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Recovery after uterine artery embolization: understanding and managing short-term outcomes.

IN the years since the introduction of uterine artery embolization (UAE) for the treatment of uterine fibroids, the published studies on the procedure have shown that it results in significant improvement in symptom status and a high degree of patient satisfaction (1–7). What has been missing is a more detailed analysis of other aspects of the outcome from embolization. In this issue of JVIR, Pron and colleagues have reported a study that gives us insight into short-term recovery (8). With this work, we have a clearer understanding of the periprocedural recovery and, in particular, the “tolerability” of the procedure. We come to this subject with relatively little experience in this type of analysis. Most interventional procedures are not painful during recovery, other than the healing of a small incision or the body adjusting to the placement of a drainage catheter. With the development and use of embolotherapy, we have discovered that ischemic pain is a side effect of the procedures that requires recognition and management. Uterine embolization has brought this issue into sharp focus. Here, rather than treating desperately ill patients with cancer or severely traumatized patients, we are treating young and otherwise healthy women. Many of these patients have never undergone any significant medical therapy and this procedure is their introduction to hospital care. From the first reports, it was clear that shortterm pain is a normal side effect of the procedure, and the degree of pain is widely variable. In a study early in our uterine embolization experience (9), we could identify no baseline variables that predicted the severity of postprocedure pain, nor did the severity of pain predict outcome. In that analysis, neither the baseline uterine size nor the size of the largest fibroid predicted pain severity. There was no correlation between narcotic dose used in the first 24 hours and the perceived pain. Moreover, the degree of pain did not appear to impact the imaging or symptomatic outcome. Patients with no pain or minor pain were just as likely to have a favorable outcome as were those with severe pain. Because this analysis was early in our experience, the impact of variation in the technique of embolization was not tested. In the current study by Pron and colleagues, a large cohort of patients was enrolled in a prospective outcome study, and the authors presented the details of recovery from the procedure (8). Each patient was interviewed at 2 weeks and 3 months after treatment. The primary focus was on pain and its severity occurring during and after the procedure. Complications that may have occurred during the hospitalization or in the initial recovery period were also analyzed. The study authors reported the midterm outcomes from this group of patients earlier (10), and they were similar to those reported in other large published series (4,7,11). However, in reviewing the shortterm outcome and aspects of the recovery, there has been some variability. For example, in the Pron et al. study, 12.3% of the patients had a length of stay greater than one night and 10% of patients had a return visit to the emergency room. By comparison, in our recent summary of complications in 400 consecutive patients with a minimum of 3 months of follow-up (12), 1.25% of patients had prolonged or recurrent pain requiring hospitalization, and 3.5% of patients had emergency room visits. Of our first 200 of these patients, only 3% stayed in the hospital more than 1 night (11). If one compares the pain experienced after the procedure, the recent series of Walker and Pelage (7) was similar to the Canadian experience. For 35% of their patients, the pain after this procedure was the equal of labor pain or worse. However, when comparing the Canadian study group to the more recently treated Fibroid Registry patients, as the authors acknowledge, the pain experienced by their patients was greater than that seen in the Fibroid Registry (7). The peak pain score on the 11-point numeric rating scale was a mean of 5.6 in the Fibroid From the Department of Radiology, Georgetown University Hospital, 3800 Reservoir Road NW, CG201, Washington, DC 20007-2197. Address correspondence to J.B.S.; E-mail: spiesj@gunet. georgetown.edu