|Year : 2022 | Volume
| Issue : 11 | Page : 1928-1930
Computed-tomography-guided interventional radiology as a tool for salvaging the uterus in a nulliparous patient
OA Olowoyeye1, OR Akinajo2, GO Babatunde3, AA Abudu2
1 Department of Radiation Biology, Radiotherapy and Radiodiagnosis, College of Medicine, University of Lagos; Department of Radiodiagnosis, Lagos University Teaching Hospital, Idi-Araba, Lagos, Nigeria
2 Obstetrics and Gynaecology, Lagos University Teaching Hospital, Idi-Araba, Lagos, Nigeria
3 Department of Radiation Biology, Radiotherapy and Radiodiagnosis, College of Medicine, University of Lagos, Idi-Araba, Lagos, Nigeria
|Date of Submission||29-Sep-2021|
|Date of Acceptance||27-Sep-2022|
|Date of Web Publication||18-Nov-2022|
Dr. O A Olowoyeye
Department of Radiation Biology, Radiotherapy and Radiodiagnosis, College of Medicine, University of Lagos
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Interventional radiology is a minimally invasive therapeutic approach that may be of benefit for some gynecological conditions. We present the case of a 40-year-old nulliparous woman with postoperative pyometra following open myomectomy who was considered for a hysterectomy, but the gynecologist requested that an attempt be made at percutaneous drainage of the abscess to salvage her uterus. We achieved a successful computed-tomography-guided percutaneous drainage of the abscess.
Keywords: Computed-tomography-guided drainage, hysterectomy, myomectomy, uterine abscess
|How to cite this article:|
Olowoyeye O A, Akinajo O R, Babatunde G O, Abudu A A. Computed-tomography-guided interventional radiology as a tool for salvaging the uterus in a nulliparous patient. Niger J Clin Pract 2022;25:1928-30
|How to cite this URL:|
Olowoyeye O A, Akinajo O R, Babatunde G O, Abudu A A. Computed-tomography-guided interventional radiology as a tool for salvaging the uterus in a nulliparous patient. Niger J Clin Pract [serial online] 2022 [cited 2022 Dec 2];25:1928-30. Available from: https://www.njcponline.com/text.asp?2022/25/11/1928/361446
| Introduction|| |
Uterine abscess is a rare infective process that may occur in patients following a surgical procedure, most especially myomectomy. It results when the cavity created after removing the fibroids is not completely occluded, hemostasis is not achieved, and a hematoma ensues., Uterine abscess may also occur in the puerperium. Uterine abscess formation is an uncommon but usually severe condition. Making a diagnosis can be challenging and treatment can be exasperating, especially for nulliparous women whose utmost desire is to conceive and have children. Hence, this condition can be a debilitating and highly emotionally draining. Hysterectomy used to be the definitive treatment; however, interventional radiology offers a revolutionary change with an option for conservative management in well-selected cases.
We present a case of a 40-year-old woman with postoperative pyometra following open myomectomy. It was successfully managed with CT-guided percutaneous drainage which is uncommon in our environment and worth documenting.
| Case Report|| |
A 40-year-old nulliparous woman had a transabdominal myomectomy at a private hospital. She developed fever and rigor postoperatively and was initially treated for malaria and had several antibiotics with no improvement. Two weeks post-myomectomy, she was referred to our tertiary hospital. At presentation, she had a persistent high-grade fever, abdominal pain, generalized body weakness, and vomiting. She was admitted for suspected intestinal obstruction by the general surgeons and invited the gynecologists based on the history of her recent myomectomy. On examination, she was cachectic, mildly pale, pyretic, tachypneic, and tachycardic with normal blood pressure. Abdominal examination revealed that an area of tenderness marked on the suprapubic region with a bulky uterus. Vaginal examination showed copious purulent vaginal discharge.
Series of investigations were done, including full septic workup, renal function test, and radiological investigations. The results were suggestive of sepsis with severe hypokalemia and commenced on parenteral antibiotics with potassium correction.
An abdominopelvic ultrasound scan done at presentation showed multiple dilated aperistaltic bowel loops. The uterus was bulky with multiple hypoechoic foci seen with it. A diagnosis of small bowel obstruction with uterine leiomyomata was made. She was managed conservatively by the general surgeons for paralytic ileus in view of her recent myomectomy. While conservative management was ongoing for clinical stability, a workup for emergency exploratory laparotomy was commenced.
