Journal of Medical Imaging and Radiation Oncology 61 (2017) 777–790

M E D I C A L I M A G I N G — R A D IA T I O N O N C O L O G Y — R E V IE W A R T I C L E

Imaging after treatment in uterine malignancies: Spectrum of

normal findings and most common complications

Journal of Medical Imaging and Radiation Oncology

Maura Micco
, Anna Maria Telesca, Benedetta Gui, Pier Paolo Grimaldi, Francesco Cambi,
Maria Giulia Marini, Anna Lia Valentini and Lorenzo Bonomo
Department of Radiological Sciences, Fondazione Policlinico Agostino Gemelli, Rome, Italy

M Micco
MD; AM Telesca MD; B Gui MD; Summary

PP Grimaldi MD; F Cambi MD; MG Marini
MD; AL Valentini MD; L Bonomo MD.
Correspondence
Dr Maura Micco
, Department of Radiological
Sciences, Fondazione Policlinico Agostino
Gemelli, Largo A. Gemelli 8, 00168 – Rome,
Italy.
Email: miccomaura@yahoo.it
Conflict of interest: All the authors declare
that they have no conflict of interest.
Submitted 3 December 2016; accepted 8 April
2017.
doi:10.1111/1754-9485.12624
Uterine malignancies account for the majority of gynaecologic cancers. Differ-
ent treatment options are available depending on histology, disease grade and
stage. Hysterectomy is the most frequent surgical procedure. Chemotherapy
and radiation therapy (CRT) represents the preferred therapeutic choice for
locally advanced uterine and cervical malignancies. Imaging of the female pel-
vis following these treatments is particularly challenging due to alteration of
the normal anatomy. Radiologists should be familiar with both the expected
post-treatment imaging findings and the imaging features of possible compli-
cations to make the correct interpretation and avoid possible pitfalls. The pur-
pose of this review is to show the expected computed tomography (CT) and
Magnetic Resonance Imaging (MRI) appearances of the female pelvis follow-
ing surgery and CRT for uterine and cervical cancer, to illustrate the imaging
findings of early and delayed most common complications after surgery and
CRT, describing the suitable imaging modalities and protocols for evaluation of
patients treated for gynaecologic malignancies.
Key words: complications; CT; gynaecologic cancers; MRI; post-therapy
imaging.

abdomen and pelvis in women with most common

Introduction
Uterine malignancies account for 68% of gynaecologic
tumours.1 Different treatment options are available
depending on histology, disease grade and stage. Hys-
terectomy, performed with different approaches, is the
most frequent surgical procedure. On the other hand,
chemotherapy and radiation therapy (CRT) represents
the treatment of choice for locally advanced uterine and
cervical malignancies. Imaging of the female pelvis fol-
lowing these treatments is particularly challenging due to
alteration of the normal anatomy. Furthermore, expected
complications may occur following surgery or CRT,
depending upon patient characteristics, extent and
approach of treatment.2 The most common complica-
tions of hysterectomy can be categorized as altered lym-
phatic drainage, infection, bleeding, genitourinary (GU)
and gastrointestinal (GI) tract injury or obstruction.
Fistulas, proctitis, enteritis, cystitis and insufficiency
fractures can be detected in immediate and long-term
post-CRT period. In this review, we will illustrate the
expected post-treatment imaging appearances of the
gynaecological cancers treated with surgery or CRT as
well as the appearances and the time course of major
post-surgical and CRT complications. Indications and
types of surgical procedures in patients with uterine and
cervical cancers will be discussed as well.
Surgery
Hysterectomy is the most common procedure performed
for both benign and malignant conditions. Endometrial
cancer remains the fourth most frequent diagnosis associ-
ated with this surgery, accounting for 12% to 15% of the
600,000 hysterectomies performed each year in the Uni-
ted States.3 Hysterectomy, in the literal sense of the word,
means removal of the uterus and it can be performed with
a transabdominal, laparoscopic even robotic, or transvagi-
nal approach. Transabdominal hysterectomy is the most
invasive type. However, depending on the kind and extent
of disease, surgery can be tailored. Characteristics of hys-
terectomy and less invasive surgical procedures in
patients with gynaecologic diseases are summarized in

