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40 Non-vascular Interventions oftheGenitourinary Tract
497
• Sometimes guidewire cannot be passed across a redundant or S-shaped ureter. In such conditions manoeuvring
with MPA and straight/angled tip guidewire or deep expiration helps in negotiating that part of the ureter and partially straightening the redundant segment.
• Once a guidewire is reached into the urinary bladder,
nephroureterostomy catheter can be advanced over the
wire. Extra length of catheter is coiled into the bladder. As
we start retracting the wire, a distal pigtail will form in the
bladder. When the wire is pulled back to the kidney, the
proximal pigtail is formed in the renal pelvis.
• Now, if we want to place a ureteric stent, after assessing
whether it will be benecial or not by doing a capping
trial of nephroureterostomy and clinical judgement as discussed above, we can proceed further.
• We can pass Amplatz superstiff wire through the nephroureterostomy catheter, and if it is not in place, then we can
take the bladder access as described above. To measure
the desired length of the ureteric stent we rst need to
know the length of the ureter. Stent length is usually
12cm for transplant kidney patients while 22cm, 24cm
or 26cm for other patients. For accurate measurement we
can use Teon coated guidewire through the catheter,
when the distal tip of the guidewire is at the desired opposition we can mark a point/clamp the wire at the skin surface. Then we retract the guide wire, when its tip reaches
at desired proximal location a second mark/clamp can be
done. The distance between these two points is the length
of the suitable size stent.
• After deciding the appropriate size stent, we can mount
it over the stiff wire, and depending upon the type of
delivery system double pigtail plastic ureteral stent
(8/10F) can be deployed. If there is no delivery system,
a stiff pusher can also be used to deploy the stent. The
distal tip is placed in the bladder beyond the UVJ and is
coiled in the bladder lumen, and the proximal end of the
stent if measured accurately will be coiled in the renal
pelvis once stiff wire and/or pusher are pulled back. If
we are doing ureteric stenting for the urinary leak, the
end hole type stent should be selected rather than holes
on the entire length which is used for the rest of the
cases.
• Sometimes ureteric strictures are too tight and do not
allow to pass stent through them. In these cases stricture
dilatation by Teon dilator or balloon dilatation/ureteroplasty of the stricture can be done. Balloon ureteroplasty
is discussed in the next section. These are painful procedures and require anaesthetist team support during the
intervention. Stiff if we are not able to negotiate the stricture, then we can extend the guidewire through the urethra
and externalize it. Antegrade ureter stenting can be done
by holding both the ends and applying traction
simultaneously.
• It is advisable to leave a nephrostomy catheter in situ until
stent patency is conrmed. Nephrostomy catheter can be
clamped/capped and the patency of the stent for internal
drainage can be assessed for at least 24h. Antegrade contrast study can be performed to see the stent patency and
passage of contrast through it by tilting the table as the
passage of urine through the stent is gravity dependent
due to loss of ureteric peristalsis. We can ask the patient to
void if we are not able to see the passage of contrast
through the stent as elevated bladder pressure can hamper
this movement. After a successful capping trial and contrast study, if the patient remains symptoms-free and able
to pass the urine, then the nephrostomy catheter can be
removed. It is important not to pull this catheter directly,
rather it should be retracted over a wire. This is done to
prevent inadvertent dislodgement of the ureteral stent
(Fig. 40.2).
40.3.2 Complications ofAntegrade Ureteral
Stent Placement
1. Most common is stent migration and the cause is improper
positioning or size of stent selection.
2. There can be stent occlusion due to blood clot (most com-
monly) or from mucosal oedema (mostly), usually these
are transient.
Figs. 40.2 Percutaneous antegrade ureteric stent placement
498
T. Pal et al.
3. A few patients complain of urinary frequency due to
bladder irritation. It resolves spontaneously within days.
4. Other complications are the same as discussed in PCN.
Any complication if not resolved requires stent removal
and re-PCN placement if indicated.
40.4 Other Percutaneous Ureteric
Interventions
40.4.1 Balloon Dilation ofUreteral Strictures
Ureteral stricture results from myriads of benign and malignant aetiologies. The treatment options include surgical,
endourological and interventional approaches. Balloon dilation of the stricture is one of the viable treatment strategies
for ureteral strictures [31]. Ideal candidates for optimal outcomes following ureteral balloon dilation include patients
with benign, short segment (2cm) strictures with a duration
of 3 months, and intact vascular supply [32]. For balloon
dilation, retrograde ureteral access is preferred rst; however, retrograde access may be difcult or not possible in
certain instances, such as neoureterovesical strictures, ureteroenteric strictures or proximal ureteric strictures [31, 32].
If the retrograde approach fails, antegrade ureteral access is
considered through the percutaneous nephrostomy route. A
percutaneous nephrostomy is performed rst, and the nephrostomy tube is left in situ till the normalization of renal
function and resolution of urinary infection if present. An
antegrade ureterogram is performed before balloon dilation
to dene the size and length of ureteral stricture [3]. An
appropriate-sized balloon (usually a high-pressure balloon
of 5–8 mm diameter) is advanced over a guidewire and
dilated at the stricture site. After the balloon dilation, an
internal ureteric stent across the stricture is left indwelling
along with the PCN catheter [31–33]. Cutting balloon has
also been described with optimal outcomes [34, 35]. The
success rate of balloon dilation ranges from 50% to 76%.
