{"paper_id":"6b16d2ce-e062-445a-8d6b-d5e7298c1730","body_text":"Articles published in Obstet Gynecol Sci are open-access, distributed under the terms of \nthe Creative Commons Attribution Non-Commercial License (http://creativecommons.\norg/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, \nand reproduction in any medium, provided the original work is properly cited.\nCopyright © 2014 Korean Society of Obstetrics and Gynecology \nCase Report\nObstet Gynecol Sci 2014;57(6):553-556\nhttp://dx.doi.org/10.5468/ogs.2014.57.6.553\npISSN 2287-8572 · eISSN 2287-8580\nwww.ogscience.org 553\nIntroduction\nRecently, many studies reported that radiofrequency ablation \n(RFA) is considered to be a safe, effective and minimal invasive \napproach with low complication rates and minimal patient \ndiscomfort in the conservative management of uterine fibroids \nin selected woman who desire to retain their uterus [1-3].\nHowever, few studies were conducted regarding the adverse \noutcomes and the most reported complications are minor \nevents such as pain, discharge and adhesion without need \nfor further intervention. Penetration and burn injuries of the \nbowel or bladder have never been reported related with RFA \nof uterine fibroids. Although it is safe and effective, several \nreports showed that RFA can give rise to severe complica -\ntions in other organs such as bronchopleural, bronchobiliary \nor renoduodenal fistula [4-6]. An enterouterine fistula occurs \nextremely rare, some cases have been reported referring to \nCrohn’s disease or diverticulitis where it was difficult to save \nthe uterus and fertility [7-10]. As in our case, a rectouterine \nfistula may occur during RFA of a uterine fibroid. Therefore, \nthorough counseling of the potential benefits and risks is es-\nsential prior to the procedure and the possibility of conductive \nthermal injury to the adjacent organs should be borne in mind \nby the surgeon.\nWe present herein, to our knowledge, the first case involv -\ning a rectouterine fistula after laparoscopic ultrasound-guided \nRFA of a uterine fibroid with pelvic endometriosis.\nCase report\nA 36-year-old, nulligravida, unwanted for pregnancy was \nreferred to our hospital due to persistent dysmenorrhea and \nlower back pain following a bilateral uterine artery emboliza-\ntion and intrauterine device (Mirena) insertion at a local clinic. \nA pelvic magnetic resonance imaging showed a 5-cm-hetero-\ngeneous mass on the posterior uterine wall, which appeared \nto be an intramural fibroid. After thorough counseling on the \nReceived: 2014.4.30.   Revised: 2014.6.4.   Accepted: 2014.6.18.\nCorresponding author: Chu Y eop Huh\nDepartment of Obstetrics and Gynecology, Kyung Hee University \nCollege of Medicine, 23 Kyungheedae-ro, Dongdaemun-gu, Seoul \n130-872, Korea\nTel: +82-2-958-8329  Fax: +82-2-958-8328\nE-mail: caduceus4u@naver.com\nRectouterine fistula after laparoscopic ultrasound-\nguided radiofrequency ablation of a uterine fibroid \nHyo Joo Jeong, Byung-Su Kwon, Young Joon Choi, Chu Yeop Huh\nDepartment of Obstetrics and Gynecology, Kyung Hee University College of Medicine, Seoul, Korea\nIn the conservative management of uterine fibroids is radiofrequency ablation (RFA) considered to be one of the \nsafe, effective and minimal invasive approaches in selected women who desire to retain their uterus. Few studies \nwere conducted on its adverse outcomes and most of the reported complications were minor events such as pain, \ndischarge, adhesion which didn’t require any intervention. However, although safe and effective, the RFA of a uterine \nmyoma can be the cause for severe complications such as penetration and burn injuries of pelvic organs. In general, \na rectouterine fistula is one of the rarest complications but can lead to serious adverse outcomes. Herein, to our \nknowledge, we report the first case involving a rectouterine fistula after laparoscopic ultrasound-guided RFA of a \nuterine myoma with pelvic endometriosis. In addition, we provide a brief review of the relevant literature.