DOI:10.2214/AJR.07.3808
AJR 2008; 191:1352-1358
© American Roentgen Ray Society
Transvaginal Drainage of Pelvic Fluid Collections: Results, Expectations, and Experience
Anuradha Saokar1,2,
Ronald S. Arellano1,
Debra A. Gervais1,
Peter R. Mueller1,
Peter F. Hahn1 and
Susanna I. Lee1
1 Department of Radiology, Massachusetts General Hospital, Boston, MA
02114.
2 Present address: Department of Radiology, Boston Medical Center, 820 Harrison
Ave., FGH Bldg. 3rd Fl., Boston, MA 02118.
Received February 8, 2008;
accepted after revision June 5, 2008.
Address correspondence to A. Saokar Rebello.
P. R. Mueller is a consultant for Cook Medical.
Abstract
OBJECTIVE. The purpose of this study was to review our 13-year
experience with sonographically guided transvaginal drainage procedures in
terms of type of transvaginal procedure, that is, aspiration or catheter
drainage, complication rate, and long-term success.
MATERIALS AND METHODS. A search of an interventional radiology
database identified 85 transvaginal drainage procedures on 67 patients.
Pertinent medical records and images were reviewed. Clinical success was
defined as no need for surgery.
RESULTS. The mean follow-up period was 36.6 months (range, 7
days–132 months). Forty-five aspiration and 40 catheter drainage
procedures were performed on 67 patients. Indications for the procedures
included postoperative fluid collection (n = 25), tuboovarian abscess
unresponsive to medical therapy (n = 17), symptomatic ovarian cyst
(n = 17), and miscellaneous causes (n = 8). Clinical success
was achieved in 50 of 67 cases (75%), including all cases of 25 postoperative
fluid collection, 12 of 17 tuboovarian abscesses (71%), and seven of 17
ovarian cysts (41%). No complications were found in patients who underwent
aspiration alone. The following minor complications occurred in patients who
underwent catheter drainage: two cases of bladder transgression, one case of
infection, and one case of catheter-related pain. Premature dislodgment of the
catheter was an issue for four of 40 patients (10%).
CONCLUSION. Postoperative fluid collections can be managed with a
high rate of success by means of transvaginal aspiration or catheter drainage.
Transvaginal catheter drainage is an alternative to surgery in the management
of tuboovarian abscesses unresponsive to medical management. Aspiration alone
is sufficient to drain ovarian cysts and provide symptomatic relief. Most
cysts recur, however, ultimately necessitating surgery. Aspiration is safe,
but catheter drainage is associated with a 10% rate of minor
complications.
Keywords: drainage • pelvis • transvaginal sonography
Introduction
Drainage of a fluid collection deep in the pelvis of a woman presents
unique technical and clinical challenges to interventional radiol ogists
[1–8].
The most common cause of fluid collection is surgery whereby collections such
as abscesses and hematomas develop after gynecologic or distal colorectal
surgery. Tuboovarian abscess is another common cause. A course of intensive
antibiotic therapy is the preferred first-line treatment, but medical
management alone is successful for only 37–88% of patients with a pelvic
abscess [9]. In these patients,
imaging-guided drainage rather than surgical excision is undertaken as a less
invasive second-line treatment. Imaging-guided drainage of benign symptomatic
ovarian cysts often is performed for palliation and to decrease the risk of
ovarian torsion in patients who are poor candidates for surgery. Such patients
include elderly or pregnant women, those with associated comorbid conditions,
and those, such as women with a single ovary, in whom surgical excision may
compromise ovarian function or fertility.
Interventional radiologists can gain access to pelvic fluid collections by
the anterior trans abdominal, transgluteal, endo rectal, and transvaginal
routes
[1–8].
The anterior percutaneous transabdominal approach is prefer red because it
maximizes patient com fort and ease of catheter placement and care. Deep
pelvic lesions occasionally are inaccessible by the transabdominal or
transgluteal approach because of intervening viscera, such as bowel, bladder,
and uterus, or vascular and osseous structures
[4]. In these situations, the
endorectal approach and, in women, the transvaginal route are useful
alternatives. The endorectal method is a relatively nonsterile technique with
limited range of motion for the radiologist. This route is useful for gaining
access to pelvic fluid collections posterior to or abutting the rectum.
