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EDUCATION EXHIBITS

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Imaging of Complications Following Gynecologic Surgery1 CME FEATURE See accompanying test at http:// www.rsna.org /education /rg_cme.html

LEARNING OBJECTIVES FOR TEST 2 After reading this article and taking the test, the reader will be able to: ■■Discuss

the role of radiologists in the evaluation of complications following gynecologic surgery. ■■List

the imaging modalities that are considered suitable for the evaluation of specific postsurgical complications. ■■Describe

the imaging features of the most common complications.

Raj Mohan Paspulati, MD • Tejas A. Dalal, MD Despite new nonsurgical treatment methods for gynecologic diseases (eg, endometrial radiofrequency ablation for dysfunctional uterine bleeding, uterine artery embolization for uterine fibroids), surgery continues to be the main treatment modality in this setting. New and improved surgical techniques include laparoscopic hysterectomy, which is performed much more frequently than abdominal hysterectomy because it offers the advantages of speedy postsurgical recovery and a short hospital stay. Nevertheless, a number of early and delayed complications continue to occur following gynecologic surgery. Radiologists with access to multiple imaging modalities play an important role in the diagnosis and management of these postsurgical complications and can assist the surgeon at this critical juncture. Improved computed tomographic and magnetic resonance imaging techniques have made imaging more reliable for early diagnosis. Familiarity with normal postsurgical anatomy, pitfalls in interpretation, and imaging-guided interventional procedures will facilitate the diagnosis and management of complications following gynecologic surgery. ©

RSNA, 2010 • radiographics.rsna.org

TEACHING POINTS See last page

Abbreviations: FSE = fast spin-echo, IVU = intravenous urography RadioGraphics 2010; 30:625–642 • Published online 10.1148/rg.303095129 • Content Codes: From the Department of Radiology, University Hospitals, Case Medical Center, Case Western Reserve University, 11100 Euclid Ave, Cleveland, OH 44106. Presented as an education exhibit at the 2008 RSNA Annual Meeting. Received June 15, 2009; revision requested July 17; final revision received January 8, 2010; accepted January 14. For this CME activity, the authors, editors, and reviewers have no relevant relationships to disclose. Address correspondence to R.M.P. (e-mail: [email protected]). 1

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Introduction

In most gynecologic diseases, surgery remains the treatment of choice. Hysterectomy is the second most common elective gynecologic surgery performed for both benign and malignant conditions of the uterus. Approximately 600,000 hysterectomies are performed each year in the United States (1). Total abdominal hysterectomy is the most common and also the most invasive type of hysterectomy. Radical hysterectomy performed for cervical and endometrial cancer involves more extensive parametrial resection and has a much higher rate of complications (2–4). Surgery also plays an important role in both the staging and treatment of ovarian cancer. Tumor debulking involves omentectomy, extensive lymph node dissection, and resection of metastatic peritoneal implants (5). The various types of gynecologic surgery and their related complications are shown in Table 1. Postsurgical complications may occur within a few days or weeks of surgery, or they may not occur for several months or even years. The imaging methods that are considered the most suitable for the detection of these complications are shown in Table 2. Hysterectomy is the most commonly performed gynecologic procedure. Total hysterectomy involves removal of the uterus and cervix, and it can be performed with either a transabdominal, laparoscopic, or transvaginal approach. Subtotal or partial hysterectomy involves removal of the uterus but not the cervix, and it is performed for benign causes such as fibroid uterus or dysfunctional uterine bleeding. Radical hysterectomy is performed for malignancy and involves removal of the uterus along with the cervix and ovaries and is commonly associated with lymph node dissection. Vaginal hysterectomy is the preferred surgical method for the treatment of benign uterine disease. Laparoscopically assisted vaginal hysterectomy is a new technique that serves as an adjunct to vaginal hysterectomy for lysis of adhesions and concomitant adnexal surgery. Total laparoscopic hysterectomy is technically more challenging and requires surgical expertise. It is indicated when vaginal hysterectomy and laparoscopically assisted vaginal hysterectomy are not possible due to a narrow pubic angle, small vagina, or immobile uterus. Total laparoscopic hysterectomy is associated with long surgical times and a higher rate of complications, especially urinary tract injuries. Laparoscopically assisted vaginal hysterectomy has significantly shorter surgical times, faster recovery,

