Mediquest - August '07 Edition

 

NON SURGICAL APPROACH TO GYNECOLOGICAL PATHOLOGY  

Prof S Devambigai MD DGO
Former Supdt. Govt R.S.R.M Lying in hospital
Dr.TNS.Sumathy, MB DGO, Consultants B.R.S.Hospital, Chennai

Introduction
In recent years, the Transcatheter and Percutaneous techniques of interventional radiology have been applied to the diseases of various organ systems, including the female pelvis. Through development of new procedures and refinement of standard techniques, the interventional radiologist can now offer many services to the obstetrician – gynaecologist. These include assistance in the treatment of vascular and nonvascular diseases.

From a vascular standpoint, substantial attention has been given recently to the nonsurgical treatment of uterine fibroids by uterine artery embolization and, to a lesser extents, to treating “Pelvic congestion syndrome” by ovarian vein embolization. Embolization was also used for many years to treat persistent postpartum hemorrhage and bleeding complications after surgery.

On the side of nonvascular interventions, fallopian tube recanalization and transvaginal drainage and biopsy are well-established procedures. More recently, percutaneous treatment of tuboovarian abscesses and uterine fluid collection has received some attention in the literature, in addition to stent placement for malignant cervical strictures.

Uterine Artery Embolization

Since Ravina reported their results in 1995, uterine artery embolization has received widespread attention as a nonsurgical alternative in the treatment of symptomatic uterine fibroids. The procedure involves selective catheterization of both uterine arteries, which are branches of the anterior division of the internal iliac artery, and embolization with a permanent agent, usually polyvinyl alcohol particles.

A more recent study by Goodwin et al [5] described a clinical success rate of 81%, with a low complication rate. Clinical success was defined as decrease in abnormal uterine bleeding or pelvic pain. Although successful pregnancies after the procedure have been reported anecdotally, the effect of embolization on fertility has yet to be studied.

Ovarian Vein Embolization

Pelvic congestion syndrome is a poorly understood condition in which incompetent valves in the ovarian veins result in pelvic varicosities. Symptoms include dyspareunia, pelvic pain, and fullness or heaviness that may be exacerbated in the upright position or by pregnancy. Since 1994, there have been reports of radiologists successfully treating this condition with embolization of the ovarian veins [6]. This treatment is accomplished with selective catheterization and coil embolization. Technical success rates range from 88.9% [7] to 96.7% [8]. Clinical success rates vary. Capasso et. al.[7] reported variable symptomatic relief in 73.7% and complete response in 57.9%, with an average follow-up of 15.4 months. Cordts et. al. [8] reported immediate relief in 88.9% of patients and 40-100% relief at 13.4-month mean follow-up in 82% of patients.

Embolization for Postpartum and Post surgical Bleeding

Diagnostic angiography with transcatheter embolotherapy has become a vital tool in treating postpartum hemorrhage and persistent bleeding after gynecologic surgery. Since late 1970's, artery embolization for postpartum hemorrhage was reported in numerous small series. In a review of the literature, Vedantham et. al. [9] reported a 97% success rate with a 6-7% complication rate. This rate includes 16 of 18 successful embolizations after cesarean delivery. The same researchers also reported excellent results in 19 patients who underwent transcatheter arterial embolization for persistent bleeding after gynecologic surgery.

The technique is basically the same as with other embolization procedures. Diagnostic angiography is initially performed with follow-up embolization of abnormal arteries that may show extravasation abnormal arteriovenous communication, truncation, or spam.

Fallopian Tube Recanalization

Well –described in the radiology literature, fallopian tube recanalization has become an accepted technique in treating infertile women with proximal tubal obstruction [7]. Techniques vary, but most involve hysterosalpingography followed by selective salpingography. If this treatment fails to open the tube, guidwires or microcaheters are passed into the tube in an attempt to recanalize the occlusion. Pregnancy rates are difficult to determine given the multifactorial causes of infertility but are reported to be in the 30% range [1].

Transvaginal Biopsy or Drainage Procedure

The transvaginal route, in conjunction with sonographic guidance, provides a safe and effective means of draining fluid collection in the deep pelvis and of sampling solid masses for diagnosis. High success rates and low complication rates have been reported for transvaginal drainage procedures. The Procedure is usually performed with an endovaginal sonography transducer to guide initial needle placement. Both seldinger and trocar techniques have been used, in conjuction with fluoroscopy, to guide catheter placement.

