60 2011
IMAGING & ONCOLOGY
are keen to be free of their very troublesome symptoms. So, in comparison with the prospect of going through initial imaging, followed by the embolisation procedure, and follow up imaging with a one in 10 potential of a further procedure, a hysterectomy, despite being highly invasive and radical, is preferred by a number of patients. Further, hysterectomy is associated with a high rate of satisfaction and is likely to eliminate menstrual symptoms in virtually all the patients. Even in patients with early post operative complications, the long term satisfaction rate is very high17
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For patients not keen to retain their uteri, hysterectomy as a treatment option, with its high efficacy, readily available expertise to perform the procedure and high satisfaction rate with time-tested results, makes consideration of any other alternative very academic.
In order for a patient to prefer one procedure over another, there must be a choice. There have certainly been cases in the past where the patients have not been informed of uterine artery embolisation as an option. There have also been cases where the clinician mentions the procedure more for completeness, neither giving the patient facts nor any information about local availability. Fortunately, such inappropriate consulting is occurring less frequently now, especially after publication of the recent National Institute for Health and Clinical Excellence (NICE) guidelines and the joint working party report.
The clinician The vast majority of patients with symptomatic fibroids are usually referred by their general practitioner to a gynaecologist for further management. The gynaecologist would usually exhaust pharmacological options prior to considering interventional procedures. For women with large fibroids (> 3cms) causing symptoms of heavy menstrual bleeding, as well as other symptoms such as dysmenorrhoea or pressure symptoms, UAE or surgery can be considered15
Also, most interventional radiologists currently performing UAE have developed this skill as consultants rather than as trainees and there certainly is a learning curve involved. This requires enthusiasm, be it visiting another centre performing these procedures, or being mentored at one`s own centre by an expert.
Availability of local skilled expertise is another factor. Whilst the majority of UK hospitals have access to interventional radiology, this may not be local. Patients therefore may have to be referred to another centre. This introduces another potential disadvantage when the patient considers her options.
All the above factors are significant, but the most important factor is education and awareness of the procedure. There is still a minority of clinicians who claim not to believe in the role of UAE in the management of fibroids. In the face of overwhelming evidence, this can only be due to ignorance or laggardness. Consequently, there are a less than par number of UAEs performed for symptomatic fibroids.
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This is the recommended generic management guideline from NICE across the range of procedures for symptomatic fibroids. Sub-group indications for the different procedures are not specified. The guidelines also recommend that any decision should be reached only after a detailed discussion regarding all treatment options has been had with the patient. Therefore, the consulting clinician plays a significant role in the choice of the treatment procedure.
To be able to discuss the available treatment options it is imperative that the gynaecologist has comprehensive knowledge of UAE including the practical patient issues, technical aspects and potential complications. The clinician should also be up-to- date on the current literature. This, in clinical practice, can be very difficult. As a result, there may be an unconscious clinician bias towards the surgical techniques. However, this problem can be overcome by interventional radiology consultations.
New procedure syndrome Uterine artery embolisation is still considered by many as a new procedure. Although clearly a safe procedure with proven efficacy in the short to medium term, long term follow-up data from the trials and registries are outstanding.
WHERE DO WE GO FROM HERE? The role of uterine artery embolisation in the management of symptomatic fibroids is now established but certain key areas will determine and secure the future of this treatment:
Clinical sub-specialty Patients deemed suitable for the procedure are referred by the clinician to interventional radiology. In a number of units, there is a lack of direct radiology involvement both before and after the procedure. Therefore the interventional radiologist becomes a technician rather than a clinical practitioner. This non-clinical approach means that the interventional radiologist carries out an invasive procedure on a patient without prior personal assessment of the patient. This is a major drawback and should be discouraged.
Ideally, patients should first be seen in an interventional radiology outpatient clinic19 .
During this consultation, the patient should be assessed by the interventional radiologist regarding the appropriate symptoms being treated; imaging reviewed; and the procedure should be discussed in detail. This includes the alternatives, practical implications and the possible complications. There should also be robust post procedure follow up by the interventional radiologist. It is our practice to follow up patients in the interventional radiology out-patient clinic at six weeks, six months and 12 months following the
In the NHS, any new procedure or service usually requires a business case to establish not only the safety and efficacy of the procedure, but also its cost effectiveness18
. Making a
robust case to start a new procedure to treat a condition with well established treatment alternatives has, in the past, been difficult. This is particularly true as the service involves incurring extra expenditure to already overstretched radiology departments. This may, at times, inhibit the development of a new service or procedure.
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