Percutaneous Drainage without Sclerotherapyfor Benign Ovarian CystsEnver Zerem, PhD, Goran Imamovic, PhD, and Safet Omerovic, MD

PURPOSE: To evaluate percutaneous short-term catheter drainage in the management of benign ovarian cysts inpatients at increased surgical risk.

MATERIALS AND METHODS: Thirty-eight patients with simple ovarian cysts were treated with drainage of fluidcontent by catheters until output stopped. All patients were poor candidates for surgery. All procedures were performedunder ultrasonographic (US) control and local anesthesia. Cytologic examination was performed in all cases. The patientswere followed up monthly with color Doppler US for 12 months. Outcome measure was the recurrence of a cyst.

RESULTS: During the 12-month follow-up period, 10 of 38 cysts recurred. Seven of the 10 cysts required furtherintervention, and three were followed up without intervention. Four of the seven patients who required furtherintervention underwent repeat transabdominal aspiration and three declined repeat aspiration and subsequentlyunderwent surgery. After repeated aspirations, two of four cysts disappeared, one necessitated follow-up only, andone necessitated surgical intervention. Cyst volume (P � .009) and diameter (P � .001) were significantly larger in thecysts that recurred. No evidence of malignancy was reported in the cytologic examination in any patient. No patientsdeveloped malignancy during follow-up. No major complications were observed. The hospital stay was 1 day for allpatients. The median duration of drainage in the groups with resolved and recurrent cysts was 1 day (interquartilerange, 1–1) and 2 days (interquartile range, 1–3), respectively (P � .04).

CONCLUSIONS: In patients considered poor candidates for open surgery or laparoscopy, percutaneous treatment ofovarian cysts with short-term catheter drainage without sclerotherapy appears to be a safe and effective alternative,with low recurrence rates.

J Vasc Interv Radiol 2009; 20:921–925

OVARIAN cysts have been increasinglydiagnosed in recent years by using ul-trasonography (US) and other imagingmethods for abdominal evaluation (1,2).

Although clinical experience withsimple ovarian cysts persisting be-yond 6 months suggests that they arerarely malignant, the frequency of ma-lignancy in these cysts is not known

From the Interventional Ultrasonography Depart-ment, University Clinical Center, Trnovac bb, Tuzla,Bosnia and Herzegovina (E.Z., G.I.); and the Depart-ment of Surgery, General Hospital Mostar, Mostar,Bosnia and Herzegovina (S.O.). Received October 8,2008; final revision received April 8, 2009; acceptedApril 14, 2009. Address correspondence to Z.E.;E-mail: zerem@bih.net.ba

None of the authors have identified a conflict ofinterest.

© SIR, 2009

DOI: 10.1016/j.jvir.2009.04.047

(3,4). Given this uncertainty, the iden-tification of an ovarian cyst continues tocause considerable anxiety for women, es-pecially in the presence of symptoms. Thesurgical management of presumed be-nign cysts may represent overtreatment,with considerable cost to both the patientand society (1). Laparoscopy of benignovarian cysts has been established as thealternative to laparotomy; however, it alsoinvolves anesthesia and hospital admis-sion (5,6).

A number of studies have advocatedpercutaneous or transvaginal aspirationof benign ovarian cysts as the alternativeto surgical intervention, especially in pa-tients who are high-risk surgical candi-dates (7–9). Some authors consider thatcyst aspiration or drainage without sclero-therapy is not effective because of fre-quent relapses (9–12) and recommendsclerotherapy with alcohol or another

sclerosing agent/medicament (1,8,13).

On the basis of currently availabledata (1,8–10,13), aspiration treatmentwith or without sclerotherapy for be-nign ovarian cysts has not been fullyevaluated. The opponents of cyst aspi-ration highlight the potential difficultiesin relation to the diagnosis of malig-nancy, risk of preoperative spill of ma-lignant cells, and high rates of cyst re-currence after aspiration.

We conducted this study to evaluatethe percutaneous US-guided short-termcatheter drainage of benign ovariancysts without sclerotherapy in patientsat increased surgical risk.