Zanetta et. al. [11] studied 101 transvaginal sonographically guided punctures for diagnosis. This study included 46 cytologic aspirates and 55 biopsies. The researchers found neither moderate nor severe complications, and the specificity rate was 100%.

Drainage of Tuboovarian Abscess

The standard treatment for tuboovarian abscess is antibiotic therapy and surgery in patients resistant to antibiotic treatment. Ample literature supports percutaneous drainage an alternative to surgery or in patients not responding to more conservative measures [3]. Casola et. al. [2] found good clinical responses in 94% of patients, 81 % of whom avoided surgery because they were treated percutaneously. The procedure may be performed from a transvaginal, transgluteal, or transabdominal approach depending on patient and operator performance and the safest access route to the abscess.
Percutaneous Drainage of Uterine Collections, with or Without Cervical Stent Placement. Percutaneous drainage of uterine fluid collection can be useful and effective procedure in appropriate clinical situations. Occasionally, drainage may need to be supplemented by cervical stent placement. This procedure was recently reported in the literature by Gooding et al.[3] in select patients with malignant cervical strictures and proved to be effective in providing symptomatic relief and improving quality of life. The technique involves placement of self-expanding metallic stents after percutaneous uterine drainage.

Neurolysis of Pain in Cancer cervix

Diagnosis of cancer incites anxiety, fear of death, fear of body deterioration, fear of insufficient treatment, fear of pain , fear of social isolation No of pain treatment procedures are available like Thalamotomy mesenchephalotomy ,cordotomy intra thecal injection of drugs etc but CT guided neurolysis of the sacral sympathetic fibres through which pain is transmitted offers a good scope of abolition of the

Pain and immediate relief to the individual.

Conclusion

The Non surgical approaches can provide many valuable services to the obstetrician-gynaecologist in both vascular and nonvascular interventional procedures. The procedures are usually elective but at times it is intervened in an emergency when bleeding complications are reported.

References

Hovsepian DM, Bonn J, Eschelman DJ, Shapiro MJ, Sullivan KL, Gardiner GA. Fallopian tube recanalization in an unrestricted patient population. Radiology 1994; 190:137-140[Abstracted]

Casola G, vanSonnenberg E, D'Agostino HB, Parker CP, Varney RR, Smith D. Percutaneous drainage of tubo-ovarian abscesses. Radiology 1992;182:399-402[Abstract]

Gooding JM, D'Agostino HB, plaxe SC. Transcervical metallic stents for drainage of uterine collections. J Vasc Interv Radiology 1999; 10:629-633[Medline]

Ravina JH, Herbreteau D, Ciraru-Vigneron N, et al. Arterial embolization to treat uterine myomata. Lancet 1995;346:671-672[Medline]

Goodwin Sc, McLucas B, Lee M, et al. Uterine artery embolization in the treatment of uterine leiomyomata midterm results. J Vasc Interv Radiol 1999; 10:1159-1165[Abstract]

Sichlau MJ, Yao JST, Vogelzang RL. Transcatheter embolotherapy for the treatment of pelvic congestion syndrome. Obstet Gynecol 1994;83:892-896[Abstract]

Capasso P, Simons C, Trotteur G, Dondeliger Rf, Henroteaux D, Gaspard U. Treatment of symptomatic pelvic varices by ovarian vein embolization. Cardiovasc Intervent Radiol 1997;20:107-111[Medline]

Cordts PR, Eclavea A, Buckley Pj, et al. Pelvic congestion syndrome:early clinical results after transcatheter ovarian vein embolization. J Vasc Surg 1998; 28:862- 868[Medline]

Vedantham S, Goodwin SC, McLucas B, Mohr G. Uterine artery embo9lization: an underused method of controlling pelvic hemorrhage . Am J Obstent Gynecol 1997;176:938-948[Medline]\VanSonnenberg E, D'Agostino HB , Casola G, Goodacre BW, Sanchez RB, Taylor B. Ultrasound-guided transvaginal drainage of pelvic abscesses and fluid collections. Radiology 1991; 181:53-56[Abstract]

Zanetta G, Brenna A, Pittelli M, Lissoni A, Tri D, Riotta S. Transvaginal ultrasound – guided fine needle sampling of deep cancer recurrences in the pelvis:Usefulness and limitations. Gynecol Oncol 1994;54:59-63[Medline]