(Radiographics. 2001;21:657-672.)
© RSNA, 2001
Transvaginal Interventional Procedures: Aspiration, Biopsy, and Catheter Drainage1
Mary Jane O’Neill, MD,
Elizabeth A. Rafferty, MD,
Susanna I. Lee, MD, PhD,
Ronald S. Arellano, MD,
Debra A. Gervais, MD,
Peter F. Hahn, MD, PhD,
Isabel C. Yoder, MD and
Peter R. Mueller, MD
1 From the Department of Radiology, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114. Presented as a scientific exhibit at the 1999 RSNA scientific assembly. Received September 29, 2000; revision requested October 19; final revision received February 15, 2001; accepted February 16. Address correspondence to M.J.O. (e-mail: moneill@partners.org).
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Abstract
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Transvaginal ultrasonographically (US) guided procedures are simple and safe and often represent the only means of access to pelvic disease. Aspiration of cystic pelvic masses and core biopsy of solid pelvic masses can be easily performed by using the transvaginal route, an endoluminal US transducer, and a needle guide. Because of concerns about false-negative diagnosis and potential tumor seeding with biopsy of primary ovarian cystic lesions, the indications for transvaginal aspiration and biopsy of ovarian and adnexal lesions are predominantly therapeutic. Similarly, using an endoluminal probe with modification of the guide, one can also perform safe and effective trocar catheter drainage of pelvic abscesses via the transvaginal route. The transvaginal route is ideally suited to pelvic abscess drainage because of the proximity of the vaginal fornices to most pelvic fluid collections. The transvaginal route has the disadvantage of being semisterile; because of the risk of superinfecting previously noninfected pelvic pathologic conditions, the transvaginal approach should be used only for solid lesions or cystic lesions that can be completely aspirated. Familiarity with the transvaginal route of access is crucial for adequate treatment of many gynecologic and nongynecologic pelvic pathologic conditions.
Index Terms: Ovary, cysts, 85.311 • Pelvic organs, abscess, 85.211, 85.2174 • Pelvic organs, interventional procedures, 85.126
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Introduction
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Aspiration, biopsy, and drainage of pathologic conditions in the female pelvis have traditionally been performed percutaneously through an anterior abdominal approach or posterior transgluteal approach. The transabdominal route usually presents a long distance to pelvic lesions, with the intervening intestine, bladder, and reproductive organs often complicating this route. The posterior approach through the greater sciatic foramen is shorter; however, it may be more painful for the patient and may be obstructed by surrounding bones, nerves, and vessels. The transvaginal approach is an ideal route to pelvic pathologic conditions because of the proximity of the vaginal fornices to most pelvic lesions (1–9). The transvaginal approach allows use of endoluminal ultrasonographic (US) probe needle guides to permit extremely accurate and speedy needle or catheter placement. Despite these advantages, the transvaginal approach has been underused by most interventional radiologists.
To familiarize radiologists with the transvaginal approach, this article describes the techniques specific to transvaginal interventional procedures and reviews the indications for and safety and efficacy of the transvaginal route for aspiration, biopsy, and drainage of pelvic pathologic conditions. Specific topics discussed are aspiration and biopsy of ovarian and adnexal lesions, transvaginal abscess drainage, and complications.
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Aspiration and Biopsy of Ovarian and Adnexal Lesions
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Significant controversy surrounds the role of cyst puncture and aspiration in diagnosis and treatment of cystic lesions of the ovaries and adnexa. Radiologic studies have reported accurate diagnosis from cytologic analysis of cyst fluid (1–5), whereas surgical studies have shown a poor correlation between aspiration results and histologic findings (10–16). Concerns about potential false-negative diagnoses, tumor seeding, and peritoneal contamination have prevented widespread use of minimally invasive approaches to diagnosis or treatment of gynecologic lesions. Although the diagnostic accuracy of ovarian cyst aspiration remains controversial, concerns regarding peritoneal contamination and seeding remain theoretical and unsubstantiated (1–9). Sampling of cystic ovarian lesions appears to be safe; however, further advances in cytologic characterization and sampling techniques are needed before percutaneous biopsy can replace laparoscopy or laparotomy in primary diagnosis of cystic ovarian lesions.
Although primary diagnosis of most ovarian cystic lesions should be performed with surgical procedures, several subgroups of patients with cystic ovarian or adnexal lesions are ideal candidates for less invasive percutaneous or transvaginal procedures. First, some patients with primary cystic ovarian lesions are poor surgical candidates or have a primary neoplasm outside the ovary. In these patients, an attempt to obtain a diagnosis percutaneously is reasonable because a positive result will direct management (17,18). However, because the management is quite complex, this approach should be undertaken only when one is working with a gynecologic oncologist. The care of patients with negative or benign biopsy results requires close follow-up and a detailed knowledge of gynecologic disease processes. Second, there are two groups of patients in whom therapy, not diagnosis, is the primary concern: (a) women with a surgically confirmed diagnosis who have recurrent symptomatic cystic ovarian or adnexal disease and (b) women with symptomatic postoperative seromas or lymphoceles.
Although diagnosis of cystic ovarian lesions by means of percutaneous aspiration is problematic and should be approached conservatively, the same principle does not hold true for solid ovarian and adnexal lesions. With solid lesions, sampling error is not as common and it is possible to use a biopsy gun to obtain multiple cores of tissue for complete histopathologic evaluation, increasing the likelihood of a positive diagnostic result (4,5,19,20).
Needle aspiration can also be used to effectively treat infected pelvic fluid collections as an alternative to catheter drainage (which is described in the "Transvaginal Abscess Drainage" section) (21). However, because there is often sloughing of infected material into the abscess cavity after aspiration, this approach may increase the number of procedures necessary to adequately treat the collection.
