HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Full Text Full Text (PDF) CME Test (opens in a new window) Submit a response Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Harisinghani, M. G. Articles by Mueller, P. R. Search for Related Content PubMed PubMed Citation Articles by Harisinghani, M. G. Articles by Mueller, P. R. Related Collections Vascular and/or Interventional Radiology Computed Tomography Genitourinary Radiology

CT-guided Transgluteal Drainage of Deep Pelvic Abscesses: Indications, Technique, Procedure-related Complications, and Clinical Outcome¹

¹ From the Department of Radiology, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114. Recipient of a Certificate of Merit award for an education exhibit at the 2001 RSNA scientific assembly. Received February 28, 2002; revision requested April 5 and received June 5; accepted June 10. Address correspondence to M.G.H. (e-mail: mharisinghani@partners.org).

View larger version (150K): [in a new window]   Figure 1.  Deep pelvic abscess due to diverticulitis. CT scan shows a needle placed in a pelvic abscess (arrow). An anterior abdominal approach was not possible due to the interposed intestine and bladder.

View larger version (100K): [in a new window]   Figure 2.  Drawing of the pelvis (midsagittal view) shows the anatomy of the greater sciatic foramen. 1 = sacral promontory, 2 = greater sciatic foramen, 3 = sacrospinous ligament, 4 = sacrotuberous ligament, 5 = lesser sciatic foramen, 6 = ischial tuberosity.

View larger version (71K): [in a new window]   Figure 3.  Drawing of the pelvis (posteroinferior view) shows the piriformis muscle exiting the greater sciatic foramen. 1 = piriformis muscle, 2 = ischial spine, 3 = obturator internus muscle, 4 = coccygeus muscle, 5 = levator ani muscle, arrow = pudendal nerve.

View larger version (115K): [in a new window]   Figure 4.  Drawing of the pelvis (midsagittal view) shows the relationship of the sacral plexus (4) and gluteal arteries to the piriformis muscle (1). 2 = coccygeus muscle, 3 = sacrotuberous ligament, straight solid arrow = superior gluteal artery, curved arrow = inferior gluteal artery, open arrow = internal iliac artery.

View larger version (79K): [in a new window]   Figure 5.  Drawing of the pelvis (anterior view) shows the sacrospinous ligament and its relation to the bony pelvis. 1 = iliac fossa, 2 = greater sciatic foramen, 3 = ischial spine, 4 = sacrospinous ligament, 5 = sacrotuberous ligament, 6 = lesser sciatic foramen.

View larger version (155K): [in a new window]   Figure 6.  CT scan shows the piriformis muscle (straight solid arrow), which underlies the gluteus maximus muscle and crosses the center of the greater sciatic foramen. Anterior to the piriformis muscle lie the inferior gluteal vessels (curved arrow). The sciatic nerve (open arrow) is seen along the anterolateral aspect of the piriformis muscle. Also identified is a deep pelvic abscess (arrowhead) and ascites.

View larger version (153K): [in a new window]   Figure 7.  CT scan obtained 1.5 cm inferior to Figure 6 in the same patient. The sacrospinous ligament (solid arrow) forms the inferior margin of the greater sciatic foramen. Posterolateral to the ligament and adjoining the acetabulum is the sciatic nerve (open arrow). The presacral abscess (arrowhead) is again seen.

View larger version (148K): [in a new window]   Figure 8.  Optimal access for transgluteal drainage in a patient with a deep pelvic abscess due to diverticulitis. CT scan shows a catheter inserted through the sacrospinous ligament (arrow) with an infrapiriformis approach and as close to the sacrum as possible, thus avoiding the sciatic nerve and gluteal vessels.

View larger version (170K): [in a new window]   Figure 9.  Postsurgical pelvic abscess. The preferred sacrospinous approach could not be used due to the overlying rectum. CT scan shows a more cephalic approach through the piriformis muscle (straight arrow). Keeping the approach medial and as close to the sacrum as possible is important to avoid injury to the sciatic nerve (curved arrow).

View larger version (157K): [in a new window]   Figure 10.  Transgluteal drainage of a postsurgical presacral abscess. CT scan shows intraluminal contrast material from an earlier diagnostic study within the intestine (curved arrow); the contrast material allows the intestine to be distinguished from the abscess (straight arrow). Without this contrast material, it would be difficult to differentiate the bowel loop from the abscess cavity.

