Gynecological surgery’s complication: a radiological anatomical based approach to the diagnosis
Gynecological surgery’s complication: a radiological anatomical based approach to the diagnosis
Andrea Cazzato, Enrica Nicosia, Giulia Francese, Matilde Mattiauda, Federica Martini, Veronica Giasotto, Carola Martinetti, Alì Attieh, Jeries Paolo Zawaideh
The aim of our poster is to show some common and uncommon surgical complications presenting in the acute, sub-acute, and chronic settings, dividing them by anatomical localization. For this purpose, we present our case-based review describing radiological findings into pelvic and extrapelvic, with the pelvic complications further divided into anterior, middle, and posterior compartments. In this way, it's faster for the radiologist the differential about which organ is affected and what is the underlying complication. We also want to underline the importance of acknowledging the type of operation performed and its timing, the presence of comorbidities, the underlying pathology and the acuity of presentation to understand better the images and give a real help to the clinicians and surgeons.
There are several gynecological surgeries for benign and malignant conditions, the most common is the cesarean, which was performed at least 1.12 million times in the EU during 2020 (according to Eurostat analysis, and it was the second most common operation done in the EU hospitals in that year), followed by total hysterectomy due to benign, such as myomas or endometriosis, and malignant condition as endometrial, cervical and ovarian cancer. Uterus removal can be done mainly by four surgical techniques: abdominal hysterectomy (AH), vaginal hysterectomy (VH), laparoscopic-assisted VH (LAVH) and total laparoscopic hysterectomy (TLH), carrying different kind and amount of morbidity, complications and reoperation rate. The laparoscopic approach is often considered the most common approach for uterine removal when feasible. This is due to its less invasive nature compared to abdominal hysterectomy, offering benefits such as a shorter recovery period, less post-operative pain, and smaller scars. Abdominal hysterectomy is usually employed when the uterus is significantly enlarged or when complications necessitate more direct access to the area. VH is associated with a shorter operating time and lower postoperative pain at 24 h than LH so when both surgical approaches are feasible, VH remains the surgery of choice for benign hysterectomy. General risk factors for post-hysterectomy morbidity include advanced age, medical comorbidities and malignancy. Each of these procedures, although some less than others, is not without complications. Therefore, for a more systematic approach and easier differentiation, we will anatomically divide the pelvis into three compartments, describing what can be encountered in each and extrapelvic structure. After the presentation of specific compartment complications, we describe mixed issues that can be seen in every area and have the same clinical meaning. Anterior compartment, which includes the bladder, ureter, and urethra, complications that can be observed include vesicouterine or vesicovaginal fistulas, ureteral stenosis, bladder wall injuries, urinary retention, and bladder prolapse. The most frequent complications in this compartment are of a urological nature: URETERAL STRICTURE A ureteral stricture is a narrowing of the ureter that results in a functional obstruction; the most common indirect sign is upstream hydronephrosis. Conventional abdominal radiography (CAR) does not have a major role in imaging ureteral pathology. Excretory urography (EUG), although now largely replaced by computed tomography (CT) urography, can be used for evaluating the renal collecting system and ureters. Ultrasonography (US) is not generally used to evaluate ureteral stricture but is useful to diagnose urinary obstruction above the stenotic point. CT after iodine endovenous administration in the urographyc phase is the imaging of choice for evaluating the ureters using MPR and MIP. It is useful to identify the site of narrowing and the extent of urothelial involvement, it allows also visualization of adjacent structures, which can help differentiate whether the stricture is due to an extrinsic or intrinsic process (as a blood clot in our case). Magnetic resonance (MR) urography is not yet commonly used and is kept as a problem-solving tool in complicated cases. URETERAL/VESICAL INJURY A ureteral/vesical injury incurred during surgery is often not suspected clinically since symptoms and signs are usually