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M Micco

Table 1. Within this variety of oncologic surgical options

Chemoradiotherapy
available, it is important for the radiologist to be aware of
the different surgical techniques to easily recognize possi- Primary CRT is used for the management of advanced
ble damages following surgery.4–6 The various types of cervical cancer. Adjuvant radiation therapy, consisting of
gynaecologic surgical approaches and their most fre- brachytherapy or combined brachytherapy with external
quently related complications are shown in Table 2. beam radiation, is used for surgically treated node-
positive cervical cancer or when surgical margins are
positive. In endometrial carcinoma, radiation therapy is
used following surgery in patients with disease extending
Table 1. Types and indications of surgical procedures in patients with
into the outer myometrium or outside the uterus. In
uterine and cervical cancer
ovarian carcinoma, CRT may be used as a palliative
Surgical Indications Description treatment.4 Pelvic irradiation may affect different struc-
procedure tures, causing different complications.
Conization or Superficial invasive and Removal of a cone-shaped
cone biopsy in situ cervical piece of tissue from the Technical suggestion
carcinoma (FIGO cervix and cervical canal
stages IA and 0), in The imaging methods that are considered the most suit-
women who want to able for the detection of post-treatment complications
preserve their fertility. are shown in Table 3.
Conization may be
used to diagnose or
treat a cervical
condition. Table 2. Various types of gynaecologic surgical approaches and their
Radical Early stages (FIGO Radical resection of the most frequent related complications
trachelectomy stages IB or lower) tumour (proximal
cervical carcinoma vaginotomy, cervical TAH TLH VH and LAVH Radical
resection, and both Hysterectomy
paracervical and
Lymphocele + + + ++
paravaginal dissection) with
Haemorrhage ++ ++ + ++
uterovaginal anastomosis. It
Haematoma
may be associated with
Infection and abscess ++ ++ + ++
pelvic lymphadenectomy
Bowel injury ++ ++ + ++
Subtotal or Benign uterine diseases Removal of body of the
Bladder injury ++ ++ + ++
partial uterus, leaving the cervix
Ureteral injury ++ ++ + ++
hysterectomy in situ
Peritoneal inclusion cyst ++ ++ + —
Total Benign and Removal of uterus and cervix
hysterectomy precancerous uterine LAVH, laparoscopically assisted vaginal hysterectomy; TAH, total
diseases abdominal hysterectomy; TLH, total laparoscopic hysterectomy; VH,
Radical Uterine and cervical Removal of uterus along with vaginal hysterectomy; +, low risk; ++, high risk.
hysterectomy malignancies vagina, cervix, tubes and
ovaries, involving an
extensive parametrial
resection and it is
Table 3. The imaging methods considered the most suitable for the detec-
associated with pelvic
tion of different post-treatment complications
lymph node dissection
Vaginal Benign uterine disease Removal of the uterus and/or Complication Diagnostic imaging
hysterectomy Fallopian tubes and ovaries
through the vagina Haemorrhage CT
Laparoscopically Benign and A procedure using a Haematoma CT, MRI
assisted precancerous uterine laparoscope to guide the Infection and abscess CT
vaginal disease removal of the uterus and/ Bowel perforation and CT, Gastrografin enema examination
hysterectomy or Fallopian tubes and obstruction
ovaries through the vagina Bladder perforation CT, cystography-CT, cystography
Tumour Ovarian cancer, Total hysterectomy with Ureteral injury Urography-CT, IVU, retrograde pyelography
debulking advanced bilateral oophorectomy, Vescicovaginal fistula MRI, cystography
gynaecologic omentectomy, extensive Rectovaginal fistula MRI, Gastrografin enema examination
malignancies lymph node dissection and Enterocutaneous and bowel CT with oral contrast material and
resection of metastatic fistula multiplanar reformation, MRI
peritoneal implants
CT, computed tomography; IVU, Intravenous urography; MRI, mag-
FIGO, The International Federation of Gynecology and Obstetrics. netic resonance imaging.

778 © 2017 The Royal Australian and New Zealand College of Radiologists
 Imaging after treatment in uterine malignancies

CT imaging protocol saturated (FS) 3D- T1 gradient echo images are generally
registered at 1 and 2 minutes and at 3–5 minutes in the
For evaluation of suspected post-operative complication,
axial plane and in the sagittal plane. Diffusion weighted
the standard CT imaging protocol includes abdomen and
images (DWI) is routinely incorporated in MR imaging
pelvis CT scan (+/ chest) before and after intravenous
protocols for gynaecological malignancies. DWI should be
administration of contrast material. The choice of the
performed at two or more b values, including low
specific protocol depends of the clinical suspect and of
(0–100 s/mm2) and high (750–1000 s/mm2) b values.
the specific imaging objective. Unenhanced scan of the
DWI may improve detection of neoplastic recurrence,
abdomen and pelvis is recommended for a better detec-
helping differentiate malignant tissue from fibrotic post-
tion of blood and free air. In case of suspected haemor-
therapy alterations.9
rhage, acquisitions in the arterial and portal phase
(respectively at 30–40 s, 70–80 s following intravenous
contrast medium administration) are required to identify Expected post-treatment pelvic
active bleeding. For a better evaluation of bowel injuries appearance
like fistulas, CT examinations may be performed with oral
contrast medium (15 mL of Gastrografin diluted in Post-surgery
250 mL of saline solution) to opacify the bowel. Cystog-
In patients with gynaecologic malignancies treated with
raphy-CT is performed if bladder injuries or fistula are
primary surgery, MRI is routinely used in differentiating
clinically suspected. The protocol for cystography-CT
post-treatment changes from recurrence. Patients with
includes scan of the pelvis before and after adequate
previous endometrial or ovarian cancer are usually fol-
bladder distention and introduction, through a Foley
lowed up with CT.
catheter insertion, of diluted mixture of contrast material
(50 mL of Gastrografin in 450 mL normal saline solu-
tion).7 Image processing using multiplanar thick-slab Vagina vault
sliding MIP or volume rendering techniques is highly rec-
In patients who have undergone prior hysterectomy, the
ommended because it helps visualization of thin fistulas
vaginal vault can be seen as a thin, symmetrical and
or leaks.8 If urinary tract injuries are suspected, Uro-
tubular structure hypointense on T1 and T2WI (Fig. 1).
graphic-CT can be useful. Urographic-CT protocol may
Post-surgical fibrotic hypointense T2WI adhesions may
include delayed phase images (obtained 7–20 minutes
be seen between the vaginal vault and the surrounding
after contrast material injection) which may be the key
organs or pelvic parietal structures, altering the linear
for demonstrating a urine leak because iodinated urine
increases the attenuation over time. Prone position
should be considered to have a better opacification of
the ureters.
(a) (b)