Figure 1.  Hematoma in a patient with vaginal bleeding who had undergone cesarean section 14 days earlier. (a) Sagittal contrast material–enhanced CT scan shows a hematoma in the endocervical canal (arrow). (b, c) Axial (b) and coronal short-axis (c) reformatted CT images show the cervical hematoma (arrow) and parametrial vessels (arrowheads) without active bleeding.

and fewer complications than do total laparoscopic hysterectomy and abdominal hysterectomy (6–8). In this article, we discuss the role of radiologists in the evaluation of complications following gynecologic surgery, enumerate the imaging modalities that are considered most suitable for the

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Table 1 Risk for Complications Associated with Different Types of Gynecologic Surgery Type of Surgery Complication Hemorrhage Infection and abscess Bowel injury Bladder injury Ureteral injury Peritoneal inclusion cyst Lymphocele Pelvic floor dysfunction Wound dehiscence Abdominal wall endometriosis

TAH

TLH

VH and LAVH

Radical Hysterectomy

Myomectomy

Cesarean Section

++ ++ ++ ++ ++ ++ + ++ + +

++ ++ ++ ++ ++ ++ + ++ ... ...

+ + + + + + + ++ ... ...

++ ++ ++ ++ ++ ... ++ ++ ... ...

++ ++ + + + + ... ... ... ...

+ + + + + ... ... ... ++ ++

Note.—LAVH = laparoscopically assisted vaginal hysterectomy, TAH = total abdominal hysterectomy, TLH = total laparoscopic hysterectomy, VH = vaginal hysterectomy, + = low risk, ++ = high risk.

Table 2 Suitable Imaging Methods for Detection of Various Complications Complication Hemorrhage Infection and abscess Bowel perforation, obstruction, and fistula Bladder perforation Ureteral injury Vesicovaginal fistula Rectovaginal fistula Enterocutaneous fistula Abdominal wall scar endometriosis

Imaging Methods Computed tomography (CT) Ultrasonography (US), CT CT, gastrografin small bowel follow-through study or enema examination CT, cystography, CT cystography Intravenous urography (IVU), CT urography, retrograde pyelography Magnetic resonance (MR) imaging, cystography MR imaging, gastrografin enema examination Fistulography, CT with oral contrast material and multiplanar reformation, MR imaging US, MR imaging

evaluation of specific complications, and discuss and illustrate the imaging features of the most common complications.

Complications of Gynecologic Surgery Hemorrhage and Hematoma Hemorrhage and hematoma formation is the most common complication following gynecologic surgery as well as cesarean section. Hemorrhage can be confined to the cesarean section wound site (Fig 1) or can extend to the pelvis and abdominal cavity (Fig 2) (6). Hemorrhage is more frequently seen in patients with a large

fibroid uterus. Vault hematoma is a common finding in the first week following hysterectomy and has no significant correlation with surgical technique or surgical blood loss. Although large hematomas are associated with febrile morbidity, most hematomas are small and self resolving (9–12). Hence, identification of a vault hematoma at CT may not necessitate transvaginal US or drainage of the collection. Abdominopelvic CT is the primary imaging modality in patients with suspected postsurgical hemorrhage. An acute hematoma has a higher CT attenuation (70–90 HU), and contrast-enhanced CT may be

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Figure 2.  Posthysterectomy pelvic hematoma. (a) Axial contrast-enhanced CT scan shows a fluid collection with heterogeneous attenuation in the pelvis (arrowheads). (b) Axial contrast-enhanced CT scan obtained at a lower level demonstrates the vaginal stump (arrowheads).

