Journal of Womens Health, Issues and Care ISSN: 2325-9795

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Research Article, J Womens Health Issues Care Vol: 2 Issue: 5

Ultrasound-guided Puncture of Complicated Ovarian Cysts: An Alternative to Surgery in Sub-Saharan Africa

Kouamé N1*, N’goan-Domoua AM1, Koné D2, N’gbesso RD1 and Kéita AK1
1Yopougon Teaching Hospital, Department of Radiology, Côte d’ivoire, Abidjan
2Yopougon Teaching Hospital, Department of Obstétrics and Gynaecology, Côte d’Ivoire, Abidjan
Corresponding author : Kouame N
Department of Radiology, Teaching Hospital of Yopougon (Abidjan-Côte d’Ivoire), 21 BP 632 Abidjan 21, Côte d’Ivoire-West Africa
Tel:
+225 05190002
E-mail: [email protected]
Received: April 13, 2013 Accepted: August 30, 2013 Published: September 05, 2013
Citation: Kouamé N, N’goan-Domoua AM, Koné D, N’gbesso RD, Kéita AK (2013) Ultrasound-guided Puncture of Complicated Ovarian Cysts: An Alternative to Surgery in Sub-Saharan Africa. J Womens Health, Issues Care 2:5. doi:10.4172/2325-9795.1000119

Abstract

Ultrasound-guided Puncture of Complicated Ovarian Cysts: An Alternative to Surgery in Sub- Saharan Africa

Ovarian cysts are tumors developed at the expense of the ovary and whose content is often fluid. They are divided into two groups: functional cysts, the most common and that regress spontaneously, and organic cysts that usually require surgical treatment. According to Coquel and Ardaens, there is no parallelism between the symptoms and the severity of the disease: functional cysts can occur in an algesic context and lead to emergency surgery; conversely cancers of the ovary, despite their aggressive nature, usually remain silent until an advanced stage. Medical imaging plays a key role in the management of cystic ovarian disease.

Keywords: Ovarian cysts; Ultrasound-guided puncture; Interventional radiology; Sub-saharan Africa

Keywords

Ovarian cysts; Ultrasound-guided puncture; Interventional radiology; Sub-saharan Africa

Introduction

Ovarian cysts are tumors developed at the expense of the ovary and whose content is often fluid. They are divided into two groups: functional cysts, the most common and that regress spontaneously, and organic cysts that usually require surgical treatment. According to Coquel and Ardaens [1], there is no parallelism between the symptoms and the severity of the disease: functional cysts can occur in an algesic context and lead to emergency surgery; conversely, cancers of the ovary, despite their aggressive nature, usually remain silent until an advanced stage. Medical imaging plays a key role in the management of cystic ovarian disease [2]. It allows accurate diagnosis with trans-vaginal ultrasound, and or magnetic resonance imaging. It can and should also be involved in the therapeutic management of ovarian cysts of benign aspect, whether organic or functional, mainly through the ultrasound-guided puncture. This role is relatively little known and discussed. However, many European and American teams [3-6] have successfully tested the ultrasound-guided puncture of benign ovarian cysts, since the 1990s. In most series, the authors use the trans-vaginal approach. In France, in 2001, Marthevet and Dargent [7] have recognized the need to perform ultrasound-guided puncture of functional cysts because of the morbidity and cost of surgery. In sub-Saharan Africa, more than morbidity, it is the cost of surgery, which is not within the reach of everyone, which forced us to perform ultrasound-guided puncture of complicated ovarian cysts. We report here our experience through a short series carried out In Abidjan (Côte d’Ivoire).

Patients and Methods

Our prospective study was carried out at the Teaching Hospital of Yopougon (Abidjan, Côte d’Ivoire) for 3 years, from January 2009 to December 2011. It involved 07 women in a period of genital activity, with a complicated ovarian cyst of benign aspect. We performed in these women an ultrasound-guided therapeutic puncture of cysts after Ivorian Ethics Committee approval.
The inclusion criteria were as follows:
• Ultrasound diagnosis of the ovarian cyst of benign aspect
• Cyst of size superior or equal to 50 mm in diameter
• Cyst accessible to trans-parietal puncture (we did not have trans-vaginal probe), without transposition of organ between cutaneous and adipose structures and the cyst
• Painful, hemorrhagic or torsional cyst, with a notion of persistence of pain despite analgesic treatment levels 1 and/or 2, and whose indication for surgery was limited by financial problems
• Informed consent of the patient
The exclusion criteria were as follows:
• Presence of ultrasound signs that make doubt about the benign character of the cyst (localized parietal thickening, irregularity of the wall, endo-cystic vegetation, the presence of several partitions and presence of internal granulation or intra-cystic tissue mass)
• Interposition of bowel loops, bladder or uterus
• Absence of informed consent of the patient
The different punctures were performed in the ultrasound room in the usual conditions for performing ultrasound. The equipment used was a 50 cc syringe, 5 cc syringe, a 18 G lumbar puncture needle, a 16 or 14 G intravenous catheter. The puncture method that we used was trans-parietal. After locating the cyst with the ultrasound, a strict asepsis was made. We then proceeded to a local anesthetic of the area and the introduction of the trocar under ultrasound guidance (Figure 1), followed by a manual syringe aspiration. Antibiotic prophylaxis based on amoxicillin 2 g/d was started one hour before each procedure (the day of the exam), and continued during 3 days after. The patient returned home with a prescription of painkillers after controlling constants (blood pressure, pulse, temperature, respiratory rate) and negative search of signs of peritoneal irritation. No progestogen hormone therapy or macroprogestatif in antigonadotropic has been associated. The aspirated fluid was sent to the cytology laboratory for analysis. Post-procedure monitoring was performed by ultrasound at day 1 (Figure 2), day 8 and day 30. Three patients were reviewed one year after.
Figure 1: (a): A 30 year old patient with a functional cyst, 75 mm in diameter and 155 cm3 in volume, in torsion. (b): Introduction of the trocar within the cyst in 30 year old patient.
Figure 2: Ultrasound post-procedure monitoring at D1 in 30 year old patient. The right ovary is normal. It is 40 mm large axis on 24 mm thick. Its architecture appears a little disorganized.

