 |
|
|
|
|
Pre-Register Online
Please use this link to preregister for your initial consultation, MRI and/or UFE procedure at St. Luke's Episcopal Hospital. Please note that if you are registering to see Dr. Fischer for an initial consultation, you will also need to go to the "online forms" section, print out the forms there, complete them and bring them with you to the office. Both of these processes will make your visit to our office more efficient. Please contact us with any questions or problems with preregistration or completion of the forms. Thank you.
|
|
|
|
|
|
|
|
|
 |
|
|
 |
|
A promise to our referring physicians:
Thank you for your interest in uterine fibroid embolization. We would like to assure you that each and every patient that you refer to our practice will be treated as one of our family members. We would like to work with you as a team to provide the best possible gynecological care to your patients. We will consult with every patient prior to the procedure and offer uterine fibroid embolization only to those patients who meet the criteria outlined in our uterine fibroid embolization protocol. We will assume full responsibility for the care of the patient in the peri-procedural period, including admitting the patient to the hospital, discharging the patient from the hospital, and managing any post-embolization syndrome symptoms or questions that may arise. It is, therefore, not necessary for patients to be referred by or evaluated by a gynecologist on staff at St. Luke's Episcopal Hospital. In fact, a majority of our referrals are from physicians outside of St. Luke's. We will see the patient in follow-up approximately one week after the procedure and will ask only that the patient you in follow-up in two to three weeks after the procedure for a routine gynecologic examination. You will only be called in the unlikely event of a severe complication or issue that cannot be handled by our service. We will keep you informed of the progress of the patient's work-up, procedure and follow-up with routine letters and/or phone calls. Please do not hesitate to contact us if you have additional questions or a patient whom you would like to refer.
Introduction:
Uterine fibroid embolization is a minimally invasive treatment for symptomatic uterine leiomyomata and has become a popular alternative to hysterectomy and myomectomy. The procedure uses angiographic techniques to embolize the uterine arteries and occlude blood supply to the fibroids resulting in ischemic infarction and subsequent degeneration. This leads to a decrease in the fibroid size and decrease or resolution in the patient's symptoms.
The UFE procedure:
Uterine fibroid embolization is an outpatient procedure. The patient is admitted the morning of the procedure and undergoes routine pre-procedural evaluation and preparation. The procedure itself is performed in an angiography suite using conscious sedation local anesthetic only. Access is gained to the right common femoral artery and a catheter is carefully inserted. Both uterine arteries are selected (usually via one access site) and bilateral uterine arteriograms are performed. A micro-catheter is then advanced into the distal aspect of each uterine artery and transcatheter embolization of each uterine artery is achieved using embosphere particles (Biosphere Medical, Rockland, Massachusetts). The entire procedure takes approximately one hour and utilizes 10 to 15 minutes of fluoroscopy time. The procedure is painless but immediately following the procedure, most patients develop what is known as the "post-embolization syndrome". For this reason, patients are admitted for 23-hour overnight observation and are discharged the following morning with specific post-procedure instructions and medications.
The post-embolization syndrome and recovery:
Most patients develop the post-embolization syndrome almost immediately following the procedure. This syndrome consists of pain, which usually increases for 8 to 12 hours after the procedure. Pain is usually well controlled using a combination of a narcotic and an anti-inflammatory medication. Approximately 50 percent of patients develop nausea and/or vomiting, usually within the first several hours after the procedure. All patients are closely observed and their symptoms managed using a combination of pain medications, antiemetics, and IV fluids. The patient's pain and nausea (if present) have usually improved significantly by the time of discharge the morning after the procedure. The patient will, however, continue to have occasional cramping, pain, low-grade fever, general feeling of malaise, and occasional vaginal discharge, all expected parts of the post-embolization syndrome. The symptoms usually resolve spontaneously in five to seven days. The average recovery time is one week.
