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MR Imaging Appearances of the Female Pelvis after Trachelectomy¹

¹ From the Department of Radiology, Homerton University Hospital, Homerton Row, London E9 6SR, England (A.S.); the Department of Radiology, St Bartholomew’s Hospital, Barts and the London NHS Trust, London (J.J., R.H.R.); and the Department of Surgical Gynaecology, St Bartholomew’s Hospital, London (J.H.S.). Presented as an education exhibit at the 2003 RSNA Scientific Assembly. Received March 17, 2004; revision requested April 14 and received May 10; accepted May 13. All authors have no financial relationships to disclose. Address correspondence to A.S. (e-mail: anju.sahdev@homerton.nhs.uk).

View larger version (94K): [in a new window]   Figure 1a.  Diagrams of the trachelectomy technique. (a) The cervix and upper vaginal vault are resected (oval dashed line). (b) The residual corpus uteri is anastomosed to the remainder of the vaginal vault. Bilateral pelvic lymphadenectomy is also performed (double dashed lines in a and b). (c) A cerclage suture is placed around the corpus uteri at the anastomosis. This suture maintains the competency of the uterus in any subsequent pregnancies.

View larger version (88K): [in a new window]   Figure 1b.  Diagrams of the trachelectomy technique. (a) The cervix and upper vaginal vault are resected (oval dashed line). (b) The residual corpus uteri is anastomosed to the remainder of the vaginal vault. Bilateral pelvic lymphadenectomy is also performed (double dashed lines in a and b). (c) A cerclage suture is placed around the corpus uteri at the anastomosis. This suture maintains the competency of the uterus in any subsequent pregnancies.

View larger version (101K): [in a new window]   Figure 1c.  Diagrams of the trachelectomy technique. (a) The cervix and upper vaginal vault are resected (oval dashed line). (b) The residual corpus uteri is anastomosed to the remainder of the vaginal vault. Bilateral pelvic lymphadenectomy is also performed (double dashed lines in a and b). (c) A cerclage suture is placed around the corpus uteri at the anastomosis. This suture maintains the competency of the uterus in any subsequent pregnancies.

View larger version (166K): [in a new window]   Figure 2.  End-to-end anastomotic appearance after trachelectomy. Sagittal T2-weighted image shows the corpus uteri anastomosed to the upper vaginal vault (arrow). On the basis of the surgical details, this is the expected postoperative appearance of the residual uterus and vagina. Twenty patients (44%) demonstrated this appearance.

View larger version (186K): [in a new window]   Figure 3a.  Posterior neofornix of the vagina. (a) Sagittal T2-weighted image shows an apparent posterior vaginal fornix (arrow). (b) Axial T2-weighted image shows the neofornix as an apparent mass posterior to the anastomosis (arrow). It is important to diagnose this finding as a normal variant of the surgical appearance and not as a recurrent mass lesion. This appearance was seen in 25 patients (56%).

View larger version (196K): [in a new window]   Figure 3b.  Posterior neofornix of the vagina. (a) Sagittal T2-weighted image shows an apparent posterior vaginal fornix (arrow). (b) Axial T2-weighted image shows the neofornix as an apparent mass posterior to the anastomosis (arrow). It is important to diagnose this finding as a normal variant of the surgical appearance and not as a recurrent mass lesion. This appearance was seen in 25 patients (56%).

View larger version (166K): [in a new window]   Figure 4.  Posterior neofornix of the vagina. Sagittal T2-weighted image shows a prominent posterior neofornix (arrow) with the anastomosis located anteriorly (arrowhead).

View larger version (160K): [in a new window]   Figure 5.  Suture artifacts. Sagittal T2-weighted image shows susceptibility artifacts produced by the cerclage and anastomotic sutures (arrow). These artifacts were seen in 10 patients (22%) but did not limit interpretation of the MR images in nine of these patients.

View larger version (161K): [in a new window]   Figure 6.  Suture artifacts. Sagittal T2-weighted image shows susceptibility artifacts produced by the anastomotic sutures (arrow).

View larger version (162K): [in a new window]   Figure 7.  Suture artifacts. Sagittal T2-weighted image shows prominent susceptibility artifacts from the cerclage suture at the anastomotic site. Pronounced susceptibility artifacts were seen only in this patient; therefore, direct visualization by means of clinical examination was performed to exclude a small recurrent mass.

View larger version (202K): [in a new window]   Figure 8.  Isthmic stenosis. Sagittal T2-weighted image shows stenosis at the anastomotic site (arrow) with resultant dilatation of the endometrial cavity. This finding was seen in one patient (2%), who presented with secondary postsurgical amenorrhea.