A repeat pelvic ultrasonogram done 2 days after presentation showed multiple collections with gas shadows within the myometrium which was suggestive of myometrial abscesses [Figure 1]a and [Figure 1]b. The result of the endocervical swab for microscopy culture and sensitivity test taken at presentation yielded Klebsiella pneumoniae. The organism was sensitive to ertapenem and piperacillin-tazobactam. Based on the drug sensitivity pattern, the patient continued meropenem, which had been commenced after the collection of culture samples.
|Figure 1: A pelvic ultrasound scan: (a) longitudinal view of the uterus showing a fluid collection with dirty shadows due to gas within a defect in the posterior uterine wall (black star) and (b) transverse view of the uterus showing the uterus and the collection in the myometrial defect (black star)|
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A CT scan done on the same day showed an enlarged uterus with a heterogenous myometrial density. There was an ill-defined collection (about 60 ml) in the posterior wall of the myometrium with pockets of air density and a rim of contrast enhancement. A smaller collection was noted in the right lateral wall. Dilated small bowel loops were seen but no structural cause of the obstruction was found. A diagnosis of myometrial abscesses with intestinal obstruction possibly due to paralytic ileum was made.
While clinically stabilizing the patient with surgery planned for when stable, a decision was made to invite the radiologist to attempt image-guided percutaneous drainage of the uterine abscess.
On the fourth day of admission, the abscess was drained percutaneously under aseptic conditions, local anesthesia, and using CT guidance [Figure 2]a. An 18-G puncture needle was placed in the posterior uterine wall to access the largest abscess pocket [Figure 2]b. The needle was exchanged over a guidewire for a size 10-Fr pigtail catheter [Figure 2c]. Ten milliliters of bloody effluent and 20 ml of gaseous content were aspirated. The catheter was sutured to the skin and connected to an external drainage bag.
|Figure 2: Axial CT scan slices of the pelvis for CT-guided abscess drainage (a) shows the uterine abscess tracking to the anterior abdominal wall, (b) shows an 18-G puncture needle placed within the abscess collection, and (c) shows a size 10-Fr pigtail catheter within the abscess|
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The culture of the aspirated effluent as well as blood culture yielded no growth. However, based on the recommendation of the microbiologists, she continued the meropenem for a total of 10 days. The drain was removed 8 days postprocedure. An ultrasound scan done at this time showed no significant myometrial collection and the patient's clinical state improved significantly. The patient was discharged home in a stable condition 2 weeks after the procedure. The delay in discharge was due to the slowly resolving paralytic ileus and some financial constraints. Her follow-up in the clinic was satisfactory. She was advised to delay attempts at conception till 6 months' postprocedure, so that it would give her body adequate time to heal. A plan was initiated to investigate other factors for conception.
Hysterectomy may be offered to patients with uterine abscess, especially in those who have completed their family. Image-guided percutaneous drainage offers a minimally invasive interventional radiology solution for draining abscesses, within the body. This was considered in this patient to preserve her uterus and the possibility of her having children.
Ultrasonography is the first choice when imaging gynecological disorders due to its relative availability, affordability, and lack of ionizing radiation. However, ultrasound may be unable to differentiate between uterine fibroids and an acute hematoma within the vascular bed postmyomectomy since both appear hypoechoic. The initial ultrasound scan done at our center noted hypoechoic masses within the endometrium but made a diagnosis of leiomyomata instead of intrauterine hematoma.
Ultrasound guidance for interventional procedures offers real-time imaging while advancing the access needle. However, the acoustic window may be impaired by gas within the abscess cavity. In the case we presented, there was a lot of gas noted within the abscess on ultrasonography [Figure 1]. The presence of gas in the collection would make it difficult to visualize the tract of the access needle on ultrasonography, so we preferred a CT-guided approach.
If CT-guided percutaneous drainage of an abscess fails, hysterectomy remains the next line of action. However, a challenge with conventional surgery such as hysterectomy when compared with an interventional radiology procedure is that it may require general anesthesia or regional block. In our case, the patient had hypokalemia and was not a suitable candidate for general anesthesia.
Times have changed from the days of Charles Dotter when there was a tricky relationship between surgeons and interventional radiologists. There are now collaborations rather than turf battles. For example, in our presented case, the gynecologists invited the interventional radiologists to drain the abscess immediately rather than wasting time while correcting the hypokalemia in preparation of general anesthesia and a surgical intervention. The nulliparous patient's uterus was thereby preserved.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]