View larger version (137K): [in a new window]   Figure 11a.  Pelvic abscess due to diverticulitis drained with the tandem-trocar technique. (a) Initial localizing CT scan shows a deep-seated pelvic fluid collection (arrow). (b) CT scan shows a 20-gauge needle advanced into the abscess cavity by using an infrapiriformis approach. (c) CT scan shows a catheter, which was introduced in tandem with the needle; the self-retaining pigtail tip is in the center of the abscess cavity. The cavity has been successfully drained, with the cavity collapsing around the catheter tip.

View larger version (148K): [in a new window]   Figure 11b.  Pelvic abscess due to diverticulitis drained with the tandem-trocar technique. (a) Initial localizing CT scan shows a deep-seated pelvic fluid collection (arrow). (b) CT scan shows a 20-gauge needle advanced into the abscess cavity by using an infrapiriformis approach. (c) CT scan shows a catheter, which was introduced in tandem with the needle; the self-retaining pigtail tip is in the center of the abscess cavity. The cavity has been successfully drained, with the cavity collapsing around the catheter tip.

View larger version (156K): [in a new window]   Figure 11c.  Pelvic abscess due to diverticulitis drained with the tandem-trocar technique. (a) Initial localizing CT scan shows a deep-seated pelvic fluid collection (arrow). (b) CT scan shows a 20-gauge needle advanced into the abscess cavity by using an infrapiriformis approach. (c) CT scan shows a catheter, which was introduced in tandem with the needle; the self-retaining pigtail tip is in the center of the abscess cavity. The cavity has been successfully drained, with the cavity collapsing around the catheter tip.

View larger version (134K): [in a new window]   Figure 12a.  Postsurgical pelvis abscess drained with the Seldinger technique. (a) Localizing CT scan shows a large air-containing pelvic abscess (arrows). Optimal drainage requires a catheter with multiple side holes coiled within the cavity. (b) CT scan shows an 18-gauge needle (arrow) advanced into the abscess cavity with an infrapiriformis approach. (c) CT scan shows a 0.038-inch guide wire (arrows) advanced over the outer sheath into the abscess. (d) CT scan shows a 12-F catheter, which was advanced over the wire into the abscess. All of the side holes are within the cavity, thus providing a large surface area for drainage.

View larger version (132K): [in a new window]   Figure 12b.  Postsurgical pelvis abscess drained with the Seldinger technique. (a) Localizing CT scan shows a large air-containing pelvic abscess (arrows). Optimal drainage requires a catheter with multiple side holes coiled within the cavity. (b) CT scan shows an 18-gauge needle (arrow) advanced into the abscess cavity with an infrapiriformis approach. (c) CT scan shows a 0.038-inch guide wire (arrows) advanced over the outer sheath into the abscess. (d) CT scan shows a 12-F catheter, which was advanced over the wire into the abscess. All of the side holes are within the cavity, thus providing a large surface area for drainage.

View larger version (154K): [in a new window]   Figure 12c.  Postsurgical pelvis abscess drained with the Seldinger technique. (a) Localizing CT scan shows a large air-containing pelvic abscess (arrows). Optimal drainage requires a catheter with multiple side holes coiled within the cavity. (b) CT scan shows an 18-gauge needle (arrow) advanced into the abscess cavity with an infrapiriformis approach. (c) CT scan shows a 0.038-inch guide wire (arrows) advanced over the outer sheath into the abscess. (d) CT scan shows a 12-F catheter, which was advanced over the wire into the abscess. All of the side holes are within the cavity, thus providing a large surface area for drainage.

View larger version (155K): [in a new window]   Figure 12d.  Postsurgical pelvis abscess drained with the Seldinger technique. (a) Localizing CT scan shows a large air-containing pelvic abscess (arrows). Optimal drainage requires a catheter with multiple side holes coiled within the cavity. (b) CT scan shows an 18-gauge needle (arrow) advanced into the abscess cavity with an infrapiriformis approach. (c) CT scan shows a 0.038-inch guide wire (arrows) advanced over the outer sheath into the abscess. (d) CT scan shows a 12-F catheter, which was advanced over the wire into the abscess. All of the side holes are within the cavity, thus providing a large surface area for drainage.

View larger version (175K): [in a new window]   Figure 13.  Pelvic hematoma after splenectomy. CT scan shows transgluteal needle aspiration, which was performed to ascertain the presence of infection. Immediate performance of a Gram stain did not reveal infection; hence, the decision to stop at needle aspiration was made.

View larger version (146K): [in a new window]   Figure 14.  Hematoma of the pelvic side wall after resection of a sacral chordoma. CT scan shows transgluteal needle aspiration. The aspirate showed no evidence of infection; hence, a catheter was not placed. A follow-up study showed resolution of the hematoma.