View larger version (175K): [in a new window]   Figure 9.  Thickening of the vaginal wall. Sagittal T2-weighted image shows diffuse thickening of both the anterior and posterior vaginal walls (arrows). These changes were seen in three patients and persisted for up to 6 months after trachelectomy. Biopsy of the diffusely thickened wall demonstrated only benign changes, but the changes in signal intensity mimic infiltrative recurrent disease.

View larger version (131K): [in a new window]   Figure 10a.  Hematoma of the vaginal wall. (a) Sagittal T2-weighted image shows a high-signal-intensity fluid collection along the posterior wall of the vagina. (b) Axial T1-weighted image obtained with fat saturation shows that the fluid collection has high signal intensity. The signal intensity properties suggest that there is blood within the fluid collection. The fluid collection was seen on postoperative follow-up images for 1 year after surgery.

View larger version (132K): [in a new window]   Figure 10b.  Hematoma of the vaginal wall. (a) Sagittal T2-weighted image shows a high-signal-intensity fluid collection along the posterior wall of the vagina. (b) Axial T1-weighted image obtained with fat saturation shows that the fluid collection has high signal intensity. The signal intensity properties suggest that there is blood within the fluid collection. The fluid collection was seen on postoperative follow-up images for 1 year after surgery.

View larger version (148K): [in a new window]   Figure 11.  Hematoma of the vaginal wall. Sagittal T2-weighted image shows a small hematoma in the anterior vaginal wall (arrow). The typical layering of blood products seen in hematomas is demonstrated in this case.

View larger version (164K): [in a new window]   Figure 12a.  Bilateral pelvic lymphoceles. (a) Axial T2-weighted image shows large lymphoceles in the external iliac distribution (arrows). (b) Axial T1-weighted image shows uniform low signal intensity within the lymphoceles (arrows). The lymphocele on the right side contains debris and is thick walled. The lymphoceles were unchanged on follow-up MR images for 2 years.

View larger version (131K): [in a new window]   Figure 12b.  Bilateral pelvic lymphoceles. (a) Axial T2-weighted image shows large lymphoceles in the external iliac distribution (arrows). (b) Axial T1-weighted image shows uniform low signal intensity within the lymphoceles (arrows). The lymphocele on the right side contains debris and is thick walled. The lymphoceles were unchanged on follow-up MR images for 2 years.

View larger version (166K): [in a new window]   Figure 13.  Bilateral pelvic lymphoceles. Axial T2-weighted image shows lymphoceles in the right deep femoral and left external iliac distributions (arrows). The ovaries are also seen (arrowheads), and there is free fluid posterior to the uterus.

View larger version (188K): [in a new window]   Figure 14a.  Exaggeration of the parametrial venous plexus. (a) Axial T2-weighted image shows the parametrial venous plexus before trachelectomy (arrows). (b) Axial T2-weighted image shows the parametrial venous plexus 3 months after trachelectomy (arrows). The uterine veins are dilated and engorged. The patient was asymptomatic. This appearance was unchanged 6, 9, and 18 months after trachelectomy.

View larger version (187K): [in a new window]   Figure 14b.  Exaggeration of the parametrial venous plexus. (a) Axial T2-weighted image shows the parametrial venous plexus before trachelectomy (arrows). (b) Axial T2-weighted image shows the parametrial venous plexus 3 months after trachelectomy (arrows). The uterine veins are dilated and engorged. The patient was asymptomatic. This appearance was unchanged 6, 9, and 18 months after trachelectomy.

View larger version (185K): [in a new window]   Figure 15a.  Adenomyosis. (a) Sagittal T2-weighted image shows small foci of high signal intensity in the myometrium. (b) Sagittal T2-weighted image shows a widened junctional zone in the residual corpus uteri. Susceptibility artifact from the cerclage suture is also noted (arrow). Concurrent adenomyosis was seen in four patients (9%). These appearances were observed only after surgery.

View larger version (157K): [in a new window]   Figure 15b.  Adenomyosis. (a) Sagittal T2-weighted image shows small foci of high signal intensity in the myometrium. (b) Sagittal T2-weighted image shows a widened junctional zone in the residual corpus uteri. Susceptibility artifact from the cerclage suture is also noted (arrow). Concurrent adenomyosis was seen in four patients (9%). These appearances were observed only after surgery.