Table 3 Risk Factors for Various Complications Complication Hemorrhage Infection and abscess Cesarean section wound dehiscence Bowel or urinary tract injury Fistula to bowel or urinary tract Bowel obstruction Abdominal wall scar endometriosis

Risk Factors Myomectomy for large fibroid uterus, large body habitus Hematoma, bowel or urinary tract injury Obesity, diabetes mellitus, previous cesarean section, retroflexed gravid uterus, prolonged labor Adhesions from previous surgery, previous radiation therapy, pelvic inflammatory disease, or endometriosis Malignancy, previous radiation therapy Previous radiation therapy, postoperative hemorrhage and infection Cesarean section

used to document active extravasation of contrast material in the presence of active bleeding (13). Transcatheter arterial embolization is a highly effective method of treatment in patients with significant active bleeding (14).

Infection and Abscess Infection and abscess formation can be a sequela of hematoma or secondary to visceral injury to the bowel, ureter, or bladder. The abscess collection may communicate with the vaginal stump and spontaneously drain through the vagina (15,16). The appearance of the abscess varies with its age, size, and location (Fig 3). CT and US are useful modalities for documenting as well as draining an abscess collection (Fig 4) (17,18).

The presence of a large amount of air within the abscess suggests communication with the gastrointestinal tract. Multiplanar reconstruction of CT data is useful in documenting the extent of the abscess collection (Fig 3) and in identifying bowel perforation or fistulous communication.

Cesarean Section Wound Dehiscence Obesity, diabetes mellitus, previous cesarean section, a retroflexed gravid uterus, and prolonged labor have been identified as risk factors for the increased prevalence of cesarean section wound dehiscence (Table 3) (19,20). Pain and postpartum bleeding are the usual presenting symptoms in affected patients. Although US and CT may demonstrate a hematoma at the cesarean section wound site (Fig 5), they are insensitive in identifying a true dehiscence. In contrast, MR

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Figure 3.  Pelvic abscess in a patient who had undergone cesarean section. Sagittal (a) and axial (b) contrastenhanced CT scans demonstrate a fluid collection with pockets of air (arrow in a, straight arrow in b) extending from the surgical wound (curved arrow in b). The abscess is distinct from the endometrial cavity (arrowhead).

Figure 4.  Drainage of a pelvic abscess in a patient who had undergone cesarean section. (a) Axial CT scan of the pelvis shows a percutaneous Yueh catheter needle being introduced into the abscess cavity (arrow). (b) Axial CT scan shows the catheter in place (arrow).

Figure 5.  Cesarean section wound dehiscence. Axial (a) and sagittal (b) transvaginal US images show a hematoma (arrowheads) at a cesarean section incision site ventral to the endometrial cavity (arrow).

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Figure 6.  Cesarean section wound dehiscence. (a–c) Sagittal (a), coronal (b), and axial (c) fast spin-echo (FSE) T2-weighted MR images show a wide-open, hyperintense cesarean section wound (arrow) and an adjacent hematoma with heterogeneous signal intensity (arrowheads). (d) On an axial gadolinium-enhanced T1-weighted MR image, the hematoma shows no enhancement (arrowheads). Arrow indicates the endometrial cavity.

imaging has a high sensitivity and specificity for the diagnosis of dehiscence. At T2-weighted MR imaging, a normal cesarean section wound will appear as a linear hyperintense focus with or without a small hematoma, whereas a 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. Moreover, a true dehiscence is usually associated with a large hematoma or abscess. Contrast-enhanced MR images are useful in confirming the fullthickness defect as well as the hematoma (Fig 6) (21,22). Radiologists must also be able to differentiate cesarean section wound dehiscence from the more common bladder flap hematoma, which is located between the anterior wall of the uterus and the bladder wall (23).

