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 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 6  |  Issue : 3  |  Page : 165-169

Ultrasound-guided percutaneous drainage of pyometra in cervical cancer patients on radiotherapy


Department of Obstetrics and Gynecology, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria

Date of Web Publication17-Mar-2017

Correspondence Address:
J C Ekweani
Department of Obstetrics and Gynecology, Ahmadu Bello University Teaching Hospital, Zaria
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2278-9596.202374

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  Abstract 

Background: Pyometra is a gynecological emergency in cervical cancer patients receiving radiotherapy because it can be complicated by perforation, sepsis, and death. It can delay initiation and continuation of treatment. For certain select patients who may not be able to undergo drainage of the lesion under anesthesia via cervical dilatation and drainage, ultrasound-guided percutaneous drainage is a good alternative. We report the successes recorded in using an alternative route for pyometra drainage in cervical cancer patients on radiotherapy when the conventional examination under anesthesia and cervical drainage was not possible.
Patients and Methods: Following institutional ethical approval, a prospective study was conducted from January 2014 to January 2016 on selected patients referred from the radio-oncology unit of Ahmadu Bello University Teaching Hospital, Zaria to the Gynecologic Oncology Unit with pyometra complicating advanced cervical cancer on radiotherapy. Initial attempts at cervical dilatation and drainage under anesthesia were unsuccessful necessitating this approach of percutaneous drainage under ultrasound guidance with mild sedation after obtaining informed consent.
Results: Six patients were managed with a mean age of 58.5 years, who were diagnosed with advanced cervical cancers clinical stages 2B to 3A on radiotherapy. An average of 200 ml of pus was drained, and culture revealed mixed infections with predominant anaerobes strongly sensitive to metronidazole. There was recurrence in 1 case (16.7%) after 1 month of follow-up requiring a repeat procedure.
Conclusion: The procedure is relatively cheap, safe, and effective in selected patients.

Keywords: Cervical cancer, percutaneous, pyometra, radiotherapy, ultrasound


How to cite this article:
Ekweani J C, Oguntayo A O, Kolawole A, Zayyan M S. Ultrasound-guided percutaneous drainage of pyometra in cervical cancer patients on radiotherapy. Arch Int Surg 2016;6:165-9

How to cite this URL:
Ekweani J C, Oguntayo A O, Kolawole A, Zayyan M S. Ultrasound-guided percutaneous drainage of pyometra in cervical cancer patients on radiotherapy. Arch Int Surg [serial online] 2016 [cited 2017 Dec 11];6:165-9. Available from: http://www.archintsurg.org/text.asp?2016/6/3/165/202374




  Introduction Top


Pyometra is an uncommon gynecological condition defined as an abnormal accumulation of purulent fluid in the endometrial cavity of the uterus.[1] This can result from congenital, infectious, traumatic, malignant, or postradiation conditions with consequent tumor-hypoxia, affecting the endometrial cavity or the uterine outflow tract, hence described by an author as “the obstructed uterus.”[2],[3],[4] The incidence of pyometra ranges 0.01–0.5% in the premenopausal women and up to 15.6% in the elderly.[5] It can complicate as much as 22.2% of malignant conditions of the female genital tract.[6] In the peri and postmenopausal women, it is often associated with malignant conditions of the endometrium and/or that of the cervix.[7] However, there can be superimposed infection. A case was reported in the postpartum period sequel to severe endometritis.[1]

Pyometra is a gynecological emergency because it could result in perforation, peritonitis, sepsis, and death.[5] Management is multidisciplinary. Hence, a high index of suspicion is required as diagnosis requires a meticulous history taking, a thorough physical examination, and investigations. Investigations often include ultrasound, computerized tomography (CT) scans, and magnetic resonance imaging (MRI).[8],[9] Pyometra in patients being managed for cervical cancer could cause delay in the initiation and continuation of radiotherapy as the presence of purulent and necrotic debris in the uterine cavity could facilitate the spread of infection and worsen hypoxia. Therefore, there is a need to promptly drain via the fastest and most practicable route.[3] Traditionally, examination under anesthesia with cervical dilatation and drainage is done, however, in certain conditions in which either the genital tract anatomy has been severely distorted by the disease or the radiation treatment, or the patient is unfit to withstand the stress of anesthesia and surgery, a less invasive technique may be required.[3] Such methods have been described in the past and have been used successfully. They include ultrasound-guided drainage per rectum or percutaneously.[10],[11] Others have used other imaging modalities such as computerized tomography (CT) and magnetic resonance imaging (MRI) techniques.[12] These have also been used successfully in draining pus-collections in other parts of the body including the liver, pancreas, head and neck regions, musculoskeletal, pleura, and the peritoneum.[13]