Indications
Because of the concerns about false-negative diagnosis and potential tumor seeding with biopsy of primary ovarian cystic lesions, the indications for transvaginal aspiration and biopsy of ovarian and adnexal lesions are predominantly therapeutic. They include aspiration of known endometriosis (Fig 1); aspiration of symptomatic hemorrhagic ovarian cysts (Fig 2); aspiration of postoperative hematomas (Fig 3), seromas (Fig 4), and lymphoceles; and aspiration of symptomatic cysts in pregnancy (Fig 5). The diagnostic indications for transvaginal aspiration and biopsy are more limited but include biopsy of solid masses (Fig 6) and biopsy of cystic masses in patients who are poor surgical candidates (Fig 7) or have other primary malignancies. The indications for transvaginal aspiration and biopsy are summarized in Table 1.
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Figure 1a. Therapeutic aspiration of endometriosis in a 34-year-old woman with a history of three laparoscopic surgeries for complications of endometriosis who presented with recurrent pelvic pain. (a) Sagittal transvaginal US scan shows a 6-cm-diameter, complex left ovarian cyst. Transvaginal aspiration of the cyst was requested because additional surgery would most likely have required laparotomy. (b) Sagittal transvaginal US scan shows an 18-gauge needle along the guide (arrow). Sixty milliliters of thick, hemorrhagic material was aspirated. The cyst was completely collapsed at postprocedure imaging.
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Figure 1b. Therapeutic aspiration of endometriosis in a 34-year-old woman with a history of three laparoscopic surgeries for complications of endometriosis who presented with recurrent pelvic pain. (a) Sagittal transvaginal US scan shows a 6-cm-diameter, complex left ovarian cyst. Transvaginal aspiration of the cyst was requested because additional surgery would most likely have required laparotomy. (b) Sagittal transvaginal US scan shows an 18-gauge needle along the guide (arrow). Sixty milliliters of thick, hemorrhagic material was aspirated. The cyst was completely collapsed at postprocedure imaging.
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Figure 2a. Therapeutic aspiration of a hemorrhagic ovarian cyst in a 21-year-old woman with cystic fibrosis and a history of recurrent symptomatic hemorrhagic ovarian cysts who presented to the emergency department with severe pelvic pain. (a) Contrast material-enhanced axial computed tomographic (CT) scan shows a large left ovarian cyst (straight arrow) anterior to the uterine fundus (curved arrow) and superior to the bladder. To avoid surgery and the associated risk of anesthesia, transvaginal aspiration was performed. The intestine or bladder obscured the anterior approach to the lesion; the uterus and bone prevented the posterior approach. (b) Coronal transvaginal US scan shows a nonlocking trocar 7-F pigtail catheter advanced along the guide (arrow). Because of the size and complexity of the lesion, the catheter was temporarily deployed in the cyst to allow complete aspiration and irrigation. (c) Coronal transvaginal US scan obtained after aspiration of 175 mL of hemorrhagic material and irrigation of the cavity shows residual ovarian parenchyma (arrow). The patient’s symptoms immediately improved. (d) Transverse transabdominal US scan obtained 4 weeks after the procedure shows continued resolution of the cyst. LTO = left ovary, UT = uterus, white arrow = bladder, black arrow = intestine.
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Figure 2b. Therapeutic aspiration of a hemorrhagic ovarian cyst in a 21-year-old woman with cystic fibrosis and a history of recurrent symptomatic hemorrhagic ovarian cysts who presented to the emergency department with severe pelvic pain. (a) Contrast material-enhanced axial computed tomographic (CT) scan shows a large left ovarian cyst (straight arrow) anterior to the uterine fundus (curved arrow) and superior to the bladder. To avoid surgery and the associated risk of anesthesia, transvaginal aspiration was performed. The intestine or bladder obscured the anterior approach to the lesion; the uterus and bone prevented the posterior approach. (b) Coronal transvaginal US scan shows a nonlocking trocar 7-F pigtail catheter advanced along the guide (arrow). Because of the size and complexity of the lesion, the catheter was temporarily deployed in the cyst to allow complete aspiration and irrigation. (c) Coronal transvaginal US scan obtained after aspiration of 175 mL of hemorrhagic material and irrigation of the cavity shows residual ovarian parenchyma (arrow). The patient’s symptoms immediately improved. (d) Transverse transabdominal US scan obtained 4 weeks after the procedure shows continued resolution of the cyst. LTO = left ovary, UT = uterus, white arrow = bladder, black arrow = intestine.
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Figure 2c. Therapeutic aspiration of a hemorrhagic ovarian cyst in a 21-year-old woman with cystic fibrosis and a history of recurrent symptomatic hemorrhagic ovarian cysts who presented to the emergency department with severe pelvic pain. (a) Contrast material-enhanced axial computed tomographic (CT) scan shows a large left ovarian cyst (straight arrow) anterior to the uterine fundus (curved arrow) and superior to the bladder. To avoid surgery and the associated risk of anesthesia, transvaginal aspiration was performed. The intestine or bladder obscured the anterior approach to the lesion; the uterus and bone prevented the posterior approach. (b) Coronal transvaginal US scan shows a nonlocking trocar 7-F pigtail catheter advanced along the guide (arrow). Because of the size and complexity of the lesion, the catheter was temporarily deployed in the cyst to allow complete aspiration and irrigation. (c) Coronal transvaginal US scan obtained after aspiration of 175 mL of hemorrhagic material and irrigation of the cavity shows residual ovarian parenchyma (arrow). The patient’s symptoms immediately improved. (d) Transverse transabdominal US scan obtained 4 weeks after the procedure shows continued resolution of the cyst. LTO = left ovary, UT = uterus, white arrow = bladder, black arrow = intestine.
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Figure 2d. Therapeutic aspiration of a hemorrhagic ovarian cyst in a 21-year-old woman with cystic fibrosis and a history of recurrent symptomatic hemorrhagic ovarian cysts who presented to the emergency department with severe pelvic pain. (a) Contrast material-enhanced axial computed tomographic (CT) scan shows a large left ovarian cyst (straight arrow) anterior to the uterine fundus (curved arrow) and superior to the bladder. To avoid surgery and the associated risk of anesthesia, transvaginal aspiration was performed. The intestine or bladder obscured the anterior approach to the lesion; the uterus and bone prevented the posterior approach. (b) Coronal transvaginal US scan shows a nonlocking trocar 7-F pigtail catheter advanced along the guide (arrow). Because of the size and complexity of the lesion, the catheter was temporarily deployed in the cyst to allow complete aspiration and irrigation. (c) Coronal transvaginal US scan obtained after aspiration of 175 mL of hemorrhagic material and irrigation of the cavity shows residual ovarian parenchyma (arrow). The patient’s symptoms immediately improved. (d) Transverse transabdominal US scan obtained 4 weeks after the procedure shows continued resolution of the cyst. LTO = left ovary, UT = uterus, white arrow = bladder, black arrow = intestine.
