- Email: [email protected]
Uterine necrosis after uterine artery embolization for leiomyoma
LETTERS TO THE EDITOR
Who Was Caring for Mary? To the Editor: Dr. Frederick Southwick’s article (OBSTET GYNECOL 2001;98:1140 –2) could well have been entitled “Who Was Caring for Debbie?,” my sister-in-law, who like Mary was admitted to a major university medical center in April 2001 for a condition that was admittedly somewhat more serious than was Mary’s. Nevertheless, she also suffered the ravages of a teaching institution with health maintenance organization overtones. In all, she spent 143 days in the hospital, most of it in an induced paralysis/coma. She was in the operating room at least 12 times, suffered a deep venous thrombosis, a pulmonary embolus, and a myocardial infarction with cardiac arrest, among other horrific iatrogenic and very preventable events. Like Mary, she was victimized by the system. It is interesting that Mary’s case was put off on an inexperienced intern. In Debbie’s case, third-year medical students were playing around (not an inadvertent word usage) with ventilator settings in the intensive care unit. I have been in practice for 25 years and have taught at a major medical institution while maintaining a private practice. Never have I seen such pathetic and worrisome care taken of critically ill patients. Fortunately, Debbie has survived and is doing reasonably well, although a return to true normalcy may not be realistic. As with Mary, there were specific physicians who were instrumental in her recovery, but only because we were proactive enough to change physicians several times during her hospitalization. A shortage of nurses, especially critical care nurses, was a considerable factor in Debbie’s complications, but it is very clear to me that I, who was unknown at this institution, could very well have walked in, stated that I was on staff and written orders or actually adjusted her vent settings, were I so inclined. Dr. Southwick concludes that some of the best clinicians are in outlying community hospitals, and there is no question in my mind that he is correct. Although sad, this is probably as it should be. It behooves the public to be aware that bigger is not better and, in fact, may be considerably worse. I am currently in practice in a small rural hospital where I would much rather be a patient than at a university medical center, and both I and my family have actually done so. Dr. Southwick’s conclusion that “the top priority for all academic medical centers must be uncompromising and outstanding patient care” is shocking. Was it not always thus?
676
0029-7844/02/$22.00
Gerald R. Harpel, MD, FACOG, FACS Chairman, Department of Obstetrics and Gynecology Harrison Memorial Hospital Cynthiana, KY
Uterine Necrosis After Uterine Artery Embolization for Leiomyoma To the Editor: We have read the case report (OBSTET GYNECOL 2001; 98:950 –2) by Godfrey and Zbella with great interest. The authors report a major complication of uterine fibroid embolization. We would like to make several comments. It seems that hysterectomy was performed because of pelvic infection rather than because of uterine necrosis. Infection leading to hysterectomy has been reported in less than 1% of cases.1 Risk factors are submucous and pedunculated subserous fibroids. Careful preprocedural evaluation using magnetic resonance imaging (MRI) is more accurate than ultrasound to precisely assess the location of uterine fibroids and exclude associated pathology. Careful monitoring of the patient postembolization is the key of success. In our practice, a woman with pelvic pain, fever, and vaginal discharge is immediately readmitted for full blood count, urinalysis, vaginal swabs, and MRI. Intravenous antibiotics are given, and a decision to remove the fibroid under hysteroscopic guidance is made. Postprocedure follow-up of patients may therefore involve gynecologists and radiologists. In Godfrey and Zbella’s paper, the histopathology does not indicate the appearance of normal myometrium. Diffuse necrosis of the fibroid is a normal finding after embolization but necrosis of normal myometrium is a rare complication.1 Embolization of both uterine arteries was performed to stasis using small polyvinyl alcohol particles. Since normal myometrium and fibroids have common arterial afferences, incomplete embolization using large particles may reduce postprocedure pain and myometrial ischemia.2 All candidates for uterine fibroid embolization should have a consult with the interventional radiologist. If a young woman seeking to conceive after embolization has been offered hysterectomy or multiple myomectomy, we believe that embolization is a valuable alternative.
OBSTETRICS & GYNECOLOGY
J. P. Pelage, MD W. J. Walker, MB, BS, FRCR Department of Radiology The Royal Surrey Hospital Guildford, United Kingdom O. Le Dref, MD Department of Radiology Hopital Lariboisiere Paris, France
REFERENCES 1. Walker WJ, Green A, Sutton C. Bilateral uterine artery embolisation for myomata: Results, complications, and failures. Min Invas Ther Allied Technol 1999;8:449 –54. 2. Spies JB, Benenati JE, Worthington-Kirsch RL, Pelage JP. Initial experience using trisacryl gelatin microspheres for uterine artery embolization for leiomyomata. JVIR 2001; 12:1059 – 63.