Results

All our results are summarized in Table 1.
Table 1: Epidemiological and clinical characteristics of patients and results of ultrasound-guided puncture of complicated ovarian cysts.
Patients’ age ranged from 22 to 35 years with a mean age of 26 years. They had an average parity of 2 (range 0-4). None of them was using hormonal contraceptives. They were all in luteal phase of menstrual cycle and had received no ovarian stimulation. Cysts were painful (2 cases), bleeding (3 cases), and in torsion (2 cases). They showed no organic character. Their average size was 74.3 mm (with extremes ranging from 59 to 120 mm) and a mean volume of 198 cm3 (with extremes ranging from 154 to 303 cm3). Technically, the evacuation of cyst was complete in 5 cases (71.4%). In 2 cases (28.6%), a second puncture was necessary at day 8. The aspirated fluid was hemorrhagic in 3 cases (42.9%) and serous in 4 cases (57.1%). Regarding the tolerance of the procedure, there were no complications at day 1, day 8 and day 30. Functional signs were dominated by pain in all cases, nausea and vomiting in 3 cases. Cytological analysis objectified no cellular atypia. With a year of follow-up, 3 women were reviewed in the context of prenatal check up. The other 4 were lost to follow up. We did not record any case of relapse.

Comments

Our study included 2 cases of cyst in torsion, 3 cases of bleeding cysts and 2 cases of simple painful cysts. According to the literature, complicated cysts are formal and urgent indications for surgery or laparoscopic surgery [7]. Our patients showed no defect, nor contra-indication to surgery. This was largely a financial problem. Ultrasound-guided puncture appeared as an alternative to surgery, given its low cost and its good tolerance described in the literature [8]. For some authors [9-12], the results of ultrasound-guided puncture of ovarian functional cysts are similar to those observed in the case of no treatment. But our results observed after puncture of complicated functional cysts seem very convincing. There were no post procedure complications. On the contrary, functional signs dominated by pain in all cases, nausea and vomiting in 3 cases immediately decreased in 3 cases at D1, in 2 cases at D1, and in 2 other cases, before D8. The management required no hospitalization. Two failures to complete removal of these complicated cysts were noted in our series. It is an absence of complete evacuation due to a biloculated or triloculated aspect of the cyst. The fine character of walls made them difficult to visualize on ultrasound, but are not an argument for the absence of benignancy of the cyst. We were cleared by the results of cytology, which showed no cellular atypia. The ultrasound-guided puncture of ovarian cysts was performed by trans-parietal approach in our study. But the most suitable approach accepted by all is the trans-vaginal one. Our choice of ultrasound-guided puncture of benign cysts by transparietal approach was justified by the fact that the trans-vaginal probe is not always available in Africa, even in the central-level hospitals like Teaching Hospitals. Our different punctures of cysts were performed in an ultrasound room under local anesthesia without sedation and under antibiotic prophylaxis. In the literature [7], this procedure is not performed in an operating theater to avoid possible infectious complications [12]. We staved off this possibility by an antibiotic prophylaxis that seems to have been effective since none of our seven patients presented infectious complications in short (D1 to D8) and medium term (D30). Our study demonstrates thus that ultrasoundguided puncture of cysts, even complicated is a procedure that is not heavy, and which can be performed in any ultrasound room. It does not threaten the obstetrical future of patients because 3 of them (42.9%) were reviewed a year after in the context of the follow-up of an evolutional pregnancy. Our follow up period in this study was one year. Probably, it was insufficient to eliminate an absence of relapse of cysts that we punctured. To prevent this relapse, some authors, such as Mesogitis et al. [13] suggest that the puncture of cysts should be complemented by an intra-cystic injection of Methotrexate.

Conclusion

Ultrasound-guided puncture of benign ovarian cysts, even complicated is a procedure that is easy to perform in a tropical environment. It is inexpensive because it requires no hospitalization nor general anesthesia and operating room rental. It is a well tolerated and effective technique that can be performed by transparietal approach, even if vaginal approach remains the most appropriate procedure that deserves to be given greater importance. The ultrasound-guided puncture of benign ovarian cysts appears as an alternative to surgery. Despite our small series, we find here the opportunity to draw our colleagues’ attention on the need for a multidisciplinary management of diseases in sub-Saharan Africa.

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