DOI: 10.1148/rg.226025039
(Radiographics. 2002;22:1353-1367.)
© RSNA, 2002
CT-guided Transgluteal Drainage of Deep Pelvic Abscesses: Indications, Technique, Procedure-related Complications, and Clinical Outcome1
Mukesh G. Harisinghani, MD,
Debra A. Gervais, MD,
Peter F. Hahn, MD, PhD,
Chie Hee Cho, MD,
Kartik Jhaveri, MD,
Jose Varghese, MD and
Peter R. Mueller, MD
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).
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Abstract
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Deep pelvic abscesses may present a unique challenge for percutaneous drainage because of numerous overlying structures, which preclude safe percutaneous access. These structures include the pelvic bones, intestine, bladder, iliac vessels, and gynecologic organs. Use of the transgluteal approach to drain these abscesses can circumvent these obstacles and provide a useful surgical alternative or a temporizing measure. The transgluteal approach requires a thorough understanding of the anatomy of the sciatic foramen region and associated anatomic structures. The ideal approach for transgluteal access is to insert the catheter as close to the sacrum as possible, at the level of the sacrospinous ligament. Transgluteal drainage can be performed with the tandem-trocar technique or the Seldinger technique. Modifications of the procedure are needle aspiration not followed by catheter placement, use of the angled gantry technique, bilateral transgluteal drainage, combined anterior and posterior drainage, and drainage of necrotic pelvic masses. The transgluteal approach is a useful option in pediatric patients. Daily catheter care is essential for successful percutaneous catheter therapy. Although pain has been cited as a common complication of the technique, this complication can be minimized with judicious use of analgesia and a meticulous technique. Other complications are hemorrhage and catheter malposition.
© RSNA, 2002
Index Terms: Abscess, percutaneous drainage, 875.1263 • Computed tomography (CT), guidance • Pelvic organs, abscess, 875.211 • Pelvic organs, interventional procedures, 875.1263
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LEARNING OBJECTIVES
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After reading this article and taking the test, the reader will be able to:
- Discuss the anatomic basis for the transgluteal approach in draining deep pelvic abscesses.
- Identify the two ways of performing transgluteal drainage.
- Describe the complications of the transgluteal approach and how to avoid them by using a meticulous technique.
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Introduction
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Percutaneous abscess drainage is the standard of care in the absence of indications for immediate surgery. For some patients, percutaneous abscess drainage may offer a safe surgical alternative or a temporizing measure for the surgery, with a subsequent surgical option depending on the nature and extent of underlying disease (1–4). A variety of disorders, as outlined in the Table, can produce fluid collections in the lower abdomen and pelvis. These fluid collections can be drained in several ways, with the success and safety of percutaneous therapy depending on safe access route planning. Although the transabdominal approach is the simplest, it may not always be feasible due to interposed intestine and other pelvic viscera (5) (Fig 1). The transgluteal approach is a useful and effective alternative in draining deep pelvic abscesses (5–8), as initially reported by Butch et al (7).
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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.
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The purpose of this article is to provide an overview of the various aspects of computed tomography (CT)–guided transgluteal drainage. Specific topics discussed are the relevant anatomy, access route planning, patient preparation, the technique of catheter placement, modifications of the technique, drainage in pediatric patients, postprocedure catheter care, and complications.
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Relevant Anatomy
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The transgluteal approach requires precise anatomic knowledge of the region to plan a safe approach to the deep-seated fluid collection and also to avoid known side effects and complications. The following is a brief anatomic description of the region pertinent to transgluteal drainage, with subsequent application of these anatomic principles to axial CT.
The greater sciatic foramen is an oval space in the posterolateral aspect of the pelvis, lying inferior to the sacroiliac articulation (Fig 2). It is bordered by the sacrum posteriorly, the sacrospinous ligament inferiorly, the ischium anteriorly, and the ilium superiorly. The piriformis muscle originates from the ventral surface of the sacrum and passes through the center of the greater sciatic foramen (Fig 3), inserting onto the greater trochanter of the femur. Lying anterior to the piriformis muscle is the sacral plexus, which continues inferiorly as the sciatic nerve. The superior and inferior gluteal arteries and veins also cross the foramen in the more cephalic aspect (Fig 4). The sacrospinous ligament, which extends from the sacrum to its insertion on the ischial spine, is an important landmark, as it marks the inferior aspect of the greater sciatic foramen (Fig 5) and all the major vascular and neural structures are located cephalad to this ligament.