In Reply: We would like to thank Dr. Pelage et al for their interest in our case report. However, we would like to make some clarifications and comments. Uterine necrosis and subsequent hysterectomy was not due to infection, specifically Trichomonas vaginalis. Cultures taken at the time of surgery were negative and consistent with aseptic necrosis. While infection leading to hysterectomy following uterine artery embolization (UAE) may have been reported in some rather obscure radiologic journal,1 we felt that it was time that a significant complication of UAE was reported in a prominent journal in the field of obstetrics and gynecology. Finally, in our litigious society, we felt it was important that gynecologists discuss UAE as an alternative to myomectomy and hysterectomy but be informed that uterine necrosis and hysterectomy is a complication of the procedure. It is also important that our radiology colleagues discuss this potential complication with their patients prior to performing UAE. Edward Zbella, MD Department of Obstetrics and Gynecology Bayfront Medical Center St. Petersburg, Florida Claire Godfrey, MD Department of Obstetrics and Gynecology University of South Florida Tampa, Florida
VOL. 99, NO. 4, APRIL 2002
REFERENCE 1. Walker WJ, Green A, Sutton C. Bilateral uterine artery embolisation for myomata: Results, complications, and failures. Min Invas Ther Allied Technol 1999;8:449 –54.
Is the Formation of a Bladder Flap at Cesarean Necessary? A Randomized Trial To the Editor: Recognizing that Hohlagschwandtner et al (OBSTET GYNECOL 2001;98:1089 –92) specifically said that their trial had only to do with short-term effects, the results do not seem to me to be of any significance. “Long-term effects, such as adhesions and fertility, remain to be evaluated.” Another long-term effect to be looked for is the formation of a window at the site of incision, covered by the bladder flap that retains the membranes and the baby. If we have an incision above the bladder flap, how many windows will we see that will function as a true rupture with extrusion of membranes and eventually rupture of membranes and the baby? A difference in delivery time of two minutes, total operating time of five minutes, no real significant difference in blood counts, is particularly unimpressive. This is not the first article to propose not raising a bladder flap. The previous one talked about how rapidly the operation can be done and talked about an average of seventeen minutes per cesarean section. I find it hard to believe that this will be a step forward for those of us who have been in practice long enough to see a layer of membranes and a baby swimming around underneath a bladder flap. James Honig, MD Diplomate American Board of Obstetrics and Gynecology Rockledge, FL 32955
In Reply: In our trial, we simply omitted the dissection of the urinary bladder from the uterus, but we did not change the level of the uterine incision at the lower segment. Extensive dissection and a very low uterine incision should be generally avoided.1 Since we perform a onelayer closure of the uterine incision in a way which has been followed up by Chapmann et al,2 we do not expect a higher rate of uterine ruptures. In our institution with
Letters to the Editor
677
Who Was Caring for Mary? To the Editor: Dr. Frederick Southwick’s article (OBSTET GYNECOL 2001;98:1140 –2) could well have been entitled “Who Was Caring for Debbie?,” my sister-in-law, who like Mary was admitted to a major university medical center in April 2001 for a condition that was admittedly somewhat more serious than was Mary’s. Nevertheless, she also suffered the ravages of a teaching institution with health maintenance organization overtones. In all, she spent 143 days in the hospital, most of it in an induced paralysis/coma. She was in the operating room at least 12 times, suffered a deep venous thrombosis, a pulmonary embolus, and a myocardial infarction with cardiac arrest, among other horrific iatrogenic and very preventable events. Like Mary, she was victimized by the system. It is interesting that Mary’s case was put off on an inexperienced intern. In Debbie’s case, third-year medical students were playing around (not an inadvertent word usage) with ventilator settings in the intensive care unit. I have been in practice for 25 years and have taught at a major medical institution while maintaining a private practice. Never have I seen such pathetic and worrisome care taken of critically ill patients. Fortunately, Debbie has survived and is doing reasonably well, although a return to true normalcy may not be realistic. As with Mary, there were specific physicians who were instrumental in her recovery, but only because we were proactive enough to change physicians several times during her hospitalization. A shortage of nurses, especially critical care nurses, was a considerable factor in Debbie’s complications, but it is very clear to me that I, who was unknown at this institution, could very well have walked in, stated that I was on staff and written orders or actually adjusted her vent settings, were I so inclined. Dr. Southwick concludes that some of the best clinicians are in outlying community hospitals, and there is no question in my mind that he is correct. Although sad, this is probably as it should be. It behooves the public to be aware that bigger is not better and, in fact, may be considerably worse. I am currently in practice in a small rural hospital where I would much rather be a patient than at a university medical center, and both I and my family have actually done so. Dr. Southwick’s conclusion that “the top priority for all academic medical centers must be uncompromising and outstanding patient care” is shocking. Was it not always thus?
