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Fig. 1. AP pelvic arteriogram demonstrates the position of the aortic bifurcation and multiple hypervascular pelvic masses originating from the uterine arteries.
Case Reference No. CC-0498-10 The patient is a 43-year-old woman, gravida 8, para 0, who complains of urinary retention, constipation, pelvic pressure, and multiple previous spontaneous abortions. Ultrasound and MR studies demonstrated multiple fibroids, the largest measuring about 46 cm. We were asked to perform fibroid embolization. A superior hypogastric nerve block was performed. A pelvic arteriogram was performed in the AP projection and a 5-F C2 catheter was placed over the aortic bifurcation (Fig. 1). The aortic bifurcation and L4L5 disc space were located on the arteriogram and centered in the fluoroscopic field. A 21-gauge diamond-tipped needle was then advanced percutaneously from an anterior approach below the umbilicus to a position just below the aortic bifurcation, aiming for the L4L5 disc space. Contrast material was injected in the AP and lateral projections to demonstrate a retroperitoneal position, as shown by a "fan-shaped" stain in the cephalocaudad direction (Figs. 2, 3). 10 mL of 0.25% bupivacaine mixed with 10 mL of normal saline was then injected to provide the nerve block (Fig. 4). Following the nerve block, each uterine artery was selectively catheterized and an initial 30 mg (3 mL) bolus of 1% lidocaine was injected intraarterially. Each uterine artery was then embolized with 355500-µm polyvinyl alcohol (PVA) particles till stasis was obtained. Intermittent 1% lidocaine flushes were performed between aliquots of PVA for a total of 150 mg (15 mL) on each side. Following the procedure, the patient was placed on a morphine PCA pump at a 1 mg bolus, no basal rate, and a 10-minute lock-out time. The patient complained of no periprocedural pain and was discharged home the following day with minimal residual pelvic discomfort. |
Fig. 2. AP pelvic spot radiograph demonstrates an angiographic catheter positioned over the aortic bifurcation. A 21-gauge diamond-tipped needle is present with the tip at the L4L5 disc space. Injection of contrast material is being performed through venous tubing and demonstrates a retroperitoneal position as shown by a "fan-shaped" stain.
Fig. 3. Lateral pelvic spot image demonstrates the "fan-shaped" stain of contrast material in the retroperitoneum.
Fig. 4. Diagram of the nerves supplying the uterus. | |
Questions: Fibroid embolization patients commonly complain of crampy pelvic pain that begins post-procedurally, peaks between 6 and 12 hours, and then abates rapidly. Our three-pronged approach to pain management (superior hypogastric nerve block with a long-acting anesthetic, intraarterial lidocaine, and a PCA morphine pump) seems to work very well. 1) Has anyone else had experience with a superior hypogastric nerve block? 2) Does anyone approach pain management for fibroid embolization differently? Related Cases: Case 997_10 --Uterine artery embolization for the treatment of a symptomatic uterine fibroid | ||
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