Ultrasonography techniques have the advantage of being affordable, radiation free, safe, easy to operate, effective. Over the past 20 years, image-guided techniques such as this have evolved from revolutionary to routine, and the procedure is gradually replacing open surgical drainage techniques in difficult cases.[8],[14]

The aim of the study was to report the successes recorded in using an alternative route for pyometra drainage in cervical cancer patients on radiotherapy when the conventional examination under anesthesia and cervical drainage was not possible.


  Patients and Methods Top


Following institutional ethical approval, a prospective study was conducted from January 2014 to January 2016 at the gynecologic oncology unit of the Obstetrics and Gynecology department of Ahmadu Bello University, Zaria, which purposively recruited patients referred from the radio-oncology department of the same hospital. The patients were diagnosed with histologically-confirmed squamous cell carcinoma of the cervix and were on radiotherapy. They were noted during the course of their radiotherapy treatment to have pyometra diagnosed by ultrasonography and/or CT scan. The traditional examination under anesthesia, dilatation, and curettage of the cervix was unsuccessful in these patients because pelvic anatomy was severely distorted by the radiotherapy and disease process. Inclusion criteria included cervical cancer patients diagnosed with pyometra while on radiotherapy, failure in achieving drainage with conventional examination under anesthesia and cervical drainage, and those who were unfit to withstand anesthesia. Exclusion criteria included those with sepsis on the abdomen and those who denied consent.

Patient preparation and work-up

Patients who met the inclusion criteria underwent investigations which included a complete blood count, clotting profile, serum urea, electrolyte, and creatinine. The patients were appropriately counseled on the intended procedure and a written consent was obtained. The suprapubic region was then shaved. The setting for the procedure was the mini theater, which had a mobile ultrasound machine. The patient was asked to empty her bladder and a gentle bimanual examination was done to determine the uterine size and its mobility. The patient was then placed in a supine position and the suprapubic region was cleaned with suitable antiseptics and draped with sterile drapes. The choice of analgesia was mild sedation using intramuscular pentazocine at a dose of 1 mg/kg body weight not exceeding 60 mg per dose. Local infiltration with 0.5% lignocaine was additionally done at the intended needle-entry area. The patient was also given a stat dose of intravenous Ceftriaxone 1 g stat.

Equipment

The materials/equipment assembled included size 16 G intravenous cannula and trocar, sterile gauze and methylated spirit, water for injection, 50 ml syringe, sample bottle with label, kidney dish, and a mobile diagnostic ultrasound machine by Toshiba® with curvilinear probe at a frequency 3.75 MHz manufactured in September, 2001 in Japan (Serial Number C1594792) and ultrasound gel.

Procedure

With an assistant, following mild application of the gel, a preliminary scout abdominopelvic scan was done locating the uterus noting the volume of its content, the ovaries and noting the presence of the intervening bowel, which can be seen as hollow structures with visible peristalsis. The presence or absence of ascites or any other mass was noted and documented. The purulent collection in the uterus was seen as a dark sonolucent area surrounded by the uterine wall which may contain some patchy opacities that can indicate some debris. The transducer was further manipulated to determine the puncture site, angulation, depth, and margin for error.

The needle was mounted on the 50 ml syringe and then used to puncture a bowel- and bladder-free area on the anterior abdominal wall under real-time ultrasound-guidance and then directed into the uterine cavity. This was possible as the sono-opaque needle was visible through the ultrasound scan as it traversed the anterior abdominal wall layers into the pus in the uterine cavity. Pus was progressively aspirated and emptied into the kidney dish with an aliquot taken for microscopy, culture, and sensitivity tests. This was done until the uterine content was less than 5 ml. In the event of blockage of the needle with debris, the syringe was disconnected from the needle and the needle was flushed with approximately 10 ml of distilled water before the procedure was continued. The needle was withdrawn and a repeat scan was done to rule out evidence of free fluid collection, which may signal peritoneal spillage of uterine contents. The vital signs of the patient were checked for stability.

