Combined Fluoroscopy and Ultrasound Guided Uterine Cavity Cannulation Enabling Hysteroscope Access Where Prior Hysteroscopy Had Failed

Purpose: To review technical aspects and procedural outcomes of image guided cannulation of the uterine cavity, providing a route of access  for hysteroscopy  in women in whom prior hysteroscopic procedures were unsuccessful.

Materials and Methods: An IRB approved retrospective review by search of the Radiology Information System was conducted of women sent to interventional radiology in our institution since September 2011 for consideration of image guided uterine cavity access after unsuccessful  hysteroscopy.  18 women had interventional radiology consultation, 2 refused.   16 women age 32-44 (mean 38.6) proceeded to procedure.  5 were nulliparous, 11 had prior pregnancies.   3 had prior trachelectomy with cervical occlusion, the remainder uterine synechiae.  11/16 reported multiple failed attempted hysteroscopies, in 8 creation of  false tracts into myometrium was described.

Results: All procedures were performed in the IR suite under IV sedation using  endovaginal ultrasound and fluoroscopy.   Fluoroscopy time was 102 - 574 seconds (mean 285.3).  Uterine cavity access was successful in  14 of 16 women (87.5%).  In one patient 2 attempts were required, the second was successful after cessation of hormonal suppression.  In 8  of 14 patients catheter / hydrophilic wire manipulation past a false passage and / or endometrial  occlusion resulted in successful access; in  6/14  sharp recanalization/ creation of a new tract with an 18 g Chiba needle was required.  In 13 / 14 successful cases a loop retention catheter,  6.5 - 12 Fr,  was inserted.  All patients were   transferred directly to the OR suite for successful same day hysteroscopic lysis of adhesions.  In 2 / 14 (12.5 %) uterine  access was unsuccessful: in both the endometrial cavity was minuscule.  1 /2  could be cannulated with a needle but wire access was not possible, the other was too small for puncture.  No complications were seen.

Conclusion: Image guided uterine cavity cannulation where  prior hysteroscopy had failed  is safe.  It  effectively enables endoscopic lysis of adhesions in women who otherwise had no minimally invasive treatment option.