment of
     Three fibroids expelled                       fibroids, many requiring further treatment.
                                                   The Department of Health wants to
     My recovery was quite eventful. Three         reduce the numbers of hysterectomies
     months after the embolisation I had great     and the NICE Clinical Guidelines Review
     pain, like labour pain and expelled a         of hysterectomy and alternatives is about
     fibroid. This happens in 5-7% of              to start.
     patients. It was so large it needed some
     help from the gynaecologists to pull it out   There are now over 50 centres in the UK
     and the slight infection, treated with        offering UAE and this number is growing
     antibiotics. Normally fibroids are expelled   all the time. In London all the teaching
     within the first month. A month later,        hospitals and most of the larger private
     with no pain, I also expelled another         hospitals offer UAE. There have been
     fibroid, with some assistance, but a third    over 3,000 UAE procedures in the UK
     fell out all my itself. Three expelled        and about 75,000 worldwide.
     fibroids are apparently a record! I was
     very pleased to be rid of them, as my         I was so delighted with my results that               UFE - MY FIBROIDS
     main concern was whether they would           we started a patient group FEmISA –
     shrink sufficiently.                          Fibroid Embolisation: Information,
                                                   Support & Advice to help to ensure that
     Now after 3 years my periods are much         women had access to embolisation and
     lighter with no pain and no need for          to support them.
     analgesic. I am much slimmer, my
     kidney and uterus have returned to their      Ginette Camps-Walsh
     normal size and have started playing


              For further details please see our web site www.femisa.org.uk
                                Other web sites of interest –
                 British Society of Interventional Radiology www.bsir.org
           Fibroids Uterine Embolization - Dr. Nigel Cowan, Churchill Hospital,
                            Oxford: http://www.fibroids.me.uk
        Fibroids Embolization - Dr. W.J. Walker, Fibroids Embolization Specialist,
                Royal Surrey Hospital, Guildford http://www.fibroids.co.uk



     UFE the method
     Uterine fibroid embolization                   material is made up of plastic particles,       buildup of dead tissue in the uterus,
     (UFE) is a treatment                           each about the size of a grain of sand,         which may require antibiotics or a D&C
                                                                         which travel through       (dilatation and curettage) procedure to
     for uterine fibroids in                                             the uterine artery and     remove tissue that is not being absorbed
     which a material                                                    block blood flow as        or passed by the body. There is also
     injected into the                                                   the artery narrows,        concern among some that the exposure
     uterine artery blocks                                               cutting off the blood      to radiation during the procedure places
     blood flow to the                                                   supply of the uterine      patients at risk, though research so far
                                                                         fibroid. The polyvinyl     has not proven that this is the case.
     fibroid, causing it to                                              alcohol material is
     shrink and eventually                                               injected until all the     During the UFE procedure a catheter is
     die.                                                                blood vessels flowing      inserted through
                                                                         to the fibroid are         the skin, into the
     Detailed Description                           completely blocked. Once the blood              femoral artery and
                                                    supply to the fibroid is blocked, the fibroid   ultimately into the
     A small nick is made at the groin and the      stops growing and dies.                         uterine artery.
     femoral artery (the large artery that runs
     the length of the femur, or thigh bone),       After treatment, patients will experience       Small particles,
     and a tube called a catheter is inserted       some discomfort (pain or nausea), and           PVA emboli, are
     into the femoral artery and fed into the       vaginal bleeding or passing of fibroid          injected through
     uterine artery. The catheter is guided         tissue (if fibroids are in the inner uterine    the catheter and flow into the branches of
     using special x-ray imaging called             lining) may occur. Also, patients may           the uterine artery and prevent blood from
     fluoroscopy. Once the catheter is in place,    experience irritation or bleeding at the        reaching the tumors.
     tiny particles called polyvinyl alcohol        incision site. In rare cases, patients have
     material (PVA or emboli) are injected into     suffered infections, prolonged pain, fever,
     the uterine artery. Polyvinyl alcohol          damage to the reproductive tract, or

