Low-Invasive Imaging Guided Low-Invasive Imaging Guided Treatment of Tubo-Ovarian Treatment of Tubo-Ovarian

AbscessAbscess

Malkhaz Mizandari, MD, PhDMalkhaz Mizandari, MD, PhDUltrasound Education Centre Ultrasound Education Centre

“GEOJEFF”“GEOJEFF”State Medical UniversityState Medical University

Tbilisi, GeorgiaTbilisi, Georgia

Etiology-PathogenesisEtiology-Pathogenesis

TOA is a complication of PIDTOA is a complication of PID (15.0 to 30.0% of cases)(15.0 to 30.0% of cases)

PathogenesisPathogenesis Ascending lower genital tract infectionAscending lower genital tract infection Tube epithelium inflammation and necrosisTube epithelium inflammation and necrosis a) Aa) Altered pH ltered pH b) Devitalized or necrotic tissue from infectionb) Devitalized or necrotic tissue from infection c) Impaired blood supply from edema c) Impaired blood supply from edema d) Pathogenic organism growth d) Pathogenic organism growth

DiagnosisDiagnosis- - Clinical Findings

Pain in Small PelvisPain in Small Pelvis

High TemperatureHigh Temperature

Vaginal Discharge (Purulent)Vaginal Discharge (Purulent)

Painful Mass in Adnexal RegionPainful Mass in Adnexal Region

Tenderness or Pain of Cervix on Physical Tenderness or Pain of Cervix on Physical ExaminationExamination

Diagnosis - ImagingDiagnosis - Imaging

UltrasoundUltrasound

CT CT

MR imagingMR imaging

Ultrasound DiagnosisUltrasound Diagnosis

Irregularly Shaped Mass in AdnexaIrregularly Shaped Mass in Adnexa

Thick WallsThick Walls

Complex Mass (Predominantly Cystic)Complex Mass (Predominantly Cystic)

Internal Septi Internal Septi

Fluid-Fluid LevelFluid-Fluid Level

Fluid-Debris levelFluid-Debris level

Gas (Gas-Forming Microorganizms)Gas (Gas-Forming Microorganizms)

Often Adnexal Region Occupied BilaterallyOften Adnexal Region Occupied Bilaterally

MicrobiologyMicrobiology

The Most Common Primary Causes:The Most Common Primary Causes: a) a) Chlamydia trachomatisChlamydia trachomatis b) Neisseria gonorrheab) Neisseria gonorrhea

Less CommonLess Common Gardneralla vaginalis, PeptostreptococcusGardneralla vaginalis, Peptostreptococcus sp, sp,

Streptococcus agalectiae, UreaplasmaStreptococcus agalectiae, Ureaplasma sp, sp, Mycobacterium tuberculosisMycobacterium tuberculosis, Haemophilus influenzae,, Haemophilus influenzae, ActinomycesActinomyces

Supplemented InfectionSupplemented Infection Escherichia Coli Escherichia Coli

TreatmentTreatment

Medical (Broad Spectrum Antibiotics for PIDMedical (Broad Spectrum Antibiotics for PID))

TOA - Content Evacuation:TOA - Content Evacuation: SurgerySurgery

Surgical options include laparoscopy or laparotomy with Surgical options include laparoscopy or laparotomy with unilateral adnexectomy or total abdominal hysterectomy unilateral adnexectomy or total abdominal hysterectomy with bilateral oophorectomywith bilateral oophorectomy

Low-Invasive Low-Invasive InterventionIntervention

Imaging guided percutaneal or endocavity Imaging guided percutaneal or endocavity

aspiration/drainage:aspiration/drainage: a) CT b) Ultrasound c)Combined (Ultrasound-a) CT b) Ultrasound c)Combined (Ultrasound-

Fluoroscopy) Fluoroscopy)