MR imaging protocol
Patient must fast 5–6 hours and receive an antispasmodic
drug, such as butylscopolamine bromide or glucagon,
administered intravenous immediately before the exam
or intramuscularly 10 minutes before the exam, in order
to reduce bowel peristalsis and to improve the visualiza-
tion of the adnexa and peritoneal surface. MR imaging
should be at 1.5 T or 3 T for higher spatial resolution and
a pelvic or cardiac array multichannel surface coil should
be used. Imaging is performed with the patient in the
supine position with an almost empty urinary bladder. It
is not recommended that urinary bladder is distended
because it increases phase ghost artefacts. Saturation
bands placed along the anterior and posterior body wall
Fig. 1. A 40-year-old patient who underwent prior radical hysterectomy
fat are useful for diminishing ghosting from respiratory
with bilateral salpingo-oophorectomy (BSO) for cervical cancer. (a) Sagittal
motion artefact.9 Images must be obtained as follows:
and (b) axial FSE T2 weighted (W) images (I) show vaginal vault as a thin,
spin-echo (SE) T1-weighted images (WI) in axial plane;
symmetrical and tubular hypointense structure. Post-surgical fibrotic
fast SE (FSE) T2WI in axial, sagittal and coronal planes hypointense T2WI adhesions may be seen between the vaginal vault and
and, upper abdomen T2WI with large-field-of-view useful the surrounding organs or pelvic parietal structures (arrowheads), corre-
to identify hydronephrosis or retroperitoneal alterations. sponding to the surgical sutures that incorporate utero-sacral and cardinal
After intravenous administration of contrast material, fat ligaments at the angle of the vagina.

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Fig. 2. A 67-year-old patient who underwent prior radical hysterectomy
with BSO and pelvic lymphadenectomy for cervical cancer. Axial FSE T2WI
demonstrates a vaginal oedema as a globular aspect of the vaginal cuff
characterized by increased signal intensity (open arrow). This aspect
resolved at the following MRI exam (not shown). Note the bullous oedema
of the posterior bladder wall mucosa (arrowhead) and the nephrostomy in
the distal part of right ureter (solid arrow).
appearance of the vaginal vault (Fig. 1). During the early
post-operative period, vaginal oedema can manifest as
reactive symmetrical thickening of the vaginal wall with
increased signal intensity on T2WI with a globular aspect
of the vaginal cuff (Figs 2, 3). This finding could be
related to the surgical suture and it is typically early,
transient and reversible, resolved by 3–6 months. In the
early MR control, it is crucial to differentiate this aspect
from other post-operative pathological conditions such
as vaginal cuff dehiscence, which is generally associated
with pelvic fluid and collections, and local recurrence
affecting and infiltrating the vaginal wall.10 On T2WI,
vaginal vault recurrence is seen as loss of the linear, low
signal intensity of the vaginal vault with associated high
signal intensity soft tissue mass.11 Recurrent tumour is
more reliably identified on DWI and on dynamic
(a)
Fig. 3. A 67-year-old patient who underwent prior radical hysterectomy with BSO and pelvic lymphadenectomy for cervical cancer. (a) Axial FSE and (b) axial
FS T2WI demonstrate bilateral small lymphoceles in the obturator region (arrowheads). Note the diffuse vaginal cuff oedema (solid arrow in a), and the FS
T2WI hyperintense perirectal space due to oedema consequent to neoadjuvant radiation treatment (open arrow in b).
780
contrast-enhanced sequences as an area of hyperintense
signal on high-b-value DWI with increased and early,
heterogeneous enhancement. Generally, CT is not the
modality of choice for evaluation of the female pelvis due
to its poor vaginal tissue characterization. The vaginal
wall is hypodense and is inseparable from the adjacent
pelvic structures (i.e. urethra anteriorly and anterior rec-
tal wall posteriorly).12 After surgery, metallic clips can be
easily detected at the site of lymph node dissection along
the pelvic side wall on CT.
Uterovaginal anastomosis
MRI is also applied to the follow-up of patients with cer-
vical cancer following trachelectomy. Typical MRI findings
after trachelectomy include: a fold of the posterior vagi-
nal wall (neo-fornix), diffuse vaginal wall oedema per-
sisting for over 1 year and vaginal wall haematomas/
submucosal fluid collections, which gradually resolve on
follow-up.13
Post-CRT
In patients with gynaecologic malignancies treated with
primary CRT, MRI is routinely used to monitor response
during and at the completion of treatment.
Uterus
In patients with cervical cancer treated with CRT, the cer-
vix and adjacent soft tissues undergo fibrotic changes,
appearing diffusely hypointense on T2WI. Furthermore,
the distinction between the junctional zone and outer
myometrium is lost, and after 6 months, the endome-
trium becomes thin and hypointense on T2WI.14 In an
early post-therapy MRI exam (2–3 months), the reconsti-
tution of the normal low signal T2WI cervical stroma was
the most reliable indicator of a tumour-free post-radia-
tion cervix.15
(b)
© 2017 The Royal Australian and New Zealand College of Radiologists

