Akademik Veri Yönetim Sistemi
European Congress of Radiology 2024, Vienna, Avusturya, 28 Şubat - 03 Mart 2024, ss.1
The role of radiologists in the evaluation of gynecologic surgery and complications of these surgical procedures through the imaging findings
In most gynecologic diseases, surgery is the primary treatment option. Various surgical procedures including open, laparoscopic, and robot-assisted surgeries are performed. As in every surgery some procedural complications may occur following surgery[1].
Hysterectomy, trachelectomy, pelvic exenteration, cesarean, oophorectomy, debulking surgeries can be count as common gynecologic surgical procedures.
Hematoma
Hematoma can be seen as a complication in any gynecologic surgery. Small hematomas are mostly asymptomatic, therefore exact incidence of hematoma is unknown. Severe hemorrhagic complication rate of hysterectomy is %2.1-%3.1. In CT scans acute hematoma is hyperdense (50-80 Hounsfield Unit) due to aggregated fibrins. In chronic stage; density decreases and they can be seen like a basic cyst. MRI scan is useful to differentiate hematoma age. In the acute stage, hematoma is hypo-isointense in T1 and T2 weighted sequences due to deoxyhemoglobin. At subacute stage hyperintense images are seen in T1 and T2 weighted sequences because of extracellular methemoglobin content. At chronic stage there is a hypointense rim in T1 and T2 weighted sequences due to hemosiderin.
Lymphocele
Lymphocele is one of the most common complications of lymph node dissections. Lymphoceles are cystic fluid collections without a real epithelial wall. It can be seen 3-8 weeks after surgery and remain up to 1 year after surgery. They are asymptomatic and resolve spontaneously. Rarely hemorrhage or infection complications can be seen. Lymphoceles are usually bilateral and can be seen as multiloculated cystic masses with thin septa [2].They are hypointense in T1 and hyperintense in T2 weighted sequences. T1 signal can increase due to complications such as hemorrhage or infection. Except complicated forms, they do not show contrast enhancement.
Endometritis
Endometritis and abscess formation are quite common complications and can be associated with urinary tract or wound site. At first, fluid collections and soft tissue density is expected in CT examination. In later stages, a contrast enhancing wall arises. In MRI, abscess formation shows intermediate intensity in T1 weighted sequences and it shows high signal in T2 weighted sequences. In later stages, necrosis and air can show heterogenous signal. Presence of gas bubbles is suspicious for infection of gram-negative bacteria [3].
Urinary / Gastrointestinal Tract Injuries
Urinary tract injury can be seen as bladder or ureteral injuries and can heal spontaneously or can lead to urinoma. They are more common in oncologic procedures. Predisposing factors for urinary tract injury are coexisting pelvic adhesion, previous irradiation history, distortion of normal pelvic configuration, , previous operation history [4].CT cystoscopy shows contrast leakage from the injured site. Intravenous pyelography and CT urography are other imaging diagnostic methods.
Fistula formation between urinary and/or gastrointestinal tract and gynecologic system is another important complication. Vesicovaginal fistula is the most common form. CT cystoscopy, pelvic MR and CT with rectal contrast can be used for diagnosis of fistula
Gastrointestinal tract injury can be seen as perforation, peritonitis,abscess formation, bowel obstruction. Small bowel injury is more common at laparoscopic hysterectomy, rectum injury is more common at vaginal hysterectomy. Gastrointestinal tract injury rates are similar with open/laparoscopic and robotic surgeries. CT is the modality of choice for these complications [5].
Cesarean Section Wound Dehiscence
Cesarean section wound dehiscence should be suggested in patients with postpartum pain and bleeding. This condition increases the morbidity and mortality. Imaging findings are important to recognize abscess formation and subcutaneous collections.
There are other rare complications such as pelvic floor dysfunction, peritoneal inclusion cyst, scar endometriosis and omental infarction.
Gynecologic surgeries have multiple early and delayed complications. Knowing post-op complications, imaging findings and suitable imaging methods is important to guide early diagnosis and appropriate treatment.
1- Paspulati, Raj Mohan, and Tejas A. Dalal. "Imaging of complications following gynecologic surgery." Radiographics 30.3 (2010): 625-642.
2- Tonolini M. Multidetector CT of expected findings and complications after hysterectomy. Insights Imaging. 2018 Jun;9(3):369-383. doi: 10.1007/s13244-018-0610-9. Epub 2018 Apr 6. PMID: 29626286; PMCID: PMC5990996.
3- Lachiewicz MP, Moulton LJ, Jaiyeoba O. Pelvic surgical site infections in gynecologic surgery. Infect Dis Obstet Gynecol. 2015;2015:614950. doi: 10.1155/2015/614950. Epub 2015 Feb 18. PMID: 25788822; PMCID: PMC4348594.
4- Bai SW, Huh EH, Jung DJ, Park JH, Rha KH, Kim SK, Park KH. Urinary tract injuries during pelvic surgery: incidence rates and predisposing factors. Int Urogynecol J Pelvic Floor Dysfunct. 2006 Jun;17(4):360-4. doi: 10.1007/s00192-005-0015-4. Epub 2005 Sep 30. PMID: 16195819.
5- AlHilli MM, El-Nashar SA, Garrett AT, Weaver AL, Famuyide AO. Use of computed tomography in the diagnosis of bowel complications after gynecologic surgery. Obstet Gynecol. 2013 Dec;122(6):1255-62. doi: 10.1097/AOG.0000000000000014. PMID: 24201687.
