Uterine Artery Occlusion (Surgical)

Key Points

• Surgical uterine artery ligation (UAL) may be useful for women wishing to avoid hysterectomy where image guided techniques are not available or otherwise not desired
• UAL. can be performed via laparotomy or laparoscopy as a stand-alone procedure, or as an adjunct to abdominal myomectomy
• The mechanism of action is analogous to that of image guided uterine artery embolization (UAE) whereupon relatively transient ischemia is typically "lethal" to the fibroid, while the uterus is preserved because of its rich collateral circulation
• Available evidence demonstrates that surgical UAL is effective and leads to fibroid shrinkage and symptom relief
• It can be performed by a gynaecologic surgeon trained to work in the retroperitoneal space, with anatomy often distorted by an enlarged uterus.
• The impact  of UAL on fertility is unknown.

As described elsewhere in this platform, the prevalence of fibroids is reported to be 20 to more than 80% in women over 35 years old. Among the available modalities for treating leiomyomas, hysterectomy is the most frequently performed method for women who have completed their families. However, for those patients who have infertility, wish to conceive in the future, or who otherwise desire to preserve their uterus, myomectomy is currently the preferred option for surgical treatment. However myomectomy, especially when removing multiple fibroids, can result in increased blood loss, prolonged operating time, postoperative complications and a prolonged hospital stay.' Moreover, about 20-25% of myomectomy cases have to be converted to hysterectomy intraoperatively (2). Thus In treating women with leiomyoma who wish to preserve their uterus, laparoscopic uterine artery ligation is one of the possible options since it avoids major surgery. (2[MAL1] ) This may be undertaken either independently or prior to myomectomy. It has been used for managing obstetrical hemorrhage, but is now used widely used in the field of gynecology (Mackoul et al 2019; Zakhari et al 2019)). 

As discussed elsewhere, uterine artery embolization not only reduces the patient's symptoms but also reduces myoma size. An alternative method for obstructing the uterine blood flow, uterine artery ligation is reported to be an effective management of myoma (Lin et al). Laparoscopic bilateral uterine artery ligation leads to size reduction due to cell apoptosis and necrosis.

Preoperative evaluation includes measuring the baseline uterine and myoma sizes usually by ultrasonography, which enables the uterine volume to be calculated, facilitating objective assessment of the results. Bleeding scores can be calculated from the menstrual flow diary.

Laparoscopic uterine artery ligation (UAL) is usually undertaken under general anesthesia, through a small, sub-umbilical incision permitting, insufflation of the abdominal cavity with CO2 and insertion of further ports in the lower quadrants. The procedure involves identification of both ureters, then the pelvic peritoneum overlying the uterine artery is dissected. The uterine artery can then be ligated with a clip, a suture or by coagulation. The uterine arteries can be ligated to include both the artery’s main branch and the cardinal ligament In addition, the parauterine collateral vessels can also be coagulated (2) In some studies, pre and post-procedure uterine Doppler can be used to assess the success of the procedure. It can also be used as a temporary measure (Hiratsuka et al 2022)

The main outcome measures for studies are symptomatic improvement, reduction in myoma/ uterine volume (calculated by ultrasonography and magnetic resonance imaging (MRI)) as well as less bleeding. At 12 months, a significant reduction in bleeding has been observed in patients having UAL either with myomectomy or on its own.

Transvaginal UAL is a relatively simple approach, requires no expensive technology or specially trained interventional radiologist and can be performed by gynecologists in developing countries. The intraoperative blood loss, mainly from the vaginal incision, can be readily treated with sutures and gauze packing, and usually decreases with more experience. (Akinola et al 2005s).

A reduction of 55.5% and 54.9%, respectively has been reported in the total uterine and dominant fibroid volumes after uterine artery ligation (Akinola et al 2005). This shrinkage appears to be maintained. Symptomatic improvement also occurred in up to 90% of women with  heavy menstrual bleeding which compared well with the results for UFE (Park).and so this appears to be inexpensive an effective therapeutic option for the treatment of uterine fibroids, and it can be used in even the poorest of countries (Akinola et al 2005)

In  a small study of 40 patients aged 41years in the embolization group and 39 years in the ligation group, complications related to embolization were fever (15%), pain (30%) and bleeding (53.8%), whereas  bleeding (20%) was the only adverse outcome that occurred in the ligation group (Park et al 2008.). 

In another study, laparoscopic uterine artery coagulation for myoma was performed by three-puncture laparoscopy, and the difference in uterine and/or myoma volume was determined every 3 months for 12 months clinically and using ultrasonographic and MRI calculations of uterine volume. In addition, pre and postprocedure uterine Doppler indices were determined. 

The outcome measures were symptomatic improvement and reduction in volume calculated by ultrasonography and magnetic resonance imaging (MRI). All treated women reported less bleeding after treatment. At 12 months, a 57% reduction in bleeding was reported as assessed using a Pictorial Blood Assessment Chart. Operating time was under 1 hour and mean hospitalization time was 32.3 hours (95% CI 29.2–35.4). The complication rates were low following the procedure (fever, infection). No patient required hysterectomy due to complications. Ninety percent of the women were satisfied with the procedure (Simsek 2006)

UFE and UAL/ UAC are effective and safe methods for treatment of uterine fibroids for many women not wishing to have a hysterectomy. The decreased blood flow to the fibroids is considered responsible for shrinking the tumors, and both UAE and UAL/ C have also been used in the control of obstetric hemorrhage based on this same principle (1). The reduction in fibroid size is due to cell apoptosis and necrosis and is probably similar for both techniques as is the improvement in symptoms. UAL is safe, inexpensive, and effective therapeutic option for the treatment of symptomatic uterine fibroids.(Akinola et al 2005). 

Based on the current evidence, both UAE and UAL can be a valuable alternative to surgical therapy in the management of symptomatic uterine myomas. The indications for the 2 approaches are similar as is the efficacy and UAL is widely available and can be undertaken by appropriately trained gynecologic surgeons. It is thus cost-effective, and potentially has less side effects compared with UAE. Although there is no long-term data, with good patient selection and careful follow-up of patients, there should be a successful outcome. Based on its frequent use, the growing body of experience, its low cost/morbidity, and its minimally invasive nature, LUC should be offered to patients with symptomatic myomas as an alternative to UAE and surgery