GU system
The bladder is the most radiosensitive organ of the uri-
nary system. An inflammatory response with tissue
oedema and hyperaemia develops within 4–6 weeks.
Radiation cystitis occurs in up to 12% of cases and is
dose dependent.16 The bladder wall becomes oedema-
tous and symmetrically thickened on CT and MRI exami-
nations. MRI well demonstrates the bladder wall mucosal
oedema characterized by high signal intensity on T2WI
(Fig. 2), enhancement of the mucosal layer on post-con-
trast images with a thickness of equal or less than 5 mm.
GI tract
Enteritis and colitis may occur as an early result of CRT
(within 2–3 months) in 1–5% of patients.16 Ileum is the
most commonly involved part of the bowel after
chemotherapy, while sigma and rectum are the most
involved after RT because they receive close to the entire
dose of radiation. At MRI, there is uniform thickening
and enhancement of the bowel wall. Increased signal
intensity of the rectal and sigmoid wall on T2WI may be
seen due to their submucosal oedema. Hyperintense
perirectal space on fat-saturated T2WI is a normal
change after radiation treatment due to adjacent oedema
(Fig. 3). CT findings include bowel wall thickening with a
halo sign, a serpentine appearance of the bowel, associ-
ated with mesenteric fat stranding and increased attenu-
ation (from 100 to 20 HU) of the mesentery related to
perivisceral oedema.17
Bone
Following RT, fatty changes in the pelvic bone marrow
appear as areas of high signal intensity on T1WI, which
can be visualized early following radiation therapy and
persist for years. Later changes may be an osteopenia
characterized by a diffuse decrease in bone density, bet-
ter visualized on CT.
Post-surgery complications
Post-surgical complications generally may be both opera-
tive and post-operative, occurring within a few days or
weeks of surgery (early complication), or they may not
occur for several months or even years (late complica-
tion).
Early complications
Lymphocele
Lymphoceles are fluid-filled cysts without an epithelial
lining that occur in 12–24% of patients who undergo rad-
ical lymphadenectomy and it usually is detectable 3–
8 weeks after surgery. Pelvic lymphocele is believed to
© 2017 The Royal Australian and New Zealand College of Radiologists
Imaging after treatment in uterine malignancies
result from surgical transection or inadequate ligation of
lymphatic vessels during lymph node dissection. The
symptoms of a lymphocele depend on its size and loca-
tion and whether a superinfection is present. Lymphoce-
les occurred most commonly in the external iliac
distribution and are slow to resolve. Lymphoceles may
cause compression and distorsion of adjacent structures
such as bladder, rectosigmoid colon and iliac vessels with
subsequent oedema and thromboembolic complications.6
At CT, it appears as unilocular thin-walled, fluid-filled
structures at imaging, without infiltration of adjacent
structures, retaining lateral relationship with adjacent
pelvic vessels. Negative attenuation values due to fat
within the fluid are rare but are highly suggestive of lym-
phocele. Calcification of the wall may be seen on rare
occasions. MRI shows a non-enhancing cystic mass fol-
lowing the course of pelvic lymph node chains, charac-
terized by high signal intensity on T2WI (Fig. 3), high or
low signal intensity on T1WI, depending on the lipid con-
tent. The wall thickening and rim enhancement would
not be expected in a simple lymphocele, and is strongly
suggestive of infection. Enhancing soft tissue within lym-
phocele may be indicative of tumour recurrence.18
Haemorrhage and haematoma
Haemorrhage and haematoma formation occurs as com-
plications following gynaecologic surgery in 0.2–2%
patients. The incidences of pelvic haematoma and vascu-
lar injuries are not significantly different between the
three routes of hysterectomy.19 Haemorrhage can be
confined to the vaginal vault, the anterior abdominal wall
near the laparotomic section wound site or near the tro-
car sites, or can extend into the pelvis and abdominal
cavity 20 originating from uterine, paracervical arteries or
veins (Fig. 4) and in case of uterine arteries pseudoa-
neurysm. Most commonly, it occurs as an early complica-
tion (mean 2–22 days). Vault haematoma is a common
finding in the first week following hysterectomy and has
no significant correlation with surgical technique. Abdo-
minopelvic CT is the primary imaging modality in patients
with suspected post-surgical haemorrhage. An acute hae-
matoma has a higher CT attenuation (70–90 HU)
(Figs 4a, 5a), and contrast-enhanced CT may be used to
document active extravasation of endovascular contrast
material in the presence of active bleeding,21 during arte-
rial and venous phase (Figs 4, 5). MRI is routinely used
to follow-up haemodynamically stable patients, more
often in suspected subacute haematomas. The imaging
appearance of blood products varies according to the age
of haematoma; for this reason, it is important to know
the date of surgery or the onset of bleeding. At MRI,
acute and subacute haematomas demonstrate high signal
intensity on T1WI and FS T1WI (Fig. 6). Over time, may
be seen as a dark and thick peripheral rim on both T1 and
T2WI, with a bright inner ring on T1WI, a finding known
as the concentric ring sign.22 The presence of air, which is
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(a) (b)

(c)

Fig. 4. A 40-year-old patient who underwent radical hysterectomy for uterine cancer (5 days before). (a) Unenhanced coronal CT image shows a large pelvic
haematic fluid (arrow), characterized by higher CT attenuation, and a peri-hepatic fluid (asterisk). (b, c) Axial post-contrast CT image demonstrates active
delayed bleeding from ovarian veins (arrowheads in c).