The success rate is even lower in patients with malignant
strictures [36, 37].
40.4.2 Temporary Ureteral Balloon Occlusion
andUreteral Embolization
Non-vascular lower urinary tract stulas are more frequent
than ureteroarterial stula and include ureteroenteric, ureterovaginal, vesicoenteric, and vesicovaginal stulas. The
three most common causes include previous lower abdominal/pelvic surgery, pelvic malignancies, and pelvic irradiation [33, 38]. Lower urinary tract stulas often cause
signicant discomfort and distress to the patients. Clinical
presentation varies depending on the site of the stula,
including non-healing surgical wounds, vaginal/rectal urinary leakage, cutaneous ulcers, abdominal pain, ank pain,
and recurrent urinary tract infection [39]. Presently, CT urogram with or without CT stulogram is the investigation of
choice in most centres for evaluation of lower urinary tract
stulas [32, 33].
Surgical repair is often challenging due to a hostile pelvis
secondary to pelvic brosis and malignancy. The general
treatment strategy includes a period of urinary diversion by
percutaneous nephrostomy that will assist in the healing of
the stulous tract [32, 33]. If percutaneous nephrostomy
fails to heal the stula, ureteric occlusion should be considered. In surgical candidates, temporary ureteric occlusion is
preferred to hasten stula healing. Fogarty balloon catheter
is used for ureteric occlusion, while percutaneous nephrostomy takes care of urinary diversion [38, 40]. In candidates
unsuitable for surgical reconstruction in whom urinary
diversion alone fails to relieve symptoms, proximal ureteric
embolization can be an option. A combination of coils and
gelatin sponge was used previously [41, 42]. Other emboliz-
ing agents used for permanent ureteric occlusion include
detachable balloons, N-butyl cyanoacrylate (NBCA) and
vascular plugs [43–45]. A sandwich technique involving
NBCA glue injection between two Amplatzer Vascular
plugs has been described to achieve immediate and longterm occlusion (Fig. 40.3) [45]. Ureteric embolization
incites an inammatory response, resulting in ureteric
occlusion by mechanical obstruction and stricture formation. In some cases, repeat embolization may be required to
achieve adequate ureteric occlusion [32, 33]. Nevertheless,
ureteric embolization is irreversible, and patients should be
adequately counselled regarding the need for lifelong percutaneous nephrostomies [45].
40.4.3 Ureteroarterial Fistula
Ureteroarterial stula (UAF) refers to an abnormal stulous
communication between the ureter and the adjacent iliac
artery. It is formed mainly at the level of the pelvic brim,
where the ureter crosses the artery [33, 46]. Typical clinical
presentation is intermittent haematuria with or without ank
pain with massive haematuria during an indwelling ureteric
catheter exchange. Unless promptly detected and managed
expeditiously, UAF may cause life-threatening haemorrhage.
Notably, haematuria resulting from UAF is often mistaken as
renal bleeding, leading to unnecessary renal artery embolization or even nephrectomy [48, 49].
UAF is classied into two groups: primary and secondary. Primary UAF results from erosion of any arterial aneurysm or vascular malformation eroding into the ureter and is
very rare. Secondary UAF is more common than primary
40 Non-vascular Interventions oftheGenitourinary Tract
Fig. 40.3 Schematic diagram
showing the ‘Sandwich
technique’ of ureteric
embolization using vascular
plugs. A compatible sheath is
placed into the ureter through
the pre-existing percutaneous
renal access. An appropriately
oversized Amplatzer vascular
plug (AVP) is placed within
the ureter, proximal to the site
of the leak, followed by
N-butyl cyanoacrylate
(NBCA) glue embolization,
and then another AVP is
deployed proximal to the
glued segment
Sheath
499
Sheath
AVP
NBCA glue
AVP
Rectum
UAF and results from predisposing factors that promote
ureteric erosion in contact with a pulsating artery [46].
Various predisposing conditions include prior surgery,
radiotherapy and chronic ureteral stents [46–48]. Contrast
ureterography is often inconclusive. Although CT angiography (CTA) may reveal contrast extravasation into the ureter
on the arterial phase, this particular nding has a low sensitivity since the stula is often tiny. Additionally, CTA may
show a pseudoaneurysm or arterial irregularity where the
ureter is close to the iliac artery. Catheter angiography is
often required to conrm the diagnosis [32, 33].
Angiographic ndings vary from subtle vascular irregularity
to frank arterial extravasation [48, 49]. A negative angiogram in a case of a high index of clinical suspicion necessi-
Fistula
Bladder
tates consideration of provocative manoeuvres, such as
removal of the ureteral catheter over a guidewire to remove
the tamponade effect and unmask the bleeding. Gentle ureteral manipulation using a balloon catheter may also be considered to dislodge the clot at the UAF site and unmask the
bleeding [50]. Of note, this manoeuvre should be performed
cautiously, and balloon catheters should be readily available
to provide immediate tamponade on both the arterial and
ureteral aspects to control the bleeding temporarily. Surgery
repair is often challenging due to prior surgery and associated inammation. The endovascular approach is increasingly used to manage UAF. The endovascular strategy
depends upon the anatomy of the stula and is schematically represented in Fig.40.4 [32, 33, 47, 51].