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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.
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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.
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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.
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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.
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It is important to translate the described anatomic principles to the axial CT images, for planning a safe access and thus avoiding major anatomic structures (Figs 6, 7).
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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.
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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.
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Access Route Planning
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Typically, for the transgluteal approach, the patient is positioned in the prone, prone oblique, or lateral decubitus position. The ideal approach for transgluteal access is to insert the catheter as close to the sacrum as possible, at the level of the sacrospinous ligament (Fig 8). At this level, as described earlier, the sciatic nerve is situated more laterally and can be easily avoided. Although the preference is to have an infrapiriformis approach to avoid the gluteal vessels and sacral plexus lying anterior to the piriformis muscle, this may not always be possible. In these situations, the sciatic nerve, sacral plexus, and gluteal vessels can be avoided by planning the entry as close to the sacrum as possible (Fig 9).
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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.
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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).
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Patient Preparation
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Prior to drainage, all patients are screened and any coagulopathies are corrected. If the patient is not receiving antibiotics, a broad-spectrum intravenous antibiotic is given 1 hour before the procedure. Administration of antibiotics immediately prior to the procedure does not interfere with cultures of fluid aspirated from the collection. The procedure is performed with a combination of intravenous conscious sedation, achieved with intravenous fentanyl and Versed (midazolam; Hoffmann–La Roche, Nutley, NJ), and local anesthesia. General anesthesia is reserved for pediatric patients and uncooperative adult patients.
Correct identification of the pelvic intestine before and during the procedure is required to plan a safe approach and also to avoid mistaking unenhanced bowel loops for an abscess. The latter is particularly important in postsurgical patients (Fig 10), who may have nonobstructive ileus.
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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.
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Technique of Catheter Placement
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Transgluteal drainage may be performed by using the tandem-trocar technique or the Seldinger technique.
Tandem-Trocar Technique
Catheter Selection.—
Although trocar catheters are available from 8 F to 16 F, at our institution we routinely use 10.2-F and 14-F catheters (Ultrathane catheters with Slip Coat hydrophilic coating; Cook, Bloomington, Ind) for transgluteal drainage. These catheters, by virtue of their hydrophilic coating, have the ability to absorb and retain water when wet, thereby reducing the friction coefficient, greatly increasing ease of insertion. The catheter tip has a locking pigtail configuration for retention.
Technique.—
An initial diagnostic scan is obtained with the skin marker in place (Fig 11). The distance of the abscess from the skin is measured by using a safe approach, applying the anatomic principles described earlier. A 20-gauge needle is inserted into the collection under CT guidance. Initial needle placement allows assessment of the characteristics of the fluid and also provides a sample for Gram stain and culture. In addition, the depth of the abscess cavity is confirmed with the needle, outlining the path for subsequent catheter placement. Care is taken not to decompress the abscess cavity. The drainage catheter is loaded with a metal stiffening cannula and inner trocar. The depth of the abscess cavity is noted on the catheter. The catheter is placed through a skin incision near the needle and is advanced perfectly parallel to the needle. With this technique, the catheter tip is guided to the abscess cavity by the needle. Once the catheter has reached the desired depth, the inner stylet is removed and the catheter is fed off of the metal cannula into the abscess cavity. The collection is completely evacuated. Postplacement CT is performed to confirm the final position of the catheter around the collapsed cavity. The catheter is secured to the skin by means of an adhesive retention device and connected to a bag for gravity drainage.
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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.
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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.
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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.
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During placement, if "accordioning" of the catheter is encountered, the exact position of the tip should be checked with CT, as this usually implies malposition of the catheter tip.
