John DeMeritt, MD, Assistant Director of Interventional Radiology, Vascular Embolization Procedures, Specializing in Uterine (Fibroid) and Prostate (BPH) embolization, talks about cervical fibroids and an “out of the box” procedure used to save one woman’s fertility.
Interview conducted by Ivanhoe Broadcast News in April 2018.
Let’s talk a little bit about fibroids, what are they and where do they wind up and what problems do they cause?
Dr. DeMeritt: The uterus or womb is basically a muscle and fibroids are benign tumors that grow in the uterus. While most women will develop fibroids only a relatively small percentage will become symptomatic. It is important to note that there is no need to treat fibroids unless they are causing symptoms. The most common presenting symptom is heavy menstrual bleeding, which is often associated with painful periods and can sometimes result in anemia. Other presenting symptoms or problems include increased waist size, pelvic pressure or pain not related to menstruation, frequent urination, constipation, and reproductive problems. Reproductive problems include a reduced likelihood of becoming pregnant, pregnancy loss, and increased complications at the time of delivery.
While many of us have heard of uterine fibroids but cervical fibroids are not talked about as commonly. Can you tell me what’s going on?
Dr. DeMeritt: Yes, fibroids can occur in three different portions of the uterus the cervix, the body and the fundus of the uterus. By far and away the overwhelming majority, in fact ninety five percent are located in the body and the fundus of the uterus. Only five percent occur in the cervix, however, they are the most difficult to treat.
What are some of the symptoms, are they the same if you have fibroids in the cervix?
Dr. DeMeritt: Similar to fibroids in other locations bleeding would be a primary presentation as we saw in MaryBeth along with urinary frequency and constipation. They can also lead to painful intercourse and reproductive problems because of their strategic location at the entrance to the uterus possibly interfering with becoming pregnant, or acting as an obstruction to labor at the time of delivery.
And you said is it about five percent?
Dr. DeMeritt: About five percent (0.6-10%) of total fibroids in general are located in the cervix.
What are the treatments?
Dr. DeMeritt: That’s a great question. Although hysterectomy can be performed for postmenopausal women the conservative management options for women of childbearing age are limited and can be challenging. Selective surgical removal of cervical fibroids can be difficult secondary to limited operative field access and contact with surrounding vital structures such as the bladder, rectum, and ureters. Uterine artery embolization (UAE) is an increasingly utilized minimally invasive therapy for fibroids that has been very successful in relieving fibroid related symptoms. Despite the significant progress and success that has been achieved in treating fibroids through UAE, the failure rate has been high in patients with cervical fibroids. The particles, which are typically delivered in the main uterine artery, have not been able to routinely shrink cervical fibroids, probably because the blood vessels supplying cervical fibroids are much smaller than fibroids elsewhere in the uterus.
What are the options then?
Dr. DeMeritt: The options are to do a challenging surgical myomectomy (selective fibroid removal) or to do a hysterectomy. A hysterectomy of course is not an option if you want to have additional children. You can also attempt a standard uterine artery embolization (UAE) but even under ideal circumstances when very small particles have been delivered into the main uterine artery, shrinkage has only been seen in about 20% of patients. Also when the smaller particles are delivered into the main uterine artery it exposes the rest of the uterus to the potentially injurious effects of the down sized particles.
How do you decide whether or not this is something that a patient should undergo? Is it you are weighing risk and benefit?
Dr. DeMeritt: What we did in this particular circumstance is try to think outside the box, we knew based on some of the existing scientific data that the perfibroid plexus or the blood vessels supplying cervical fibroids are much smaller than in the remainder of the uterus. Based on that knowledge we decided to try and thread an even smaller catheter than is normally used for UAE directly in to the artery that feeds the cervix (cervicovaginal artery). The cervicovaginal artery is a branch of the main uterine artery and by selecting that vessel we were able to deliver the smaller particles directly into the cervical fibroid. We also injected a vasodilator drug directly into cervicovaginal artery in order to have it accept a greater volume of the particles. These are some of techniques that we borrowed from prostate artery embolization (PAE), which is a new minimally invasive therapy for symptomatic BPH in men, an additional focus of mine. By adapting those techniques for cervical fibroid embolization we had a very successful outcome in this case.
Can you walk me through how the procedure goes?
Dr. DeMeritt: Yes, what we normally do is puncture the main leg artery near the hip with a needle after appropriate anesthesia and perform a catheterization of the artery with a thin tube. We then thread the catheter into the main artery in the pelvis called the hypogastric artery or internal iliac artery that ultimately supplies the main uterine artery. We then identify the uterine artery and advance an even smaller microcatheter through the primary catheter, ultimately navigating into the uterine artery, aided by a thin steerable microwire. And in this particular case pushing the technique to another level, we identified the even smaller artery that directly supplies the cervix. Subsequently, we navigated the smaller than usual microcatheter directly into small artery that supplies the cervix. This artery is called the cervicovaginal artery since it can supply both the cervix and the upper portion of the vagina. We then went on to perform something called a cone-beam CT on the angiography table, a technique that can define the cross sectional anatomy of the vascular territorial supply by the catheter. The primary reason we did the cone-beam CT was to make sure that we were not supplying the normal vagina in any significant way. The cone-beam CT enabled us to confirm supply to the cervical fibroid while at the same time ensuring that the particles would not be delivered to the upper portion of the vagina or for that matter the remainder of the uterus., thereby minimizing the risk of the procedure. This was a novel application of cone-beam to increase the safety of MaryBeth’s procedure.