View larger version (151K): [in a new window]   Figure 15a.  Central pelvic abscess in a patient with Crohn disease. (a) Initial diagnostic CT scan shows a central pelvic abscess cavity (straight solid arrow) with an adjoining thickened bowel loop (curved arrow) and the appendix (open arrow). (b) Localizing CT scan obtained for an attempted anterior approach shows no clear path devoid of bowel loops (straight arrows) leading to the abscess (curved arrow). Posteriorly, there is also no access due to the bony pelvis. (c) CT scan obtained after placing the patient in the prone position and angling the CT gantry shows that an inferior-to-superior route is available for draining the cavity. Cursors indicate the path of the needle and catheter. (d) CT scan shows successful deployment of a catheter in the abscess cavity. (e) Postdrainage CT scan obtained a few days later shows a well-drained abscess around the catheter tip (arrow).

View larger version (159K): [in a new window]   Figure 15b.  Central pelvic abscess in a patient with Crohn disease. (a) Initial diagnostic CT scan shows a central pelvic abscess cavity (straight solid arrow) with an adjoining thickened bowel loop (curved arrow) and the appendix (open arrow). (b) Localizing CT scan obtained for an attempted anterior approach shows no clear path devoid of bowel loops (straight arrows) leading to the abscess (curved arrow). Posteriorly, there is also no access due to the bony pelvis. (c) CT scan obtained after placing the patient in the prone position and angling the CT gantry shows that an inferior-to-superior route is available for draining the cavity. Cursors indicate the path of the needle and catheter. (d) CT scan shows successful deployment of a catheter in the abscess cavity. (e) Postdrainage CT scan obtained a few days later shows a well-drained abscess around the catheter tip (arrow).

View larger version (165K): [in a new window]   Figure 15c.  Central pelvic abscess in a patient with Crohn disease. (a) Initial diagnostic CT scan shows a central pelvic abscess cavity (straight solid arrow) with an adjoining thickened bowel loop (curved arrow) and the appendix (open arrow). (b) Localizing CT scan obtained for an attempted anterior approach shows no clear path devoid of bowel loops (straight arrows) leading to the abscess (curved arrow). Posteriorly, there is also no access due to the bony pelvis. (c) CT scan obtained after placing the patient in the prone position and angling the CT gantry shows that an inferior-to-superior route is available for draining the cavity. Cursors indicate the path of the needle and catheter. (d) CT scan shows successful deployment of a catheter in the abscess cavity. (e) Postdrainage CT scan obtained a few days later shows a well-drained abscess around the catheter tip (arrow).

View larger version (170K): [in a new window]   Figure 15d.  Central pelvic abscess in a patient with Crohn disease. (a) Initial diagnostic CT scan shows a central pelvic abscess cavity (straight solid arrow) with an adjoining thickened bowel loop (curved arrow) and the appendix (open arrow). (b) Localizing CT scan obtained for an attempted anterior approach shows no clear path devoid of bowel loops (straight arrows) leading to the abscess (curved arrow). Posteriorly, there is also no access due to the bony pelvis. (c) CT scan obtained after placing the patient in the prone position and angling the CT gantry shows that an inferior-to-superior route is available for draining the cavity. Cursors indicate the path of the needle and catheter. (d) CT scan shows successful deployment of a catheter in the abscess cavity. (e) Postdrainage CT scan obtained a few days later shows a well-drained abscess around the catheter tip (arrow).

View larger version (155K): [in a new window]   Figure 15e.  Central pelvic abscess in a patient with Crohn disease. (a) Initial diagnostic CT scan shows a central pelvic abscess cavity (straight solid arrow) with an adjoining thickened bowel loop (curved arrow) and the appendix (open arrow). (b) Localizing CT scan obtained for an attempted anterior approach shows no clear path devoid of bowel loops (straight arrows) leading to the abscess (curved arrow). Posteriorly, there is also no access due to the bony pelvis. (c) CT scan obtained after placing the patient in the prone position and angling the CT gantry shows that an inferior-to-superior route is available for draining the cavity. Cursors indicate the path of the needle and catheter. (d) CT scan shows successful deployment of a catheter in the abscess cavity. (e) Postdrainage CT scan obtained a few days later shows a well-drained abscess around the catheter tip (arrow).

View larger version (176K): [in a new window]   Figure 16a.  Bilateral pelvic abscesses in an intravenous drug abuser. (a, b) CT scans show initial placement of needles (straight arrows) in the abscess cavities (curved arrows) to obtain aspirates for a Gram stain. (c) CT scan shows bilateral catheters, which were placed with the tandem-trocar technique. Note the subcutaneous loop in the right catheter, which was subsequently corrected.