Sonographically guided transvaginal drainage of pelvic fluid collections
was described in the early 1990s
[4,
5]. This approach is not widely
used, however, owing to radiologists' lack of familiarity with the procedure
and the paucity of data to guide case selection and prediction of long-term
clinical outcome. We review our 13-year experience with sonographically guided
transvaginal procedures, including the technique, whether aspiration or
catheter drainage was used, the complication rate, and whether long-term
success was achieved.
Materials and Methods
The hospital institutional review board approved this retrospective study.
Informed consent from patients was not required. The study was
HIPAA-compliant.
Medical Record Review
A search of the interventional radiology database at our institution for
records of all women who underwent sonographically guided transvaginal
procedures from 1994 to 2006 identified 85 transvaginal procedures performed
on 67 patients. One radiologist retrospectively reviewed and abstracted data
from all institutional medical records, including outpatient, emergency
department, and hospital admission and discharge notes; relevant diagnostic
and procedure-related imaging reports; and surgical, pathologic,
microbiologic, and other laboratory reports. The following data were
abstracted: patient demographic character istics; underlying cause, size, and
location of cyst or fluid collection; type of transvaginal inter vention
(aspiration alone or catheter placement); needle or catheter size; volume of
fluid aspirated; duration of catheter drainage; presence or absence of resi
dual fluid; and procedure complications. Follow-up clinical data documenting
recurrent fluid collection, symptoms, and subsequent imaging-guided procedures
or surgery were recorded.
Sonographically Guided Transvaginal Procedure
The sonographically guided transvaginal drainage procedures were performed
as pre viously described [10].
A team consisting of one of 19 attending staff interventional radiologists (a
pool that included five of the authors) and an interventional radiology fellow
performed the procedures. All procedures were performed with conscious
sedation induced by IV administration of 1–4 mg of midazolam
hydrochloride and 20–100 µg of fentanyl citrate. Immediately before
the procedure, 1 g of ampicillin, 80 mg of gentamicin, and 600 mg of
clindamycin were administered IV. Patients not undergoing long-term IV
antibiotic therapy were treated with 150 mg clindamycin orally every 8 hours
for 5 days after the procedure.
The patient was asked to drain her bladder immediately before the
procedure, or a Foley catheter was placed. The patient was placed in the
lithotomy position, and the perineum and vaginal vault were cleaned with 10%
povidone–iodine (Betadine, Purdue Frederick). A sheathed transvaginal
ultrasound probe with a guide was placed in the vaginal fornix closest to the
lesion, and the projected drainage path was scrutinized for intervening
structures, such as intestine, bladder, and blood vessels. Once the probe was
well positioned, the needle guide was aligned in the center of the lesion, and
a 16- to 20-gauge needle or an 8- to 12-French trocar locking pigtail catheter
(Dawson-Mueller Drainage Catheter, Cook) was advanced into the fluid
collection under continuous sonographic visualization. No incision was made in
the vaginal fornix before needle or catheter placement. In patients who
underwent aspiration alone, with either needle or catheter, the fluid was
completely drained to minimize the risk of superinfection of the residual
contents. Specimens of all fluid collections were obtained for microbiologic
examination. Specimens of ovarian cysts and of fluid collections after
resection of malignant tumors were obtained for cytologic examination.
Catheter Care
The catheter was attached to a gravity drainage system and secured to the
anterior aspect of the thigh with a rubber leg band. The catheter was flushed
every 8 hours with 10 mL of sterile saline solution and was removed once
output decreased to less than 10 mL/24 hours and symptoms diminished. Imaging
with CT or sonography usually was performed to document complete drainage
before catheter removal.
