Download CT imaging of complications related to gynecological

CT imaging of complications related to gynecological
therapeutic procedures
Poster No.:
C-1006
Congress:
ECR 2011
Type:
Educational Exhibit
Authors:
R. H. Castro , D. Rocha , M. Castro , T. C. Fernandes , A. J. B. S.
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Madureira ; Espinho/PT, Porto/PT, Vila Praia de âncora/PT
Keywords:
CT, Genital / Reproductive system female
DOI:
10.1594/ecr2011/C-1006
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Page 1 of 19
Learning objectives
To describe and illustrate CT findings in the early and late follow-up of patients submitted
to gynecologic therapeutic procedures.
Background
In the treatment of gynecologic pathology, procedures of increasing complexity, either
surgical or non-surgical (such as radiation therapy), are performed. Subsequent anatomic
alterations should not be confounded with pathologic entities. On the other hand, due to
proximity of uterus and ovaries to other important pelvic structures (bladder, ureters, small
and large bowel, rectum, muscular, nervous, vascular and lymphatic structures), when
iatrogenic complications occur, they assume a large diversity of presentations, being a
important diagnostic challenge.
Despite not being a first line imaging modality in the diagnosis and characterization
of the most common gynecologic pathologies (role generally reserved for ultrasound
and MRI), multislice CT is a reliable technique to detect surgical and radiation therapy
complications.
Imaging findings OR Procedure details
SURGICAL PROCEDURES
There are multiple therapeutic procedures used for uterine and adnexal pathology,
such as vaginal, abdominal or laparoscopic hysterectomy, oophorectomy and salpingooophorectomy.
In the last years, it appeared minimal invasive procedures like hysteroscopic surgery and
uterine fibroid embolization.
The choice of the procedure depends on the pathology and the physicians preference.
Page 2 of 19
Fig.: 1. Post operatory of laparoscopic ovary transposition (arrows) to parietocolic
gutters. Ovary suspension (by laparoscopy or laparotomy), is performed before pelvic
radiation therapy in order to preserve ovaric function.
References: R. H. Castro; Espinho, PORTUGAL
Page 3 of 19
Fig.: 2. Sagittal reconstruction of CT performed to a patient submitted to hysterectomy
due to uterine leiomyomas. It is shown the normal disposition of anatomic structures:
bladder (B), vagina (arrow).
References: R. H. Castro; Espinho, PORTUGAL
RADIATION THERAPY SEQUELAE
In the last decades, radiation therapy emerged as an effective treatment for uterine
and adnexal pathology, either used in isolation or combined with chemotherapy and/ or
surgery.
The main complications of this therapeutic modality are colitis (figure 3), rectovesical fistulae, rectal stenosis, ureteral stenosis, cystitis (figure 4) and osteoarticular
complications such as radic osteonecrosis or insufficiency sacral fractures (figure 5).
Page 4 of 19
Fig.: 3. Sigmoiditis in a 63-year-old woman, with cervical uterine carcinoma treated
with surgery and radiation therapy. It is observed parietal concentric thickening of the
colon, with preservation of parietal stratification (arrow).
References: R. H. Castro; Espinho, PORTUGAL
Page 5 of 19
Fig.: 4. Patient previously submitted to pelvic radiation therapy, with complaints of
dysuria and urinary urgency. It is noted densification of the surrounding fat planes and
diffuse thickening of the vesical walls. These alterations are suggestive of radic cystitis.
References: R. H. Castro; Espinho, PORTUGAL
Page 6 of 19
Page 7 of 19
Fig.: 5. a), b) and c) CT images show extensive changes in the normal bone
trabeculation of the pelvis and femoral head with multiple fractures in the right iliopubic
branch, acetabulum and sacrum, in a patient with a history of radiotherapy for cervical
carcinoma.
References: R. H. Castro; Espinho, PORTUGAL
It must be pointed out, that in CT imaging, it may be difficult to differentiate between
neoplastic recurrence and post-radiation fibrosis (figure 6). For this purpose, MRI is a
more indicated technique.
Fig.: 6. Follow-up of a patient submitted to radiation therapy due to cervical uterine
carcinoma. It is depicted significant thickening of rectal walls (arrows) and densification
of the pre-sacral fat (arrow-head). These findings are suggestive of radic fibrosis.
References: R. H. Castro; Espinho, PORTUGAL
NEOPLASTIC RECURRENCE
Page 8 of 19
To detect local pelvic recurrence and to differentiate it from residual fibrosis, MRI is
thought to be a more sensitive and specific modality, due to greater contrast resolution.
For the detection of nodal recurrence (figure 7) or distant metastization (figure 8 and 9),
CT is a reliable exam, with detection rates similar to those of MRI.
Fig.: 7. 54-year-old woman, with relapsing uterine cervical carcinoma, 14 years after
hysterectomy. Presence of adenopathies in the external iliac chain (arrow-heads) and
soft-tissue mass contiguous to the vaginal dome.
References: R. H. Castro; Espinho, PORTUGAL
Page 9 of 19
Fig.: 8. 61-year-old woman, diagnosed with ovarian cystadenocarcinoma. It is
demonstrable neoplastic peritoneal involvement, with ascites (asterisks) and
nodulariform great omentum thickening.