nonspecific. EUG shows abnormal findings, but the level and extent of injury are not clearly identifiable. US It can serve as an initial imaging that doesn't show specific findings, but visualizes a collection of free fluid in the pelvis or adjacent to the site of injury. CT urography is the imaging of choice to precisely visualize the affected point and better quantify the extent of urinary leakage. To visualize minor bladder injuries and suspected urinomas also CT cystography can be used, it is performed using a Foley catheter with retrograde filling with at least 250 ml of diluted contrast (1:8)of the bladder, this can confirm bladder wall integrity, ruling out possible leakages. MESH DISPLACEMENT COMPLICATIONS Pelvic floor reconstruction using mesh implants can lead to complications such as erosion, extrusion, infection and urethral angulation resulting in urinary retention. MRI with T2 weighted sequences is the best imaging modality to allow an early assessment of the position, integrity, and interaction of mesh with adjacent structures, guiding timely intervention. Middle compartment which includes the vagina, uterus, and ovaries, potential complications involve post-cesarean section wound dehiscence with or without abscess formation, uterine hematoma, vaginal vault hematoma, and pelvic dysfunction. CESAREAN SECTION WOUND DEHISCENCE There are some risk factors for the development of uterine dehiscence (the process of gradual myometrial rupture without a rupture of membranes) or fracture (full-thickness rupture of the uterine wall at the site of the previous cesarean section) such as obesity, diabetes mellitus, previous cesarean section, a retroflexed gravid uterus and prolonged labor. Typical presenting symptoms include postpartum pain and bleeding. US and CT may demonstrate a hematoma at the cesarean section wound site, and can clearly demonstrate a uterine rupture allowing to localize and describe the width of the lesion, but are insensitive in identifying a true dehiscence. MRI with T2-weighted imaging can show a normal cesarean section wound as a linear hyperintense focus with or without a small hematoma, whereas true dehiscence will appear as a hyperintense focus of varying width extending through the full thickness of the uterine wall from the serosa to the endometrium. Contrast-enhanced MR images are useful in confirming the full-thickness defect as well as the hematoma. PERITONEAL INCLUSION CYST It is a type of cyst-like structure that appears about the peritoneal surfaces and adjacent to the adnexal structure, which results from a non-neoplastic reactive mesothelial proliferation. It occurs almost exclusively in premenopausal women with a history of previous surgery, trauma, pelvic inflammatory disease, or endometriosis and clinically manifests as abdominal discomfort or pain, depending on the size. US shows a large anechoic formation with oval irregular margins, possible thin internal septations, and no vascular signals upon Color Power Doppler (CPD) evaluation; a perceptible wall is rarely present with the technique. Invagination of surrounding structures into the cyst, often the ovary, can occur. CT shows a localized loculated fluid collection conforming to the peritoneal space, with a normal ipsilateral ovary within it or adjacent to its wall. Septations within the localized fluid can also be observed. MRI allows for precise delineation of the relationship between the septated cystic formation and the ipsilateral ovary, highlighting wall enhancement after gadolinium administration. PELVIC FLOOR DYSFUNCTION Pelvic floor weakness is associated with abnormal descent of the pelvic floor upon straining which can lead to a rectocele, cystocele, enterocele, or intussusception. Symptoms vary according to the organ prolapsed. CR with fluoroscopic defecography can evaluate the presence and the grade of prolapse of the rectum and the presence of intussusception but does not provide precise information about the middle and anterior compartments. MRI with T2 saggital dynamic imaging, after rectal filling with a soft substance that is similar to the consistency (usually gel), allows for a precise assessment of the positions of organs in all three pelvic compartments during contraction, straining, and evacuation. Additionally, coronal T2-weighted scans provide valuable information about the tone and symmetry of the levator ani muscles. Posterior compartment consisting of the sigmoid colon and rectum, one might encounter fistulas between these organs and the female reproductive tract, deep pelvic endometriosis, and rectal injuries. INTESTINAL