\nKeywords: Myolysis; Radiofrequency catheter ablation; Rectouterine fistula\n\nwww.ogscience.org554\nVol. 57, No. 6, 2014\npotential risks and benefits of the procedure and the possible \nalternative surgical treatments was the laparoscopic ultrasound-\nguided RFA performed under general anesthesia. A dense ad-\nhesion was found in the right cul-de-sac between uterus and \ncolon. Adhesiolysis and biopsies were performed of the adhe-\nsive band and peritoneum and an endometriosis was later con-\nfirmed. A 16-gauge RFA needle was percutaneously inserted \nand placed within the target fibroid under laparoscopic video \nand transvaginal ultrasound guidance. The RF delivery system \n(M1004, RF Medical Co., Seoul, Korea) was applied twice with \na maximum power of 120 watt and a maximum temperature \nof 85℃ for 5 minutes. The patient was discharged without \nany complications. However, she visited the hospital for bloody \nanal discharge and vaginal leakage of stool after two weeks \nof discharge. During her visit were the vital signs stable, but a \nleukocytosis (white blood cell 12,820/μL) and an elevation of C-\nreactive protein (1.4 mg/dL) were observed. The colonoscopy \nshowed a white, marginal protruding mucosal defect about 9 \ncm above the anal verge (Fig. 1). A pelvic computed tomog -\nraphy and a hysterosalpingogram revealed a fistula between \nthe posterior uterine wall and the rectum (Fig. 2). The patient \nunderwent a rectal fistula wedge resection and ileostomy and \ntotal abdominal hysterectomy due to severe inflammation and \nnecrosis in the uterine cavity. Two months later, the fluoroscopic \nexamination of the pouchgram showed an improved rectouter-\nine fistula and no leakage of contrast media, thus a take-down \nof the ileostomy was performed. There was no further clinical \nproblem afterward for one year of follow-up.\nDiscussion\nRFA has become a widespread technique for achieving local \ncontrol of tumors in various organs which are no resection can-\nFig. 1. The colon oscopy shows a white, marginal protruding, mucosal \ndefect about 9 cm above the anal verge. \nFig. 2. (A) The pelvic computed tomography and (B) hysterosalpingogram reveals a fistula between the posterior uterine wall and the rectum.\nA B\n\nwww.ogscience.org 555\nHyo Joo Jeong, et al. Rectouterine fistula after myolysis\ndidates involving the liver, kidney and lungs. Especially, in the \nconservative management of uterine fibroids is RFA considered \nto be one of the safe, effective and minimal invasive approach-\nes for women who desire to retain their uterus [1-3]. Recent \nstudies showed about 65% to 80% of myoma volume reduc-\ntion 6 months after the procedure. The symptoms improvement \nrate was about the same [1,2]. \nComplications after RFA are rare, but Kim et al. [2] presented \nlower abdominal pain and vaginal discharge that improved \nwithin 2 weeks and Garza et al. [1] also described abdominal \npain, urinary tract infection and abdominal vascular injury \nwhich were solved without any problem. However, severe ther-\nmal injuries and complications can occur during RFA of uterine \nfibroids. There was an unusual case where a total abdominal \nhysterectomy was performed due to a uterine abscess which \nwas formed after myolysis [11]. Also there are several case re-\nports on severe complications after RFA in other organs, espe-\ncially fistulas, such as bronchopleural, bronchobiliary and reno-\nduodenal which were treated by massive antibiotics or surgical \nresection [4-6]. \nGenerally, fistulous