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Figure 3. Therapeutic aspiration of a postoperative hematoma in a 48-year-old woman who presented with pelvic pain 3 weeks after total abdominal hysterectomy and bilateral salpingo-oophorectomy for cervical cancer. Transabdominal and transvaginal US scan (transverse view) shows an 8-cm-diameter, complex cystic lesion in the left adnexa and pelvic side wall. Because the patient had recently undergone surgery and the cause of the collection was known, transvaginal aspiration was requested. Note the prominent fluid-fluid level in the hematoma (arrow) and its proximity to the probe in the left vaginal fornix. The collection was completely aspirated with an 18-gauge needle.
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Figure 4a. Therapeutic aspiration of a postoperative seroma in a 46-year-old woman who presented with progressive pelvic pain 2 months after total abdominal hysterectomy and bilateral salpingo-oophorectomy for fibroids. (a) Sagittal transvaginal US scan shows a large, bilobed, simple fluid collection in the pelvis. Note the two separate collections. (b) Sagittal transvaginal US scan shows an 18-gauge needle advanced along the guide into the superior component of the seroma (arrow). Eighty-five milliliters of clear, straw-colored fluid was removed. (c) Sagittal transvaginal US scan shows the needle advanced along the guide into the lower component of the seroma (arrow). Seventy-five milliliters of clear, straw-colored fluid was removed. The collection did not recur at follow-up performed at 6 and 12 months.
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Figure 4b. Therapeutic aspiration of a postoperative seroma in a 46-year-old woman who presented with progressive pelvic pain 2 months after total abdominal hysterectomy and bilateral salpingo-oophorectomy for fibroids. (a) Sagittal transvaginal US scan shows a large, bilobed, simple fluid collection in the pelvis. Note the two separate collections. (b) Sagittal transvaginal US scan shows an 18-gauge needle advanced along the guide into the superior component of the seroma (arrow). Eighty-five milliliters of clear, straw-colored fluid was removed. (c) Sagittal transvaginal US scan shows the needle advanced along the guide into the lower component of the seroma (arrow). Seventy-five milliliters of clear, straw-colored fluid was removed. The collection did not recur at follow-up performed at 6 and 12 months.
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Figure 4c. Therapeutic aspiration of a postoperative seroma in a 46-year-old woman who presented with progressive pelvic pain 2 months after total abdominal hysterectomy and bilateral salpingo-oophorectomy for fibroids. (a) Sagittal transvaginal US scan shows a large, bilobed, simple fluid collection in the pelvis. Note the two separate collections. (b) Sagittal transvaginal US scan shows an 18-gauge needle advanced along the guide into the superior component of the seroma (arrow). Eighty-five milliliters of clear, straw-colored fluid was removed. (c) Sagittal transvaginal US scan shows the needle advanced along the guide into the lower component of the seroma (arrow). Seventy-five milliliters of clear, straw-colored fluid was removed. The collection did not recur at follow-up performed at 6 and 12 months.
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Figure 5a. Therapeutic aspiration of a theca lutein cyst of pregnancy in a 27-year-old woman with a desired 8-week intrauterine pregnancy who presented with symptoms of an ovarian cyst. (a) Coronal transvaginal US scan of the left adnexa shows a large left ovarian cyst. Because surgical intervention would have placed the fetus at risk, transvaginal aspiration was performed. (b) Sagittal transvaginal US scan shows an 18-gauge needle along the guide (arrow). (c) Sagittal transvaginal US scan obtained after aspiration shows complete resolution of the abnormality. Note the normal-appearing residual ovarian parenchyma (arrow). The patient’s symptoms initially resolved.
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Figure 5b. Therapeutic aspiration of a theca lutein cyst of pregnancy in a 27-year-old woman with a desired 8-week intrauterine pregnancy who presented with symptoms of an ovarian cyst. (a) Coronal transvaginal US scan of the left adnexa shows a large left ovarian cyst. Because surgical intervention would have placed the fetus at risk, transvaginal aspiration was performed. (b) Sagittal transvaginal US scan shows an 18-gauge needle along the guide (arrow). (c) Sagittal transvaginal US scan obtained after aspiration shows complete resolution of the abnormality. Note the normal-appearing residual ovarian parenchyma (arrow). The patient’s symptoms initially resolved.
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Figure 5c. Therapeutic aspiration of a theca lutein cyst of pregnancy in a 27-year-old woman with a desired 8-week intrauterine pregnancy who presented with symptoms of an ovarian cyst. (a) Coronal transvaginal US scan of the left adnexa shows a large left ovarian cyst. Because surgical intervention would have placed the fetus at risk, transvaginal aspiration was performed. (b) Sagittal transvaginal US scan shows an 18-gauge needle along the guide (arrow). (c) Sagittal transvaginal US scan obtained after aspiration shows complete resolution of the abnormality. Note the normal-appearing residual ovarian parenchyma (arrow). The patient’s symptoms initially resolved.
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Figure 6a. Biopsy of a solid mass in a 33-year-old woman 2 months after total abdominal hysterectomy and bilateral salpingo-oophorectomy for uterine sarcoma. (a) Axial CT scan shows a small solid mass (straight arrow) in the vicinity of the right vaginal fornix, displacing the right ureter (curved arrow). All other approaches were complicated by bone, the bladder, the right ureter, and blood vessels. (b) Coronal US scan shows a predominantly solid mass in the right adnexa. Note the small region of cystic necrosis at the medial aspect of the mass (arrow). (c) Sagittal transvaginal US scan shows a guide and biopsy needle (arrow). Care was taken to direct the needle toward the solid portion of the mass. The specimen was positive for recurrent leiomyosarcoma.