MATERIALS AND METHODS

Patients

This study was conducted betweenApril 2002 and March 2007. Forty-

three patients who were referred with

921

922 • Percutaneous Treatment of Benign Ovarian Cysts July 2009 JVIR

the diagnosis of a persistent symptom-atic ovarian cyst with benign charac-teristics at US were considered candi-dates for the study. Five of the 43patients were excluded. Two patientswere excluded because they had indi-cators of malignancy (eg, neovascular-ity of the cyst) at color Doppler US,and three patients declined the proce-dure. Thus, a total of 38 patients wereincluded in the study. Patients rangedin age from 21 to 70 years (mean age �standard deviation, 41.5 years � 13.5).All patients gave written informedconsent, and the study was approvedby the local ethics committee. Inclu-sion criteria were as follows: (a) a uni-lateral symptomatic simple ovariancyst defined at US as a cyst with con-tent that appeared anechoic or hypo-echoic, with clearly defined wall andthrough enhancement of back-wallechoes, causing lower abdominal orpelvic pain or menstrual disordersthat persisted for more than 6 monthsbefore the procedure; (b) cyst diameterlonger than 30 mm because the tips ofour catheters have pigtail shape, withdiameter of about 20–25 mm (there-fore, the minimal diameter of a cyst toaccomodate that size without catheterkinking should have been at least 30mm); (c) patients who had been deemedsuboptimal candidates for laparoscopyor open laparotomy; (d) no family his-tory of ovarian cancer; (e) normal pre-procedure CA-125 level before theprocedure (�35 IU/mL); and (f) min-imal free fluid in the pouch of Douglasprecluding the possibility of ovariantorsion.

Exclusion criteria were malignancydetected at color Doppler US, ovariancysts with poor presentation at ab-dominal US, and patients who de-clined the procedure. The indicators ofmalignancy were neovascularity of thecyst and blood flow analysis (PI � 1and/or RI � 0.40, centrally locatedvessels) (13).

Procedure

All patients were admitted on theday of the procedure. The patient’ssymptoms, allergies, medication, andprevious interventions were recorded.The procedure was performed withthe patient in the supine position andwith local anesthesia only. No con-scious sedation was applied. The loca-

tion of the cyst was defined, and its

relation to the ovarian tissue was de-lineated. Careful localization of thecyst and proper selection of the entrysite were required to avoid bowel andother adjacent organs. Aspirationswere performed transabdominally un-der US guidance with a Logiq 400 ma-chine (GE Medical Systems, Milwau-kee, Wisconsin) and a 3.5-MHzcurvilinear transducer. The tip of thecatheter was placed in the center of thecyst. A free-hand technique using a5-F trocar catheter was employed forpuncturing the large and easily ap-proachable cysts. For deeper smallercysts, a 5-F catheter was coaxially ad-vanced through a 14-gauge trocar nee-dle as a one-step procedure to avoidinadvertent displacement of the cystand loss of access. The cyst contentswe aspirated entirely. The volume ofthe aspirated fluid and its appearancewere recorded. A fluid sample wassent for cytologic examination.

The catheter was then secured tothe skin for continuous external drain-age and the patient sent back to theward. After the procedure, the patientwas confined to bed rest for 2 hours. Ifpatients were without symptoms, dis-charge from the hospital was allowedon the following day. If, after 24 hours,there was no catheter output and acyst cavity was collapsed, the catheterwas removed. If a residual cavity waspresent, residual loculations of a cystwere treated with catheter reposition-ing and aspiration. To keep the cystwalls in close contact, we applied neg-ative pressure by aspirating the airfrom the cyst cavity. The catheter wasleft in situ until it stopped producingany content. US was repeated everyday until the catheter was removed.All patients were followed up in amonthly outpatient clinic with colorDoppler US for 12 months after thetreatment. The procedure was consid-ered to have failed if the diameter ofthe recurrent cyst, detected with US,was longer than half of the diameterbefore the procedure.

Statistical Analysis

Statistical analyses were per-formed with MedCalc software (ver-sion 8.1.0.0 for Windows; MedCalc,Belgium). Quantitative variableswere compared by using the two-sided t test for independent samples,

whereas categorical variables were

analyzed with the Fischer exact test.A P value of less than .05 was con-sidered statistically significant.

RESULTS

All patients were considered poorcandidates for open surgery or laparos-copy for the following reasons: Twenty-one patients had previously undergonepelvic surgery (eight of the 21 patientshad previously undergone surgery forovarian cysts), five patients were high-risk patients for anesthesia, and 12 pa-tients were unsuitable for laparoscopydue to obesity. Twenty-six of the 38 pa-tients were premenopausal, and 12 werepostmenopausal. Before the interven-tion, patients were symptomatic for amean of 8.3 months � 1.5 (range, 6–11months). The symptoms were chronicpelvic pain in 24 patients (63%), ab-dominal swelling in six (16%), andmenstrual disorders in eight (21%).

The hospital stay was 1 day for allpatients. After discharge from the hos-pital, all patients were followed up in anoutpatient clinic, with a median of 1.0day (interquartile range, 1–2 days) untildrainage stopped, when the catheterwas removed. The median duration ofdrainage in the groups with resolvedand recurrent cysts was 1 day (inter-quartile range, 1–1) and 2 days (inter-quartile range, 1–3), respectively (P �.04). There were 18 right and 20 leftovarian cysts. The initial percutaneousdrainage was technically successful inall patients. All patients experienced re-lief of symptoms immediately after theprocedure. The initial diameter of thecysts ranged from 33 to 127 mm (mean,69.2 mm � 27.5). The median amount offluid drained was 58 mL (interquartilerange, 39–130 mL). The fluid was clearin 29 patients and dark-chocolate col-ored in nine. Table 1 shows the distri-bution of patients according to the out-come and the study variables. Theaspirated fluid was routinely sent forcytologic analysis, and there was no ev-idence of malignancy in any of the aspi-rates.

