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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. 1 2 2 1 1 2 3 3 Madureira ; Espinho/PT, Porto/PT, Vila Praia de âncora/PT Keywords: CT, Genital / Reproductive system female DOI: 10.1594/ecr2011/C-1006 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. www.myESR.org 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. Page 11 of 19 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). Page 12 of 19 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. Page 14 of 19 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 Jeong YY, Kang HK, Chung TW, Seo JJ, Park JG: Uterine cervical carcinoma after 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 Page 19 of 19