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Figure 6b. Biopsy of a solid mass in a 33-year-old woman 2 months after total abdominal hysterectomy and bilateral salpingo-oophorectomy for uterine sarcoma. (a) Axial CT scan shows a small solid mass (straight arrow) in the vicinity of the right vaginal fornix, displacing the right ureter (curved arrow). All other approaches were complicated by bone, the bladder, the right ureter, and blood vessels. (b) Coronal US scan shows a predominantly solid mass in the right adnexa. Note the small region of cystic necrosis at the medial aspect of the mass (arrow). (c) Sagittal transvaginal US scan shows a guide and biopsy needle (arrow). Care was taken to direct the needle toward the solid portion of the mass. The specimen was positive for recurrent leiomyosarcoma.
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Figure 6c. Biopsy of a solid mass in a 33-year-old woman 2 months after total abdominal hysterectomy and bilateral salpingo-oophorectomy for uterine sarcoma. (a) Axial CT scan shows a small solid mass (straight arrow) in the vicinity of the right vaginal fornix, displacing the right ureter (curved arrow). All other approaches were complicated by bone, the bladder, the right ureter, and blood vessels. (b) Coronal US scan shows a predominantly solid mass in the right adnexa. Note the small region of cystic necrosis at the medial aspect of the mass (arrow). (c) Sagittal transvaginal US scan shows a guide and biopsy needle (arrow). Care was taken to direct the needle toward the solid portion of the mass. The specimen was positive for recurrent leiomyosarcoma.
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Figure 7a. Biopsy of a cystic mass in a 63-year-old postmenopausal woman with severe chronic obstructive pulmonary disease. (a) Axial CT scan shows an enlarging cystic mass (arrow) in the right ovary. Because of the patient’s comorbid condition, aspiration and biopsy were requested to make sure that surgery was required. The lesion was quite far from the transgluteal and transabdominal windows, and a standard needle would not have reached it. (b) Sagittal transvaginal US scan shows an 18-gauge needle in the cyst (arrow). (c) Sagittal transvaginal US scan shows an 18-gauge core biopsy gun (arrow) in the periphery of the lesion after it was fully aspirated. The fragment of tissue obtained in the core was positive for serous cystadenoma. Although the procedure was helpful in this poor surgical candidate, aspiration and biopsy of ovarian cystic masses should be used only in select cases.
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Figure 7b. Biopsy of a cystic mass in a 63-year-old postmenopausal woman with severe chronic obstructive pulmonary disease. (a) Axial CT scan shows an enlarging cystic mass (arrow) in the right ovary. Because of the patient’s comorbid condition, aspiration and biopsy were requested to make sure that surgery was required. The lesion was quite far from the transgluteal and transabdominal windows, and a standard needle would not have reached it. (b) Sagittal transvaginal US scan shows an 18-gauge needle in the cyst (arrow). (c) Sagittal transvaginal US scan shows an 18-gauge core biopsy gun (arrow) in the periphery of the lesion after it was fully aspirated. The fragment of tissue obtained in the core was positive for serous cystadenoma. Although the procedure was helpful in this poor surgical candidate, aspiration and biopsy of ovarian cystic masses should be used only in select cases.
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Figure 7c. Biopsy of a cystic mass in a 63-year-old postmenopausal woman with severe chronic obstructive pulmonary disease. (a) Axial CT scan shows an enlarging cystic mass (arrow) in the right ovary. Because of the patient’s comorbid condition, aspiration and biopsy were requested to make sure that surgery was required. The lesion was quite far from the transgluteal and transabdominal windows, and a standard needle would not have reached it. (b) Sagittal transvaginal US scan shows an 18-gauge needle in the cyst (arrow). (c) Sagittal transvaginal US scan shows an 18-gauge core biopsy gun (arrow) in the periphery of the lesion after it was fully aspirated. The fragment of tissue obtained in the core was positive for serous cystadenoma. Although the procedure was helpful in this poor surgical candidate, aspiration and biopsy of ovarian cystic masses should be used only in select cases.
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Patient Preparation
The procedure is performed in the US suite with the patient in the lithotomy position. Although patient discomfort is minimal with simple transvaginal aspiration or biopsy and many procedures can be performed without intravenous sedation, in our experience, sedation with midazolam and fentanyl citrate decreases patient anxiety and increases patient acceptance of this alternative approach. When conscious sedation is used, it is necessary to follow institutional guidelines regarding preprocedure patient evaluation and selection, and the patient must take nothing by mouth for at least 6 hours prior to the procedure.
Initially, a preliminary transvaginal US scan is obtained to localize and characterize the cystic or solid pelvic mass. After the mass has been adequately assessed, the perineum and vaginal vault are sterilely cleaned with povidone-iodine. The vaginal preparation is accomplished by using a sterile speculum, forceps, and sponges. Intravenous antibiotics (1 g of ampicillin, 80 mg of gentamicin, and 1 g of clindamycin) are administered prior to the procedure. Patients receive a 5-day course of clindamycin (300 mg every 6 hours) after the procedure. The transvaginal route has the disadvantage of being semisterile, even following vaginal preparation with povidone-iodine. Because of the risk of superinfecting previously noninfected pelvic pathologic conditions, the transvaginal approach should be used only for solid lesions or cystic lesions that can be completely aspirated.
Equipment
The equipment for transvaginal aspiration and biopsy is listed in Table 2.
Transvaginal Aspiration
When the transvaginal route is used for aspiration, the probe should be placed in the vaginal fornix closest to the lesion so that the distance between the lesion and the access is minimized. The region between the fornix and the lesionshould be scrutinized for intervening structures such as the intestine, the bladder, or vessels. Once the probe has been adequately positioned, the needle guide should be aligned in the center of the lesion. When the transvaginal route is used, it is usually not possible to adequately anesthetize the puncture site with local anesthesia. For this reason, it is important to minimize the amount of needle manipulation while accessing the lesion. When the muscular vaginal fornix is being traversed, the probe should be advanced until resistance is felt so that the vaginal vault is stretched over the transducer head; then, slow, steady forward pressure should be applied until the needle has traversed the vaginal muscle and advanced into the lesion. Occasionally, the needle causes tenting of the vaginal muscle without passing easily through. In these cases, a short (1–2 cm), rapid forward thrust of the needle may be necessary to traverse the vaginal tissue. The needle can then be advanced into the lesion under direct guidance.