500
T. Pal et al.
abc
CIA
EIA
IIA
Coil
Fig. 40.4 Schematic representation of the management of ureteroarterial stula (UAF): (a) stula between the ureter and IIA requires embolization of IIA both proximal and distal to stula to prevent retrograde
lling from the branches of IIA; (b) when stula between the ureter and
CIA/EIA occurs adjacent to iliac bifurcation, internal iliac artery is
Ureter
EIA
References
1. Farrell TA, Hicks ME. A review of radiologically guided percutaneous nephrostomies in 303 patients. J Vasc Interv Radiol.
1997;8:769–74.
2. Hausegger KA, Portugaller HR. Percutaneous nephrostomy and
antegrade ureteral stenting: technique-indications complications.
Eur Radiol. 2006;16:2016–30.
3. Laurin S, Sandstrom S, Ivarsson H.Percutaneous nephrostomy in
infants and children. Acad Radiol. 2000;7:526–9.
4. Millward SF. Percutaneous nephrostomy: a practical approach. J
Vasc Interv Radiol. 2000;11:955–64.
5. Nariculam J, Murphy DG, Jenner C, etal. Nephrostomy insertion
for patients with bilateral ureteric obstruction caused by prostate
cancer. Br J Radiol. 2009;82:571–6.
6. Romero FR, Broglio M, Pires SR, Roca RF, Guibu IA, Perez
MD. Indications for percutaneous nephrostomy in patients with
obstructive uropathy due to malignant urogenital neoplasias. Int
Braz J Urol. 2005;31:117–24.
7. Shokeir AA, El-Diasty T, Eassa W, et al. Diagnosis of ureteral
obstruction in patients with compromised renal function: the role of
noninvasive imaging modalities. J Urol. 2004;171:2303–6.
8. Stables DP. Percutaneous nephrostomy: techniques, indications,
and results. Urol Clin North Am. 1982;9:15–29.
9. Wilson JR, Urwin GH, Stower MJ.The role of percutaneous nephrostomy in malignant ureteric obstruction. Ann R Coll Surg Engl.
2005;87:21–4.
10. Zagoria RJ, Hodge RG, Dyer RB, Routh WD.Percutaneous nephrostomy for treatment of intractable hemorrhagic cystitis. J Urol.
1993;149:1449–51.
11. Pabon-Ramos WM, Dariushnia SR, Walker TG, et al. Quality
improvement guidelines for percutaneous nephrostomy. J Vasc
Interv Radiol. 2016;27:410–4.
12. Aytekin C, Boyvat F, Harman A, Ozyer U, Colak T, Haberal
M. Percutaneous therapy of ureteral obstructions and leak after
renal transplantation: long-term results. Cardiovasc Intervent
Radiol. 2007;30:1178–84.
13. American College of Radiology. ACR–SIR–SNIS–SPR practice
parameter for the clinical practice of interventional radiology.
Available at: https://www.acr.org/- /media/ACR/Files/Practice-
Parameters/IRClin- Prac- Mgmt.pdf?la=en. Accessed January 9,
2020.
CIA
IIA
Ureter
Stent graft
EIA
CIA
Ureter
IIA
embolized rst followed by exclusion of the stula using a stent graft
within the CIA/EIA; (c) only stent graft placement sufces if stula
between ureter and CIA/EIA occurs at a substantial distance from iliac
bifurcation. IIA Internal iliac artery, CIA Common iliac artery, EIA
External iliac artery
14. ICRP, Khong PL, Ringertz H, et al. ICRP publication 121: radiological protection in paediatric diagnostic and interventional radiology. Ann ICRP. 2013;42:1–63.
15. Miller DL, Balter S, Wagner LK, etal. Quality improvement guidelines for recording patient radiation dose in the medical record. J
Vasc Interv Radiol. 2004;15:423–9.
16. American College of Radiology. ACR–SIR practice parameter for
minimal and/or sedation/analgesia. Available at: https://www.acr.
org/- /media/ACR/Files/Practice- Parameters/Sed- Analgesia.pdf.
Accessed December 28, 2020.
17. Lee WJ, Mond DJ, Patel M, Pillari GP. Emergency percutaneous
nephrostomy: technical success based on level of operator experience. J Vasc Interv Radiol. 1994;5:327–30.
18. Lewis S, Patel U. Major complications after percutaneous
nephrostomy- lessons from a department audit. Clin Radiol.
2004;59:171–9.
19. Morris DS, Wei JT, Taub DA, Dunn RL, Wolf JS Jr, Hollenbeck
BK.Temporal trends in the use of percutaneous nephrolithotomy. J
Urol. 2006;175:1731–6.
20. Cochran ST, Barbaric ZL, Lee JJ, Kashan P. Percutaneous nephrostomy tube placement: an outpatient procedure? Radiology.
1991;179:843–7.
21. Gray RR, So CB, McLoughlin RF, Pugash RA, Saliken JC,
Macklin NI. Outpatient percutaneous nephrostomy. Radiology.
1996;198:85–8.
22. Hogan MJ, Coley BD, Jayanthi VR, Shiels WE, Koff
SA.Percutaneous nephrostomy in children and adolescents: outpatient management. Radiology. 2001;218:207–10.