The prevalence of bowel injury is similar with laparoscopic and open gynecologic surgery. The small bowel is more commonly injured during laparoscopic hysterectomy, whereas the rectum is at increased risk during vaginal hysterectomy (24,25). The prevalence of bowel injury is higher in patients with adhesions from previous surgery, radiation therapy, pelvic inflammatory disease, or endometriosis (Table 3). Further complications of bowel injury include perforation, peritonitis, abscess formation, bowel obstruction, and fistula formation (3–5). The presence of excess intraperitoneal air or persistent pneumoperitoneum after the first postoperative week is an indicator of bowel perforation. CT may demonstrate loculated fluid collections with air-fluid levels and extravasation of oral contrast material (Fig 7).

Bowel Perforation

Fistula

In gynecologic surgery, both the small bowel and the rectosigmoid colon are at risk for injury.

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 the body surface or to

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Figure 7.  Small bowel perforation in a patient who had undergone total abdominal hysterectomy 4 days earlier, a procedure that was complicated by pelvic adhesions. (a) Axial unenhanced CT scan demonstrates a pelvic collection with an air-fluid level (arrow). (b) Axial unenhanced CT scan shows the abscess collection (arrow) and extravasation of oral contrast material (arrowheads).

Figure 8.  Posthysterectomy enterocutaneous fistula in a patient with bowel injury at the time of surgery. (a) Axial unenhanced CT scan shows a cutaneous fistula (arrow). (b, c) Axial (b) and sagittal (c) gadolinium-enhanced T1-weighted MR images demonstrate communication of the small bowel (arrowheads) with the cutaneous fistula (arrow).

another hollow organ. Fistulas can be early as well as delayed complications following surgery, and they can be secondary to bowel or urinary

tract injury. The nature of a fistula is related to the type of malignancy or surgery and to any associated radiation therapy. The prevalence of fistulas is higher following radical hysterectomy and radiation therapy for cervical cancer (26). Fistulous connections may be vesicovaginal, rectovaginal, enterocutaneous (Fig 8), enterovesical, enteroenteral (Fig 9), enterovaginal (Fig 10), or ureterovaginal (27), with the most common being vesicovaginal and rectovaginal

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Figure 9.  Posthysterectomy sigmoid colon– small bowel fistula in a patient with bowel injury at the time of surgery. Follow-up fluoroscopic spot image obtained after the rectal administration of contrast material demonstrates a fistula (arrow) between the sigmoid colon (white arrowhead) and the small bowel (black arrowhead). Figure 10.  Posthysterectomy small bowel fistula. Fluoroscopic spot image from a small bowel follow-through study demonstrates a fistula (arrow) between the small bowel (white arrowhead) and the vagina (black arrowhead).

fistulas. Enterovesical fistulas involve the dome of the bladder, whereas vesicovaginal fistulas involve the posterior bladder wall. There are also reports of fistula between the uterus and bladder following cesarean section, manifesting with vaginal urine leakage, cyclic hematuria, and amenorrhea (Youssef syndrome) (28,29). The clinical presentation varies with the type of fistula. Women with fistula between urinary and genital tracts present with dribbling of urine from the vagina, whereas those with enterovesical fistula present with pneumaturia and dysuria. Diagnostic work-up includes conventional fluoroscopic barium studies, IVU, retrograde pyelography, and fistulography, as well as crosssectional imaging (CT and MR imaging). The appropriate imaging method depends on the anatomic location of the fistula. Cutaneous fistula to the gastrointestinal or genitourinary tract is better delineated with fluoroscopic fistulography than with cross-sectional imaging. Ureterovaginal fistulas are visualized with both IVU and CT urography. Vesicovaginal, rectovaginal, and enterovesical fistulas are well visualized at crosssectional imaging. Because of improved technique with faster imaging and better resolution, CT and MR imaging are replacing conventional

barium studies and IVU as the primary imaging methods for the evaluation of postsurgical fistulas. MR imaging is especially well suited for the diagnosis of vesicovaginal and rectovaginal fistulas owing to its superior soft-tissue contrast resolution. Axial thin-section CT scans with multiplanar reformatted images are helpful in the detection of fistulas and their morphologic features (30). MR imaging has an advantage in delineating complex fistulous tracts because of its multiplanar capability. T2-weighted MR images will demonstrate fistulas as hyperintense tracts with peripheral hypointense wall due to fibrosis and chronic inflammation. Gadoliniumenhanced images show enhancement of the inflammatory wall and improve detection of the fistulas (31).