View larger version (184K): [in a new window]   Figure 16b.  Bilateral pelvic abscesses in an intravenous drug abuser. (a, b) CT scans show initial placement of needles (straight arrows) in the abscess cavities (curved arrows) to obtain aspirates for a Gram stain. (c) CT scan shows bilateral catheters, which were placed with the tandem-trocar technique. Note the subcutaneous loop in the right catheter, which was subsequently corrected.

View larger version (185K): [in a new window]   Figure 16c.  Bilateral pelvic abscesses in an intravenous drug abuser. (a, b) CT scans show initial placement of needles (straight arrows) in the abscess cavities (curved arrows) to obtain aspirates for a Gram stain. (c) CT scan shows bilateral catheters, which were placed with the tandem-trocar technique. Note the subcutaneous loop in the right catheter, which was subsequently corrected.

View larger version (194K): [in a new window]   Figure 17a.  Large pelvic abscess due to diverticulitis. (a) CT scan shows initial needle placement with anterior and posterior components in a complex pelvic abscess (arrows). (b) CT scan shows successful catheter drainage of the abscess with the combined approach. The catheters were placed with the tandem-trocar technique. Note that, with the collapse of the abscess cavity around the anterior catheter tip, the enhanced intestine (arrow) has regained its pelvic position surrounding the catheter tip. This phenomenon may produce a false appearance of catheter malposition within the intestine on a single axial image, and all images need to viewed in conjunction with the predrainage axial images.

View larger version (197K): [in a new window]   Figure 17b.  Large pelvic abscess due to diverticulitis. (a) CT scan shows initial needle placement with anterior and posterior components in a complex pelvic abscess (arrows). (b) CT scan shows successful catheter drainage of the abscess with the combined approach. The catheters were placed with the tandem-trocar technique. Note that, with the collapse of the abscess cavity around the anterior catheter tip, the enhanced intestine (arrow) has regained its pelvic position surrounding the catheter tip. This phenomenon may produce a false appearance of catheter malposition within the intestine on a single axial image, and all images need to viewed in conjunction with the predrainage axial images.

View larger version (139K): [in a new window]   Figure 18a.  Palliative transgluteal drainage of a large necrotic pelvic mass in a preterminal patient with intractable pain. (a) CT scan shows needle placement in a necrotic mass (arrowheads). (b) CT scan shows catheter insertion alongside the needle (arrow) (tandem-trocar technique).

View larger version (122K): [in a new window]   Figure 18b.  Palliative transgluteal drainage of a large necrotic pelvic mass in a preterminal patient with intractable pain. (a) CT scan shows needle placement in a necrotic mass (arrowheads). (b) CT scan shows catheter insertion alongside the needle (arrow) (tandem-trocar technique).

View larger version (118K): [in a new window]   Figure 19a.  Pelvic abscess due to ruptured appendicitis. (a) Initial localizing CT scan shows a pelvic abscess (arrows) anterior to the contrast material-filled rectum. (b) CT scan shows transgluteal deployment of a catheter in the abscess with the tandem-trocar technique.

View larger version (121K): [in a new window]   Figure 19b.  Pelvic abscess due to ruptured appendicitis. (a) Initial localizing CT scan shows a pelvic abscess (arrows) anterior to the contrast material-filled rectum. (b) CT scan shows transgluteal deployment of a catheter in the abscess with the tandem-trocar technique.

View larger version (161K): [in a new window]   Figure 20.  Multiloculated pelvic abscess after pelvic surgery. CT scan shows a bilobed abscess, which thus required bilateral drainage catheters. After insertion of the left catheter, a needle (straight arrow) was advanced on the right side. The patient experienced sharp pain radiating to the leg. The tip of the needle is seen close to the sciatic nerve (curved arrow), thus explaining the patient’s symptoms.

View larger version (148K): [in a new window]   Figure 21.  Presacral postsurgical pelvic abscess. After drainage, the patient experienced severe local pain that required intravenous analgesia. CT scan shows catheter placement through the piriformis muscle (arrow), thus explaining the patient’s symptoms.