The procedure was well-documented on operation notes for record keeping, and relevant samples sent to the laboratory. The patient was cleaned and allowed to recover fully from the procedure before discharge on broad spectrum antibiotics and analgesics. The antibiotics regimen contained anti-anaerobes such as metronidazole.

At discharge, the patient was instructed to report immediately to the hospital should symptoms suggestive of peritonitis develop such as vomiting, constipation, fever, and abdominal distension. This will be managed according to local protocols.

The following precautions were taken to minimize the risk of complications

  • Care was taken to minimize the number of puncture/needle entry points to less than two. Higher numbers of puncture sites may increase the risk of peritoneal spillage and infection
  • Antibiotics was given at the commencement of the procedure and afterwards to minimize risk of infection
  • Meticulous puncture site preparation with shaving, antiseptic cleaning, draping, and use of sterile equipment
  • Good analgesia made the patient calm and cooperative.


Follow-up

This was usually after a week where a repeat ultrasound scan was done at follow-up to reassess the uterus and its content. This period additionally coincided with their subsequent appointment at the radio-oncology unit.

Potential complications of the procedure included peritonitis following spillage of pus into the peritoneal cavity, bowel perforation, bladder perforation, and inadvertent entry into major vessels.


  Results Top


Six patients with pyometra were managed with this method during the study period. The pyometra developed following radiotherapy for cervical cancer. The patients' ages ranged from 52 to 65 years, with a mean of 58.5 years. The average volume of the purulent fluid aspirated was 200 ml (range: 40–560 ml) and the average uterine size was 16 weeks. The culture yielded mixed infections in all the cases with Bacteroides reported in all but one of the cases (83.3%), which were strongly sensitive to metronidazole.

There were no complications following the procedure, and the procedure was well tolerated in all the patients. There was one case of recurrence (16.7%) after 1 month of follow up requiring a repeat procedure. Patients' satisfaction with the procedure was good.

[Table 1] summarizes the most important features.
Table 1: A summary of patient/disease characteristics and procedure outcome

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It was noted that, in the first four patients, though their uterine sizes were in the same range, the volume of aspirates varied widely. This was because, in some of the patients, considerable uterine wall thickening was observed. Furthermore, a solitary fibroid measuring 6 cm × 6 cm was found located at the fundus in the third patient. In the first patient, none of these was observed.


  Discussion Top


Sonographically-guided percutaneous drainage of pyometra was done for 6 patients with advanced cancer of the cervix on radiotherapy with success. It is an effective means of evacuating the uterus when the patients are not able to undergo cervical dilatation under anesthesia either because their genital anatomy is distorted whereby the surgery may pose greater risk.[3] It is also effective when they are not fit for anesthesia or able to withstand more aggressive surgeries. It has the advantage of being cheap, effective, and safe because the risk of ionizing radiation is very low or nonexistent.[8] However, it may be limited in that it may not be possible to leave a drain after the procedure for continuous drainage, and hence the possibility of recurrence, as was seen in one case. Serious complications were averted because there was careful patient selection, meticulous patient preparation, counselling, and the procedure was done by experienced personnel. This minimized trauma to contiguous organs.

Though this may not be the recommended standard of care for patients who are diagnosed with this ailment, this procedure is relevant in contemporary practice among patients for whom carrying out the standard have either failed or may not be practicable. This was exemplified in the patients managed in this series whose pelvic anatomies were considerably altered by the disease process and radiotherapy.

This procedure was generally well-tolerated with less pain and bleeding. Patients' satisfaction was also good. The cost saved by not doing a theatre procedure. Also, there is the additional benefit of avoiding the waiting time to get on the operation list.