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Figure 11.  Right ureteral injury in a patient who had undergone cesarean section. (a) Axial unenhanced CT scan shows an enlarged postpartum uterus (curved arrow) and a right pelvic hematoma with heterogeneous attenuation (arrowheads) encasing a right ureteral stent (straight arrow). (b) Axial unenhanced CT scan shows right hydronephrosis (arrowhead). (c) Cystogram demonstrates extravasation of contrast material (arrowheads) from the distal right ureter (straight arrow) and the ureteral stent (curved arrow).

In certain situations, multiple imaging methods may be required for diagnosis, preoperative evaluation, and surgical planning.

Urinary Tract Complications The prevalence of urinary tract injuries is higher following radical hysterectomy than after total abdominal hysterectomy for benign indications (32). Bladder laceration, which is usually recognized and corrected at primary surgery, is the most common injury (33,34). Predisposing factors include distortion of the pelvic anatomy by adhesions due to previous surgeries, radiation therapy, or pelvic inflammatory disease (Table

3) (32,35). The stage of the underlying malignancy, obesity, diabetes mellitus, and postoperative infection are other predisposing factors for urinary tract complications (34). The prevalence of ureteral injuries is much higher following radical hysterectomy with lymph node dissection for pelvic malignancy than after hysterectomy for benign disease. Such injuries may occur due to direct trauma during surgery or secondary to ischemia from stripping of the periureteral fascia. Bladder and ureteral injuries may heal without complications or lead to urinoma (Fig 11), ureteral

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Figures 12, 13.  (12) Left ureteral stricture in a patient who had undergone radical hysterectomy. Coronal CT urogram (a) and retrograde ureterogram (b) demonstrate a left distal ureteral stricture (arrow) and hydronephrosis. (13) Right ureteral injury in a patient who was undergoing laparoscopic hysterectomy and a retropubic (Burch) colposuspension. (a) Coronal CT urogram shows right hydronephrosis and hydroureter. (b) Coronal CT scan demonstrates a retracted distal right ureter with stricture (arrow). (c) Intraoperative retrograde ureterogram helps confirm stricture of the distal right ureter (arrow).

stricture and obstruction (Figs 12, 13), and ureterovaginal (Fig 14) or vesicovaginal fistula (27,32,36). IVU, cystography, retrograde pyelography, CT urography, and CT cystography are the preferred imaging methods for demonstrating ureteral and bladder injuries. CT has the advantage of demonstrating other associated intraabdominal processes and is replacing IVU

as the primary imaging method for evaluating ureterovesical injuries. The primary imaging sign of ureteral injury is ureteral obstruction with or without contrast material extravasation. Extraluminal extension of contrast material into the vagina confirms a ureterovaginal fistula and is better depicted with CT urography. Conventional cystography and CT cystography have a similar sensitivity for demonstrating active urine leak due to bladder injury (37,38).

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Figure 14.  Left ureterovaginal fistula in a patient who had undergone radical hysterectomy. The patient presented with pain and dribbling of fluid into the vagina. (a) Intravenous urogram of the abdomen and pelvis shows narrowing of the distal left ureter (arrow) and contrast material in the vagina (arrowhead). (b) Delayed intravenous urogram of the pelvis shows a fistula between the distal left ureter (arrow) and the contrast material–filled vagina (arrowheads).