During the 12-month follow-up, thecyst recurred in 10 of the 38 patients(26%). Four of the 10 cysts recurred inthe 1st month of follow-up, four cystsrecurred in the 2nd month, one cyst re-curred in the 3rd month, and one cystrecurred in the 5th month. In three pa-tients, recurrent cysts were asymptom-

atic, with diameters shorter then 40 mm,

arti

art

Zerem et al • 923Volume 20 Number 7

and they did not necessitate additionaltreatment. Seven of the 10 patients withrecurrent cysts needed further interven-tion. These patients were offered a sec-ond aspiration attempt, but three pa-tients declined it. They chose to undergosurgery, which disclosed benign cysts inall three cases. The remaining four pa-tients underwent second aspirations.Two of the four patients who under-went repeat aspiration developed recur-rence. One patient underwent surgicalremoval of the recurrent cyst after thesecond aspiration, and the remainingpatient was treated conservatively. Intotal, four of the 38 patients (10%) un-derwent surgery for cyst removal dur-

Table 1Distribution of Patients according to Ou

Characteristics

Patient age (y)�2525–3435–4445–44�55

Cyst diameter (mm)�5051–80�80

Aspirated volume (mL)�3030–5960–89�90

Median duration of drainage (d)*

* Numbers in parentheses are the interqu

Table 2Comparison of Some Characteristics of P

CharacteristicsRes

Mean patient age (y) 4Mean cyst diameter (mm) 6Mean aspirated volume (mL) 7Cyst location

LeftRight

Appearance of aspirateClearDark

Median duration of drainage (d)†

† Numbers in parentheses are the interqu

ing the study period. None of the cysts

removed surgically showed evidence ofmalignancy.

Nine of 10 recurrences were in pre-menopausal patients. None of the fivepregnant patients experienced cyst re-currence.

The mean initial diameter of recur-rent cysts and those that did not recurwas 92 mm � 22.9 and 61.1 mm �24.5, respectively (P � .001). The aver-age amount of aspirated fluid of recur-rent cysts and those that did not recurwas 137.2 mL � 82.4 and 72.7 mL �56.0, respectively (P � .009). Table 2shows the patient and cyst character-istics in relation to the outcomes.

Overall, the procedure was well tol-

me and Study Variables

esolved Cysts(n � 28)

Recurrent Cysts(n � 10)

2 17 38 55 16 0

12 012 34 7

9 09 24 36 5

1 (1–1) 2 (1–3)

le range.

ients and Cysts according to Outcome

ed Cysts28)

Recurrent Cysts(n � 10) P Value

�14.4 35.8 � 8.6 .12� 24.5 92 � 22.9 .001� 56.0 137.2 � 82.4 .009

.7214 614 4

.6722 7

6 31–1) 2 (1–3) .04

ile range.

erated by patients and no major com-

plications were observed. Eight pa-tients reported mild pelvic pain, andfour others reported dizziness duringor after the procedure. These minorcomplications were managed with bedrest, and they all subsided spontane-ously within 2 hours. No complica-tions such as infection, hemorrhage, orexcessive pain were encountered.

DISCUSSION

Our study shows that the manage-ment of benign ovarian cysts with per-cutaneous drainage without a sclero-sant is a safe alternative to surgery.After the first procedure, we observedeither complete resolution or the re-currence of small and asymptomaticcysts that did not require additionaltreatment for more than 80% of cysts.Only one patient required surgical in-tervention after the second interven-tion failed. The success of percutane-ous cyst drainage is dependent oncareful patient selection. It is most im-portant that malignancy is excluded be-fore performing the procedure. The useof cytologic analysis alone to excludemalignancy is inadequate, and it mustbe used in combination with US analy-sis and clinical follow-up. We per-formed Doppler US on all control exam-inations. All aspirated specimens wereroutinely sent for cytologic analysis, andno malignant cells were identified inany patient. None of the patients werediagnosed with or developed gyneco-logic malignancy during the study pe-riod.

The catheter drainage in our studytook 1–3 days, with 1-day drainage inmost patients (83%). We used the tro-car method for the treatment of easilyaccessible and large cysts. For smallerand deeply located cysts, we used amodified technique whereby a 5-Fcatheter was introduced through a 14-gauge needle. The reason for that isthe fact that introducing the needleinto the cyst cavity is much simplerthan introducing the catheter. Likeother investigators (14,15), we rou-tinely used Doppler US for needleplacement and examination of the nee-dle route to eliminate unnecessarytrauma to surrounding blood vesselsand ensure an uncomplicated proce-dure.