23. Zagoria RJ, Dyer RB.Do’s and don’t’s of percutaneous nephrostomy. Acad Radiol. 1999;6:370–7.
24. Papanicolaou N.Renal anatomy relevant to percutaneous interventions. Semin Intervent Radiol. 1995;12:163–72.
25. American College of Radiology. ACR–SIR– SPR practice parameter on informed consent for image-guided procedures. Available
at: https://www.acr.org/- /media/ACR/Files/Practice- Parameters/
InformedConsentImagGuided.pdf?la=en. Accessed January 9,
2020.
26. Rody LA, Brown KT, Covey AM, et al. Routine urine culture at
the time of percutaneous urinary drainage: does every patient need
one? Cardiovasc Intervent Radiol. 2006;29(4):595–8.
27. Segura JW, Patterson DE, LeRoy AJ, etal. Percutaneous removal
of kidney stones: review of 1000 cases. J Urol. 1985;134:1077–81.
40 Non-vascular Interventions oftheGenitourinary Tract
501
28. Lang EK.Percutaneous nephrostolithotomy and lithotripsy: a multiinstitutional survey of complications. Radiology. 1987;162:25–30.
29. Lee WJ, Smith AD, Cubelli V, etal. Complications of percutaneous
nephrolithotomy. AJR Am J Roentgenol. 1987;148:177–80.
30. Dyer RB, Assimos DG, Regan JD.Update on interventional uroradiology. Urol Clin North Am. 1997;24:623–52.
31. Vasudevan VP, Johnson EU, Wong K, etal. Contemporary management of ureteral strictures. J Clin Urol. 2019;12(1):20–31. https://
doi.org/10.1177/2051415818772218.
32. Popuri R, Zuckerman DA. Ureteral interventions. Semin
Intervent Radiol. 2011;28(4):392–5. https://doi.org/10.1055/s- -
0031- 1296081. PMID: 23204637; PMCID: PMC3312173.
33. Adamo R, Saad WE, Brown DB.Percutaneous ureteral interventions. Tech Vasc Interv Radiol. 2009;12(3):205–15. https://doi.
org/10.1053/j.tvir.2009.09.004. PMID: 19945661.
34. Steiner D, Johns-Putra L, Lyon S.Ureteroplasty with a cutting balloon: a novel approach to ureteric anastomotic strictures. Australas
Radiol. 2007;51(2):143–6. https://doi.org/10.1111/j.1440- -
1673.2007.01683.x. PMID: 17419858.
35. Atar E, Bachar GN, Eitan M, Graif F, Neyman H, Belenky
A.Peripheral cutting balloon in the management of resistant benign
ureteral and biliary strictures: long-term results. Diagn Interv
Radiol. 2007;13(1):39–41. PMID: 17354194.
36. Shapiro MJ, Banner MP, Amendola MA, Gordon RL, Pollack
HM, Wein AJ. Balloon catheter dilation of ureteroenteric strictures: long-term results. Radiology. 1988;168(2):385–7. https://doi.
org/10.1148/radiology.168.2.3393656. PMID: 3393656.
37. DiMarco DS, LeRoy AJ, Thieling S, Bergstralh EJ, Segura
JW. Long-term results of treatment for ureteroenteric strictures.
Urology. 2001;58(6):909–13. https://doi.org/10.1016/s0090-
4295(01)01420- 0. PMID: 11744456.
38. Avritscher R, Madoff DC, Ramirez PT, Wallace MJ, Ahrar K,
Morello FA Jr, Gupta S, Murthy R, Wright KC, Hicks ME.Fistulas
of the lower urinary tract: percutaneous approaches for the management of a difcult clinical entity. Radiographics. 2004;24(Suppl
1):S217–36. https://doi.org/10.1148/rg.24si045508. PMID:
15486242.
39. Dorairajan LN, Hemal AK.Lower urinary tract stula: the minimally invasive approach. Curr Opin Urol. 2009;19(6):556–62.
https://doi.org/10.1097/MOU.0b013e32833140aa. PMID:
20072105.
40. Schild HH, Günther R, Thelen M.Transrenal ureteral occlusion:
results and problems. J Vasc Interv Radiol. 1994;5(2):321–5.
https://doi.org/10.1016/s1051- 0443(94)71494- 9. PMID:
8186602.
41. Bing KT, Hicks ME, Picus D, Darcy MD.Percutaneous ureteral
occlusion with use of Gianturco coils and gelatin sponge. Part
II. Clinical experience. J Vasc Interv Radiol. 1992;3(2):319–21.
https://doi.org/10.1016/s1051- 0443(92)72034- x. PMID: 1627880.
42. Shindel AW, Zhu H, Hovsepian DM, Brandes SB.Ureteric embolization with stainless-steel coils for managing refractory lower urinary tract stula: a 12-year experience. BJU Int. 2007;99(2):364–8.
https://doi.org/10.1111/j.1464- 410X.2006.06569.x. Epub 2006 Oct
9. PMID: 17026590.
43. Günther R, Klose K, Alken P. Transrenal ureteral occlusion with
a detachable balloon. Radiology. 1982;142(2):521–3. https://doi.
org/10.1148/radiology.142.2.7054847. PMID: 7054847.
44. Chau M, Bangash H, Goodwin R. Ureteral embolisation for the
management of persistent uretero-ileal anastomotic leak. Urol Case
Rep. 2022;45:102260. https://doi.org/10.1016/j.eucr.2022.102260.