16
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Fibroids and the radiologist
Dr Woodruff Walker, Consultant Interventional Radiologist, heads the worlds largest
single centre trial for Fibroid Embolisation
At the Royal Surrey County                                1990s. The first series of uterine artery embolisation    There are, however, complications of the procedure; a
Hospital and The London                                   was published in the Lancet in 1995. Over 45,000          small number of patients between 0.5 to one per cent
                                                          embolisations have now been carried out world wide.       of infection leading to hysterectomy and two per cent
Clinic, we are conducting the                                                                                       of our patients required hysteroscopic resection of
largest single centre trial for                           The procedure itself which is carried out under local     impacted fibroid material, and a number of patients
Fibroid Embolisation. Since                               anaesthetic and intravenous sedation is relatively        also may develop troublesome vaginal discharge
our trial began in December                               painless. It involves the insertion of a small catheter   requiring hysteroscopy.
1996 we have carried out 960                              into the femoral artery in the groin. Then under X-ray
                                                          TV control, the catheter is manipulated into the two      Our figures show a success rate for the procedure of
procedures. An analysis of                                arteries that supply the uterus. Tiny particles (like     more than 85 per cent with average fibroid shrinkages
            our first 400                                 grains of sand) 355-500 microns in size of PVA            above 60 per cent and patient satisfaction rates at
             patients with                                (polyvinyl alcohol) are injected through the catheter     more than 90 per cent. Fibroid embolisation does
              follow up for a                             into the arteries. These particles pass selectively to    appear to have a significant success rate in a properly
              period of four                              the vessels supplying the fibroids, these vessels         selected group of patients where the gynaecologist
                                                          become silted up thereby depriving the fibroid of         and radiologist work together as a team.
             years was                                    blood which infarcts and shrinks, or in the case of
            published in BJOG,                            some submucous fibroids, may be expelled through          Pregnancy data, after embolisation world wide, is still
               November 2002                              the vagina.                                               restricted but in our series we have had 37
                 (Vol.109 pp                                                                                        pregnancies most of which have been successful or
                  1262-1272).                             Following the procedure patients usually experience       ongoing.
                                                          pain over the next 12 to 24 hours. The pain varies
                            Uterine fibroid               from mild to severe which needs treatment with heavy      For further detailed medical information on the results
                             embolisation was first       doses of oral analgesics. The patient spends two          of our trial on fibroid embolisation visit our website
                             carried out sporadically     nights in hospital and should be off work for one to      www.fibroids.co.uk
                              in France in the early      two weeks.



          terine Artery Embolisation - a practical versus the
U         rose tinted approach (managing expectations)
By Dr John Reidy
                                                          ultrasound study and will make a clinical judgement        essentially treats each fibroid individually whereas
                                                          that the fibroids are responsible for significant          UAE by occluding the blood supply to most of the
                                                          symptoms. Only when this has been established              uterus has a global approach and will treat all the
                                                          should any form of treatment be considered.                fibroids.