PERFORATION A lesion on the small or large intestine that represents potentially serious complications, especially if unrecognized at the time of surgery. It results in the leakage of luminal content and inflammation of the wall, which clinically presents with pain. Abdominal X-ray allows the visualization of the presence of subdiaphragmatic free air as areas of radiolucency external to the intestinal loops and colonic shadows. CT highlights the presence of free air in the abdomen or pelvis with greater precision and sensitivity, detecting even microbubbles and covered perforations. Additionally, it enables the accurate visualization of free fluid collections and provides an idea of the possible location of the perforation. In the Extrapelvic area, indirect signs of pathology can manifest as free air, adynamic bowel (paralysis after surgery mimicking obstruction), thrombosis, omental infarction and distant abscesses. In surgical procedures involving the abdominal wall, there can be complications specific to that approach. These may include hematomas or abscesses within the abdominal wall, as well as the presence of superficial or distant endometriotic implants. We should always keep on mind the possible formation of adhesions between pelvic organs or between bowel loops (which can bring to stenosis or volvulus formation in the chronic setting), vascular and lymphatic structures damage, which can be found in every compartment described before and can bring to common complications as hematoma, abscess, lymphocele and thrombosis. DISTANT ENDOMETRIOSIS Endometriotic implants are more commonly observed after a cesarean section than after abdominal hysterectomy and are usually located in the skin and subcutaneous tissue at the abdominal incision site, and less frequently in the rectus muscles of the abdomen. Patients usually present a few years after surgery with an abdominal mass at the incision site accompanied by cyclic or noncyclic pain. Abdominal wall scar endometriosis may be mistaken for chronic hematoma, incisional hernia, suture granuloma, fibrosis, or desmoid tumor, so it's necessary to know the history and have the suspicion of finding it. US shows a nonspecific hypoechoic mass with variable cystic and solid components due to cyclic hemorrhage. At color Doppler evaluation it may show internal vascularity of the mass. CT displays a heterogeneous mass that may contain hyperdense foci if it has recently bled, and exhibits post-contrast enhancement. MR imaging features are also nonspecific and variable due to the menstrual cycle. Gadolinium-enhanced images demonstrate a T1-hypointense mass similar to the rectus muscle with variable T2 hyperintensity and enhancement. T1 hyperintensity within an abdominal wall mass at the surgical scar due to subacute hemorrhagic blood products helps differentiate endometriosis from postsurgical fibrosis or desmoid tumor. ADYNAMIC BOWEL It is a paralysis after surgery mimicking occlusion which happens commonly after surgical procedure and is self-limiting. Xray allows visualization of the intestinal loops and colonic distension with possible air-fluid levels. CT allows the right differential diagnosis between adynamic bowel and obstruction: in the first condition we can't see the transitional point or signs of strangulation, but just a mild/moderate distension of all bowel loops. MIXED COMPLICATIONS HEMATOMA/ABSCESS A hematoma is a localized collection of blood in extravascular space and it can form virtually anywhere. Hematomas are usually sterile when first formed and the majority remain uninfected. However, superinfection is seen forming a hemorrhagic abscess. Small hematomas may be asymptomatic. Large ones may present with lower abdominal pain, dysuria, anemia and fever when they become infected and turn into abscess collections. US hematoma presents as a heterogeneous solid region with a variable amount of fluid component. The presence of gas foci strongly suggests infection and abscess formation. CT shows a heterogeneous formation with slightly hyperattenuating fluid density, and in the acute phase, during post-contrast phases, a blush may be recognizable. In the case of an abscess, there is a hyperemic wall and the presence of internal air microbubbles within the collection. MRI is usually not necessary, in addition to the information provided by CT, it allows for the differentiation of blood products, providing better dating of the hematoma. LYMPHOCELE Lymphoceles are collections of lymphatic fluid that result from surgical injury to the lymphatic system. Strongly associated with lymph node dissection after