References: R. H. Castro; Espinho, PORTUGAL
Page 10 of 19
Fig.: 9. Follow-up CT after total hysterectomy due to cervical uterine carcinoma. It is
observed a hypovascular metastasis in the right lobe of the liver.
References: R. H. Castro; Espinho, PORTUGAL
SURGICAL COMPLICATIONS
The most common complications after hysterectomy are ureteral or vesical lesions,
lymphoceles, pelvic or abdominal infections, hemorrhagic complications, intestinal
lesions (figure 10) or nervous structures lesions.
Gynecologic therapeutic procedures are the main cause of ureteral injuries, occurring in
0,1 - 1 % of all major pelvic surgeries. Early diagnosis of this complication is fundamental,
to avoid significant morbidity.
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Fig.: 10. Intestinal occlusion caused by adherences in a patient with previous radical
hysterectomy. Small bowell dilation, with gas-fluid levels (arrowheads). The transition
zone (arrow) is located in the ileum.
References: R. H. Castro; Espinho, PORTUGAL
Post-operative pelvic collections are a common dillema faced by the radiologist. These
are very frequent, being, most of the times, small seromas or lymphoceles, predominantly
when lymphadenectomy is performed. Sometimes, if symptomatic, they may require
drainage (figure 11).
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Fig.: 11. 68-year-old patient with ovarian carcinoma submitted to hysterectomy,
oophorectomy and lymphadenectomy. CT coronal images (a and b) demonstrate a
collection (arrows) surrounding iliac vessels (arrowheads). In (b) it can be seen surgical
clips (open arrow). These characteristics are suggestive of a lymphocele. Due to the
presence of fever, a follow-up CT was performed (c). It shows small gas bubbles
(arrows), suggesting super-infection. It was decided to insert a percutaneous drainage
catheter (d).
References: R. H. Castro; Espinho, PORTUGAL
Page 13 of 19
Fig.: 12. 62 years-old woman presents in the ER with sepsis. One month early, she
was submitted to a laparoscopic total hysterectomy. Contrast enhanced axial CT
shows a large pelvic abscess, containing a fluid/gas level. The following laparotomy
showed a bowel wall perforation in the rectum / sigmoid colon transition.
References: R. H. Castro; Espinho, PORTUGAL
Differentiation between sterile and infected collections can be difficult. The presence of
parietal enhancement and inner gas bubbles raises the probability of infection. In the
remaining cases, temporal evolution and clinical and laboratory results correlation may
aid in the diagnosis.
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Fig.: 13. CT performed two-days after total hysterectomy. It is observed the presence
of hyperdense fluid in the pelvic cul-de-sac, corresponding to a probable hematoma.
The patient was asymptomatic and was discharged a few days later, without any
complication being reported.
References: R. H. Castro; Espinho, PORTUGAL
Page 15 of 19
Fig.: 14. CT performed to a patient with fever in the post-operatory of total
hysterectomy. It is observed a large pelvic collection with small gas bubbles (arrows).
The imagiologic characteristics are suggestive of textiloma / gossypiboma. The
presence of a retained gauze was confirmed in revision laparotomy.
References: R. H. Castro; Espinho, PORTUGAL
Page 16 of 19
Fig.: 15. CT performed in a patient with fever, few days after total hysterectomy.
Figure (a) shows a large intra-abdominal collection, containing gas (asterisks). It is
noted enhancement of the vaginal walls (arrowhead). Coronal reconstruction (b),
shows that this collection extends from subhepatic planes to the vaginal dome (arrow).
Direct examination revealed dehiscence of the vaginal dome with purulent discharge.
References: R. H. Castro; Espinho, PORTUGAL
Page 17 of 19
Fig.: 16. Patient with fever and leukocytosis after laparoscopic hysterectomy. In (a)
it is noted a liquid collection (arrow) between small intestine loops. In (b) and (c), a
second collection is observed contiguous to one of the entrance orifices of laparoscopic
trocars (asterisk). Presence of parietal enhancement and gas bubbles associated with
fever and leukocytosis strongly support the diagnosis of an infected collection.
References: R. H. Castro; Espinho, PORTUGAL
Conclusion
CT is a reliable modality in the post-treatment evaluation of patients with gynecologic
pathology. For this purpose, it is essential for the reading radiologist to be familiarized
with the most common alterations, the possible iatrogenic complications and also the
common sites of neoplastic recurrence.
Page 18 of 19
Personal Information
References
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therapy: CT and MR imaging findings. Radiographics 2003: 32:969 -981
Cosson M, Lambaudie E, Boukerrou M, Querleu D, Crepin G:
Vaginal, laparoscopic, or abdominal hysterectomies for benign disorders:
immediate and early postoperative complications. European Journal of Obstetrics &
Gynecology and Reproductive Biology 2001: 231-236
Kasales CJ, Langer, JE, Arger PH: Pelvic pathology after hysterectomy - a pictorial
essay. Clinical imaging 1995;19:210-217
Sheth SS, Vaginal hysterectomy. Best Practice & Research Clinical Obstetrics and
Gynaecology 2005;19 307-332
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