View larger version (181K): [in a new window]   Figure 16a.  Endometriomas. (a) Axial T2-weighted image shows a large right ovarian endometrioma (left arrow) with layering of blood within the endometrioma. A smaller left ovarian endometrioma is also present (right arrow). Arrowhead = right iliac lymphocele. (b) Axial T1-weighted image shows high signal intensity within both endometriomas. (c) Axial T1-weighted image obtained with fat saturation shows that blood is present in both endometriomas. The smaller left-sided endometrioma was noted before trachelectomy, but the larger right-sided endometrioma developed in the postoperative period.

View larger version (150K): [in a new window]   Figure 16b.  Endometriomas. (a) Axial T2-weighted image shows a large right ovarian endometrioma (left arrow) with layering of blood within the endometrioma. A smaller left ovarian endometrioma is also present (right arrow). Arrowhead = right iliac lymphocele. (b) Axial T1-weighted image shows high signal intensity within both endometriomas. (c) Axial T1-weighted image obtained with fat saturation shows that blood is present in both endometriomas. The smaller left-sided endometrioma was noted before trachelectomy, but the larger right-sided endometrioma developed in the postoperative period.

View larger version (141K): [in a new window]   Figure 16c.  Endometriomas. (a) Axial T2-weighted image shows a large right ovarian endometrioma (left arrow) with layering of blood within the endometrioma. A smaller left ovarian endometrioma is also present (right arrow). Arrowhead = right iliac lymphocele. (b) Axial T1-weighted image shows high signal intensity within both endometriomas. (c) Axial T1-weighted image obtained with fat saturation shows that blood is present in both endometriomas. The smaller left-sided endometrioma was noted before trachelectomy, but the larger right-sided endometrioma developed in the postoperative period.

View larger version (163K): [in a new window]   Figure 17a.  Appearances of the residual uterus during pregnancy. (a) Axial T2-weighted image shows an intrauterine pregnancy. A left external iliac lymphocele is also present (arrowhead). (b) Sagittal T2-weighted image shows the gravid uterus. The cervical anastomosis is noted (arrow) with a cerclage suture maintaining competency during the pregnancy.

View larger version (175K): [in a new window]   Figure 17b.  Appearances of the residual uterus during pregnancy. (a) Axial T2-weighted image shows an intrauterine pregnancy. A left external iliac lymphocele is also present (arrowhead). (b) Sagittal T2-weighted image shows the gravid uterus. The cervical anastomosis is noted (arrow) with a cerclage suture maintaining competency during the pregnancy.

View larger version (154K): [in a new window]   Figure 18a.  Local recurrence of cervical carcinoma. (a) Sagittal T2-weighted image shows a small soft tissue mass within the posterior neofornix of the vagina (arrow). (b) Axial T2-weighted image shows that the mass is located along the left lateral margin of the anastomosis (arrow). (c) Coronal image of the pelvis obtained with fluorine-18 fluorodeoxyglucose positron emission tomography shows active disease at the site of the mass. Transvaginal biopsy demonstrated recurrent disease at this site.

View larger version (159K): [in a new window]   Figure 18b.  Local recurrence of cervical carcinoma. (a) Sagittal T2-weighted image shows a small soft tissue mass within the posterior neofornix of the vagina (arrow). (b) Axial T2-weighted image shows that the mass is located along the left lateral margin of the anastomosis (arrow). (c) Coronal image of the pelvis obtained with fluorine-18 fluorodeoxyglucose positron emission tomography shows active disease at the site of the mass. Transvaginal biopsy demonstrated recurrent disease at this site.

View larger version (80K): [in a new window]   Figure 18c.  Local recurrence of cervical carcinoma. (a) Sagittal T2-weighted image shows a small soft tissue mass within the posterior neofornix of the vagina (arrow). (b) Axial T2-weighted image shows that the mass is located along the left lateral margin of the anastomosis (arrow). (c) Coronal image of the pelvis obtained with fluorine-18 fluorodeoxyglucose positron emission tomography shows active disease at the site of the mass. Transvaginal biopsy demonstrated recurrent disease at this site.

View larger version (168K): [in a new window]   Figure 19a.  Local and distant recurrence of cervical carcinoma. (a) Axial T2-weighted image shows a mass at the left lateral margin of the anastomosis (arrow). Despite chemotherapy and radiation therapy, the recurrent disease progressed. (b) Axial T1-weighted image shows left para-aortic lymphadenopathy (arrow).

View larger version (117K): [in a new window]   Figure 19b.  Local and distant recurrence of cervical carcinoma. (a) Axial T2-weighted image shows a mass at the left lateral margin of the anastomosis (arrow). Despite chemotherapy and radiation therapy, the recurrent disease progressed. (b) Axial T1-weighted image shows left para-aortic lymphadenopathy (arrow).