Advantages.—
Advantages of the tandem-trocar technique are as follows:
- The stiffness of the catheter-cannula-stylet combination allows more directional control of the catheter when traversing the large gluteal muscle mass.
- It does not require serial dilation. This is particularly important in patients with well-developed gluteal muscles, in whom serial dilations can be more painful.
- Single-step placement is achieved.
- It is more rapid than the Seldinger technique.
Disadvantages.—
Disadvantages of the tandem-trocar technique are as follows:
- Larger complex abscess cavities with a larger surface area may require a multi–side-hole catheter for drainage. The catheters used for the tandem-trocar technique typically have fewer side holes than some catheters that can be placed only with the Seldinger technique. However, this can be overcome by creating additional side holes along the catheter shaft.
- It is difficult to reposition the catheter in cases of malposition. In these cases, reinsertion is necessary. Malposition can also be minimized by meticulous attention to detail in placing the catheter parallel to the guiding needle.
Seldinger Technique
Catheter Selection.—
The 10.2-F and 12-F trocar catheters (Ultrathane catheters with Slip Coat hydrophilic coating; Cook) can also be used with the Seldinger technique for transgluteal drainage. However, in large, complex, multiloculated abscesses, it may be preferable to use a multi–side-hole catheter such a 10- or 12-F Cope catheter (Cook). In addition to the catheter, the Seldinger technique uses an 18-gauge sheathed needle (Long Dwell needle; Baxter Healthcare, Round Lake, Ill). The outer sheath allows insertion of a 0.038-inch guide wire through it into the collection.
Technique.—
After acquisition of the initial localizing scan for assessing the depth of and approach to the pelvic abscess, an 18-gauge sheathed needle is advanced into the fluid collection (Fig 12). The position of the needle in the cavity is confirmed with CT, and the outer sheath is advanced from the trocar needle. The needle is then removed. A 0.038-inch guide wire with a floppy tip is inserted through the sheath and coiled in the cavity. The sheath is then removed over the wire, and serial dilation is performed with dilators. We typically dilate to 12 F. Once dilatation has been achieved, the catheter of choice is advanced over the wire, taking care to ensure that all side holes are within the cavity for adequate drainage and to avoid contamination of the adjacent spaces.
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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.
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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.
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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.
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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.
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Advantages.—
Advantages of the Seldinger technique are as follows:
- It may facilitate drainage of large, multiloculated, deep pelvic fluid collections.
- It is more controlled than the tandem-trocar technique and hence may be useful in difficult-to-access fluid collections.
Disadvantages.—
Disadvantages of the Seldinger technique are as follows:
- It is time-consuming compared with the tandem-trocar technique. The Seldinger technique may also be more painful in patients with well-developed gluteal muscles.
- The guide wire is not visualized in its entirety due to the axial CT acquisition. Hence, guide-wire kinking may increase the complexity of the case. This problem can be resolved by repeating the scout image instead of an axial acquisition when advancing the guide wire into the cavity.
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Modifications of the Technique
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Needle Aspiration Not Followed by Catheter Placement
The technique of needle aspiration only is reserved for certain specific indications. It should be performed in aspiration of noncomplex fluid collections, especially postsurgical hematomas, where the question is to ascertain the presence of infection (Figs 13, 14). In these situations, needle aspiration is performed, followed by a Gram stain. If the returning aspirate is infected, then needle aspiration should be followed by catheter placement. The viscous nature of the fluid may make aspiration difficult; hence, if no aspirate is obtained with the 20-gauge needle, aspiration with an 18-gauge needle should be tried.
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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.
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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.
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Use of Angled Gantry Technique
The development of abscesses in the upper pelvis, especially in patients with appendicitis or Crohn disease, can pose a challenge for percutaneous drainage. This is due to the central location of the cavity, which is surrounded by the intestine anteriorly and the bony pelvis posteriorly. In these cases, we have resorted to the angled gantry technique. Angling the CT gantry can provide an approach route free of the overlying intestine and bony pelvis (Fig 15).
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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).
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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).
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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).
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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).
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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).
