IR-Guided Access to Uterine Cavity in a Case of Severe Cervical Stenosis

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Video Description

A 42-year-old G1P1 woman presented with a history of adenocarcinoma in situ that was treated with a complete LEEP excision.

She had severe cervical stenosis with no external os visible that prevented ongoing endocervical monitoring. Due to a desire to preserve fertility, she declined a hysterectomy. She underwent multiple attempted hysteroscopies without any success.

Thus, she was booked for an interventional radiology (IR)-guided cannulation of her cervix and hysteroscopic release of cervical stenosis. Here, we demonstrate a case of IR-guided access to uterine cavity in a case of severe cervical stenosis.

Presented By

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Dr. Caroline Lee
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Dr. Lindsay Machan
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Dr. Neeraj Mehra


University of British Columbia

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What is IR-Guided Access to Uterine Cavity in a Case of Severe Cervical Stenosis?

IR-guided access to the uterine cavity in a case of severe cervical stenosis involves the use of interventional radiology (IR) techniques to safely navigate and dilate the cervical canal, which is abnormally narrowed in cervical stenosis. Cervical stenosis is a condition where the entrance to the uterus, the cervix, becomes significantly narrowed or completely closed due to various causes such as previous surgical procedures, radiation therapy, or certain medical conditions.

In cases of severe cervical stenosis, traditional methods of accessing the uterine cavity, such as dilatation and curettage (D&C) under direct visualization, may be difficult, risky, or impossible. IR-guided access utilizes real-time imaging techniques, such as fluoroscopy (live X-ray), to accurately guide the insertion of instruments through the narrowed cervix. This method allows for precise dilatation of the cervix and enables access to the uterine cavity for further procedures, such as hysteroscopy, endometrial biopsy, or intrauterine device (IUD) placement, with minimized risk of injury to the cervix or uterine wall.

What are the Risks of IR-Guided Access to Uterine Cavity in a Case of Severe Cervical Stenosis?

The use of interventional radiology (IR)-guided access to the uterine cavity in cases of severe cervical stenosis, while beneficial for navigating through the narrowed cervix and facilitating various uterine procedures, carries its own set of potential risks and complications. These include:

  • Infection: Any procedure that involves entering the uterine cavity carries a risk of introducing bacteria, potentially leading to infection of the uterus or pelvic region.
  • Bleeding: The process of dilating the cervix and accessing the uterine cavity can cause bleeding. While usually minimal, in some cases, it may be significant and require further intervention.
  • Uterine or Cervical Injury: The instruments used to dilate the cervix and access the uterus may inadvertently cause injury to these structures, such as perforation or tearing, which could necessitate additional treatment or surgical repair.
  • Radiation Exposure: Although the radiation dose used in IR-guided procedures is typically low, there is a risk associated with exposure to ionizing radiation, particularly with repeated procedures.
  • Contrast Allergy: If contrast material is used during the procedure for better visualization, there is a risk of allergic reaction to the contrast agent, ranging from mild to severe.
  • Failure to Access: In some cases, despite the use of IR guidance, severe cervical stenosis may still prevent successful access to the uterine cavity, necessitating alternative approaches.
  • Post-Procedure Pain: Patients may experience discomfort or pelvic pain following the procedure, usually temporary and manageable with medication.

Despite these risks, IR-guided access is often chosen for its precision, minimally invasive nature, and the potential to avoid more invasive surgical procedures. It’s important for patients to discuss these risks thoroughly with their healthcare provider, considering the benefits of the procedure against the potential complications, to make an informed decision. Healthcare providers will take measures to minimize these risks, including the use of sterile techniques, careful monitoring during the procedure, and post-procedure follow-up care.

Video Transcript: IR-Guided Access to Uterine Cavity in a Case of Severe Cervical Stenosis

The purpose of this video is to demonstrate an IR-guided approach to accessing the uterine cavity in a case of severe cervical stenosis. The authors have no relevant conflicts of interest to disclose. Here we present a case of a 42-year-old woman with a history of adenocarcinoma in situ and a complete LEEP excision. Ongoing follow-up was required to monitor her endocervical status, but this could not be completed due to severe cervical stenosis of both the internal and external cervical os.

At initial counselling she expressed a strong desire to preserve her fertility and thus declined a hysterectomy. Multiple attempted hysteroscopies had been performed with the goal of locating her cervical canal and gaining access to her uterine cavity. Thus we planned for an interventional radiology-guided cervical cannulation and hysteroscopy guided release of cervical stenosis. Leading up to the procedure, she declined menstrual suppression, despite ongoing cyclical pelvic pain. On the day of her procedure, she underwent a preoperative endovaginal ultrasound.

The ultrasound revealed moderate distension of the cervical canal and mild to moderate distension of the endometrial cavity. These findings had not been seen on previous ultrasounds. This video demonstrates a dynamic transverse view of the uterine cavity and the cervical canal on ultrasound. Under Fleroscopic guidance, we gained access to their uterine cavity. Distension of the uterus and cervix was seen. A loop catheter was positioned in the cervical canal and 400 millilitres of fluid was collected.

The patient was then brought from the interventional radiology suite to the operating suite. The 8.5 French pigtailed catheter was removed, leaving the guide wire in place. We used a vaginoscopy approach to follow the guide wire up to the endocervical canal. Hysteroscopic scissors were then used to lyse the cervical stroma and gain access to the endocervical canal. The hysteroscope was then removed and os finders were used to enter the cervix. We confirmed that we had entered the uterine cavity after we identified the release of menstrual fluid.

The cervix was serially dilated, first with larger os finders and subsequently with Pratt dilators. The hysteroscope was reinserted and the uterine cavity could now be evaluated. We noted that the guide wire had entered the uterine cavity just anterior to the true internal cervical os. Once we were in the uterine cavity, we were able to identify the left cornea and right cornea. A panoramic view of the uterine cavity revealed a thin endometrial lining. This final view illustrates the uterus and the dilated cervical canal just below it.

Subsequently, an endocervical curettage was performed. A 24 French Foley catheter was used as a uterine and cervical stent. This was then secured in place. She was discharged on the same day with a seven-day prescription for doxycycline and metronidazole. The uterine and cervical stent was removed on postoperative day number seven. The final pathology revealed fibrovascular tissue with scanty fragments of endometrial and endocervical tissue.

In conclusion, IR-guided cervical and uterine cannulation was successful in this patient with complete external cervical os stenosis. Access into the uterus and cervix was assisted by the fact that the patient was not on mental suppression and the subsequent development of hematometras and hematocolpos. This technique is a useful alternative method to consider in cases of failed hysteroscopic attempts due to cervical stenosis.