It is important to perform a complete aspiration so that the risk of superinfection of the residual contents is minimized. If complete aspiration cannot be achieved, catheter placement should be considered. Specimens should be sent for cytologic, microbiologic, cell count, and chemical analysis and measurement of cancer antigen 125, cancer antigen 19-9, and estradiol levels.
Transvaginal Aspiration and Biopsy
Transvaginal aspiration and biopsy of solid and cystic lesions is performed in much the same way as aspiration alone. After the needle aspiration, a core biopsy gun is advanced through the same needle guide and two or three core tissue samples are obtained. When biopsy of a predominantly cystic mass is performed, care should be taken to aspirate the fluid component completely prior to acquisition of the tissue samples. Complete aspiration will decrease the likelihood of superinfection of residual cyst contents and should increase the yield of solid material with the core biopsy of the cyst wall.
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Transvaginal Abscess Drainage
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Percutaneous abscess drainage is well established in the treatment of abdominal abscesses resulting from gastrointestinal disorders such as perforating appendicitis, diverticulitis, and Crohn disease as well as postoperative abscesses (21–23). Gynecologic infections, perhaps because of the typical location deep within the pelvis, have traditionally been managed with medical therapy or surgical drainage. However, recent studies have demonstrated the significant benefit of percutaneous drainage of infected gynecologic fluid collections, particularly those associated with pelvic inflammatory disease (24–26). The transvaginal route is ideally suited to pelvic abscess drainage because of the proximity of the vaginal fornices to most pelvic fluid collections.
Indications
The indications for transvaginal drainage of pelvic fluid include both gynecologic and nongynecologic conditions. These include simple tubo-ovarian abscesses (Fig 8), complex tubo-ovarian abscesses (Fig 9), postoperative abscesses (Fig 10), and diverticular abscesses (Fig 11). The indications for transvaginal drainage are summarized in Table 3.
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Figure 8a. Drainage of a simple tubo-ovarian abscess in a 33-year-old woman with fever, pelvic pain, leukocytosis, and a palpable pelvic fluid collection. (a) Coronal transvaginal US scan shows an 8-cm-diameter right adnexal fluid collection with a prominent fluid-fluid level (arrow). Cervical cultures demonstrated Escherichia coli. The patient did not respond to 48 hours of intravenous antibiotic therapy, and the decision was made to drain this simple tubo-ovarian abscess. Most tubo-ovarian abscesses larger than 4 cm in diameter will not resolve with antibiotics alone, and up-front drainage is indicated in most cases. Note the proximity of the fluid collection to the end of the probe within the right vaginal fornix. (b) Sagittal US scan obtained after catheter deployment shows the catheter within the fluid collection (arrow). One hundred twenty milliliters of grossly purulent material was drained, and the catheter was irrigated. The patient’s pain and fever resolved within 24 hours of catheter placement. The catheter was removed on the 3rd postprocedure day. No fluid collection was seen at 3-week follow-up US.
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Figure 8b. Drainage of a simple tubo-ovarian abscess in a 33-year-old woman with fever, pelvic pain, leukocytosis, and a palpable pelvic fluid collection. (a) Coronal transvaginal US scan shows an 8-cm-diameter right adnexal fluid collection with a prominent fluid-fluid level (arrow). Cervical cultures demonstrated Escherichia coli. The patient did not respond to 48 hours of intravenous antibiotic therapy, and the decision was made to drain this simple tubo-ovarian abscess. Most tubo-ovarian abscesses larger than 4 cm in diameter will not resolve with antibiotics alone, and up-front drainage is indicated in most cases. Note the proximity of the fluid collection to the end of the probe within the right vaginal fornix. (b) Sagittal US scan obtained after catheter deployment shows the catheter within the fluid collection (arrow). One hundred twenty milliliters of grossly purulent material was drained, and the catheter was irrigated. The patient’s pain and fever resolved within 24 hours of catheter placement. The catheter was removed on the 3rd postprocedure day. No fluid collection was seen at 3-week follow-up US.
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Figure 9a. Drainage of complex tubo-ovarian abscesses in a 29-year-old woman with fever, leukocytosis, and severe abdominal pain 2 months after elective cesarean section. (a) Contrast-enhanced axial CT scan shows a complex right adnexal fluid collection (straight arrow). A right-sided fundal fibroid is incidentally noted (curved arrow). (b) Contrast-enhanced axial CT scan obtained inferior to a shows a left adnexal fluid collection (arrow). Surgical therapy would most likely have involved hysterectomy; therefore, transvaginal drainage was attempted. (c) Coronal transvaginal US scan shows bilateral large, complex adnexal fluid collections (arrows). (d) Sagittal transvaginal US scan shows a trocar-catheter assembly (arrow) in the right adnexal collection along the guide. (e) Sagittal US scan obtained after drainage of 100 mL of pus from the right tubo-ovarian abscess shows the catheter (arrow) deployed within a much smaller fluid collection. Both fluid collections were completely drained with single catheters, and the patient had no residual fluid collections at 3- and 6-month follow-up.
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Figure 9b. Drainage of complex tubo-ovarian abscesses in a 29-year-old woman with fever, leukocytosis, and severe abdominal pain 2 months after elective cesarean section. (a) Contrast-enhanced axial CT scan shows a complex right adnexal fluid collection (straight arrow). A right-sided fundal fibroid is incidentally noted (curved arrow). (b) Contrast-enhanced axial CT scan obtained inferior to a shows a left adnexal fluid collection (arrow). Surgical therapy would most likely have involved hysterectomy; therefore, transvaginal drainage was attempted. (c) Coronal transvaginal US scan shows bilateral large, complex adnexal fluid collections (arrows). (d) Sagittal transvaginal US scan shows a trocar-catheter assembly (arrow) in the right adnexal collection along the guide. (e) Sagittal US scan obtained after drainage of 100 mL of pus from the right tubo-ovarian abscess shows the catheter (arrow) deployed within a much smaller fluid collection. Both fluid collections were completely drained with single catheters, and the patient had no residual fluid collections at 3- and 6-month follow-up.