(a) (b) (c)

Fig. 5. A 50-year-old patient who underwent radical hysterectomy with BSO for endometrial cancer (3 days before). (a) Unenhanced CT axial image shows a
hyperdense abdomino-pelvic fluid, corresponding to acute haematoma. (b) Axial and (c) coronal post-contrast CT images demonstrate active arterial bleeding
from left uterine artery originating from left internal iliac artery (open arrow in b and c).

seen as a signal void on MR images within the haema-
toma, suggests an infection.23
Abscess
Pelvic abscess may occur as early complication (after 5–
10 days) in 10% of total and radical transabdominal
hysterectomy.4 Some of the most common infectious
complications after hysterectomy are vaginal cuff cellulitis
– that is unique to this procedure – and the infection of the
surgical wound.19 Abscess may be a sequela of haema-
toma or secondary to visceral injury to the bowel, ureters
or bladder; neoadjuvant CRT may increase the probability
of these complications. The appearance of the abscess

782 © 2017 The Royal Australian and New Zealand College of Radiologists

(a) (b)
Fig. 6. A 35-year-old patient who underwent prior radical hysterectomy with
BSO and pelvic lymphadenectomy for cervical cancer. (a) Axial T1W and (b) FS
T1W images show a small hyperintense subacute vaginal cuff haematoma,
characterized by high signal intensity in both sequences (small arrow). Note
the hypointense fibrotic adhesions between the sigmoid colon, the rectum
and the small bowel loops, due to the recent surgery (curved arrow in a).
may vary with its age, size and location. At CT, abscess
appears as a relatively low attenuated collection with
irregular and thick capsule and ring enhancement after
(a) (c)
(b)
Fig. 7. A 55-year-old patient who underwent prior radical hysterectomy with BSO and pelvic lymphadenectomy for endometrial cancer. (a) Axial CT images
show a pelvic fluid collection with thick margins (small arrow), with some air bubbles within (arrowhead). (b) Axial and (c) sagittal CT images demonstrate
the presence of fistulous tract between the pelvic abscess, the pelvic bowel (open arrow in b) and the vaginal stump (solid arrow in c).
© 2017 The Royal Australian and New Zealand College of Radiologists
Imaging after treatment in uterine malignancies
infusion of contrast material. Common CT findings are also
inflammatory fat stranding of surrounding tissues, free
fluid and mass effect to the adjacent organs. Presence of
air within the abscess suggests communication with the
GI tract or aerobic infection (Fig. 7). Multiplanar recon-
struction of CT data is useful in documenting the extent of
the collection and in identifying bowel perforation or fistu-
lous communication (Fig. 7). CT and ultrasound (US) are
useful modalities for documenting as well as draining an
abscess collection.24,25 Although CT imaging must be con-
sidered the first choice if an infection/abscess is clinically
suspected, also MRI can provide information. An abscess
is depicted as a fluid mass with thick, irregular walls, char-
acterized by low to intermediate signal intensity on T1WI
and high signal intensity on T2WI. If present, debris is
seen as an underlying hypointense area on T2WI. Most
specific finding of abscess is the presence of gas, seen as
signal voids on MRI.26 The thick wall and surrounding soft
tissue inflammatory changes are intensely enhanced on
fat-suppressed 3D- T1 gradient echo.27
Bowel perforation
In gynaecologic surgery, both the small bowel and the rec-
tosigmoid colon are at risk for injury. It occurs generally in
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0.1–1% of patient the first week after surgery. The preva-
lence of bowel injury is similar with all the three surgical
approaches.4 The damage mechanism may be thermal
(during laparoscopy), direct or mechanical (during adhesi-
olysis) or rarely indirect (by reducing the vascularity). The
small bowel is more commonly injured during laparoscopic
hysterectomy, whereas the rectum is at increased risk dur-
ing vaginal hysterectomy.28,29 The prevalence of bowel
injury is higher in patients with adhesions from previous
surgery, radiation therapy, during chemotherapy and
in patients with history of pelvic inflammatory disease, or
endometriosis. Further complications of bowel injury
include peritonitis, abscess formation, bowel obstruction
and fistulas. After abdominal X ray, CT is the first choice if
bowel perforation is suspected. The presence of excess
intraperitoneal air or persistent pneumoperitoneum after
the first post-operative week is an indicator of bowel
perforation. Other specific CT findings include extravasa-
tion of oral contrast material or faecal debris, focal bowel
wall defects and non-enhancing segmental bowel wall
(Fig. 8). Less specific findings include bowel wall thicken-
ing, free fluid, peritoneal enhancement and mesenteric
stranding.30Furthermore, fistulas may be seen with
other colon or small bowel loops, with bladder or vagina.31
In the early post-operative period, MRI is not indicated
for the known limitations related to the long duration of
the exam and the worst evaluation of intra-abdominal air.
GU tract injuries
Urinary tract injuries are reported in approximately 1%
of women who undergo pelvic surgery. The prevalence of
urinary tract injuries is higher following radical
hysterectomy than after total abdominal hysterectomy:
during hysterectomy, the vesicocervical and vesicovagi-
nal space is dissected to separate the bladder from the
cervix. Clarke-Pearson et al. reported a rate of bladder
injury of 1% for abdominal, 2.1% for laparoscopic and
1.2% for vaginal hysterectomy.19 Other studies estimate
a range from 0.3% to 1.2% for abdominal, 0.2% to
8.3% for laparoscopic and 0.7% to 4% for vaginal hys-
terectomy.32 A Cochrane Review found no difference in
the rate of GU tract injury (bladder or ureter) based on
subtype of hysterectomy.33–35 There was an increased
risk of GU (combined bladder and ureter) injury during
laparoscopic hysterectomy when compared with abdomi-
nal hysterectomy and with vaginal hysterectomy.19 Blad-
der and ureteral injuries may lead to urinoma, ureteral
stricture and obstruction, and ureterovaginal or vesicov-
aginal fistula formation. Actually, urography-CT and cys-
tography-CT are the preferred imaging methods for
demonstrating ureteral and bladder injuries. Bladder lac-
eration, which is usually recognized and corrected at pri-
mary surgery, is the most common injury.30,36
Predisposing factors include distortion of the pelvic anat-
omy by adhesions due to previous surgeries, radiation
therapy, or pelvic inflammatory disease. At unenhanced
CT, bladder injuries may manifest with fluid-attenuation
collection surrounding the bladder within the pelvis, or
with blood clot into the bladder.30,36 Cystography-CT
signs of bladder laceration are active leak of iodinated
urine and extraluminal extension of contrast material
into the pelvis (Fig. 9) or in the surrounding organs, such
as vagina. The prevalence of ureteral injuries is much
higher following radical hysterectomy with lymph node
dissection. Such injuries may occur due to direct trauma