Criteria for Patient Selection
The decision to intervene was initiated by a referring clinician on the
basis of the patient's clinical presentation and after consultation with the
interventional radiologist. Postoperative fluid collections were drained if
symptomatic, that is, pain or signs of infection were present, and if the
collection seen at imaging was the likely cause of the symptoms. Tuboovarian
abscesses caused by pelvic inflammatory disease were drained if the patient
did not respond to medical treatment alone. Tuboovarian abscesses caused by
bowel lesions were drained if the patient had symptoms and signs of infection,
such as fever and an elevated WBC. Definitive surgery, such as sigmoid
colectomy or appendectomy, was performed after the inflammatory process sub
sided. Aspiration of ovarian cysts was considered if the clinical team
considered the cyst the likely cause of pelvic pain. The imaging appearance of
the ovarian cyst also was considered before aspiration. Except in a few
unusual circumstances, only simple benign-appearing ovarian cysts were
considered for aspiration.
Type of Transvaginal Procedure: Aspiration or Catheter Drainage
The choice of aspiration alone or catheter drainage was made by the
attending radiologist performing the procedure in consultation with the
referring clinical service. All fluid was initially aspirated with a needle. A
catheter was left in place if the aspirated material was purulent, if residual
fluid was present after an attempt at complete aspiration was unsuccessful, or
if bowel communication was suspected.
Data Analysis and Statistics
Technical success was defined as complete drainage of the fluid. Clinical
success was defined as long-term avoidance of surgery. Complications were
classified as major or minor according to the Society of Interventional
Radiology criteria [11]. Tests
and summary measures of association were performed with the chi-square test
(www.graphpad.com/quickcalcs/chisquared1.cfm).
A bayes ian calculator
(www.causascientia.org/math_stat/ProportionCI.html)
was used to calculate the 95% CI of proportions.
Results
Descriptive Statistics of Study Population
Table 1 summarizes the
characteristics of the patients and fluid collections drained. Eighty-five
transvaginal procedures (45 aspirations, 40 catheter placements) were
performed on 67 patients. Ten patients under went two transvaginal procedures
in the same session to address two separate fluid collections managed with two
catheter place ments (six patients), two aspirations (three patients), and an
aspiration and a catheter placement (one patient). Five patients underwent a
second transvaginal procedure because of recurrence (four patients) or because
the catheter was dis lodged (one patient).
Type of Transvaginal Procedure: Aspiration Alone or Catheter Drainage
The transvaginal route was chosen only if the fluid collection was
inaccessible with the percutaneous method, that is, the transabdominal or
transgluteal approach. Table 2
categorizes the procedures by underlying cause and type of procedure, that is,
aspiration or catheter placement. For complete drainage, aspiration alone
sufficed for all 23 symptomatic ovarian cysts (Fig.
1A,
1B); catheter placement was
needed for 91% (20 of 22) of tuboovarian abscesses persis tent after medical
therapy (Fig. 2A,
2B). Post operative fluid
collections were managed with aspira tion for 45% (14 of 31) of patients and
with catheter drainage for 55% (17 of 31) of patients. The mean duration of
catheter drainage was 4.5 days (range, 2–12 days). Catheter placement
was successful in every case in which it was attempted. In the case of one
tuboovarian abscess, although initial aspira tion yielded pus, a catheter was
not left in place because intervening vessels pre cluded a safe trajectory for
catheter placement.
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Fig. 2A —20-year-old woman with pelvic inflammatory disease who
underwent catheter drainage of right tuboovarian abscesses. Transvaginal
sonographic images show tuboovarian abscess before (A) and after
(B) catheter deployment into fluid collection.
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Fig. 2B —20-year-old woman with pelvic inflammatory disease who
underwent catheter drainage of right tuboovarian abscesses. Transvaginal
sonographic images show tuboovarian abscess before (A) and after
(B) catheter deployment into fluid collection.
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Complications
According to the Society of Interventional Radiology criteria, no
complications occurred in patients who underwent aspiration alone. Among
patients who underwent catheter placement, there were no major complications
but four minor complications. In two cases, the catheter transgressed the
urinary bladder and was discovered on days 1 and 7 after the procedure. The
first patient presented with urinary leak through the transvaginal catheter on
postprocedure day 1. Bladder transgression was confirmed with CT of the
abdomen and pelvis and catheter injection (Fig.
