Postmyomectomy Diverticulum
Myomectomy is increasingly performed for the management of menorrhagia and infertility. Following resection of a submucous fibroid, a focal myometrial defect may persist, appearing as a small uterine diverticulum—typically less than 1.5 cm in diameter—at the site of surgery (Fig. 1). These diverticula are usually incidental findings on hysterosalpingography and are considered clinically insignificant when small and not associated with distortion of the uterine cavity.
 |
| Fig-1 |
Findings: Hysterosalpingography shows a small, smooth-margined contrast-filled diverticulum arising from the uterine cavity at the site of prior myomectomy. The remaining uterine cavity contour is preserved with no significant distortion. No evidence of contrast extravasation or irregularity is seen.
Conclusion: Imaging findings are consistent with a postmyomectomy uterine diverticulum. The lesion is small and does not distort the uterine cavity, suggesting minimal clinical significance. Correlation with clinical symptoms is advised, and further evaluation is warranted only if the patient is symptomatic.
Patient Symptoms
Patients may be asymptomatic. When present, symptoms include secondary infertility, post-menstrual spotting, prolonged menstrual flow, or mild pelvic pain following myomectomy.
Procedure (Hysterosalpingography)
The study is performed in the early proliferative phase (day 7–10). Under aseptic precautions, a cervical cannula is placed and water-soluble iodinated contrast is injected slowly under fluoroscopic guidance to evaluate uterine cavity contour and tubal patency.
Contrast Medium & Administration
A water-soluble iodinated contrast agent such as Iohexol or Iopamidol (concentration 300–350 mg iodine/mL) is used for hysterosalpingography. The patient is positioned in the lithotomy position on the fluoroscopy table under strict aseptic precautions. A sterile vaginal speculum is inserted to visualize the cervix, followed by gentle cervical stabilization using a tenaculum if required.
Instruments Used
- Sterile vaginal speculum (Cusco’s or Sims’)
- Uterine tenaculum (single-tooth or vulsellum)
- Leech–Wilkinson cannula
- Rubin cannula
- Balloon HSG catheter (Foley-type or dedicated HSG catheter)
- 10–20 mL sterile Luer-lock syringe
- Sterile connecting tubing
- Antiseptic solution (povidone-iodine or chlorhexidine)
- Sterile gloves and drapes
- Fluoroscopy unit / C-arm
- Radiographic table with lithotomy attachments
- Lead apron and radiation protection accessories
A Leech–Wilkinson cannula, Rubin cannula, or a balloon HSG catheter is introduced into the cervical canal to achieve a snug seal. Contrast is administered slowly using a 10–20 mL syringe under continuous fluoroscopic monitoring. The typical injected volume ranges from 8–12 mL, with initial uterine filling achieved using 4–6 mL, followed by gradual injection to assess tubal filling and peritoneal spill.
Slow, low-pressure injection is essential to minimize uterine spasm, patient discomfort, and the risk of contrast intravasation. Intermittent imaging is performed during early filling, full uterine distension, and delayed phases to evaluate contrast pooling within the diverticulum.
Safety Considerations
Pregnancy must be excluded prior to the procedure. A history of contrast allergy or pelvic infection should be assessed. Strict aseptic technique is essential. Mild cramping is common; severe pain, fever, or discharge warrants evaluation.
Related Conditions
Important differentials include cesarean scar niche (isthmocele), congenital uterine diverticulum, adenomyotic cyst communicating with the cavity, and post-surgical pseudodiverticulum. Correlation with clinical history and imaging features helps differentiation.
Declaration
The authors declare that this case is presented for educational and academic purposes only. Patient identity has been fully anonymized, and no personally identifiable information is disclosed. Informed consent was obtained in accordance with institutional guidelines. The authors report no conflict of interest.
No comments:
Post a Comment