IUD Perforation? Try Laparoscopic Removal First

Steven Fox

December 07, 2011

December 7, 2011 — A majority of intrauterine devices (IUDs) that cause uterine perforations may be safely removed with laparoscopy, rather than resorting to more invasive surgery, according to researchers who reviewed nearly 40 years of research on the topic.

On the basis of their review, Richdeep Gill, MD, from the Department of Surgery, University of Alberta, Edmonton, Canada, and colleagues suggest that the laparoscopic approach be first-line therapy in patients who present with symptoms, and that it be considered a reasonable option in patients without symptoms.

Their article appears in the January 2012 issue of Contraception .

"Uterine perforation by [IUDs] is a rare but well recognized complication," they write. However, "[o]ur review demonstrates that a majority of IUD perforations may be amenable to laparoscopic retrieval." Furthermore, they say, the location of the perforated IUD within the abdomen does not appear to be a major factor in outcomes.

According to some estimates, anywhere from 0 to 1.3 per 1000 women implanted with the devices will experience uterine perforation.

In the past, patients who presented with adhesions and perforated viscera often required laparotomy to remove their IUDs, but in recent years improvements in laparoscopic technique and technology have allowed surgeons to use the less-invasive approach to achieve the same results, the authors say.

To find out more about how advances in laparoscopic surgery have affected the management of patients with perforated IUDs, the authors conducted a systematic search of the literature from 1970 through 2009, using MEDLINE/PubMed, Embase, Cochrane Library, and OCLC PapersFirst.

The authors identified 179 cases in which surgeons attempted to use laparoscopy to remove perforated IUDs. Mean age of the patients was 26 years, with an age range from 17 to 49 years. More than three-quarters of the women had previously given birth at least twice.

The patients presented with various symptoms, the most common being pain and unexpected pregnancy, the authors say. All participants initially underwent diagnostic laparoscopy.

The authors report that this initial laparoscopy was successful in all 179 cases. Surgeons subsequently used laparoscopy to successfully remove the perforated IUDs in 64.2% (115/179) of cases.

Laparotomy was done in 34.6% (62/179) of cases, either after diagnostic laparoscopy or after laparoscopic removal had been attempted.

The presence of adhesions appeared to be a factor in unsuccessful outcomes with laparoscopy. Among women who required laparotomy to remove their IUDs, 75% (15/20) reported the presence of adhesions.

In contrast, women whose IUDs were successfully removed by laparoscopy reported a 37.7% (20/53) incidence of adhesions.

Perforated IUDs were found in a variety of locations, including the omentum (26.7%), pouch of Douglas (21.5%), colonic lumen secondary to perforation (10.4%), myometrium (7.4%), broad ligament (6.7%), free within the abdomen (5.2%), small bowel serosa (4.4%), colonic serosa (3.7%), and mesentery (3%). The remaining 11% were found in rare locations, including the bladder, appendix, abdominal wall, fallopian tube, ovary, retroperitoneum, and small bowel. The location appeared to have little effect on the outcomes, the reviewers say.

They conclude: "[T]his systematic review highlights how advances in laparoscopic technique and skill have allowed surgeons to safely retrieve IUDs without laparotomy. We recommend an attempt at laparoscopic removal as first-line treatment in symptomatic patients and as a reasonable treatment option in asymptomatic patients."

The authors have disclosed no relevant financial relationships.

Contraception. 2012;85:15-18. Abstract

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