Tell me a little bit about the procedure itself, is it inpatient, how long was MaryBeth in the hospital?
Dr. DeMeritt: Those are great questions. Fibroid embolization in general is either done as an overnight stay or more recently as an outpatient procedure. We kept her overnight in this particular circumstance and she had very little in the way of post embolization symptoms.. In general when you perform a typical UAE you embolize the whole uterus, often resulting in a post embolization syndrome. The patient can have low-grade fever, pelvic pain, nausea and fatigue that can last for 2 to 3 days days. The post embolization syndrome can be minimized with various supportive medications. MaryBeth had a very minimal post embolization syndrome, which I suspect was largely due to the fact that we only embolized a very small portion of the uterus, namely the cervix sparing the remainder of the normal uterus.
Do fibroids come back, can they come back?
Dr. DeMeritt: Fibroids can occasionally regrow and yes they can be retreated. We only retreat recurrent fibroids if they become symptomatic again or are causing a problem.
Tell me a little bit more about MaryBeth’s case. In her case she wanted to make sure she avoided a total hysterectomy.
Dr. DeMeritt: Correct. MaryBeth had presented with rather significant vaginal bleeding that had been ongoing and did not stop to the point where she did have to be transfused I believe because of a fainting spell and a low blood count. She was presented with a number of options one of which was a possible total hysterectomy. A cervical myomectomy (selective surgical removal) can be can be a difficult operation with limited operative field access and might lead to a total hysterectomy. We were approached by Marybeth’s gynecologist and asked if there was anything else that we could offer to treat her and at the same time preserve her fertility. We already knew that cervical fibroids do not respond well to traditional UAE. After a literature search we devised a treatment plan based on the available data and our prior experience with embolizing the small arteries that feed the prostate gland in men for BPH (PAE).
Obviously the treatment was successful?
Dr. DeMeritt: Yes, the treatment was successful beyond all our expectations. MaryBeth immediately stopped bleeding and was discharged the next day. We did a follow up MRI scan at three months and surprisingly the fibroid had shrunk by about 92 %, ultimately shrinking by 96 % at 14 months. Traditional UAE usually results in an average fibroid volume reduction of 40 % at 3 months and 60 % at 6 months. So this was beyond a typical volume reduction that we see and in a relatively short period of time. We found out very shortly after we did the first follow up MRI scan at 3 months that MaryBeth became pregnant. She had a normal healthy pregnancy with no cervical incompetency. Sometimes the cervix can be incompetent where it dilates and thins prior to delivery, threating the pregnancy. In addition the cervix functioned normally during the actual birthing process with no obstruction to labor, she delivered vaginally without the need for a cesarean section So the cervix functioned properly both throughout the pregnancy and the during actual birthing process.
Who would not be a good candidate for a procedure like this?
Dr. DeMeritt: I can’t think of many contraindications to pursuing cervicovaginal artery embolization (CAE) if someone has a symptomatic cervical fibroid and we could identify the cervicovaginal arteries. This technique needs to be reproduced and a case registry needs to be established in order to confirm its safety and efficacy in other patients. We are actively seeking other appropriate candidates for the procedure.
Is there anything I didn’t ask you that you want to make sure that people know?
Dr. DeMeritt: I would just like to say something about how patients can find an interventional radiologist. Often we are behind the scenes, but interventional radiologists are in the majority of hospitals throughout the country. A doctor may contact us about one of his or her patients but patients can also contact us directly about their medical conditions. We see patients in the office just like other physicians. A list of procedures performed by interventional radiologists and a doctor finder can be found on the Society of interventional Radiology web site: www.sirweb.org.
How would know that you really need and interventional radiologist.
Dr. DeMeritt: Almost everyone will likely someday need or benefit from the skills of an interventional radiologist. We treat many vascular and nonvascular conditions with minimally invasive procedures. Once again I would refer you to the Society of interventional Radiology web site: www.sirweb.org
I just wanted to make sure there was anything else about this particular procedure that you might want to make sure people know.
Dr. DeMeritt: Striving to provide individual or tailored medicine along with teamwork is the key to coming up with innovative solutions to difficult medical conditions
END OF INTERVIEW
This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.
If you would like more information, please contact:
Sheri Hensley, PR
551-996-3586
sheri.hensley@hackensackmeridian.org
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