View larger version (143K): [in a new window]   Figure 22a.  Large postsurgical pelvic abscess containing extraluminal contrast material. (a) CT scan shows a large pelvic abscess (straight solid arrow) that contains extraluminal contrast material. A catheter (curved arrow) that was introduced via the transpiriformis approach to drain the abscess has fallen back. There is asymmetric enlargement of the piriformis muscle (open arrow) due to a hematoma accompanied by presacral hemorrhage (arrowhead). The patient was experiencing bleeding along the catheter tract. (b) CT scan shows that the hemorrhage (arrow) courses superiorly in the extraperitoneal space. (c) Diagnostic angiogram shows a pseudoaneurysm (arrow) of the inferior gluteal artery. (d) Radiograph shows coil embolization of the inferior gluteal artery, which successfully controlled the hemorrhage.

View larger version (141K): [in a new window]   Figure 22b.  Large postsurgical pelvic abscess containing extraluminal contrast material. (a) CT scan shows a large pelvic abscess (straight solid arrow) that contains extraluminal contrast material. A catheter (curved arrow) that was introduced via the transpiriformis approach to drain the abscess has fallen back. There is asymmetric enlargement of the piriformis muscle (open arrow) due to a hematoma accompanied by presacral hemorrhage (arrowhead). The patient was experiencing bleeding along the catheter tract. (b) CT scan shows that the hemorrhage (arrow) courses superiorly in the extraperitoneal space. (c) Diagnostic angiogram shows a pseudoaneurysm (arrow) of the inferior gluteal artery. (d) Radiograph shows coil embolization of the inferior gluteal artery, which successfully controlled the hemorrhage.

View larger version (121K): [in a new window]   Figure 22c.  Large postsurgical pelvic abscess containing extraluminal contrast material. (a) CT scan shows a large pelvic abscess (straight solid arrow) that contains extraluminal contrast material. A catheter (curved arrow) that was introduced via the transpiriformis approach to drain the abscess has fallen back. There is asymmetric enlargement of the piriformis muscle (open arrow) due to a hematoma accompanied by presacral hemorrhage (arrowhead). The patient was experiencing bleeding along the catheter tract. (b) CT scan shows that the hemorrhage (arrow) courses superiorly in the extraperitoneal space. (c) Diagnostic angiogram shows a pseudoaneurysm (arrow) of the inferior gluteal artery. (d) Radiograph shows coil embolization of the inferior gluteal artery, which successfully controlled the hemorrhage.

View larger version (138K): [in a new window]   Figure 22d.  Large postsurgical pelvic abscess containing extraluminal contrast material. (a) CT scan shows a large pelvic abscess (straight solid arrow) that contains extraluminal contrast material. A catheter (curved arrow) that was introduced via the transpiriformis approach to drain the abscess has fallen back. There is asymmetric enlargement of the piriformis muscle (open arrow) due to a hematoma accompanied by presacral hemorrhage (arrowhead). The patient was experiencing bleeding along the catheter tract. (b) CT scan shows that the hemorrhage (arrow) courses superiorly in the extraperitoneal space. (c) Diagnostic angiogram shows a pseudoaneurysm (arrow) of the inferior gluteal artery. (d) Radiograph shows coil embolization of the inferior gluteal artery, which successfully controlled the hemorrhage.

View larger version (131K): [in a new window]   Figure 23a.  Small postsurgical pelvic abscess. (a) Localizing CT scan shows a small postsurgical abscess (straight arrow) with an anterior surgical clip (curved arrow). (b) CT scan obtained during initial catheter placement with the tandem-trocar technique shows the catheter extending beyond the abscess cavity. (c) CT scan obtained after withdrawing the catheter and repositioning it within the abscess cavity shows successful drainage. Note that the catheter tip (straight arrow) is proximal to the surgical clip (curved arrow).

View larger version (130K): [in a new window]   Figure 23b.  Small postsurgical pelvic abscess. (a) Localizing CT scan shows a small postsurgical abscess (straight arrow) with an anterior surgical clip (curved arrow). (b) CT scan obtained during initial catheter placement with the tandem-trocar technique shows the catheter extending beyond the abscess cavity. (c) CT scan obtained after withdrawing the catheter and repositioning it within the abscess cavity shows successful drainage. Note that the catheter tip (straight arrow) is proximal to the surgical clip (curved arrow).

View larger version (134K): [in a new window]   Figure 23c.  Small postsurgical pelvic abscess. (a) Localizing CT scan shows a small postsurgical abscess (straight arrow) with an anterior surgical clip (curved arrow). (b) CT scan obtained during initial catheter placement with the tandem-trocar technique shows the catheter extending beyond the abscess cavity. (c) CT scan obtained after withdrawing the catheter and repositioning it within the abscess cavity shows successful drainage. Note that the catheter tip (straight arrow) is proximal to the surgical clip (curved arrow).