Potential complications:
Major complications have been reported in less than 4 percent of patients undergoing uterine fibroid embolization. Uterine ischemia requiring hysterectomy is very rare, occurring in only .05 percent of all patients. Less severe infections are also rare and can usually be treated with intravenous antibiotics. Pulmonary embolus, a rare but potentially severe complication, has been reported in 1 of 500 patients. There have been four deaths reported in the world's literature after uterine fibroid embolization, two from sepsis and two from pulmonary embolus. Another relatively uncommon side effect is ovarian failure leading to premature menopause. Early ovarian failure has been reported in 1 to 5 percent of patients undergoing uterine fibroid embolization and the relative risk is dependent on the patient's age (peri-menopausal women are most susceptible). Other rare side effects not specific to uterine fibroid embolization include bleeding, damage to arteries during catheterization and/or an allergy to the contrast agent.
Results and fertility issues:
After UFE average fibroid reduction is approximately 40 percent at three months and 65% at one year (overall approximately 50 percent reduction). The overall uterine volume also decreases an average of 40-50 percent. Published studies to date show that symptoms will be significantly improved or will resolve in 80 to 95 percent of patients. Although midterm results from several centers show that successfully treated fibroids do not recur, long-term outcomes are currently unknown. While there have been multiple anecdotal reports of normal pregnancies following UFE, the effects of post-procedural fertility in the patient's ability to carry a normal pregnancy to term is currently unknown. Therefore, UFE is not currently recommended as a first line therapy in patients who still desire future fertility. In special instances, patients who have failed other therapies (i.e. myomectomy) and still desire fertility may be considered candidates for UFE as a last resort.
This is an example of a fibroid uterus before and after embolization.
The ideal candidate for UFE:
The ideal candidate for uterine fibroid embolization is a patient with multiple small-to-moderate size fibroids, menorrhagia, and no desire for future fertility. There are several inclusion and exclusion criteria, which have been summarized in our uterine fibroid embolization protocol page. In general, inclusion criteria include women with symptomatic uterine leiomyomata suffering from menorrhagia and/or bulk related symptoms. Exclusion criteria include any evidence for a gynecologic malignancy. All patients are required to have a negative Pap smear within the last 12 months. There should be no suspicious ovarian masses present. Some patients may require an endometrial biopsy, depending on their symptoms. There should also be no evidence for active pelvic or gynecologic infection. As a general rule, women with large pedunculated fibroids, uterus sizes greater than 24 weeks, and/or dominant fibroid size greater than 10 cm are not ideal candidates for uterine fibroid embolization. Desire for future fertility is a relative contraindication. As discussed above, in special instances, patients who desire fertility may be considered candidates for UFE only if other treatment options have been exhausted. Lupron and similar hormonal therapy should be avoided if at all possible for two to three months prior to embolization. All patients are required to undergo a pelvic MRI and MRA to assess the exact size, number, location, and blood supply to the fibroids.
Click here for a printable version of our UFE protocol.
How to refer a patient:
Referring a patient is easy. Simply have one of your office staff members or the patient contact us directly to schedule a consultation. We meet with each patient prior to the procedure and perform a complete history and physical examination, as well as a thorough review of the patient's medical records (if available). Assuming that the patient appears to be an appropriate candidate, we will arrange for the patient to undergo routine pelvic MRI to assess the exact size, number, location, and vascularity of the fibroids. We will also manage all necessary insurance preauthorization and/or predetermination issues for each patient. Occasionally, we may need an official referral from your office depending on the patient's insurance plan. We admit all patients to the hospital, manage any peri-procedural pain or other symptoms that the patient may have, and discharge them the following morning. We follow each patient in clinic 7 to 10 days after the procedure and simply ask that they follow up with you for routine gynecologic exam and evaluation two to three weeks after the procedure. Assuming that there are no questions or concerns at that time, they simply need to resume normal gynecologic care and we will plan for routine follow-up MRI of the pelvis in six to nine months to asses the results of embolization.
|
|
|
|