resection of gynecologic tumours. US is not very sensitive, showing tubular hypoechoic formations depending on the evolutionary phase, devoid of vascular signals on CPD, localized along the course of the vessels. CT e MRI characteristic appearance of a lymphocele is a laterally positioned pelvic collection with homogeneous fluid attenuation and signal intensity, generally adjacent to surgical clips and along iliac blood vessels. On early postoperative studies, lymphoceles lack a perceptible wall; later they progressively become round- or ovoid-shaped and better demarcated, developing a thin regular fibrotic wall. FISTULA A fistula is defined as an abnormal communication between two epithelial surfaces resulting from an injury or disease. It connects an abscess cavity or hollow organ to to another hollow organ. Fistulas can be early as well as delayed complications, and they can be secondary to bowel or urinary fistulas. US in some cases is able to detect the fistulous tract asan hypoechoic pathway connecting two organs with a classic "beack sign". Anorectal, transrectal, and transvaginal US can help to identify better a fistulous tract and its relation to the adjacent anatomical structures. CT is the modality of choice for the diagnosis of fistulae and the assessment of possible complication, but in many cases, it may not be visualized. If there is suspicion of a fistula involving the bladder, performing a CT cystography is useful, while if the doubt is with the rectum, a contrast enema can be administered rectally via a catheter; the presence of contrast material in the adjacent organ confirms the presence of a fistulous tract. MRI has excellent intrinsic soft tissue resolution together with multiplanar imagining capability allows an accurate depiction of fistulous tract without the necessity of direct opacification required in CT scanning. On T2-weighted images, the fistula typically produces a high-signal-intensity, fluid-filled communication, whereas the air-filled fistulous tract is seen as a low signal intensity, THROMBOSIS Is the formation of a blood clot (partial or complete blockage) within blood vessels, whether venous or arterial, limiting the natural flow of blood. rarely leads to pronounced and specific symptoms; therefore, it is often encountered as an incidental finding on imaging. US is of limited use unless there is a precise indication regarding the vessel to be studied; in such cases, the vessel will appear hypoechoic and the flow, as assessed by CPD, will be absent or present only in the portion of the vessel that is not yet thrombosed. In CT scans after contrast administration, the involved vessel shows a lack of opacification. MRI reveals an absence of flow void caused by stasis or slowing of blood flow due to the endoluminal thrombus. Scans after the administration of contrast material yield findings similar to those highlighted on CT scans. OMENTAL INFARCTION It is a focal fat infarction, a rare cause of acute abdomen which presents with sudden strong pain. It is usually larger than 5 cm, which helps distinguish it from epiploic appendagitis. This condition is often self-limiting and can be managed conservatively US shows a focal area of increased echogenicity in the omental fat, in the very right place where the pain arising. CT is useful to confirm the suspect, without contrast injection allows to see a focal area of fat stranding with hyperdense peripheral halo and sometimes also visible a swirling of omental vessels in omental torsion.
Sagittal T2 TSE abdominal image with compartmental division: extrapelvic structures (green) and pelvic organs, divided into those of the anterior compartment (yellow), middle compartment (red), and posterior compartment (purple)
A postpartum woman undergoes an urgent CT scan for dystocia due to non-reassuring cardiotocography (CTG), followed by sudden embolization of uterine arteries for persistent bleeding. On the ninth day post-cesarean section, a CT scan is performed due to fever with shakings and pain in the right flank. Transvaginal ultrasound (TVU) shows an anterior collection adjacent to the uterus. -TC images with MPR in portal phase, the gravid uterus on the ninth day shows a corpuscular/hemorrhagic content with contextual air bubbles (star). There is solution of continuity in the anterior-right wall, site of the cesarean incision (straight arrow), with an anterior extrauterine collection with hyperemic walls and thin serous capsule (rhombus), communicating with the uterine canal. The findings are located in the middle compartment and extend partially into the anterior compartment.