PMID: 36267341; PMCID: PMC9576536.
45. Jin MX, Mohabir AD, Caplin DM, Lobko I, Siegel DN.Transrenal
ureteral embolization utilizing Amplatzer vascular plugs and N-butyl
cyanoacrylate glue. J Endourol Case Rep. 2018;4(1):108–10.
https://doi.org/10.1089/cren.2018.0027. PMID: 30065957;
PMCID: PMC6057752.
46. Fernandopulle CL, Jeyaraj R, Alchanan R, Huang DY.Ureteroarterial
stula: imaging diagnosis and endovascular management. BMJ
Case Rep. 2020;13(9):e236011. https://doi.org/10.1136/bcr-
2020- 236011. PMID: 32900737; PMCID: PMC7478047.
47. Darcy M. Uretro-arterial stulas. Tech Vasc Interv Radiol.
2009;12(3):216–21. https://doi.org/10.1053/j.tvir.2009.09.005.
PMID: 19945662.
48. Adams PS Jr. Iliac artery-ureteral stula developing after dilatation
and stent placement. Radiology. 1984;153(3):647–8. https://doi.
org/10.1148/radiology.153.3.6238346. PMID: 6238346.
49. Escobar PF, Howard JL, Kelly J, Roland PY, Grendys EC, Dosoretz
DE, Orr JW Jr. Ureteroarterial stulas after radical pelvic surgery:
pathogenesis, diagnosis, and therapeutic modalities. Int J Gynecol
Cancer. 2008;18(4):862–7. https://doi.org/10.1111/j.1525- -
1438.2007.01079.x. Epub 2007 Nov 6. PMID: 17986251.
50. Vandersteen DR, Saxon RR, Fuchs E, Keller FS, Taylor LM Jr,
Barry JM.Diagnosis and management of ureteroiliac artery stula:
value of provocative arteriography followed by common iliac artery
embolization and extraanatomic arterial bypass grafting. J Urol.
1997;158(3 Pt 1):754–8. PMID: 9258074.
51. Pillai AK, Anderson ME, Reddick MA, Sutphin PD, Kalva
SP. Ureteroarterial stula: diagnosis and management. AJR Am
J Roentgenol. 2015;204(5):W592–8. https://doi.org/10.2214/
AJR.14.13405. PMID: 25905967.
Female Genital Tract andObstetric
Interventions
VijayKubihal, S.H.Chandrashekhara, andG.S.Triveni
41
Key Messages
1. Recent advances in interventional radiology in women’s
health have led to an increase in the female genital tract
and obstetric conditions that can be treated by interventional radiology.
2. Fallopian tube recanalization is a minimally invasive
procedure for the treatment of proximal tubal occlusion,
with a technical success rate reaching up to 90%.
3. Amniocentesis and chorionic villous sampling are two
common procedures for prenatal genetic work and diagnosis of chromosomal abnormality.
4. Amniocentesis is generally performed any time after
15weeks of gestation, whereas chorionic villous sampling is performed between 10 and 14weeks.
5. Amniocentesis is useful in the diagnosis of amniotic
uid infection and fetal infections, and also in Rh isoimmunization and fetal alloimmunization.
6. Amnioinfusion can be used to treat oligogydramnios,
and decompression amniocentesis to treat
polyhydramnios.
7. Cordocentesis can be used for the diagnosis and treatment of severe fetal anemia, diagnosis and response
assessment of neonatal alloimmune thrombocytopenia,
and evaluation of non-immune fetal hydrops.
8. Monochorionic twins can be associated with unique
angioarchitecture characterized by connections between
the vasculature of both fetuses, with net dynamic bidirectional blood ow between fetuses.
V. Kubihal
Interventional Radiology, Department of Radiodiagnosis,
K S Hegde Medical Academy, Mangalore, India
S. H. Chandrashekhara (
Department of Radiodiagnosis and Interventional Radiology,
IRCH, All India Institute of Medical Sciences, Delhi, India
G. S. Triveni
Department of Obstetrics and Gynecology, Vardhman Mahavir
Medical College and Safdarjung Hospital, Delhi, India
*)
9. Unique complications associated with monochorionic
twin pregnancy include twin-twin transfusion syndrome,
twin reverse arterial perfusion sequence, severe intrauterine growth restriction, and severe discordant twins.
10. In many circumstances, selective termination of abnormal fetuses in monochorionic pregnancy is required to
improve the survival of normal fetuses. Umbilical cord
ablation cuts off blood supply to an abnormal fetus
allowing selective fetal termination of an abnormal
fetus.
11. Fetoscopic laser ablation of causative placental anastomosis is the treatment of choice in twin-twin transfusion
syndrome.
12. Large fetal hydrothorax, or intrathoracic cystic lesion
can lead to fetal lung hypoplasia, and sometimes, fetal
hydrops. Thoracocentesis and thoracoamniotic shunt
can help re-expansion of the fetal lung.
13. Untreated lower urinary tract obstruction in a fetus can
lead to irreversible renal damage, severe oligohydramnios, and subsequently lung hypoplasia. Vesicocentesis
and vesicoamniotic shunt can be considered in these
patients to decompress the high-pressure urinary
system.