3A,
3B,
3C,
3D). The patient was treated
conservatively with re moval of the pigtail catheter and placement of a Foley
catheter for 10 days. The second patient had a transvaginal catheter in place
because of a tuboovarian abscess secondary to sigmoid diverticulitis. This
patient had no symptoms related to bladder transgression, which was an
incidental finding on postprocedure day 7 at cystoscopy performed for stent
placement. The pigtail catheter was removed, and the patient was treated
conservatively with placement of a Foley catheter for 21 days. In one case,
infection introduced into a postoperative fluid collection via the
transvaginal catheter necessitated additional antibiotic therapy. The fluid
was initially sterile and grew Escherichia coli on day 7. One patient
had severe catheter-related pain presumably due to irritation at the catheter
insertion site that was relieved with catheter removal.
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Fig. 3A —30-year-old woman with pelvic inflammatory disease who
underwent catheter drainage of tuboovarian abscess located posterior to
uterus. Transvaginal sonographic images show abscess before (A) and
during (B) catheter placement. In A, calipers Aand B measure
lesion dimensions as 3.9 and 3.0 cm, respectively.
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Fig. 3B —30-year-old woman with pelvic inflammatory disease who
underwent catheter drainage of tuboovarian abscess located posterior to
uterus. Transvaginal sonographic images show abscess before (A) and
during (B) catheter placement. In A, calipers Aand B measure
lesion dimensions as 3.9 and 3.0 cm, respectively.
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Fig. 3C —30-year-old woman with pelvic inflammatory disease who
underwent catheter drainage of tuboovarian abscess located posterior to
uterus. Axial CT scan obtained 1 day after procedure shows that catheter has
transgressed urinary bladder (opacified with contrast medium).
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Fig. 3D —30-year-old woman with pelvic inflammatory disease who
underwent catheter drainage of tuboovarian abscess located posterior to
uterus. Fluoroscopic image from catheter injection study performed 1 day after
CT shows opacification of urinary bladder (long arrow) on injection
of inferior catheter (short arrow). Superior catheter
(arrowhead) was placed under CT guidance and did not communicate with
urinary bladder or bowel.
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In addition to the foregoing complications, the catheter was dislodged
prematurely after 10% of drainage procedures (four of 40), in one case on the
day of the procedure and in three cases on postprocedure days 1, 2, and 6.
Imaging showed no residual fluid in two of these cases, so no further
intervention was needed. In one case the residual fluid collection was managed
with repeated transvaginal catheter placement, and in the other case, with
percutaneous drainage under CT guidance.
Long-Term Clinical Success
Table 3 shows clinical
success in avoidance of surgery. Overall, surgery was avoided by 75% (50 of
67) of patients, including all patients with postoperative fluid collections,
71% (12 of 17) of patients with tuboovarian abscesses unresponsive to medical
therapy, and 41% (seven of 17) of patients with symptomatic ovarian cysts.
Twenty-five percent (17 of 67) of patients needed surgery, including five
patients with tuboovarian abscesses, 10 with symptomatic ovarian cysts, one
with hydrosalpinx, and one with pyometra. Four patients with tubo ovarian
abscess were unsuccessfully treated and had recurrence of the fluid collection
after catheter removal, which necessitated surgery for sigmoid diverticulitis
(n = 3) and pelvic inflammatory disease (n = 1). One patient
with a tuboovarian abscess secondary to sigmoid diverticulitis was
successfully treated but needed sigmoid colectomy for definitive management.
One case of hydro salpinx and one of pyometra necessitated surgery. Ten
patients with ovarian cysts reported symptom relief immediately after
aspiration but needed surgery for cyst and symptom recurrence.
Two patients with serous tumors of borderline malignant tumors were
referred by an experienced gynecologist specializing in gynecologic oncology
with full understanding that the tumors might not be benign. The lesion in a
56-year-old patient with multiple myeloma and breast cancer was discovered at
staging CT. We aspirated this lesion both for diagnosis and to stabilize the
patient's condition until she became fit for laparoscopic resection. The
second patient was 23 years old at presentation and had a history of left
oophorectomy and right cystectomy for serous borderline tumor. Beginning in
1992, she underwent aspiration of recurrent cysts on four occasions in a
successful effort to preserve fertility until elective surgical resection in
2006 (Fig. 4). Neither patient
with borderline tumor had evidence of tumor recurrence after 5 years and 1
year of follow-up.