(a) (b) (c)

Fig. 8. (a) A 43-year-old patient who underwent laparoscopic radical hysterectomy with BSO and sigmoid colon resection for locally advanced ovarian can-
cer (7 days before). Sagittal post-contrast CT image shows a small bowel dilatation associated with free fluid and large amount of intraperitoneal air (pneu-
moperitoneum), relating to bowel perforation. Note the less enhancing segmental large bowel wall (arrowhead), suspicious for the site of bowel wall
perforation. (b and c) A 55-year-old patient who underwent prior radical hysterectomy with BSO and pelvic lymphadenectomy for endometrial cancer. (b)
Axial and (c) sagittal post-contrast CT images demonstrate presence of faecal debris in the peri-rectum space (open arrow in b and c) and in the left iliac
fossa (solid arrow in b) related to rectum perforation.

784 © 2017 The Royal Australian and New Zealand College of Radiologists
 Imaging after treatment in uterine malignancies

(a) (c)

(b)

Fig. 9. A 40-year-old patient who underwent laparoscopic radical hysterectomy with BSO and bilateral pelvic lymphadenectomy for locally advanced cervical
cancer (1 day before), after neoadjuvant CRT. (a) Axial post-contrast CT image shows a large pelvic fluid collection (asterisk). (b, c) The delayed CT phase
images demonstrate iodinated urine filling the collection, due to bladder laceration.

(a) (b)

Fig. 10. A 44-year-old patient who underwent prior laparoscopic radical hysterectomy with BSO and bilateral pelvic lymphadenectomy for locally advanced
cervical cancer, after neoadjuvant CRT. (a) Axial delayed post-contrast CT image shows iodinated urine filling the vaginal canal (small arrow), while no con-
trast is present inside the bladder (big arrow). (b) The coronal MIP image well demonstrates iodinated urine extravasation from the left ureter into the vagi-
nal canal (arrow). In the operatory room, left ureter injury with ureteral-vagina fistula was confirmed.

during surgery or secondary to ischaemia from stripping
of the periureteral fascia.34 At urography-CT, acute uret-
eral injuries manifest with extravasation of iodinated
urine adjacent to the injured ureteral segment. It may
extend inferiorly along the iliopasoas muscle, or in sur-
rounding structures, or rarely into the peritoneal cavity
causing urinary ascites (Fig. 10). Urine extravasates
into the retroperitoneum can cause lipolysis of the sur-
rounding fat with resultant encapsulation of urine, form-
ing an urinoma. An urinoma is an encapsulated collection
of chronically extravasated urine, typically located in the
perirenal or retroperitoneal space along the iliopsoas,