formation rarely occurs between the \nuterus and intestinal tract and it is thought to be related to the \ngreat thickness of the uterine wall. The causes implicated are \ntraumatic or spontaneous rupture of a gravid uterus, perfora-\ntion of the uterine wall and bowel with an intrauterine device, \ninflammatory diseases or malignancy of pelvic organs [7-10]. \nPatchell et al. [7] reported a rectouterine fistula after the mal-\npositioned Cu-7 intrauterine contraceptive device with spon-\ntaneous closure. Stoddard et al. [8] presented a patient with a \nrectouterine fistula in Crohn’s disease after the performance of \na transverse colostomy without hysterectomy. Dias et al. [10] \nalso reported a patient with ileouterine fistula in Crohn’s dis-\nease, which was corrected by an ileocecal resection and surgical \nrepair of the uterus. Sentilhes et al. [9] reported a colouterine \nfistula, secondary to diverticulitis, which was treated with an en \nbloc resection of the uterus and sigmoid colon. In the treatment \nof an enterouterine fistula, an active surgical treatment is usual-\nly indicated depending upon the etiology, the patient’s age and \nthe state of lesions, etc. So, each case must be individualized as \nsoon as it is encountered. \nDuring a RFA, the fibroid should be carefully monitored by \nultrasonography and the duration of ablation should be de -\ntermined based on the increased echogenicity of the fibroid \nto minimize a thermal injury due a RFA. The progression of \nablation is considered to be good if a postechogenic shadow \nis observed. The ablation should be discontinued when the \nfibroid exhibits high echogenicity during ablation and the area \nof high echogenicity reaches 90% of the fibroid. Generally, an \nincreased echogenicity disappears 20 minutes after ablation. \nThe complete ablation of a 3-cm-large myoma usually takes \n5 minutes, while that of an approximately 5-cm-sized myoma \ntakes almost 10 minutes. Multiple overlapping ablation cycles \nto obtain complete ablation should be carefully performed for \nfibroids with a mean diameter greater than 5 cm [12].\nIn our thought, a uterus related fistula may generally less oc-\ncur due to the thickness of the myometrium. However, a fistula \nin adjacent organs can occur during RFA of a uterine fibroid by \nthermal damage if safe procedure guidelines such as depth of \nneedle insertion, duration of lysis and monitoring by ultraso -\nnography are not kept.\nRecently, several studies proved the safety and effectiveness \nof RFA for uterine fibroids either by a laparoscopic transabdomi-\nnal or transvaginal approach. However, there is no comparative \nstudy between the laparoscopic transabdominal and transvagi-\nnal approach. In our opinion, the laparoscopic transabdominal \napproach would minimize the thermal damage in cases of sus-\npected severe adhesions or co-existing endometriosis.\nBefore the RFA of uterine fibroids should be considered \nmyoma-related symptoms, previous medical treatment, number \nof myoma and the plan for future pregnancies [2,3]. Generally, \nRFA is not recommended for cases of huge multiple myoma, \ncurrent pregnancy, suspected malignancy, abnormal coagula-\ntion test, recent pelvic inflammatory disease and so on [1-3]. Up \nto now, there has been no complete consensus on its indica-\ntions and contraindications.\nNo safety on RFA in uterine fibroids has established yet in \nwomen with future planned pregnancy. Several adverse out-\ncomes related to subsequent pregnancies, such as uterine \nrupture were reported after RFA [13,14]. However, Phillips et \nal. [15] reported cases of uncomplicated full-term pregnancies \nindicating that viable pregnancies were possible after laparo-\nscopic myolysis and Kim et al. [2] reported three patients that \nexperienced successful conception and childbirth after RF my-\nolysis procedure. Therefore, it is important to carefully select pa-\ntients for RFA, considering the number, size and location of the \nmyoma as well as the age and pregnancy plans of the patients.