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Fig. 4 —33-year-old woman with history of borderline malignant tumor
of ovary. Sonographic image obtained immediately before sonographically guided
transvaginal aspiration of complex ovarian cystic lesion shows thick irregular
walls and septations that had recurred after four transvaginal aspirations.
Lesion was surgically removed and at pathologic examination proved to be
serous ovarian tumor of borderline malignancy. Calipers 1 and 2 measure lesion
dimensions as 7.1 and 4.6 cm, respectively.
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The mean follow-up period was 36.6 months (range, 7 days–132 months).
The mean follow-up periods were 7.9 months (range, 7 days–60 months) for
patients who needed surgery and 47.4 months (range, 2–132 months) for
those who did not need surgery.
Requirement for Additional Imaging-Guided Procedures
Table 4 shows the
imaging-guided procedures performed after the initial transvaginal drainage
procedure. Overall, 10% (seven of 67) of the patients needed additional
imaging-guided procedures. Three patients with postoperative fluid collections
needed a second procedure because the catheter was dislodged prematurely
(n = 2) or because of the presence of residual undrained fluid
(n = 1). All of these patients avoided surgery. Three patients with
symptomatic ovarian cysts underwent repeated transvaginal aspiration because
of cyst recurrence but ultimately needed surgical resection. In two of the
three patients, cysts recurred 3 and 5 months after the procedure. The third
patient was the 23-year-old patient with borderline malignancy discussed
earlier, and she needed four transvaginal aspiration procedures. The patient
with pyometra underwent repeated transvaginal catheter drainage 3 months after
the initial procedure because of reaccumulation of fluid and eventually
underwent hysterectomy.
Discussion
Previous studies have proved the feasibility and clinical efficacy of
sonographically guided transvaginal drainage of deep pelvic fluid collections
of various underlying causes
[4,
5,
12–15].
These reports present differing recommendations on the technique required,
that is, aspiration alone versus continuous catheter drainage, for effective
management of pelvic fluid collections with either short- or long-term
success. We report on, to our knowledge, the largest series of transvaginal
catheter placement procedures to date and analyze the efficacy of the
technique on the basis of the cause of the fluid collection, complication
rate, and long-term clinical success.
Postoperative fluid collections were amenable to transvaginal drainage, and
all patients avoided additional surgery. Neither aspiration nor catheter
placement was used preferentially. However, additional drainage procedures
were needed by a small proportion of these patients (12%, three of 25) because
of premature catheter displacement or presence of residual undrained fluid.
Our high success rate with transvaginal drainage of postoperative pelvic fluid
collections is similar to that reported for percutaneous drainage under
sonographic or CT guidance
[16–18].
Uncomplicated tuboovarian abscesses are typically managed with
broad-spectrum IV anti biotics. The rate of success of medical treatment alone
has been reported to range from 34% to 87.5%
[14]. When symptoms persist or
if rupture is suspected, surgical intervention, either laparoscopy or
laparotomy, is required. Percutaneous or transvaginal drainage has proved to
be a useful alternative to surgery if an abscess persists despite medical
therapy [14,
15,
19–21].
In a large series of 302 patients with tuboovarian abscess who were treated at
presentation with a combination of IV antibiotics and transvaginal aspiration,
Gjelland et al. [14] reported
an overall success rate of 93.4%, with 34.8% of patients needing repeated
aspiration procedures. In contrast, in our study, all patients with a
tuboovarian abscess had already undergone a course of IV antibiotic therapy.
In this setting, most of the fluid collections in our series (91%, 20 of 22)
necessitated catheter placement for complete drainage; 71% patients (12 of 17)
avoided surgery. No additional imaging-guided procedures were needed by any of
the patients treated successfully. Thus, even in patients with tuboovarian
abscesses unresponsive to medical management, transvaginal catheter drainage
remains a relatively effective therapeutic option for avoiding surgery.