Figure 15.  Omental infarction in a patient with acute abdominal pain who had undergone laparoscopic hysterectomy 5 days earlier. Axial (a) and coronal (b) contrast-enhanced CT scans show a heterogeneous fat-attenuation mass (arrowheads) with a central curvilinear hyperattenuating vein (arrow).

Omental Infarction Although most cases of omental infarction are idiopathic, a small fraction of cases have been associated with prior surgery. Omental infarction usually occurs in young or middle-aged adults, who typically present with acute lower abdominal pain. Its clinical manifestation mimics that of other causes of acute lower abdominal pain such as acute appendicitis and diverticulitis. Infarction commonly involves the right aspect of the omentum, since this is the most mobile segment of the omentum and the portion that is richest in

fat. CT features include (a) a triangular or oval area of heterogeneous fat attenuation, and (b) a mass in the right middle or lower abdomen, deep to the ventral abdominal wall, anterior to the transverse colon, and anteromedial to the ascending colon (Fig 15). A whorled pattern of concentric fat stranding has also been described. Its relatively large size and its location deep to the ventral abdominal wall help differentiate omental infarction from epiploic appendagitis. The former

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Figure 16.  Small bowel obstruction due to postsurgical adhesions in a patient who had undergone abdominal hysterectomy for fibroids 4 years earlier. (a) Coronal reformatted CT image demonstrates a dilated, fluid-filled small bowel. (b) Sagittal reformatted CT image shows adhesions between small bowel loops (arrow). (c) Sagittal reformatted CT image demonstrates small bowel adhesions to the presacral soft tissues in the pelvis (arrow).

disease entity initially has ill-defined margins and later develops a hyperattenuating rim similar to that seen in epiploic appendagitis. In contrast, epiploic appendagitis manifests as an oval, fingerlike fat-attenuation pericolic mass with surrounding fat stranding and is most commonly seen in proximity to the sigmoid colon in the left lower quadrant. Omental infarction is managed conservatively, and the radiologic diagnosis of this entity helps avoid unnecessary surgery (39,40).

Bowel Obstruction Although bowel obstruction can be an early complication, it is most often seen as a delayed complication secondary to adhesions. Small bowel obstruction is more common than colonic obstruction. The prevalence of bowel obstruction is higher following total abdominal hysterectomy and radical hysterectomy than after laparoscopically assisted supracervical hysterectomy or cesarean section (41–43). The

prevalence of bowel obstruction is also higher in patients who have a history of radiation therapy for malignancy (Table 3) (42). Bowel obstruction that is seen as an early complication in the immediate postoperative period is usually secondary to mass effect from a pelvic hematoma or inflammation and volvulus. CT is the primary imaging method for evaluation of suspected bowel obstruction. Multidetector CT with multiplanar reconstruction improves accuracy and confidence in identifying the transition zone and the cause of obstruction (Figs 16, 17) (44,45). Conventional barium studies of the small and large bowel are complementary to CT and are used to assess the severity of obstruction, which has an impact on treatment. Partial small bowel obstruction with the extension of contrast material beyond the transition point is treated conservatively with observation. There are several reports of water-soluble small bowel studies performed for the follow-up and conservative management of partial small bowel obstruction (46,47).

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Figure 17.  Large bowel obstruction in a patient with adhesions from omental resection who had undergone cytoreduction surgery for ovarian carcinoma. (a) Axial CT scan shows dilatation of the small bowel and proximal colon, along with the “whirl sign” (arrow), caused by twisting of the midtransverse colon around an adhesive band. (b) Coronal reformatted CT image shows narrowing and angulation of the midtransverse colon (arrow). (c) Spot image from a gastrografin enema examination helps confirm partial volvulus of the midtransverse colon (arrow).