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Bilateral Transgluteal Drainage
The presence of separate bilateral pelvis abscesses (Fig 16) or a complex multiloculated abscess requires drainage by two separate catheters inserted from opposite sides. Deployment of bilateral catheters may make it uncomfortable for the patient to lie prone.
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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.
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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.
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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.
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Combined Anterior and Posterior Drainage
Occasionally, complex postsurgical or diverticular abscesses accumulate in a manner that requires simultaneous anterior and posterior approaches for adequate drainage. This combined drainage technique (Fig 17) requires optimal enhancement of the intestine to prevent inadvertent bowel catheterization. Although placement of the two catheters on the same side of the abdomen and in the same axial plane is desirable, this may not always be possible and placement should be guided by the size and shape of the abscess.
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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.
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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.
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Drainage of Necrotic Pelvic Masses
Rarely, transgluteal drainage can be used in palliative therapy for a large necrotic or infected pelvic tumor. This technique, although not routine practice, is used as a last resort for preterminal patients who are poor surgical risks, especially if the mass is causing intractable pain, infection, or bowel obstruction (Fig 18).
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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).
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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).
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Drainage in Pediatric Patients
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In a recent original report, Gervais et al (5) described successful use of the transgluteal approach in draining deep pelvic abscesses in seven pediatric patients, who ranged in age from 3 to 12 years. In children, percutaneous catheter therapy for deep pelvic abscesses is restricted to the transrectal and transgluteal approaches, as the transvaginal approach is not possible. However, the transrectal approach may be limited by a relatively high position of the abscess relative to the rectum, leaving the transgluteal approach as a useful option. The tandem-trocar technique or Seldinger technique can be used effectively. Catheter sizes ranging from 8 to 10 F can be used in most children except in neonates, in whom smaller sizes (7 F) may be required. Common pediatric deep pelvic abscesses amenable to transgluteal drainage include those due to perforated appendicitis (Fig 19) and postsurgical abscesses. In the former, the technique can be used as a temporizing measure prior to elective appendectomy, offering a relatively clean surgical field following successful percutaneous therapy.
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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.
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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.
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Postprocedure Catheter Care
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Daily catheter care is an essential requisite for successful percutaneous catheter therapy. At our institution, the interventional team involved in placing the catheter provides this service, thereby making important decisions regarding the catheter.
After placement, catheters are left to gravity drainage and daily catheter outputs are monitored in addition to the patient’s vital signs. Daily irrigation of the catheter is performed every 8 hours with 10-mL aliquots of normal sterile saline solution. Of the 10 mL, 5 mL is flushed into the cavity and 5 mL is flushed into the tubing to clear any debris. The patient is seen on a daily basis by the interventional radiology service. During these daily rounds, the catheter position is inspected and the patient is questioned regarding tolerance to the catheter. Decisions to remove the catheter are based on clinical and imaging criteria. Positive clinical signs include a reduced fever, improvement in white blood cell count, and constitutional improvement. Catheter-related criteria relate to a diminution in daily drainage amounts, which is usually associated with an improvement in the imaging appearance of the disease process. Care needs to be exercised to make sure that the diminution in daily catheter outputs is not due to debris clogging the catheter.
Although it is not necessary to specifically examine all patients for a fistulous communication with the intestine prior to catheter removal, attention should be paid to the tube output to ensure that it decreases over time. A fistulous communication to the intestine is suspected when catheter outputs continue to remain high and change in character from pus to bowel contents. In these instances, the catheter should be left in place until definitive surgery is performed or repeated catheter injection confirms resolution of the fistula.
Transcatheter thrombolytic agents can be used in complex multiloculated abscesses or infected pelvic hematomas to lyse the intervening septa and facilitate effective catheter drainage. At our institution, we typically administer 125,000 U of streptokinase twice a day for 3 days through the catheter. After transcatheter administration, the catheter is clamped for 30 minutes, after which irrigation is performed and gravity drainage is restarted. In our experience, this technique improves the success rate of percutaneous drainage in patients with multiloculated fluid collections and infected hematomas.