41.1 Introduction
Recent advances in interventional radiology in women’s
health, and its minimally invasive nature, have led to a rapid
increase in the conditions that can be treated by interventional radiology. Infertility is seen in nearly 15% of couples
of reproductive age group, and tubal obstruction is the most
common cause of female infertility. Fallopian tube recanalization is a minimally invasive procedure for the treatment of
proximal tubal occlusion, with a technical success rate reaching up to 90%. Interventional radiology is also useful in the
diagnosis and treatment of certain obstetric conditions.
Amniocentesis and chorionic villous sampling are two common procedures for prenatal genetic work and diagnosis of
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2024
S. H. Chandrashekhara (ed.), Textbook of Interventional Radiology, https://doi.org/10.1007/978-981-97-9601-4_41
503
504
V. Kubihal et al.
chromosomal abnormality. In addition, amniocentesis is useful in the diagnosis of fetal infection, and amniotic uid
infection, and also assesses the severity of fetal Rh isoimmunization and alloimmunization. It can also be used in the
treatment of polyhydramnios (decompression amniocentesis) and oligohydramnios (amnioinfusion). Cordocentesis
can be used for the diagnosis and treatment of severe fetal
anemia by intrauterine fetal transfusion, diagnosis and
response assessment of neonatal alloimmune thrombocytopenia, and evaluation of non-immune fetal hydrops. In
monochorionic twin pregnancies at risk of impending fetal
death of an abnormal twin, an elective fetal terminal of an
abnormal twin can be considered to improve the survival of
a normal twin. Umbilical cord ablation of the abnormal twin
cuts off blood supply to the abnormal twin causing selective
fetal terminal and also prevents exsanguination of normal
fetus, through placental vascular communications, if any.
Twin transfusion syndrome is a unique uncommon complication seen in monochorionic twin pregnancy due to the
existence of unidirectional placental vascular communication. Fetoscopic laser ablation of causative placental anastomosis is the treatment of choice in twin-twin transfusion
syndrome. Large fetal hydrothorax, or intrathoracic cystic
lesion, can lead to fetal lung hypoplasia, and sometimes,
fetal hydrops, and can be treated by thoracocentesis and thoracoamniotic shunt. Untreated lower urinary tract obstruction in the fetus can lead to irreversible renal damage, severe
oligohydramnios, and subsequently lung hypoplasia.
Vesicocentesis and vesicoamniotic shunt can be considered
in these patients to decompress the high-pressure urinary
system.
41.2 Fallopian Tube Recanalization (FTR)
Infertility is dened as the inability to conceive after 1year
of time, appropriate, and unprotected sexual intercourse [1].
Infertility is seen in nearly 15% of couples of reproductive
age group and is more common in developing countries [1].
Tubal obstruction is the most common cause of female infertility [2]. Tubal obstruction can involve the proximal, mid, or
distal portion. Proximal tubal obstruction accounts for
10–25% of tubal causes of infertility [3] and can be due to
muscular spam, accumulation of viscous secretion, mucosal
agglutination, intrinsic luminal lling defect, inammatory
scarring, and salpingitis isthmica nodosa [1, 2, 4].
Fallopian tube recanalization (FTR) was pioneered by
Amy Thurmond in the 1980s [3]. FTR is a minimally invasive, cost-effective alternative to invitro fertilization (IVF),
for treating proximal tubal obstruction with a technical success rate of almost 90% [1, 4]. FTR allows women to conceive naturally, at their own pace, and avoids the risks
associated with IVF including ovarian hyperstimulation syndrome, and multiple pregnancies. Common contraindications to the procedure include contrast allergy, pregnancy,
and pelvic infection [3].
Imaging to Diagnose Proximal Tubal Obstruction
Hysterosalpingography (HSG) is an important investigation
in the evaluation of tubal pregnancy. HSG is performed in
the follicular phase of the menstrual cycle under uoroscopic
guidance. It permits the evaluation of fallopian tube patency,
in addition to uterine abnormalities such as adhesions, polyps, myoma, congenital anomalies, etc. [2, 3]. HSG has
approximately 70% correlation with laparoscopy, or hysteroscopy, with a false positive rate of 6–25%, and a false negative rate of 8–24% [2]. The major complication is infection,
which is seen in 1–3% of patients undergoing HSG;
Antibiotic prophylaxis is recommended when there is a history of prior pelvic infection. Other complications include
pain, contrast intravasation, and hypersensitivity reaction to
iodinated contrast. Non-steroidal anti-inammatory drugs
(NSAIDs) can be given 1h prior to the procedure to reduce
discomfort [2].
41.2.1 Technique
FTR is a minimally invasive procedure, performed in an
ambulatory setting, during the follicular phase of the menstrual cycle, between days 6 and 11 [3, 4]. Patients are
advised to abstain from unprotected sexual intercourse from
the day of last menstruation. Preprocedural antibiotic prophylaxis is often recommended, such as doxycycline 100mg
twice a day for 5days, starting 2days prior to the procedure.
The procedure is often performed under moderate sedation,
and the patient is advised to be nil per oral (NPO) 6h prior to
the procedure [3, 4].