© 2017 The Royal Australian and New Zealand College of Radiologists 785

et al.
M Micco
(a)
(b)
Fig. 11. A 45-year-old patient who underwent prior laparoscopic radical hysterectomy with BSO and bilateral pelvic lymphadenectomy for locally advanced
cervical cancer, after neoadjuvant CRT. (a) Axial post-contrast CT image shows a small fluid collection in the left obturator region (open arrow). (b) Axial and
(c) coronal delayed phase post-contrast CT images demonstrate the progressive increase of its attenuation due to entering of contrast-enhanced urine into
the collection. This finding is characteristic for urinoma.
and associated to hydronephrosis. At unenhanced CT,
urinoma usually manifests as a fluid collection with water
attenuation. However, the attenuation can increase pro-
gressively after intravenous administration of contrast
material because contrast-enhanced urine enters the uri-
noma (Fig. 11).37 Percutaneous aspiration and drainage
may allow confirmation of the diagnosis and treatment.
Delayed complications
Bowel obstruction
Although bowel obstruction can be an early complication,
it is most often seen as a delayed complication sec-
ondary to adhesions. Most frequent pathogenetic mecha-
nisms of early obstruction are volvulus and compressive
effect from pelvic haematoma or abscess. Small bowel
obstruction is more common than colonic obstruction.
The prevalence of bowel obstruction is higher following
total abdominal hysterectomy and radical hysterectomy
than after laparoscopically assisted supracervical hys-
terectomy.19,20 The prevalence of bowel obstruction is
also higher in patients who have a history of radiation
therapy. After abdominal X ray, CT is the primary imag-
ing method for evaluation of suspected bowel obstruc-
tion. Multidetector CT with multiplanar reconstruction
improves accuracy and confidence in identifying the tran-
sition zone and the cause of obstruction. Common CT
findings include: a distinct transition point where bowel
calibre changes, with dilated bowel loops proximal to the
786
(c)
transition point and collapsed bowel distal to the transi-
tional point, bowel wall thickening, fecaloid luminal con-
tent within the dilated loops, surrounding mesenteric fat
stranding and free fluid. Conventional barium studies of
the small and large bowel may be complementary to CT
to assess the severity of obstruction, which has an
impact on treatment. Partial small bowel obstruction with
the extension of contrast material beyond the transition
point is treated conservatively with observation.
Peritoneal inclusion cyst
Peritoneal inclusion cyst is defined as fluid accumulation
between ovaries and peritoneal surfaces. It occurs
almost exclusively in premenopausal women with a his-
tory of pelvic or abdominal surgery, trauma, pelvic
inflammatory disease, or endometriosis. Failure of the
abnormal peritoneum to absorb fluid from the function-
ing ovaries results in a loculated serous or haemorrhagic
fluid collection around the ovary. US, CT and MRI demon-
strate a uni- or multiloculated cystic mass ranging in size
from few millimetres to 20 cm or more. Characteristic
radiologic findings are cystic wall outlined by the pelvic
wall, pelvic organs and bowel loops, with the ovary
located either in the centre (creating a ‘spider in a web’
appearance) or at the periphery of the mass (Fig. 12).
Demonstration of a normal ovary within this cystic mass
is the key to differentiate peritoneal inclusion cyst from
other cystic pelvic masses such as ovarian cyst, parao-
varian cyst and hydrosalpinx.37
© 2017 The Royal Australian and New Zealand College of Radiologists

Fig. 12. A 35-year-old patient who underwent previous pelvic surgery.
Axial FSE T2WI shows a hyperintense cystic pelvic mass, with smooth mar-
gins outlined by the pelvic structures, with the left ovary located centrally,
creating the ‘spider in a web’ appearance. This finding is characteristic for
inclusion peritoneal cyst.
Abdomino-pelvic granuloma
Abdomino-pelvic granuloma can occur as localized
inflammatory reactions in response to unintentionally
retained surgical material. A foreign body retained in the
abdominal cavity after surgery is a persistent problem
that may lead to complications, including adhesions, per-
foration, and abscess or fistula formation. Gawande et al.
revealed that the abdomen and pelvis are the most com-
mon locations for a retained foreign body, such as
sponges, instruments, and although they will often
become symptomatic in the early post-operative period,
it is possible for a foreign body to go unnoticed for
months or even years.38 Imaging plays a very important
role in the diagnosis of abdominal granuloma, which is
often an unexpected finding and is not necessarily
related to the patient’s symptoms. Since the advent of
CT, retained foreign bodies have been recognized more
easily and frequently. The appearance of retained
sponges at CT is highly variable. A retained sponge is
seen as a soft tissue-attenuation mass and may show a
whorled texture or a spongiform pattern containing gas
bubbles. Rim or internal calcification is a possible finding
(Fig. 13).
Post-CRT complications
Early complications
GU tract complications
Severe early and delayed changes after CRT treatment
may affect the bladder. In the early period, both radiation
and chemotherapy can result in severe haemorrhagic
cystitis secondary to necrosis of the urothelium. At
© 2017 The Royal Australian and New Zealand College of Radiologists
Imaging after treatment in uterine malignancies
(a) (b)
Fig. 13. A 44-years-old patient with ovarian cancer underwent pelvic sur-
gery 10 years before. (a) Sagittal CT image shows the pelvic neoplasm (as-
terisk), and an upper abdominal round hypodense mass (arrow), with
internal hyperdense material. (b) Axial CT image better demonstrates the
presence of a radiopaque marker inside the mass (arrow), which was misin-
terpreted as calcification by the radiologist, corresponding to a metallic
retained foreign body (granuloma).
imaging, there is focal or diffuse irregular thickening of
the bladder wall, and decreased distensibility. Hypervas-
cularity in the wall and bleeding vessels with intraluminal
clots may be visible at enhanced CT. MRI may show pari-
etal inflammation and oedema as high signal intensity in
T2WI (Fig. 2) and can enable to distinguish focal thick-
ness from clots which appears hyperintense on T1WI. In
the chronic phase, the bladder has a small volume and
cannot be fully distended due to the fibrosis, appearing
as a thin band of low signal intensity on T2WI on the
inner aspect of the bladder wall.31 The distal ureters are
less commonly affected by pelvic irradiation, but their
involvement may cause stricture formation, resulting in
hydroureter and, ultimately, hydronephrosis.16 Fistulas
with adjacent organs may occur due to ischaemic
changes and interstitial fibrosis induced by pelvic RT
(Fig. 14).
Fistulas
A fistula is defined as an abnormal communication
between two epithelial surfaces resulting from an injury
or disease. It may connect an abscess cavity or hollow
organ to the body surface or to another hollow organ.
The nature of a fistula is related to the type of surgery
and to any associated RT. The prevalence of fistulas is
higher following radical hysterectomy – secondary to
bowel or urinary tract injury – and following RT in cervical
cancer 19 – secondary to fibrosis, loss of soft tissue
planes and necrosis. Fistulas most commonly occur
787