A 27-years-old patient on the second day after left salpingectomy presents with poorly localized flank pain. Abdominal ultrasound shows minimal bilateral calyceal-pelvic ectasia (11 mm right side and 20 mm left side) and proximal left ureteral mild dilation, without obstructive stone formation in the escretory system.CT scan confirms the dilation of the calyceal-pelvic system and the proximal ureter with stenosis in the mid-distal segment, in the majority of cases due to post-surgical adhesion, but this time was caused by blod clot formed by elettro-bistury. The premeatal ureteral segment appears normal. Late-phase CT image with MPR demonstrating regular iodinated urine excretion from the right ureter (yellow arrow); lack of opacification in the left urinary tract due to delayed urine excretion caused by downstream obstruction (blue arrow).2- Ultrasound image with a convex probe (2-6 MHz) revealing the left kidney characterized by a 20 mm dilation of the renal pelvis (blue arrow) and normal sonographic morphology. Findings are located extrapelvically.
CT scan on 12.02.23 reveals intestinal perforation following hysterectomy and iliaco-otturatory lymphadenectomy.A 65-year-old patient on the third day post elective hysterectomy and bilateral salpingo-oophorectomy for endometrial neoplasia, along with iliaco-otturatory lymphadenectomy, presents with hypotension and acute abdomen.Emergency CT scan shows indirect signs of intestinal perforation with free air in the abdomen (straight arrow) and multiple abdominopelvic collections due to surgical dehiscence (rhombus).
Due to the high frequency of cesarean delivery and the growing number of detection and surgical treatment of uterine pathologies, surgical complications aren't so unusual encountered in the everyday clinical and radiological practice in emergency department. The knowledge of physiological findings should reduce further examination and useless follow-up. In our opinion these complications, especially in the acute phase, cannot arrive at radiologist attention only in the hub centers, but also in any spoke hospital which has an emergency department especially if it has a gynaecological department, so, not only dedicated urogenital radiologist, but also other radiologists should be familiar with these scenarios. Multiple imaging modalities, play a crucial role in the diagnosis and management of these postsurgical complications, providing valuable assistance to clinicians and surgeons. We brought at your attention also a rare challenging complication, a chronic gossypiboma due to a gauze left in the abdomen (arriving at our department years later for gastrointestinal problems not related with the reproductive/gynecological system) to highlight the importance of a good anamnesis and multidisciplinary discussion. The anatomical localization of the complication, using the division proposed in the poster, can facilitate differential diagnosis and lead to a faster and more accurate diagnosis
In 2020, the patient underwent to a laparoscopic myomectomy; after two years she come for abdominal discomfort, so it was performed an MRI which detected a sac-like formation with heterogeneous fluid-filled content. It extended from the ileal loops in the subumbilical region to the pelvis, measuring 16x10 cm, and lacked macroscopic adipose content.The CT scan confirmed the presence of an encapsulated collection with fluid-filled content devoid of solid vascularized components, without adding more information. A Xifopubic Laparotomy (LPT) procedure was carried out to remove this formation which was identified as a foreign body: a surgical gauze. This developed a pelvic abscess with a pseudocapsule creating a big gossypiboma. 1-Coronal T2 TSE MRI 2- Sagittal T2 TSE FAT-SAT MRI 3- Sagittal Post-Contrast T1 DIXON MRI 4- Axial T1 TSE MRI 5- Axial T2 TSE STIR MRI 6- Sagittal venous-phase CT A voluminous formation located in the anterior/extrapelvic compartment, with heterogeneous content, predominantly liquid signal, and a thin outer capsule with contrast enhancement. It is well-demarcated from adjacent anatomical structures, some of which are displaced. This corresponds to the previously mentioned gossypiboma (rhombus). A liquid formation with thin walls and internal septa with contrast enhancement, located in the mid-para-uterine compartment, indicative of an adnexal cyst (straight arrow).