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Figure 9c. Drainage of complex tubo-ovarian abscesses in a 29-year-old woman with fever, leukocytosis, and severe abdominal pain 2 months after elective cesarean section. (a) Contrast-enhanced axial CT scan shows a complex right adnexal fluid collection (straight arrow). A right-sided fundal fibroid is incidentally noted (curved arrow). (b) Contrast-enhanced axial CT scan obtained inferior to a shows a left adnexal fluid collection (arrow). Surgical therapy would most likely have involved hysterectomy; therefore, transvaginal drainage was attempted. (c) Coronal transvaginal US scan shows bilateral large, complex adnexal fluid collections (arrows). (d) Sagittal transvaginal US scan shows a trocar-catheter assembly (arrow) in the right adnexal collection along the guide. (e) Sagittal US scan obtained after drainage of 100 mL of pus from the right tubo-ovarian abscess shows the catheter (arrow) deployed within a much smaller fluid collection. Both fluid collections were completely drained with single catheters, and the patient had no residual fluid collections at 3- and 6-month follow-up.
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Figure 9d. Drainage of complex tubo-ovarian abscesses in a 29-year-old woman with fever, leukocytosis, and severe abdominal pain 2 months after elective cesarean section. (a) Contrast-enhanced axial CT scan shows a complex right adnexal fluid collection (straight arrow). A right-sided fundal fibroid is incidentally noted (curved arrow). (b) Contrast-enhanced axial CT scan obtained inferior to a shows a left adnexal fluid collection (arrow). Surgical therapy would most likely have involved hysterectomy; therefore, transvaginal drainage was attempted. (c) Coronal transvaginal US scan shows bilateral large, complex adnexal fluid collections (arrows). (d) Sagittal transvaginal US scan shows a trocar-catheter assembly (arrow) in the right adnexal collection along the guide. (e) Sagittal US scan obtained after drainage of 100 mL of pus from the right tubo-ovarian abscess shows the catheter (arrow) deployed within a much smaller fluid collection. Both fluid collections were completely drained with single catheters, and the patient had no residual fluid collections at 3- and 6-month follow-up.
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Figure 9e. Drainage of complex tubo-ovarian abscesses in a 29-year-old woman with fever, leukocytosis, and severe abdominal pain 2 months after elective cesarean section. (a) Contrast-enhanced axial CT scan shows a complex right adnexal fluid collection (straight arrow). A right-sided fundal fibroid is incidentally noted (curved arrow). (b) Contrast-enhanced axial CT scan obtained inferior to a shows a left adnexal fluid collection (arrow). Surgical therapy would most likely have involved hysterectomy; therefore, transvaginal drainage was attempted. (c) Coronal transvaginal US scan shows bilateral large, complex adnexal fluid collections (arrows). (d) Sagittal transvaginal US scan shows a trocar-catheter assembly (arrow) in the right adnexal collection along the guide. (e) Sagittal US scan obtained after drainage of 100 mL of pus from the right tubo-ovarian abscess shows the catheter (arrow) deployed within a much smaller fluid collection. Both fluid collections were completely drained with single catheters, and the patient had no residual fluid collections at 3- and 6-month follow-up.
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Figure 10a. Drainage of a complex nongynecologic pelvic abscess in a 20-year-old woman with fever, leukocytosis, and severe pelvic pain 2 days after laparoscopic cholecystectomy. (a) Contrast-enhanced axial CT scan shows a complex fluid collection with a component (solid white arrow) adjacent to the bladder (black arrowhead) and a separate component in the cul-de-sac (black arrow). The two components communicated over the superior surface of the uterus. An anterior approach was complicated by the presence of the colon (white arrowhead) and uterus (open white arrow). (b) Sagittal US scan obtained before drainage shows a fluid-debris level within the cul-de-sac. Arrow = uterus. (c) Coronal US scan shows a trocar (arrow) advanced into the fluid collection.
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Figure 10b. Drainage of a complex nongynecologic pelvic abscess in a 20-year-old woman with fever, leukocytosis, and severe pelvic pain 2 days after laparoscopic cholecystectomy. (a) Contrast-enhanced axial CT scan shows a complex fluid collection with a component (solid white arrow) adjacent to the bladder (black arrowhead) and a separate component in the cul-de-sac (black arrow). The two components communicated over the superior surface of the uterus. An anterior approach was complicated by the presence of the colon (white arrowhead) and uterus (open white arrow). (b) Sagittal US scan obtained before drainage shows a fluid-debris level within the cul-de-sac. Arrow = uterus. (c) Coronal US scan shows a trocar (arrow) advanced into the fluid collection.
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Figure 10c. Drainage of a complex nongynecologic pelvic abscess in a 20-year-old woman with fever, leukocytosis, and severe pelvic pain 2 days after laparoscopic cholecystectomy. (a) Contrast-enhanced axial CT scan shows a complex fluid collection with a component (solid white arrow) adjacent to the bladder (black arrowhead) and a separate component in the cul-de-sac (black arrow). The two components communicated over the superior surface of the uterus. An anterior approach was complicated by the presence of the colon (white arrowhead) and uterus (open white arrow). (b) Sagittal US scan obtained before drainage shows a fluid-debris level within the cul-de-sac. Arrow = uterus. (c) Coronal US scan shows a trocar (arrow) advanced into the fluid collection.