The patient is positioned comfortably on a uoroscopic
table, with the aid of leg supporters, and slight elevation of
the pelvis using foam pads. FTR consists of three components: (i) uterine access; (ii) HSG; and (iii) recanalization
procedure. Sterile preparation and draping are performed. A
slightly warmed metallic or plastic speculum is inserted in
the vagina to visualize the cervix. The cervix is identied and
cleansed using an iodine solution. Uterine access is achieved
using balloon balloon-occluded sheath or catheter. HSG is
performed by slow injection of 30–50% diluted watersoluble iodinated contrast. Once tubal occlusion is suspected
on HSG, selective salpingography (SSG) is performed using
a co-axial 5F or 3F catheter system wedged at the tubal
ostium, to conrm the proximal tubal occlusion. FTR can be
attempted by gently probing the 0.035-inch guidewire
through the occlusion. If several attempts fail, a co-axial
41 Female Genital Tract andObstetric Interventions
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41.3 Amniocentesis
Amniocentesis is the procedure performed to obtain fetal
cells within the amniotic uid for prenatal diagnosis of chromosomal abnormalities in the fetus [5]. It is the most commonly performed fetal sampling procedure during pregnancy
[6]. Its use has decreased in frequency due to increased utilization of cell-free fetal DNA screening [6].
Fig. 41.1 Schematic diagram of fallopian tube recanalization
2.7F microcatheter system with a 45-degree angled tip
microwire can be used through a corneal catheter wedged at
the tubal ostium. Once the tubal ostium is crossed, an intratubal salpingogram is performed by slow contrast injection
(Fig. 41.1). After successful recanalization, SSG is performed through a cornual catheter wedged at the tubal
ostium. Post-procedure cramping and mild vaginal bleeding
are common and can be managed symptomatically. Most
patients are discharged on the same day and are advised to
try to conceive the same week [2–4].
41.2.2 Complications
Mild complications such as vaginal bleeding and mild
cramping pain are common, and are self-limiting, and often
resolve in 1–3 days. Serious complications are rare and
include tubal perforation, ectopic pregnancy, and adnexal
infection. Radiation dose to gonads can be of concern.
However, the radiation dose to ovaries is often less than
10mGy (1rad), with an average dose of 2.7mGy. Performing
FTR immediately after diagnostic HSG can reduce the radiation dose and cost of the procedure [3, 4].
41.2.3 Results
41.3.1 Indications
Amniocentesis can be used for both diagnostic and therapeutic purposes.
Diagnostic indications [6, 7] include
1) Advanced maternal age of 35years or above.
2) Known family history of genetic disorder.
3) Positive aneuploidy screening test.
4) Presence of anomalies in USG.
5) Abnormal parental karyotype.
6) Parental balanced translocation.
7) Assessment of severity of Rh isoimmunization.
8) Amniotic uid bilirubin levels to assess the severity of
alloimmunization.
9) Diagnose amniotic uid infection (chorioamnionitis).
10) Diagnose fetal infection—Toxoplasma,
Cytomegalovirus, Parvovirus.
11) Diagnosis of neural tube defects by amniotic uid alpha-
fetoprotein (AFP), and acetylcholinesterase [6].
Therapeutic indications [7] include
1) Polyhydramnios to relieve maternal discomfort and instill
intra-amniotic drugs.
2) Decompression amniocentesis in twin pregnancy with
polyhydramnios-oligohydramnios sequence.
3) Amnioinfusion in fetus with oligohydramnios to prevent
fetal lung hypoplasia, and cord compression during labor.
The technical success rate is approximately 71–90%.
Variations of uterine position can cause technical difculties
in performing FTR, which can be overcome by adequate cervical traction in most cases. Angled catheters may be required
during difcult cannulation. Other causes of technical failure
include uterine malformation, leiomyoma, and polyp.
Patency rates are reported to be approximately 60% up to
1year, and pregnancy rate is reported between 30 and 60%
following FTR.Re-occlusion can occur and can be treated
with repeat FTR procedures. Patients with previous tubal
surgery and multifocal tubal disease have poor outcomes following FTR [3, 4].
41.3.2 Contraindications [7]
No absolute contraindications exist for amniocentesis.
Relative contraindications include
1) Fetal oligohydramnios.
2) Maternal infections—can be transmitted from maternal
circulation to the fetus during the procedure.
3) Oral anticoagulation therapy should be stopped 48–72h
before the procedure and may be shifted to low molecular
weight heparin.
506
V. Kubihal et al.
41.3.3 When toPerform Amniocentesis
It may be performed at any gestation age after 15weeks and
is the only fetal sampling procedure during second and third
trimesters [6]. Early amniocentesis performed between 9 and
14weeks, for evaluation of rst-trimester aneuploidy screening, is controversial and is often not recommended due to the
high risk of pregnancy loss, spontaneous miscarriage, and
fetal talipes equinovarus [8–10].
41.3.4 Technique
Aseptic preparation of the USG probe and skin surface
should be ensured prior to the procedure. Local anesthetic is
often not required. Prophylactic antibiotics are not routinely
required.
