Early CT after vaginal hysterectomy: normal or abnormal?

An 80-year-old G1P1 female patient with an unremarkable past medical history undergoing elective vaginal hysterectomy to manage uterine prolapse. Suffering from abdominal distension, vague pelvic pain and low-grade fever during the first postoperative days.
No significant abnormalities of laboratory test, consistent with minimal (<100 mL) intraoperative blood loss.

Four days after surgery, the attending gynaecologist requested contrast-enhanced multidetector CT (Fig.1) to rule out postoperative complications. Compared to the expected CT (Fig.2) and MRI (Fig.3) appearance after abdominal hysterectomy, the moderately distended vagina showed loss of the usual H- or band-shaped configuration in transverse planes, circumferential mural thickening and marked, uniform mucosal enhancement.
On the basis of clinical findings (including physical examination, minimal intraoperative blood loss, normal leukocyte count and acute phase reactants) and absent CT findings suggesting vaginal vault haematoma (Fig.4), abscess (Fig.5), lymphocoele (Fig.6) and urinoma (Fig.7) consultation between radiologist and gynaecologist concluded for normal findings reflecting diffuse vaginal oedema after uncomplicated vaginal hysterectomy.
The patient was then successfully discharged on good clinical conditions.

Despite development of alternative therapies for benign conditions, hysterectomy remains the second most common gynaecological operation after Caesarean section (annual overall rates 1.2-4.8/1000 women) and may be performed using either abdominal, laparoscopic or vaginal approach [1, 2].
Compared to open surgery, vaginal hysterectomy (VH) offers significant advantages such as decreased morbidity, shorter hospital stay and faster recovery, and is therefore preferable with the majority of patients with non-malignant disorders, particularly for genital prolapse. Relative contraindications include obesity, nulliparity, marked uterine enlargement. In VH, the uterus is approached, excised, anteverted and extracted through the vagina. Laparoscopically-assisted VH allows to manage adhesions and extrauterine involvement such as in endometriosis or pelvic inflammatory disease [3, 4].
Although lower compared to abdominal hysterectomy (overall complication rates 3.2% versus 6.2%), VH is associated with non-negligible risks, both systemic (venous thromboembolism, sepsis, cardiopulmonary dysfunction) and local. Among the latter, vaginal vault haematoma (VVH) and surgical site infections (SSI) are by far the most prevalent. More frequent in premenopausal women with larger highly vascularised uteri, VVH occurs in up to 25-40% of operated patients, manifests with decreasing haematocrit and fever, is often self-limiting but may require transfusions. SSI (including vaginal cuff cellulitis, pelvic infection and abscess) result from ascending polymicrobial contamination and typically manifest 5-10 days after surgery as tender inflammatory swelling and purulent vaginal discharge [5-8].
Nowadays, contrast-enhanced multidetector CT is increasingly requested to detect or rule out postsurgical complications after most abdominal and pelvic surgeries, including hysterectomy. Although in a limited number of patients, we have consistently observed a characteristic, expected CT appearance of the vagina shortly after uncomplicated VH: compared to the well-known CT (Fig.2) and MRI (Fig.3) findings after abdominal hysterectomy, VH causes loss of the usual H- or band-shaped configuration of the vagina in transverse planes, with circumferential oedematous mural thickening and thin, marked mucosal enhancement. When interpreting early post-VH CT studies, radiologists should thoroughly search for hyperattenuating blood (Fig.4), abscess collections (Fig.5) and urinoma (Fig. 7) at the surgical site. Additionally, the vaginal vault should be carefully scrutinised for mural discontinuity and fat herniation, which should suggest cuff dehiscence, which represents a very rare (0.08% of cases) but serious complication [5, 9, 10].