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Figure 11a. Drainage with a portable unit of a tubo-ovarian abscess in a 63-year-old woman with fever, leukocytosis, and hypotension 2 months after laparoscopic appendectomy. (a) Axial CT scan shows a large pelvic abscess containing an air-fluid level and extravasated oral contrast material (arrow). The patient was in septic shock, and her condition was too unstable for her to leave the intensive care unit; transvaginal drainage was performed. Intestine and bone completely obscured the transabdominal and transgluteal drainage routes. (b) Coronal US scan obtained with a portable unit shows the complex fluid collection within the cul-de-sac very close to the left vaginal fornix (arrow). (c) Coronal US scan shows a 14-F catheter (arrow), which was advanced into the fluid collection via the left vaginal fornix. (d) Sagittal US scan obtained after aspiration and irrigation shows no residual fluid collection with the catheter in place (arrow). One hundred milliliters of purulent material was drained. Cultures demonstrated E coli. The patient responded to drainage with resolution of the septic parameters; however, 48 hours after catheter placement, the catheter became dislodged. The fluid collection was incompletely drained, and the patient ultimately required surgical drainage of the abscess; however, surgical drainage was able to be performed after the patient was hemodynamically stable and out of the intensive care unit.
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Figure 11b. Drainage with a portable unit of a tubo-ovarian abscess in a 63-year-old woman with fever, leukocytosis, and hypotension 2 months after laparoscopic appendectomy. (a) Axial CT scan shows a large pelvic abscess containing an air-fluid level and extravasated oral contrast material (arrow). The patient was in septic shock, and her condition was too unstable for her to leave the intensive care unit; transvaginal drainage was performed. Intestine and bone completely obscured the transabdominal and transgluteal drainage routes. (b) Coronal US scan obtained with a portable unit shows the complex fluid collection within the cul-de-sac very close to the left vaginal fornix (arrow). (c) Coronal US scan shows a 14-F catheter (arrow), which was advanced into the fluid collection via the left vaginal fornix. (d) Sagittal US scan obtained after aspiration and irrigation shows no residual fluid collection with the catheter in place (arrow). One hundred milliliters of purulent material was drained. Cultures demonstrated E coli. The patient responded to drainage with resolution of the septic parameters; however, 48 hours after catheter placement, the catheter became dislodged. The fluid collection was incompletely drained, and the patient ultimately required surgical drainage of the abscess; however, surgical drainage was able to be performed after the patient was hemodynamically stable and out of the intensive care unit.
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Figure 11c. Drainage with a portable unit of a tubo-ovarian abscess in a 63-year-old woman with fever, leukocytosis, and hypotension 2 months after laparoscopic appendectomy. (a) Axial CT scan shows a large pelvic abscess containing an air-fluid level and extravasated oral contrast material (arrow). The patient was in septic shock, and her condition was too unstable for her to leave the intensive care unit; transvaginal drainage was performed. Intestine and bone completely obscured the transabdominal and transgluteal drainage routes. (b) Coronal US scan obtained with a portable unit shows the complex fluid collection within the cul-de-sac very close to the left vaginal fornix (arrow). (c) Coronal US scan shows a 14-F catheter (arrow), which was advanced into the fluid collection via the left vaginal fornix. (d) Sagittal US scan obtained after aspiration and irrigation shows no residual fluid collection with the catheter in place (arrow). One hundred milliliters of purulent material was drained. Cultures demonstrated E coli. The patient responded to drainage with resolution of the septic parameters; however, 48 hours after catheter placement, the catheter became dislodged. The fluid collection was incompletely drained, and the patient ultimately required surgical drainage of the abscess; however, surgical drainage was able to be performed after the patient was hemodynamically stable and out of the intensive care unit.
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Figure 11d. Drainage with a portable unit of a tubo-ovarian abscess in a 63-year-old woman with fever, leukocytosis, and hypotension 2 months after laparoscopic appendectomy. (a) Axial CT scan shows a large pelvic abscess containing an air-fluid level and extravasated oral contrast material (arrow). The patient was in septic shock, and her condition was too unstable for her to leave the intensive care unit; transvaginal drainage was performed. Intestine and bone completely obscured the transabdominal and transgluteal drainage routes. (b) Coronal US scan obtained with a portable unit shows the complex fluid collection within the cul-de-sac very close to the left vaginal fornix (arrow). (c) Coronal US scan shows a 14-F catheter (arrow), which was advanced into the fluid collection via the left vaginal fornix. (d) Sagittal US scan obtained after aspiration and irrigation shows no residual fluid collection with the catheter in place (arrow). One hundred milliliters of purulent material was drained. Cultures demonstrated E coli. The patient responded to drainage with resolution of the septic parameters; however, 48 hours after catheter placement, the catheter became dislodged. The fluid collection was incompletely drained, and the patient ultimately required surgical drainage of the abscess; however, surgical drainage was able to be performed after the patient was hemodynamically stable and out of the intensive care unit.
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Seldinger Technique versus Trocar Technique
Most authors who advocate transvaginal routes of drainage use the Seldinger technique for catheter delivery, which requires a combination of US for the initial needle placement and fluoroscopy for tract dilation (27–30). Placement of catheters with the Seldinger technique requires multiple steps: needle introduction, wire insertion, serial tract dilation, and catheter delivery. Although the Seldinger technique works well for catheter placement in most locations, it is particularly problematic when used in the transvaginal route because tract dilation through the thick muscular vaginal fornix is arduous and the distance of the operator’s hands from the point of wire insertion can lead to wire kinking and displacement during exchanges. These technical limitations of the Seldinger technique when used during transvaginal abscess drainage increase both procedure time and patient discomfort.
Only a few descriptions of the trocar method of catheter delivery during use of the transvaginal route for abscess drainage are found in the literature. Hovsepian (30) and Nosher et al (31) described a method of trocar drainage of pelvic fluid collections via the transrectal route by using transabdominal imaging. These authors placed a gloved finger alongside the catheter within the rectum or vagina to serve as a guide for catheter placement. This method involves the risk of a needle stick for the operator and does not take advantage of the continuous real-time imaging afforded by the endoluminal probe guide to ensure accurate catheter placement. vanSonnenberg et al (29) reported a case in which transvaginal drainage was performed with US and the trocar technique, but they did not elaborate on the type of guide used or the mode of catheter delivery.
