Available online 24 April 2024, 100954

Author links open overlay panelAbstract

Uterine artery embolization has an over 25-year track record of safety and efficacy. It has been evident for quite some time that this procedure can performed in an office-based lab. In this article, some of the prerequisites to performing uterine artery embolization in an office-based lab are reviewed.

Section snippetsExperience with UAE

A consensus statement was developed by a panel comprised of interventional radiologists on the Society of Interventional Radiology (SIR) Uterine Artery Embolization Task Force and members of the SIR Standards Division6. This statement recommended the following: “To ensure patient safety and a successful outcome, UAE should be performed by physicians trained to properly select and evaluate patients for treatment, technically skilled to perform the procedure, and capable of periprocedural patient

No adenomyosis

No interest in future fertility

Patients with significant medical co-morbidities (e.g. poorly controlled hypertension, Ehlers-Danlos, marked obesity with potential airway issue, renal insufficiency) are probably best handled in the hospital setting.

Patient Evaluation

Patient evaluation in the office consists of a through history and review of pelvic imaging. While pelvic ultrasound has already been obtained in most patients that are seen in the office, I believe it is not adequate to rely on ultrasound alone.

Magnetic resonance imaging (MRI) is the best imaging modality to diagnose, map, and characterize fibroids. MRI can also diagnose other benign (ex. adenomyosis) or malignant concurrent pelvic pathology, which may also be contributing to symptoms. This

Post-Procedural Care

Post-procedural care actually begins in the pre-procedural office consultation. Patients and their family members need assurances that the physician performing the UAE procedure in the office is not compromising the quality of care. Each of our physicians gives out their mobile phone number to their patients. This is reassuring to the patient, as it provides improved and direct communication with the patient's physician. Inaccessibility in the post-procedural period may lead to costly and

Opioids

The pain protocol should begin prior to the UFE procedure. Opioids have been frequently used alone, or more commonly, in combination with nonsteroidal anti-inflammatory drugs (NSAIDs) in the management of postprocedural pain. The combination is synergistic and decreases the amount of narcotic use when compared to using opioids alone. Our Center's combination consists of intravenous ketorolac and an intravenous narcotic (e.g. hydromorphone) prior to discharge and oral oxycodone and meloxicam on

Acetominophen

Using acetaminophen (1000mg either iv or po) also has been shown to be an important component of the pain protocol. Bilhim and Pisco reported a mean pain of 2.5 out of 10 in the first 8 hours where pain is typically the highest. They reported no readmissions for pain control using this protocol.13

Steroids

Glucocorticoids are potent anti-inflammatory agents. It is believed that by decreasing inflammatory mediators following ischemia that the pain should be more manageable. Kim et al demonstrated that the single (10mg) dose administration of dexamethasone prior to the embolization was effective in reducing pain and inflammation (as measured by reductions in C-reactive protein, interleukin-6, and cortisol during the first 24 hours following embolization)14. Unless contraindicated (e.g. diabetic

Other medications

There may be value in an acid-suppressing agent (ex. omeprazole 20mg) to reduce the gastric side effects from the NSAID that is used. Other medications that we use include an anxiolytic (e.g. lorazepam), an antihistamine (ex. Diphenhydramine 25-50mg), and a stool softener (ex. docusate).

Superior Hypogastric Nerve Block (SHNB)

Rasuli et al reported on performing SHNB for pain control in outpatient fibroid embolization15. Under fluoroscopic guidance a needle is placed into the hypogastric nerve

Intra-arterial lidocaine

Based on the years of experience with hepatic chemoembolization, intra-arterial lidocaine was administered pre-embolization in a study by Keyoung in an effort to reduce post-procedural pain in UAE procedures 19. However, this caused significant uterine artery vasospasm and concomitant under-embolization which led to treatment failures from incomplete fibroid infarction. Noel-Lamy et al used preservative free intraarterial lidocaine immediately post-embolization and showed both reduction in pain

Epidural or spinal anesthesia

Both spinal and epidural anesthesia have been shown to be effective for reducing pain, reducing medication requirements, and improved overall patient satisfaction21.

However, this must be weighed against a significant increase in cost, availability of anesthesia in the OBL, and other solutions which are easier to implement in the OBL and appear equally as effective.

Fentanyl Patch

These patches are not approved for opioid-naïve patients and their use would be considered off-label in patients post fibroid embolization. They deliver a slow and differing amount of fentanyl into the blood stream; often up to 72 hours. Song et al studied 42 embolization patients for fibroids or adenomyosis. Half of these patients received an opioid/NSAID combination and the other half that same combination plus a fentanyl patch. They concluded that pain scores were significantly lower 6 hours

Summary

Over the past 25 years, the safety of uterine artery embolization (UAE) and the progressive improvement in managing the associated post-procedural pain has enabled the treatment of fibroids and adenomyosis to transition from an inpatient to an outpatient setting. More recently, patients are finding the same (or better) care in the OBLs that are dedicating the care specifically around these patients. Those centers performing UAE should have physicians that see these patients in the office and

Declaration of competing interest

The author reports no potential conflicts of interest

References (22)SC Goodwin et al.Uterine artery embolization for treatment of leiomyomata: long-term outcomes from the FIBROID Registry

Obstet Gynecol

(2008)

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