Amniocentesis is often performed transabdominally using
USG guidance. It is often performed by two operators. Often,
the main operator holds the ultrasound probe and guides the
needle under USG guidance [9]. The assistant handles the
syringe for the withdrawal of amniotic uid. A 20- to
22-gauge needle is used to assess the amniotic cavity under
continuous USG guidance. It is to be ensured that the needle
tip is in a clear region of amniotic uid with no fetal parts,
umbilical cord, or placenta (Fig. 41.2). Slow aspiration of
amniotic uid is performed. Initial 1–2ml of amniotic uid
is discarded because of high chance of maternal cell con-
tamination. The required quantity of amniotic uid is then
aspirated (18–20ml for karyotyping, and 2–5ml for enzyme
deciency testing). Needle access is removed at the end of
the procedure [7].
41.3.5 Complications
Complications after amniocentesis can be divided into
maternal and fetal complications. The risk of complications
is high when three or more pricks are used to obtain the
amniotic uid sample. If more than two pricks are required,
the procedure can be re-attempted after 24h.
Maternal complications [7, 9]—Most maternal complications are often minor complications and self-limited. Serious
complications are rare.
1) Post-procedure pain and discomfort.
2) Fetomaternal hemorrhage—2.6% risk.
3) Vaginal bleeding—2–3% risk.
4) Rh isoimmunization in Rh-negative mother and Rh-
positive fetus.
5) Amniotic uid embolism.
6) Internal organ injury.
Fetal complications [7, 9].
1) Pregnancy loss, and spontaneous miscarriage—Average
fetal loss rate is 0.11%.
2) Amniotic uid leak which may result in oligohydram-
nios, fetal lung hypoplasia, and respiratory distress.
3) Fetal injuries like club foot, ocular injuries, and cord inju-
ries might occur.
Fig. 41.2 Schematic diagram of amniocentesis
41.4 Chorionic Villous Sampling (CVS)
Chorionic villous sampling is the procedure to obtain placental tissue for prenatal genetic workup [11]. It is the most
commonly used invasive prenatal diagnostic procedure during rst trimester [6, 10]. Similar to amniocentesis, the frequency of CVS has been reduced with the use of cell-free
DNA screening [6].
41.4.1 Indications
Indications for CVS are similar to amniocentesis [11].
1) Advanced maternal or paternal age.
2) Known family history of genetic disorder.
3) Positive aneuploidy screening test.
41 Female Genital Tract andObstetric Interventions
4) Presence of anomalies on USG.
5) Abnormal parental karyotype.
6) Parental balanced translocation.
41.4.2 Contraindications
Relative contraindications include:
1) Maternal alloimmunization.
2) Maternal infections—can be transmitted from maternal
circulation to fetus during the procedure.
3) Oral anticoagulation therapy.
41.4.3 When toPerform CVS
CVS is most commonly performed between 10 and 14weeks
of gestation. Early CVS performed before 9weeks of gestational age, is not recommended due to the associated high
risk of congenital limb deformities in the fetus [6].
507
41.4.4 Technique
Both trans-abdominal and trans-cervical approaches can be
used, based on placental location and provider’s preference
[11]. Trans-cervical route is technically demanding, may
require multiple insertions, and may cause more vaginal
bleeding. While few studies report higher pregnancy loss
and spontaneous miscarriage when trans-cervical route is
used, some other studies report no difference in both
approaches [8].
For abdominal approach, the patient is placed in supine
position, and the abdomen is cleaned and draped. The ideal
site exposing the longest length of the placenta is identied.
Local anesthetic can be used. An 18–20 gauge lumbar puncture needle is used to enter the placenta, under continuous
USG guidance (Fig. 41.3). Once the stylet is removed, a
20ml syringe containing media is connected to the end of the
needle. The needle is moved up and down the placenta, while
positive suction pressures are applied to the syringe. Examine
the collected sample to ensure sufcient chorionic villi are
sampled.
For trans-cervical approach, the patient is placed in lithotomy position. Sterile speculum is placed in the vagina, and
the cervix is cleaned. In trans-cervical approach, samples can
be obtained using small biopsy forceps or a trans-cervical
CVS catheter. Trans-cervical CVS catheter contains a malleable guidewire with an echogenic tip that can be easily
identied on USG.Under continuous USG guidance catheter
is placed in the placenta. A 20ml syringe containing media
is attached to the back end of the catheter, and continuous
Fig. 41.3 Schematic diagram of chorionic villous sampling
positive suction pressure is applied to obtain the sample. The
sample is evaluated for adequacy before ending the
procedure.
41.4.5 Complications
Risks associated with CVS in early pregnancy are similar to
mid-trimester amniocentesis; however, they are less compared to early amniocentesis [8, 10]. Complications associated with CVS are similar to amniocentesis and include
vaginal bleeding, amniotic uid leak, pregnancy loss, spontaneous miscarriage, infection, bleeding, premature rupture of
membrane, and uncertain results. Pregnancy loss following
CVS is approximately 2% during any time in pregnancy [11].
Fetal complications following CVS are uncommon, and
include limb defects and oromandibular hypogenesis.
CVS uses placental cytotrophoblasts and extraembryonic
mesoderm for analyses, in comparison to amniocentesis
which used free fetal cells in amniotic uid. Therefore, false
positive and false negative results can be obtained in CVS,
when the placenta and fetus are genetically discordant [12].
False positive results are often the result of conned placental mosaicism, with normal fetus. This can be associated
with poor placental function, fetal growth restriction, and
maternal hypertension [11, 12]. Follow-up second-trimester
amniocentesis can be performed when false positive results
are suspected, particularly in fetus with no structural anomaly on USG [12].