McGahan et al (32) successfully used the trocar technique for transvaginal catheter drainage of pelvic abscesses in a small series of patients by attaching the catheter directly to the endoluminal probe along the needle guide groove with rubber bands. Because they did not use a physical guide to secure the catheter to the probe, manual stabilization of the catheter in the rectum or vagina by the operator was necessary. A simple trocar method of catheter placement that adapts the existing needle guide of endoluminal US probes to stabilize the catheter along the probe guide tract is described in the remainder of this section. The modified guide can be easily removed from both the probe and the catheter, allowing safe, quick, and easy drainage of deep pelvic fluid collections.
Patient Preparation
Patients are prepared for transvaginal drainage in a similar fashion as for aspiration and biopsy.
Equipment
The equipment for transvaginal trocar drainage is listed in Table 4.
Guide and Probe Preparation
To deliver a trocar catheter by using the transvaginal probe guide, the guide apparatus needs to be modified to allow placement of large-bore catheters and removal of the guide from the catheter after deployment. One way of accomplishing this goal is to attach a simple peel-away sheath (Cook, Bloomington, Ind) to the probe in the groove meant for the guide by using sterile rubber bands. However, in most instances, the peel-away sheath is not quite stiff enough to hold the catheter in place along the guide.
We recommend attaching the catheter protector that comes with the trocar catheter packaging to the guide to ensure more accurate catheter delivery. This stiff plastic tube is large enough to accept up to a 14-F trocar catheter. It needs to be preslit along its length so that it can be removed from the catheter after deployment (Fig 12) and cut to the correct length so that at least 5 cm of catheter protrudes past the end of the guide when it passes through the lumen of the guide (Fig 13a). Once the modified guide has been made, it is attached to the probe along the groove intended for the metal probe guide. First, coupling gel is placed within a sterile probe cover and the transvaginal probe is covered. The modified guide is then attached to the probe in the same location where the needle guide would be attached and secured by means of proximal and distal rubber bands. Care is taken to ensure that the guide does not project past the transducer head (Fig 14). The entire probe-guide assembly is then covered with a second sterile probe cover. This cover will be punctured during catheter placement.
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Figure 12a. Modified guide. (a) Photograph shows a scalpel blade advanced along one surface of the plastic catheter protector to fashion a very stiff guide that can be peeled off the catheter once the catheter has been delivered. (b) Schematic shows the modified probe guide. Before the modified guide is attached to the probe, the distal end of the slit is splayed (arrows) to ease the peeling away process.
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Figure 12b. Modified guide. (a) Photograph shows a scalpel blade advanced along one surface of the plastic catheter protector to fashion a very stiff guide that can be peeled off the catheter once the catheter has been delivered. (b) Schematic shows the modified probe guide. Before the modified guide is attached to the probe, the distal end of the slit is splayed (arrows) to ease the peeling away process.
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Figure 13a. Catheter delivery and probe-guide removal. (a) Photograph shows the trocar catheter advanced through the guide and projecting approximately 5 cm past the end of the probe (arrow). The guide needs to be cut to the right length to allow at least 5 cm of catheter advancement so that the catheter can be advanced through the vaginal vault. (b) Photograph shows that the catheter has been fed off and the pigtail has been formed (straight white arrow). The inner needle of the trocar has been removed for safety, but the outer metal cannula stiffener (curved arrow) is left in the straight portion of the catheter to stiffen it and ease the peeling away of the guide from the catheter (black arrow).
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Figure 13b. Catheter delivery and probe-guide removal. (a) Photograph shows the trocar catheter advanced through the guide and projecting approximately 5 cm past the end of the probe (arrow). The guide needs to be cut to the right length to allow at least 5 cm of catheter advancement so that the catheter can be advanced through the vaginal vault. (b) Photograph shows that the catheter has been fed off and the pigtail has been formed (straight white arrow). The inner needle of the trocar has been removed for safety, but the outer metal cannula stiffener (curved arrow) is left in the straight portion of the catheter to stiffen it and ease the peeling away of the guide from the catheter (black arrow).
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Figure 14. Probe-guide assembly. The modified guide is securely attached to the probe with two sterile rubber bands (straight arrows). It should not project past the transducer head (curved arrow).
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Catheter Deployment
The initial steps used in transvaginal drainage are identical to those used for transvaginal aspiration. Before placement of a large-bore catheter in a suspected pelvic abscess, diagnostic aspiration should always be performed.
Once the aspiration confirms the presence of pus, the aspiration needle is removed and the trocar is advanced to the surface of the vaginal fornix. With slow, steady forward pressure, the trocar is advanced through the vaginal wall into the collection under continuous US guidance. No routine local anesthesia is used because of the low likelihood that the same site will be used for actual catheter puncture. The catheter is then fed off the trocar assembly approximately 2.5 cm to allow pigtail formation and the pigtail is secured (Fig 13b). The sharp inner component of the trocar assembly is then removed, leaving the outer metal stiffener in the lumen of the catheter. The modified guide-catheter combination is then separated from the probe by first cutting away the distal rubber band and outer probe cover. The probe is carefully pulled out of the vaginal vault, then the proximal rubber band is cut and the guide is detached from the probe. Once the probe has been separated, the plastic guide is peeled away from the catheter. Leaving the metal stiffener in the lumen of the catheter greatly facilitates this process (Fig 13b). The metal stiffener is then removed, leaving the catheter in place.
Postprocedure Catheter Care
At the time of catheter placement, the catheter is attached to a gravity drainage system; then, the fluid collection is aspirated and irrigated until clear with sterile saline solution. A rubber band is placed around the proximal thigh, and the catheter is secured to the band at the anterior aspect of the thigh. The catheter is taped with slight slack so that it stays anteriorly located in the perineum and out of the fecal stream. The catheter is flushed every 8 hours with 10 mL of sterile saline solution. Catheter output is monitored with daily rounds. Once the catheter output totals less than 10 mL per day, CT or US is performed to ensure resolution of the fluid collection and the catheter is removed.
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Complications
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Abstract
Introduction