Invasive Ultrasound - Invasive Ultrasound - AdvantagesAdvantages

No Ionizing RadiationNo Ionizing Radiation

Real-Time TechniqueReal-Time Technique

Doppler CapabilityDoppler Capability

Puncture Aiming and Needle Puncture Aiming and Needle Movement Guidance CapabilityMovement Guidance Capability

Abdominal and Endocavity Abdominal and Endocavity ApproachApproach

Cost-SavingCost-Saving

Material and MethodsMaterial and Methods

TOA – 28 patientsTOA – 28 patients

Percutaneal approach (Drainage) – 4 patientsPercutaneal approach (Drainage) – 4 patients

Perrectal approach (Aspiration, Rinsing) – 4 Perrectal approach (Aspiration, Rinsing) – 4 patientspatients

Pervaginal approach (Aspiration, Rinsing) – 22 Pervaginal approach (Aspiration, Rinsing) – 22 patient patient

(Note – all patients received antibiotics according (Note – all patients received antibiotics according the findings of bacteriology of aspirated material) the findings of bacteriology of aspirated material)

ProceduresProcedures

Rinsing (Saline and Antiseptics) was performed Rinsing (Saline and Antiseptics) was performed to all patientsto all patientsProteolythic Enzyme Injection was performed to Proteolythic Enzyme Injection was performed to

6 patients because of inadequate rinsing due 6 patients because of inadequate rinsing due to TOA Septi and viscous contentto TOA Septi and viscous contentSingle Procedure - 7 patients total (2 Single Procedure - 7 patients total (2 percutaneal drainages and 5 aspirations)percutaneal drainages and 5 aspirations)2 procedures – 10 patients (among them – 1 2 procedures – 10 patients (among them – 1 after percutaneal drainage)after percutaneal drainage)3 and more procedures – 11 patients (among 3 and more procedures – 11 patients (among them – 1 after percutaneal drainage)them – 1 after percutaneal drainage)

Abdominal vs. endocavity Abdominal vs. endocavity approach - Indicationsapproach - Indications

Abdominal Approach – Relatively Big Abdominal Approach – Relatively Big Mass, Fixed to Anterior Abdominal Wall Mass, Fixed to Anterior Abdominal Wall (advantage – Drainage Easily Performed)(advantage – Drainage Easily Performed)

Rectal Approach – Big Amount of Purulent Rectal Approach – Big Amount of Purulent Vaginal Discharge, Painful Vaginal Vaginal Discharge, Painful Vaginal Examination, Virgo PatientExamination, Virgo Patient

Vaginal Approach – Small Masses Easily Vaginal Approach – Small Masses Easily Achievable for Puncture Achievable for Puncture

Needle Inserted in TOA

Saline Injection

Rinsing (Bubbles in TOA cavity)

Betadine Injected

Aspiration (Cavity is Collapsing)

Aspiration (Cavity is Collapsing)

Aspiration (Cavity Collapsed)

ResultsResults

Positive Result was Achieved in 27 Positive Result was Achieved in 27 (96.6%) cases(96.6%) cases

Open Surgery RequiredOpen Surgery Required ( (TTotal otal Abdominal Hysterectomy with Bilateral Abdominal Hysterectomy with Bilateral Oophorectomy) – 1 (3.4Oophorectomy) – 1 (3.4 %) %) casecase

SummarySummary

Low-Invasive Treatment (LIT) under Imaging Low-Invasive Treatment (LIT) under Imaging Guidance Control Is Safe, Effective and Cost-Guidance Control Is Safe, Effective and Cost-Saving TechniqueSaving Technique

LIT is Easily Tolerated by Patients (Multiple LIT is Easily Tolerated by Patients (Multiple Procedures)Procedures)

Combination of Percutaneal Drainage and Combination of Percutaneal Drainage and Endocavity Aspiration Might Be HelpfulEndocavity Aspiration Might Be Helpful

LIT Should Be Used as a First Choice Treatment LIT Should Be Used as a First Choice Treatment Procedure in TOA Patients ManagementProcedure in TOA Patients Management