The appropriate treatment of benignovarian cysts remains the subject of

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much debate. Some authors consider

924 • Percutaneous Treatment of Benign Ovarian Cysts July 2009 JVIR

that spontaneous resolution of ovariancysts often occurs in patients treatedconservatively (16). In our study, allcysts were present for at least 6 monthsbefore intervention and did not appearto be resolving spontaneously. In addi-tion, the diagnosis of an ovarian cyst isoften a source of anxiety for both pa-tients and clinicians, mainly because ofthe concern for malignancy (17). Manyof these cysts are managed with laparos-copy or laparotomy. Simple ovariancysts do not usually become malignant,and most ovarian cysts removed at sur-gery are benign (17,18). Thus, surgerymay represent overtreatment in thesepatients, and costs and risks may out-weigh the benefits. Eight patients in ourstudy underwent surgical interventionfor the removal of benign ovarian cystsbefore percutaneous treatment, with un-favorable outcomes. The trend in man-agement of symptomatic ovarian cystshas been more strongly in favor of min-imally invasive approaches such astransabdominal or transvaginal aspira-tion (7–9).

Several conditions must be met toachieve complete obliteration of thecyst cavity. The complete removal ofliquid and air, which is necessary tokeep the cyst walls in close contact,constitutes the mechanical aspect ofobliteration.

Referring to cysts in other organs(19,20), our initial hypothesis was thatshort-term catheter drainage couldyield better results than single-sessionsclerotherapy because the content ofthe cyst was evacuated continuously,resulting in the destruction of the cys-tic epithelium and obliteration of thecyst cavity. With single-session sclero-therapy, however, the collapsed cystafter aspiration of the content mighthave many folds with pursed areas,inaccessible to sclerosant. Thus, all cys-tic epithelium may not be fully obliter-ated with sclerotherapy or pharmaco-therapy, and, subsequently, the cystsmay enlarge due to secretions from in-tact epithelium. We achieved a greaterresolution rate with smaller cysts (Table2). There was a strong positive correla-tion between cyst recurrence and cystvolume, as all recurrences had a volumegreater than 60 mL at the initial aspira-tion. In our study, we saw a significantdifference between recurrent and re-solved cysts with respect to the maxi-mum diameter (P � .001) and aspirated

volume (P � .009).

Ovarian cysts are a common gyne-cological problem. Some authors con-sider that large ovarian cysts shouldbe treated with laparotomy (5). Therecent trend in the management ofsymptomatic ovarian cysts has beentoward a less-invasive laparoscopicapproach (4–6) that offers to the pa-tients the benefits of less postoperativepain, faster recovery, and earlier re-turn to normal activity. However, thistreatment also involves anesthesia andlonger hospital stay than transabdomi-nal or transvaginal aspiration and sev-eral authors consider that surgery mayrepresent overtreatment in these pa-tients (1,7,11–13,16,17,21). Some authorshad good results with a single aspira-tion of a cyst’s content, with recurrencerates of 16.1% (7) and 26.3% (21). Otherstudies (9–12) demonstrated oppositeresults, with recurrence rates from 50%(11) to 75% (9), and they considered thatcyst aspiration without sclerotherapywas not effective and led to a high re-currence rate because secretions of theepithelial cell lining into the cyst cavityinhibited obliteration of the cyst. Theysuggested that a single aspiration with-out sclerothrerapy could not be a defin-itive treatment. The studies that usedmethotrexate (1), tetracycline (8), and al-cohol and erythromycin (13) as a scle-rosing agent to produce further coagu-lation-induced necrosis of the cystepithelium and result in definitive oblit-eration of the cyst yielded good results.

Our study demonstrated similar orbetter results than the above-mentionedstudies, with a recurrence rate of symp-tomatic cysts of 18.4% after the first pro-cedure and only four of 38 (10%) pa-tients eventually undergoing surgery.Our study indicates that percutaneousdrainage without sclerotherapy ofsymptomatic benign ovarian cysts is asafe and effective alternative to the cur-rently used methods for managing suchcases.

There are several limitations to ourstudy. This is a retrospective designwithout a comparison group and witha relatively small series of patientswho were treated over a large span oftime. Some of the ovarian cysts (espe-cially the large cysts) had an irregularshape and border, and the maximaldiameters of cysts measured beforetreatment did not always correlate tothe volumes of aspirated contents ofthe cysts.

We conclude that, in patients consid-

ered poor candidates for open surgeryor laparoscopy, percutaneous treatmentof benign ovarian cysts with short-termcatheter drainage without sclerotherapyappears to be a safe and effective alter-native, with low recurrence rates.

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