Results of some studies
[22–26]
support the use of sonographically guided therapeutic aspiration of
symptomatic ovarian cysts as a viable alterative to surgical excision. Those
authors emphasize the need for careful patient selection and recommend that
the procedure be attempted only on patients with cysts thought to be benign
after thorough clinical and imaging evaluation. Some authors
[22,
27–31]
argue against therapeutic aspiration of ovarian cysts, citing high recurrence
rates and concern about peritoneal spillage of malignant cells should an
occult malignant tumor be drained. The reported recurrence rates after
sonographically guided aspiration of symptomatic ovarian cysts range from 25%
to 75%
[22–26,
32]. In our series, aspiration
alone completely drained all ovarian cysts and led to symptomatic relief for
all patients. However, more than one half of these patients (59%, 10 of 17)
ultimately needed surgery because of recurrence. Noting similarly high rates
of cyst recurrence, previous investigators
[33,
34] have proposed the use of
alcohol as a sclerosing agent. Because cyst recurrence can indicate that a
lesion is not benign, as in the cases of two lesions in our series, surgical
resection of a recurrent cyst rather than repetition of drainage with
sclerosis is indicated.
Previous results [4,
5,
12–15,
35,
36] on transvaginal drainage
show it to be a relatively safe procedure. In our series, no complications
occurred after aspiration alone. Catheter drainage, however, was associated
with a 10% complication rate (four of 40 patients). All complications were
classified as minor according to the Society of Interventional Radiology
criteria. In general, the potential complications of trans vaginal drainage
are similar to those of the percutaneous approach, including bleed ing and
bowel or bladder injury. Two cases of bladder injury were encountered in our
series. One case of bladder transgression occurred during drainage of a
6-cm-diameter cul-de-sac collection, and the second during drainage of a 3-cm
right adnexal collection. Both patients had tuboovarian abscesses. Super
infection and fistula formation are complications specifically related to
trans vaginal drainage. One case of the former occurred in our series
[4]. Premature dislodgment of
the catheter is a management issue likely more common in transvaginal drainage
because the catheter cannot be secured with sutures. Five percent (two of 40)
of catheter drainage patients in our study needed a second imaging-guided
drainage procedure because the catheter was dis lodged prematurely. Therefore,
the transvaginal route is less desirable if long-term drainage is
anticipated.
Limitations of this study were the retrospective nature and the relatively
small population in comparison with previous series of percutaneous drainage
procedures. Because at our institution surgery is the therapeutic option of
choice for tuboovarian abscesses unresponsive to medical therapy and for any
symptomatic ovarian cysts, our cohort of patients referred for imaging-guided
drainage favored those who declined surgery or were considered poor candidates
for surgery. This selection bias would likely have increased the incidence of
comorbid conditions in our study population, for which we have not accounted.
The relatively small sample size in each subcategory restricted our ability to
draw conclusions with reasonable statistical certainty to only the three most
common causes. We did not contact the referring clinicians to determine
whether any of their patients underwent follow-up with additional procedures
or surgery at an institution other than ours. Finally, our cases were acquired
over a period spanning several generations of sonography and other imaging
techniques and included a large pool of interventional radiologists with a
range of procedural experience. However, throughout the study, common
guidelines were followed in case selection, choice of technique, procedure
performance, and postprocedure follow-up.
Sonographically guided transvaginal aspiration or catheter drainage of
pelvic fluid collections is a useful alternative when the percutaneous
approach is not feasible. Postoperative fluid collections can be managed
successfully with this approach. Transvaginal drainage appears to be a
reasonable option for avoiding surgery on tuboovarian ab scesses that are
unresponsive to medical management. Cath eter placement usually is necessary
to avoid repeated drainage procedures. In our series, catheter drainage was
associated with minor complications in 10% of patients. Ovarian cysts were
reliably drained, and symptomatic relief was achieved with aspiration alone.
However, most cysts recur, and those that do should be surgically resected to
exclude the possibility that they are lowgrade or frankly malignant
neoplasms.
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Abstract
Introduction