Abdominal Wall Scar Endometriosis The most common site of extrapelvic endometriosis is the abdominal wall, where it is always associated with surgical scar. There are isolated reports of spontaneous abdominal wall endometriosis without surgical scar. Abdominal wall scar endometriosis is more common following cesarean section than after abdominal hysterectomy, with a prevalence of less than 1%. There is no association with prior endometriosis. Abdominal wall scar endometriosis is most commonly seen in the skin and subcutaneous tissues at the abdominal incision site, and less frequently in the rectus sheath and muscle. Patients usually present a few years after surgery with an abdominal mass at the incision site accompanied by

cyclic or noncyclic pain (48,49). A high degree of suspicion is necessary for diagnosis, since abdominal wall scar endometriosis may be mistaken for chronic hematoma, incisional hernia, suture granuloma, fibrosis, or desmoid tumor. US shows a nonspecific hypoechoic mass with variable cystic and solid components due to cyclic hemorrhage. Evaluation with Doppler US may show internal vascularity of the mass (Fig 18a, 18b) (50). MR imaging features are also nonspecific. Gadolinium-enhanced images demonstrate a T1-hypointense mass similar to the rectus muscle with variable T2 hyperintensity and enhancement (51). T1 hyperintensity within an abdominal wall

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Figure 18.  Abdominal wall scar endometriosis in a patient with a history of two prior cesarean sections. The patient presented with a ventral abdominal mass and cyclic pain. (a) US image shows a lobulated, heterogeneous midline mass of the ventral abdominal wall (arrowheads). (b) Color Doppler US image and spectral waveform show low-resistance arterial flow within the mass. (c–e) Axial FSE non-fat-saturated T2-weighted (c), fat-saturated T2-weighted (d), and fat-saturated T1-weighted (e) MR images show a lobulated mass (arrowheads) with hyperintense hemorrhagic contents and hypointense central fibrosis. (f) On an axial gadoliniumenhanced fat-saturated T1-weighted MR image, the mass shows only minimal enhancement.

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Figure 19.  Pelvic floor dysfunction in a patient with a remote history of hysterectomy who presented with chronic constipation and a bulging perineum. (a) Coronal FSE T2-weighted MR image shows thin and atrophic bilateral levator ani muscles (arrows). (b) MR defecogram reveals abnormal descent of the pelvic floor, with a cystocele (arrowhead), enterocele (straight arrow), and rectocele (curved arrow).

mass at the surgical scar due to subacute hemorrhagic blood products helps differentiate endometriosis from postsurgical fibrosis or desmoid tumor (Fig 18c–18f). Diagnosis is established with surgical excision and histopathologic analysis (48,49).

ani muscles. Coronal FSE T2-weighted MR images are useful for demonstrating atrophy, tears, and symmetry of the levator ani muscles. Normal levator ani muscles are arched upward, and loss of normal tone is depicted as inferior convexity.

Pelvic Floor Dysfunction

A lymphocele is an abnormal collection of lymphatic fluid that can occur following gynecologic surgery, especially in patients who have undergone resection of a large amount of lymphatic tissue. Hence, this finding is more common following radical hysterectomy and lymph node dissection for the treatment of cervical and endometrial carcinoma (55). A lymphatic vessel is susceptible to continuous leakage once it has been injured, due to the absence of platelets and a low concentration of clotting factors. Most lymphoceles are asymptomatic and resolve spontaneously without intervention. At US and CT, lymphoceles are seen as multiloculated cystic masses with thin septa (Fig 20). Large and symptomatic lymphoceles causing mass effect on adjacent vascular structures require surgical management or percutaneous catheter drainage with or without sclerotherapy (56,57).