                                                          It is important to remember that the symptoms of           There are no treatments for fibroids which guarantee
                                                          fibroids are non-specific and that other pathologies       success and that do not carry some risk and UAE is no
                                                          may co-exist. Also, in UAE unlike surgery no               exception. The results of 2 randomised controlled
                                                          pathological specimen is obtained and there is always      studies are awaited but the data from uncontrolled
Since uterine artery                                      the rare spectre that a condition such as a uterine        studies suggests that around 85% of women are
                                                          sarcoma could be missed. Some have advocated MRI           happy with the result of their embolisation procedure.
embolisation (UAE) first                                  as part of the routine assessment but there are cost       The procedure necessitates an overnight admission as
emerged in 1996 as a                                      implications and many would not consider it to be          a result of pain that occurs immediately after the
uterus- conserving                                        necessary.                                                 procedure which usually needs strong
                                                                                                                     analgesics.Significant complications are rare the most
minimally invasive                                        Once a decision has been made that the fibroids are        severe being infection that leads to a hysterectomy in
alternative to surgery there                              causing significant symptoms, many women will              about 1%.It is important that the referring
has been considerable                                     choose not to have a hysterectomy for a variety of         gynaecologist has knowledge of the procedure as in
                                                          reasons. These include a wish to keep their womb,          addition to routine followup there are sometimes
interest by women, much                                   sometimes associated with the desire for a possible        concerns and occasionally ancillary procedures may
enthusiasm by radiologists                                future pregnancy and also wanting to avoid the             be needed after UAE. There are concerns about fertility
and a cautious concern by                                 morbidity and long convalescence associated with           after UAE and especially in younger women but data
gynaecologists. If a                                      surgery. Once a woman has decided that she does not        are emerging that suggest that normal pregnancy can
                                                          want a hysterectomy there are only limited options         occur similar to that in post-myomectomy women.
radiologist is to perform                                 available. Medical treatment has no role except prior
these procedures it is                                    to surgery and new treatments such as MRI guided           UAE has a very definite role to play in the management
essential to work in close                                laser and ultrasound ablation techniques are only of       of women with symptomatic fibroids.When woman
                                                          very limited availability. The practical choice then       chooses not to have a hysterectomy UAE should be
co-operation with a                                       lies between a myomectomy and UAE.                         considered along with a myomectomy. Ideally the
gynaecologist.                                                                                                       Gynaecologist should have a working knowledge of
                                                          The great majority of myomectomies are performed via       UAE as well as being able to offer myomectomy.For
Fibroids are very common in women and their               the abdominal route and not all gynaecologists are         the interventional radiologist it is important the women
prevalence increases up to the time of the menopause.     enthusiastic about the technique. Clearly where there      are given detailed information about the procedure and
A majority of fibroids are asymptomatic and as such       are a small number of fibroids and these are on the        its risks and expectations.Also the radiologist must be
no treatment is indicated. A gynaecologist will usually   outside of the uterus a myomectomy might be more           available to answer any questions or concerns they
make the diagnosis of fibroids based on a clinical        suitable but multiple fibroids in a submucous location     might have about UAE.
history and examination, supplemented by an               are much more difficult to deal with. Myomectomy
                                                                                                                                                                                17
Capital C L I N I C
     Pre-Operative hormone therapy before hysterectomy or myomectomy
     Fibroid growth is stimulated by oestrogen, and             • hysterectomy appeared to be easier                         Myomectomy had advantages for those women who
     gonadotrophin releasing agonists (GnRHa) which             • less operating time for hysterectomy and more              wish to preserve or enhance their fertility, but is
     induce a state of hypoestrogenism have been                  patients were able to have a vaginal rather than           regarded as a more difficult procedure. the method must
     investigated as a potential treatment. GnRHa treatment       an abdominal procedure                                     be distinguished in the evaluation of pretreatment with
     causes fibroids to shrink but cannot be used long term     • reduced hospital stay                                      GnRHa. There are advantages associated with reduced
     because of unacceptable symptoms and bone loss.            • blood loss and rate of vertical incisions were             blood loss during the operation, ease of operability and
     Therefore GnRHa may be useful pre-operatively both to        reduced for both myomectomy and                            better anatomic reconstruction, but there is also a
     reduce fibroid and uterine volume and control bleeding.      hysterectomy                                               concern that the fibroids may not ‘shell out’ cleanly.
                                                                                                                             Pretreatment of patients with GnRHa prior to
     In a review of clinical trials to asses                    The main effects of this treatment are the temporary         hysterectomy has been advocated for patients with
     the value of GnRHa 1, the following                        control of bleeding and a reduction in fibroid and           severe anaemia and in order to reduce blood loss. Other
     results were recorded:                                     uterine size. However, side effects include menopausal       indications have included large fibroids or other factors
     • pre- and post-operative haemoglobin and                  symptoms and bone loss with long term use. After             that may make surgery technically difficult. Pretreatment
       haematocrit were significantly improved prior to         therapy is stopped, there is regrowth of both the fibroids   may also enable the greater use of more conservative
       surgery                                                  and the uterus almost to their pretreatment size and a       surgical options.
     • uterine volume, uterine gestational size and             recurrence of symptoms. Therefore, although the role
       fibroid volume were all reduced                          for these agents as a sole approach is limited, there is     1. Lethaby A, Vollenhoven B, Sowter M. Pre-operative
     • pelvic symptoms were also reduced but some               clearly a useful role in their use as a pre-operative        GnRH analogue therapy both hysterectomy or
       adverse events were more likely during GnRHa             adjunct to surgery.                                          myomectomy for uterine fibroids (Cochrane Review). In:
       therapy                                                                                                               The Cochrane Library, Issue 2, 2003.