The importance of sending the aspirated pus for microbiological examination cannot be overemphasized because the results will guide the choice of antibiotics to be used. As can be seen from this report and from previous studies, anaerobes formed a major component of the microbial flora in this entity.[4] This required the use of such potent antianaerobe drugs such as metronidazole among others to control the infection and minimize the risk of recurrence. This study also showed that it is possible to have a sterile culture, which can be possible in an environment where people abuse antibiotics or there are inappropriate transport/culture media for microbiological examinations. Hence, these studies should guide the use of broad spectrum antibiotics routinely after such procedures.

The role of the radiologist needs to emphasized as well as their services may be required initially during the learning process of this procedure. Though interventional radiologists are scarce in the environment where we practice. There is the need for training and retraining of both gynecologists and radiologists in life-saving procedures such as this. However, the ball still rests in the court of the gynecologist as most ultrasound scans of this nature are done by them. Hence, the onus rests on them to further investigate this procedure among these kind of patients in other centers as cancer of the cervix with similar sequelae that ensue are common findings in gynecological practice in our environment.


  Conclusion Top


The abovementioned procedure was a cheap, safe, and effective means of evacuating pyometra. The gynecologist who is directly involved in genital cancer management needs to be equipped with this skill in the event of emergencies of this nature, requiring prompt evacuation in selected patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Deutchman ME, Hartman KJ. Postpartum pyometra: A case report. J Fam Pract 1993;36:449-53.  Back to cited text no. 1
    
2.
Scott Jr W, Rosenshein N, Siegelman SS, Sanders R. The obstructed uterus. Radiology 1981;141:767-70.  Back to cited text no. 2
    
3.
Babarinsa I, Campbell O, Adewole I. Pyometra complicating cancer of the cervix. Int J Gynecol Obstet 1999;64:75-6.  Back to cited text no. 3
    
4.
Muram D, Drouin P, Thompson F, Oxorn H. Pyometra. Can Med Assoc J 1981;125:589.  Back to cited text no. 4
    
5.
Shapey I, Nasser T, Dickens P, Haldar M, Solkar M. Spontaneously perforated pyometra: An unusual cause of acute abdomen and pneumoperitoneum. Ann R Coll Surg Eng 2012;94:e15-e7.  Back to cited text no. 5
    
6.
Chan LY, Lau TK, Wong SF, Yuen PM. Pyometra. What is its clinical significance? J Reprod Med 2001;46:952-6.  Back to cited text no. 6
    
7.
Chan LY-s, Yu V, Ho L, Lok Y, Hui S. Spontaneous uterine perforation of pyometra. A report of three cases. J Reprod Med 2000;45:857-60.  Back to cited text no. 7
    
8.
Samett EJ, Cho K. Percutaneous Abscess Drainage. 2012.  Back to cited text no. 8
    
9.
Lang E, Baharamipour P, Patel Y. Interventional Radiologic Procedures in the Management of Inflammatory and Neoplastic Conditions in the Female Pelvis. Radiology of the Female Pelvic Organs. Springer; 1998. p. 215-39.  Back to cited text no. 9
    
10.
Algin O, Erdogan C, Kilic N. Ultrasound-guided percutaneous drainage of neonatal pyometrocolpos under local anesthesia. Cardiovasc Intervent Radiol 2011;34:271-6.  Back to cited text no. 10
    
11.
Yik-Si Chan L, Wing-Kit Lo K, Cheung TH. Radiographic appearance of pyometra on computer tomography mimicking pelvic abscess. Acta Obstet Gynecol Scand 2006;85:1144-5.  Back to cited text no. 11
    
12.
Kakizawa H, Toyota N, Hieda M, Hirai N, Tachikake T, Matsuura N, et al. Gynecologic abscess: CT-guided percutaneous drainage. Hiroshima J Med Sci 2006;55:97-100.  Back to cited text no. 12
    
13.
Biron VL, Kurien G, Dziegielewski P, Barber B, Seikaly H. Surgical vs ultrasound-guided drainage of deep neck space abscesses: A randomized controlled trial: Surgical vs ultrasound drainage. J Otolaryngol Head Neck Surg 2013;42:1.  Back to cited text no. 13
    
14.
Shaw W, Hawkins J. Shaw's textbook of operative gynaecology. Setchell ME, Hawkins j, editors. 6th ed. Hudson CN, India: Elsevier; 2009. 12 p.  Back to cited text no. 14
    



 
 
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Introduction
Patients and Methods
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