\nIn summary, a rectouterine fistula is very rare, but it can pos-\nsibly occur during the RFA of a uterine fibroid. In such cases, \nit may be difficult to conduct the conservative management \npreserving the uterus or fertility due to severe inflammation or \nnecrosis of the endometrium. Therefore, thorough counseling \nof the potential benefits and risks is essential prior to the proce-\n\nwww.ogscience.org556\nVol. 57, No. 6, 2014\ndure and the possibility of conductive thermal injury to the ad-\njacent organs should be borne in mind by the surgeon in cases \nwith suspected severe adhesions or co-existing endometriosis. \nHerein, to our knowledge, we report the first case involving a \nrectouterine fistula after laparoscopic ultrasound-guided RFA of \na uterine fibroid together with a literature review. \nConflict of interest\nNo potential conflict of interest relevant to this article was \nreported.\nReferences\n1. Garza Leal JG, Hernandez Leon I, Castillo Saenz L, Lee \nBB. Laparoscopic ultrasound-guided radiofrequency \nvolumetric thermal ablation of symptomatic uterine leio -\nmyomas: feasibility study using the Halt 2000 Ablation \nSystem. J Minim Invasive Gynecol 2011;18:364-71. \n2. Kim CH, Kim SR, Lee HA, Kim SH, Chae HD, Kang BM. \nTransvaginal ultrasound-guided radiofrequency myolysis \nfor uterine myomas. Hum Reprod 2011;26:559-63.\n3. Guido RS, Macer JA, Abbott K, Falls JL, Tilley IB, Chud -\nnoff SG. Radiofrequency volumetric thermal ablation \nof fibroids: a prospective, clinical analysis of two years’ \noutcome from the Halt trial. Health Qual Life Outcomes \n2013;11:139.\n4. Li W, Huang L, Han Y, Zhou Y, Lu Q, Li X. Broncho -\npleural fistula after non small cell lung cancer radiofre -\nquency ablation: what it implying to us? Diagn Pathol \n2013;8:202. \n5. Kim YS, Rhim H, Sung JH, Kim SK, Kim Y, Koh BH, et al. \nBronchobiliary fistula after radiofrequency thermal ablation \nof hepatic tumor. J Vasc Interv Radiol 2005;16:407-10.\n6. De Arruda HO, Goldman S, Andreoni C, Maia RS, Sze -\njnfeld J, Ortiz V. Renoduodenal fistula after renal tumor \nablation with radiofrequency. Surg Laparosc Endosc Per -\ncutan Tech 2006;16:342-3.\n7. Patchell RD. Rectouterine fistula associated with the \nCu-7 intrauterine contraceptive device. Am J Obstet Gy -\nnecol 1976;126:292-3. \n8. Stoddard CJ, Irvin TT. Rectouterine fistulation in Crohn’s \ndisease. Br Med J 1977;1:1574-5. \n9. Sentilhes L, Foulatier O, Verspyck E, Roman H, Scotte M, \nMarpeau L. Colouterine fistula complicating diverticulitis: \na case report and review of the literature. Eur J Obstet \nGynecol Reprod Biol 2003;110:107-10.\n10. Dias VC, Lago P , Santos M. Ileouterine fistula: an unusual \ncomplication of Crohn’s disease. Inflamm Bowel Dis \n2008;14:1465-6.\n11. Kim HW, Han KH, Cha DS, Kim TH, Kwon MS, Park EY. \nUterine abscess after radiofrequency myolysis of uter -\nine myoma: a case report. Korean J Obstet Gynecol \n2007;50:1778-81.\n12. Kim JH. Radiofrequency myolysis of uterine myoma. J \nWomens Med 2008;1:1-5. \n13. Vilos GA, Daly LJ, Tse BM. Pregnancy outcome after lapa-\nroscopic electromyolysis. J Am Assoc Gynecol Laparosc \n1998;5:289-92.\n14. Arcangeli S, Pasquarette MM. Gravid uterine rupture af -\nter myolysis. Obstet Gynecol 1997;89:857. \n15. Phillips DR, Milim SJ, Nathanson HG, Haselkorn JS. Ex -\nperience with laparoscopic leiomyoma coagulation and \nconcomitant operative hysteroscopy. J Am Assoc Gyne -\ncol Laparosc 1997;4:425-33.","source_license":"CC0","license_restricted":false}