Pelvic floor weakness is associated with abnormal descent of the pelvic floor upon straining, which can lead to a rectocele, cystocele, enterocele, or intussusception. The clinical presentation varies depending on the involved pelvic compartment. Patients may present with recurrent urinary tract infection, urinary incontinence, obstructed defecation or constipation, chronic pelvic pain, sexual dysfunction, or prolapse. Trauma to the pelvic floor musculature and nerves during pelvic surgery, especially total abdominal hysterectomy, is associated with pelvic floor weakness. This weakness is compounded by the postmenopausal state and loss of estrogen stimulation (52). Pelvic floor dysfunction can be well evaluated with dynamic MR imaging of the pelvis (Fig 19a) and, in selected cases, with conventional fluoroscopic defecography (Fig 19b) (53,54). MR imaging has the advantage of allowing evaluation of the morphologic features as well as the tone of the levator

Lymphocele

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Figure 20.  Lymphocele in a patient with dull pelvic pain who had undergone hysterectomy 2 years earlier. Transvaginal color Doppler US image of the pelvis demonstrates a multiloculated cystic mass with thin septa and no vascularity. These findings remained unchanged at follow-up US performed over the next 2 years.

Peritoneal Inclusion Cyst Peritoneal inclusion cysts occur almost exclusively in premenopausal women with a history of pelvic or abdominal surgery, trauma, pelvic inflammatory disease, or endometriosis. Failure of the abnormal peritoneum to absorb fluid from the functioning ovaries results in a loculated serous or hemorrhagic fluid collection around the ovary. Most patients with peritoneal inclusion cysts present with pelvic pain or a pelvic mass. US and CT demonstrate a uni- or multiloculated cystic adnexal mass, with the ovary located either in the center or at the periphery of the mass (Fig 21) (58,59). Demonstration of a normal ovary within this cystic mass is the key to differentiating peritoneal inclusion cyst from other cystic adnexal masses such as ovarian cyst, paraovarian cyst, and hydrosalpinx. Peritoneal inclusion cysts should be treated conservatively. Oral contraceptives and gonadotropinreleasing hormone analog therapy can be used to suppress ovulation and thus decrease ovarian fluid. Pain medications can be used to control pain, and transvaginal fluid aspiration can be performed for large collections (60,61).

Conclusions

Obstetric-gynecologic surgery is associated with several early and delayed complications. Radiologists with access to multiple imaging modalities can assist the surgeon in both diagnosis and management at this critical juncture.

Figure 21.  Peritoneal inclusion cyst in a patient with pelvic pain who had undergone laparoscopically assisted supracervical hysterectomy 6 years earlier. (a) Transvaginal color Doppler US image demonstrates a lobulated cystic mass with thin septa (arrowheads). (b) Sagittal FSE T2-weighted MR image of the pelvis demonstrates the septated mass (arrowheads) and a normal ovary (arrow).

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Teaching Points

May-June Issue 2010

Imaging of Complications Following Gynecologic Surgery Raj Mohan Paspulati, MD • Tejas A. Dalal, MD RadioGraphics 2010; 30:625–642 • Published online 10.1148/rg.303095129 • Content Codes:

Page 627 Vault hematoma is a common finding in the first week following hysterectomy and has no significant correlation with surgical technique or surgical blood loss. Although large hematomas are associated with febrile morbidity, most hematomas are small and self resolving (9–12). Page 630 Radiologists must also be able to differentiate cesarean section wound dehiscence from the more common bladder flap hematoma, which is located between the anterior wall of the uterus and the bladder wall (23). Page 633 MR imaging has an advantage in delineating complex fistulous tracts because of its multiplanar capability. T2-weighted MR images will demonstrate fistulas as hyperintense tracts with peripheral hypointense wall due to fibrosis and chronic inflammation. Gadolinium-enhanced images show enhancement of the inflammatory wall and improve detection of the fistulas (31). Page 637 A high degree of suspicion is necessary for diagnosis, since abdominal wall scar endometriosis may be mistaken for chronic hematoma, incisional hernia, suture granuloma, fibrosis, or desmoid tumor. Page 640 Demonstration of a normal ovary within this cystic mass is the key to differentiating peritoneal inclusion cyst from other cystic adnexal masses such as ovarian cyst, paraovarian cyst, and hydrosalpinx.