Pain Management During Uterine Artery Embolization for Symptomatic Uterine Fibroids

We read with interest the publication in CardioVascularand Interventional Radiology on results from the random-ized prospective Emmy trial [1]. The Emmy trial was de-signed to compare uterine artery embolization (UAE) andhysterectomy as a treatment for symptomatic fibroids.From the beginning in 1995 [2] the knowledge on UAE isincreasing and extensive. Most published data andacknowledged information are based on large case series.Nowadays UAE is no longer considered experimental andhas definitely found its place in the whole spectra oftreatment options for symptomatic uterine fibroids. One ofthe advantages of UAE is the significantly earlier recoveryafter the procedure compared to hysterectomy [3].A structural comparison of individual pain experiencebetween UAE and hysterectomy has never been publishedin a randomized trial before. Unfortunately, no conclusionscan be drawn from the publication by Hehenkamp et al.with regard to pain experience in patients after UAE andhysterectomy, since the study was not designed for thispurpose. Many participating centers performed only a fewUAEs, without a fixed pain management protocol.We feel that a fixed and extensive pain managementprotocol is crucial when performing UAE. At our center,where we perform an average of 140 UAEs per year, adedicated pain management protocol is followed. In theEmmy trial, several analgesic approaches have been men-tioned such as epidural anesthesia, opiates, nonsteroidalanti-inflammatory drugs (NSAIDs), paracetamol, andcombinations. All analgesics used before, during, and afterthe procedure until discharge were recorded. Three subdi-visions in terms of pain management could be extracted:paracetamol and NSAIDs only, opiates and or NSAIDs,and epidural anaesthesia. After discharge most patientswere on medication such as paracetamol and/or NSAIDs.Pain after discharge was obviated and patient analgesic userecorded during 6 weeks. As already expected, patientsfrom the hysterectomy arm had significantly higher painscores during the first 24 hours after treatment. Averagepain scores >5 during hospitalization occurred in 31% ofthe UAE group versus 52% in the hysterectomy arm(p = 0.012). The majority of patients in both groups neededopiates during the first 24 hours as the strongest analgesicoption. Consequently, these patients had higher painscores, except for three individuals in the UAE arm whoneeded epidural anesthesia because of unbearable paindespite the administration of opiates.Many protocols have been described for UAE, varyingfrom standard epidural anaesthesia to patient-controlledanalgesia (PCA) in combination with NSAIDs and parac-etamol [4]. Some authors even advocate performing UAEunder general anesthesia [5]. Interpatient variations occurand pain experience as well as pain intensity is unpre-dictable [6]. No correlations have been detected concerningage, embolization technique, and embolization materialsize and type (spherical or nonspherical particles), as wellas size and/or localization of uterine fibroids, although aclear and significant relation was demonstrated between