Uterine perforation at the time of brachytherapy for carcinoma of the cervix

Abstract

Objective The reported incidence of uterine perforation by tandems at the time of vaginal brachytherapy for management of cervical cancer ranges from 1.75% to 10% per application. The potential ramifications of afterloading a tandem that is outside the uterine cavity within the pelvis are sufficiently severe, in terms of bowel injury, that a reliable means of determining tandem positioning at the time of placement is essential. Methods We examined a representative patient that underwent tandem placement for Federation Internationale of Gynecologic Oncologist (FIGO) stage Ib1 cervical Squamous Cell Carcinoma (SCCA). The information provided by conventional radiographic assessment and clinical impression was not helpful in ultimately determining tandem placement. Results Direct endoscopic visualization provided accurate and irrefutable evidence of tandem location and positioning prior to leaving the operating room. Conclusion A variety of techniques have been described to assist in accurate placement of the uterine tandem prior to afterloading, when utilizing definitive chemoradiation in the management of cervical carcinoma. These include postoperative plain films or computerized tomography, versus intraoperative transabdominal or transrectal ultrasound guidance at the time of placement. Postoperative techniques that confirm perforation necessitate a second visit to the operating room, a second general anesthetic, as well as a treatment delay that may impact negatively upon central control rates in the long term. Intraoperative techniques have their limitations as well, particularly in the obese patient. With difficult or questionable insertions, direct endoscopic evaluation at the time of tandem insertion is the only means of knowing definitively the location of the tandem prior to leaving the operating room.