676
0029-7844/02/$22.00
Gerald R. Harpel, MD, FACOG, FACS Chairman, Department of Obstetrics and Gynecology Harrison Memorial Hospital Cynthiana, KY
Uterine Necrosis After Uterine Artery Embolization for Leiomyoma To the Editor: We have read the case report (OBSTET GYNECOL 2001; 98:950 –2) by Godfrey and Zbella with great interest. The authors report a major complication of uterine fibroid embolization. We would like to make several comments. It seems that hysterectomy was performed because of pelvic infection rather than because of uterine necrosis. Infection leading to hysterectomy has been reported in less than 1% of cases.1 Risk factors are submucous and pedunculated subserous fibroids. Careful preprocedural evaluation using magnetic resonance imaging (MRI) is more accurate than ultrasound to precisely assess the location of uterine fibroids and exclude associated pathology. Careful monitoring of the patient postembolization is the key of success. In our practice, a woman with pelvic pain, fever, and vaginal discharge is immediately readmitted for full blood count, urinalysis, vaginal swabs, and MRI. Intravenous antibiotics are given, and a decision to remove the fibroid under hysteroscopic guidance is made. Postprocedure follow-up of patients may therefore involve gynecologists and radiologists. In Godfrey and Zbella’s paper, the histopathology does not indicate the appearance of normal myometrium. Diffuse necrosis of the fibroid is a normal finding after embolization but necrosis of normal myometrium is a rare complication.1 Embolization of both uterine arteries was performed to stasis using small polyvinyl alcohol particles. Since normal myometrium and fibroids have common arterial afferences, incomplete embolization using large particles may reduce postprocedure pain and myometrial ischemia.2 All candidates for uterine fibroid embolization should have a consult with the interventional radiologist. If a young woman seeking to conceive after embolization has been offered hysterectomy or multiple myomectomy, we believe that embolization is a valuable alternative.
OBSTETRICS & GYNECOLOGY
J. P. Pelage, MD W. J. Walker, MB, BS, FRCR Department of Radiology The Royal Surrey Hospital Guildford, United Kingdom O. Le Dref, MD Department of Radiology Hopital Lariboisiere Paris, France
REFERENCES 1. Walker WJ, Green A, Sutton C. Bilateral uterine artery embolisation for myomata: Results, complications, and failures. Min Invas Ther Allied Technol 1999;8:449 –54. 2. Spies JB, Benenati JE, Worthington-Kirsch RL, Pelage JP. Initial experience using trisacryl gelatin microspheres for uterine artery embolization for leiomyomata. JVIR 2001; 12:1059 – 63.
In Reply: We would like to thank Dr. Pelage et al for their interest in our case report. However, we would like to make some clarifications and comments. Uterine necrosis and subsequent hysterectomy was not due to infection, specifically Trichomonas vaginalis. Cultures taken at the time of surgery were negative and consistent with aseptic necrosis. While infection leading to hysterectomy following uterine artery embolization (UAE) may have been reported in some rather obscure radiologic journal,1 we felt that it was time that a significant complication of UAE was reported in a prominent journal in the field of obstetrics and gynecology. Finally, in our litigious society, we felt it was important that gynecologists discuss UAE as an alternative to myomectomy and hysterectomy but be informed that uterine necrosis and hysterectomy is a complication of the procedure. It is also important that our radiology colleagues discuss this potential complication with their patients prior to performing UAE. Edward Zbella, MD Department of Obstetrics and Gynecology Bayfront Medical Center St. Petersburg, Florida Claire Godfrey, MD Department of Obstetrics and Gynecology University of South Florida Tampa, Florida
VOL. 99, NO. 4, APRIL 2002
REFERENCE 1. Walker WJ, Green A, Sutton C. Bilateral uterine artery embolisation for myomata: Results, complications, and failures. Min Invas Ther Allied Technol 1999;8:449 –54.
Is the Formation of a Bladder Flap at Cesarean Necessary? A Randomized Trial To the Editor: Recognizing that Hohlagschwandtner et al (OBSTET GYNECOL 2001;98:1089 –92) specifically said that their trial had only to do with short-term effects, the results do not seem to me to be of any significance. “Long-term effects, such as adhesions and fertility, remain to be evaluated.” Another long-term effect to be looked for is the formation of a window at the site of incision, covered by the bladder flap that retains the membranes and the baby. If we have an incision above the bladder flap, how many windows will we see that will function as a true rupture with extrusion of membranes and eventually rupture of membranes and the baby? A difference in delivery time of two minutes, total operating time of five minutes, no real significant difference in blood counts, is particularly unimpressive. This is not the first article to propose not raising a bladder flap. The previous one talked about how rapidly the operation can be done and talked about an average of seventeen minutes per cesarean section. I find it hard to believe that this will be a step forward for those of us who have been in practice long enough to see a layer of membranes and a baby swimming around underneath a bladder flap. James Honig, MD Diplomate American Board of Obstetrics and Gynecology Rockledge, FL 32955
In Reply: In our trial, we simply omitted the dissection of the urinary bladder from the uterus, but we did not change the level of the uterine incision at the lower segment. Extensive dissection and a very low uterine incision should be generally avoided.1 Since we perform a onelayer closure of the uterine incision in a way which has been followed up by Chapmann et al,2 we do not expect a higher rate of uterine ruptures. In our institution with
Letters to the Editor
677