et al.
M Micco
Fig. 14. A 50-year-old patient with cervical cancer during CRT treatment.
The sagittal reconstruction from cystography-CT well demonstrates the fis-
tulous tract between the bladder, anteriorly, and the cervical canal, posteri-
orly, referring to a vescicovaginal fistula.
between the bladder or rectum and the vagina (vescicov-
aginal and rectovaginal fistula) (Figs 14, 15), but can
also involve the small bowel. The most appropriate imag-
ing method depends on the clinical suspect of anatomic
location of the fistula (Table 2). CT and MR imaging are
replacing conventional barium studies and intravenous
urography (IVU) as the primary imaging methods for the
evaluation of acquired fistulas. At CT, it is important to
recognize indirect signs of fistula. These signs include
the presence of air or iodinated oral contrast agent in
(a) (b)
Fig. 15. (a and b) A 56-year-old patient who underwent total hysterectomy, BSO and adjuvant RT for endometrial cancer. (a) Axial and (b) sagittal T2WI
show a high-signal-intensity fistulous tract between the rectum and the vaginal cuff (open arrow). (c) A 40-year-old patient who underwent previous radical
hysterectomy and CRT for cervical cancer. Sagittal T2WI demonstrates irregular thickening of the posterior bladder wall, associated with a decreased disten-
sibility of the organ due to previous RT. A T2W high-signal-intensity fistulous tract with peripheral hypointense wall due to fibrosis is identified between the
vaginal cuff and the posterior bladder wall (solid arrow).
788
bladder and/or focal thickening of the bladder or bowel
wall.16 Rectal administration of water-soluble iodinated
contrast agent is useful for identification of enteric fistu-
las, while the evaluation of delayed excretory phase (ob-
tained 7–20 minutes after contrast material injection) or
cystography-CT images should always be considered for
ureteral or vesical fistulas (Figs 10, 14). Three-dimen-
sional reconstruction of the CT data should also be stan-
dard practice to optimize visualization (Fig. 10). MRI is
especially well suited for the diagnosis of vesicovaginal
and rectovaginal fistulas owing to its superior soft tissue
contrast resolution.13,14 On T2WI, the fistulous tract may
be identified as a high-signal-intensity tract with periph-
eral hypointense wall due to fibrosis and chronic inflam-
mation (Fig. 15). Enhancement of the inflammatory wall
of the fistulous tract may also be visualized on images
obtained following the administration of intravenous
gadolinium-based contrast material.9 It is important to
consider the possibility that a fistulous tract has been
caused by pelvic recurrent disease invading adjacent
organs. Therefore, careful evaluation for the presence of
soft tissue mass or other features of malignancy such as
lymphadenopathy should routinely be performed.9
Delayed complications
Cervical stenosis
Stricture formation of the cervical canal is a late complica-
tion usually secondary to radiation treatment, occurring
several months (3–6 months) or even years after comple-
tion of treatment. The stenosis appears as a focal T2WI
hypointense stricture (<2.5 mm) with distension
upstream. A frequent complication after trachelectomy,
occurring in 10–15% of patients, is the isthmic stenosis,
(c)
© 2017 The Royal Australian and New Zealand College of Radiologists

presenting with secondary amenorrhoea, pelvic pain and
possible evolution in hematometra, hematosalpinx and
pelvic endometriosis. MRI may show the endometrial cav-
ity distension by haematic heterogeneous material with
high signal intensity on T1WI and variable signal intensity
on T2WI.39
Pelvic insufficiency fractures
The most common sites of insufficiency fractures are the
sacrum and pubic rami. Insufficiency fractures are com-
monly symmetric. At CT, the fracture line is observed
with bone window settings. At MR imaging, it appears as
high signal intensity representing bone marrow oedema
on T2WI and having low signal intensity on T1WI with
the characteristic H-shaped pattern across the sacrum
representing bilateral fractures of the sacral ala.16
Conclusions
Interpretation of the post-treatment appearances of the
female pelvis can be difficult. A comprehensive knowledge
of the most common findings seen after surgery,
chemotherapy and radiation therapy helps in making the
correct interpretation and avoiding possible pitfalls. Radi-
ologists should be familiar with early and delayed post-
treatment appearances of the pelvis, including both the
modified aspect of pelvic organs and different complica-
tions specifically related to the therapy. The most common
complications of hysterectomy can be categorized as
altered lymphatic drainage, infection, bleeding, genitouri-
nary and gastrointestinal tract injury, inclusion peritoneal
cyst and granuloma. Post-CRT imaging plays a fundamen-
tal role in the evaluation of therapy response. Expected
changes in pelvic appearance occur following CRT includ-
ing proctitis, enteritis and cystitis. Complications such as
fistulas and insufficiency fractures can be detected in
immediate and long-term post-treatment period.
Acknowledgement
This study was not funded.
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