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Complications
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Pain
Earlier reports cited pain as the main side effect of transgluteal drainage in as many as 20% of adult patients undergoing this procedure (6–8). However, since the initial report of transgluteal drainage, advances in pain control and sedation, both for catheter placement and discomfort after the procedure, have made transgluteal catheters acceptable to most patients. Procedure-related pain can be divided into three broad categories: (a) pain radiating to the leg during the procedure, (b) immediate postprocedure local pain, and (c) postprocedure local pain that requires sustained patient-controlled analgesia. These categories of pain can be explained on the anatomic basis outlined earlier.
Pain radiating to the leg during the procedure is most likely to happen if the needle or catheter insertion is lateral and close to the ischial spine (Fig 20), thereby irritating the sciatic nerve or sacral plexus branches.
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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.
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Immediate postprocedure pain and sustained postprocedure pain that requires patient-controlled analgesia are most often due to use of the transpiriformis approach (Fig 21). As mentioned earlier, the sacral plexus lies anterior to the piriformis muscle. Although an infrapiriformis approach avoids this problem, the location of the abscess cavity may warrant a transpiriformis approach.
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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.
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Hemorrhage
As outlined earlier, branches of the superior and inferior gluteal vessels lie anterior to the piriformis muscle in the superior aspect of the greater sciatic foramen. Hence, there is a theoretical risk of vessel injury when the transpiriformis approach is used, with the catheter placed through the center of the muscle (Fig 22). However, since the procedure is CT guided, injury to the gluteal vessels is an uncommon complication with the transgluteal approach.
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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.
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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.
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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.
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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.
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Catheter Malposition: Overshooting in Small Abscesses
Use of the tandem-trocar technique can result in malposition of the catheter beyond the expected location, especially if the abscess is small (Fig 23). Overlying taut gluteal muscle may prevent precise placement of the catheter. In some of these cases, aspirating the abscess with a needle only may suffice.
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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).
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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).
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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).
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Conclusions
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CT-guided transgluteal drainage is a safe and effective alternative to surgery for draining deep pelvic abscesses. Major complications are rare. Although intra- and postprocedure pain may occur, use of a meticulous technique and access planning can reduce the incidence.
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References
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- Bouali K, Magotteaux P, Jadot A, et al. Percutaneous catheter drainage of abdominal abscess after abdominal surgery: results in 121 cases. J Belge Radiol 1993; 76:11-14.[Medline]
- Feld R, Eschelman DJ, Sagerman JE, Segal S, Hovsepian DM, Sullivan KL. Treatment of pelvic abscesses and other fluid collections: efficacy of transvaginal sonographically guided aspiration and drainage. AJR Am J Roentgenol 1994; 163:1141-1145.[Abstract/Free Full Text]
- Fulcher AS, Turner MA. Percutaneous drainage of enteric-related abscesses. Gastroenterologist 1996; 4:276-285.[Medline]
- Gazelle GS, Haaga JR, Stellato TA, Gauderer MW, Plecha DT. Pelvic abscesses: CT-guided transrectal drainage. Radiology 1991; 181:49-51.[Abstract/Free Full Text]
- Gervais DA, Hahn PF, O’Neill MJ, Mueller PR. CT-guided transgluteal drainage of deep pelvic abscesses in children: selective use as an alternative to transrectal drainage. AJR Am J Roentgenol 2000; 175:1393-1396.[Abstract/Free Full Text]
- Ryan JM, Murphy BL, Boland GW, Mueller PR. Use of the transgluteal route for percutaneous abscess drainage in acute diverticulitis to facilitate delayed surgical repair. AJR Am J Roentgenol 1998; 170:1189-1193.[Free Full Text]
- Butch RJ, Mueller PR, Ferrucci JT, Jr, et al. Drainage of pelvic abscesses through the greater sciatic foramen. Radiology 1986; 158:487-491.[Abstract/Free Full Text]
- Mueller PR, Saini S, Wittenburg J, et al. Sigmoid diverticular abscesses: percutaneous drainage as an adjunct to surgical resection in 24 cases. Radiology 1987; 164:321-325.[Abstract/Free Full Text]
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Abstract
LEARNING OBJECTIVES