     Bead Block: New innovative embolic microsphere
     Bead Block™ a product of British-based medical device      "PVA has been used safely in the body for decades and        Biocompatibles markets its Bead Block through its’
     company Biocompatibles (BII:FTSE) is a precisely           calibrated microspheres have become a preferred              distribution partner Terumo Corporation. Terumo is a
     calibrated, compressible, visibility-tinted microsphere    design standard for embolisation, because they are less      global medical technology company based in Japan
     made from polyvinyl alcohol (PVA), an established          likely to aggregate in the delivery catheter than is         that supplies a range of products for angiography,
     material in embolisation therapy. Interventional           particulate PVA. Sizes of the microspheres can also be       cardiology, cardiovascular systems and other medical
     radiologists use embolotherapy to block blood flow to      chosen to selectively occlude a vessel of a specific         products. Terumo has an established presence in the
     tumours or vascular malformations. Embolotherapy has       diameter. Because Bead Block is made from a PVA              interventional radiology community and is recognised
     become a minimally invasive treatment alternative for      hydrogel, this embolic agent also has the added benefit      as a provider of excellent products and services.
     conditions such as uterine fibroids, for which             of compressibility, making delivery through a
     hysterectomies are often performed                         microcatheter easy and reliable."                            Bead Block is currently marketed in the the US and
                                                                                                                             Europe and is expected to be launched in the Far East
     "Bead Block will be a valuable addition to the             Bead Block received CE Mark approval in June 2003            later this year.
     interventional radiologists’ portfolio," said Doug Redd,   and in the US Bead Block has FDA clearance for the
     MD, Chief of Vascular & Interventional Radiology at        treatment of hypervascularlized tumours and
     Emory University Hospital in Atlanta, Georgia (US).        arteriovenous malformations.

     Uterine Artery Embolisation - A gynaecologists View By Mr Adrian Lower FRCOG
     Uterine artery embolisation (UAE) is a useful technique    In our experience UAE is ideal for women with larger         a few months of unprotected intercourse 18months
     for dealing with fibroids in certain cases where a         submucous fibroids which can be very difficult to            after surgery.
     woman wishes to avoid the risks of surgery. It should      resect and can require two or three procedures before
     not be regarded as the only option and fits into a range   the fibroid is completely removed. Typically these are       For more information about the various
     of potential treatment options for this most common of     the fibroids which will pass spontaneously after UAE.        options for management of fibroids visit
     gynaecological conditions. UAE is not without risk         The other type of fibroid which does well with               the London Fibroid Clinic Website at
     itself and as yet we are unsure of the long term           embolisation is the larger interstitial fibroid especially   www.fibroidspecialist.co.uk.
     outcome or whether there are any adverse effects as far    when multiple fibroids are present. These will often
     as pregnancy is concerned. We do know that a               reduce in size dramatically and symptoms can
     number of women have conceived after UAE and have          completely resolve. Exophytic subserous fibroids do
     had satisfactory pregnancies and deliveries but we do      not respond so well to UAE and are more likely to give
     not know if there are subgroups that we may be able to     rise to infection.
     identify who may not be able to conceive or who are
     likely to develop problems. There have been                We have also employed UAE in combination with
     complications associated with serious infection and        myomectomy. The embolisation procedure being
     very large fibroids may not be so suitable for             performed first and then the patient is taken to theatre
     embolisation.                                              on the same day for a standard myomectomy either
                                                                open or laparoscopic depending on the size of the
     At present UAE is still regarded as an experimental        fibroids. UAE enables the surgeon to operate in an
     procedure although large numbers have been                 almost bloodless field whch enables him to remove the
     performed. It is important that a register is kept of      larger, exophytic fibroids more safely. He can also not             Complex multi-fibroid uterus before
     women undergoing UAE so that they can be followed          worry about the smaller fibroids which may be situated
     up and we can see how many of those who wish to            deep in the myometrium since these will shrink away
     conceive are able to do so.                                later. The pictures below show one such massive
     I think it is important for a woman with fibroids to be    complex fibroid which was easily dealt with following
     assessed by a gynaecologist with close links to an         embolisation. There is a large 10cm in diameter broad
     interventional radiologist so that women who are most      ligament fibroid and an 8 cm anterior wall fibroid
     suitable for the procedure can be identified and those     arisng from the lower segment and another exophytic
     who are not can be offered alternatives such as            fibroid of 8cm below that. The fundus of the uterus
     laparoscopic or hysteroscopic myomectomy, which            can be seen close to the surgeons index finger with a
     offer a minimal access approach and thus address           normal left Fallopian tube arising from the cornu and
     some patients objections to surgery.                       stretched over the broad ligament fibroid. The
                                                                appearance of the uterus after surgery is demonstrated
                                                                in the second picture. This patient conceived after only
                                                                                                                                      Complex multi-fibroid uterus after
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