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Gynecol Oncol. 2018 Dec;151(3):573-578. doi: 10.1016/j.ygyno.2018.10.011. Epub 2018 Oct 15.

Decrease in uterine perforations with ultrasound image-guided applicator insertion in intracavitary brachytherapy for cervical cancer: A systematic review and meta-analysis.

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Department of Radiation Oncology, AC Camargo Cancer Center, São Paulo, SP, Brazil; Department of Radiation Oncology, Hospital Central do Exército do Rio de Janeiro (HCE-RJ), Rio de Janeiro, RJ, Brazil. Electronic address:
Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
Department of Statistics and Epidemiology, AC Camargo Cancer Center, São Paulo, SP, Brazil. Electronic address:
Department of Radiation Oncology, Hospital Federal dos Servidores do Estado (HFSE-RJ), Rio de Janeiro, RJ, Brazil.
Department of Gynecologic Oncology, AC Camargo Cancer Center, São Paulo, SP, Brazil.



To estimate uterine perforations rates during intracavitary brachytherapy for cervical cancer with and without ultrasound (US) image guidance.


A systematic search of databases (PubMed and EMBASE) was performed. The pooled summary uterine perforation rate (detected by postinsertion CT or MRI) for the un-guided insertion group and the guided insertion group was calculated by using the random-effects model weighted by the inverse variance.


A total of 690 articles were initially found, resulting in 12 studies that met the inclusion criteria. A total of 1757 insertions and 766 patients were included in the meta-analysis. The overall uterine perforation rate per insertion was 4.56% (95%CI: 2.35-8.67) and per patient was 7.39% (95%CI: 3.92-13.50). The pooled perforation rate per insertion without image guidance was 10.54% (95%CI: 6.12-17.57) versus 1.06% (95%CI: 0.41-2.67) with image guidance (p < 0.01). The pooled perforation rate per patient without guidance was 16.67% (95%CI: 10.01-26.45) versus 2.54% (95%CI: 1.21-5.24) with image guidance (p < 0.01). The ratio of perforations in the un-guided/guided groups was 9.94 and 6.56, per insertion and per patient, respectively. The most common sites of perforation were the posterior wall (>47 events) and the uterine fundus (24 events). None of the studies reported significant acute clinical consequences. Prophylactic antibiotic after perforation was used in 3 of the 4 studies that described the management.


Using postinsertion CT or MRI to detect the perforation, the rate of uterine perforation per insertion in patients who received US-guided intracavitary brachytherapy insertion is 90% lower than with un-guided insertion.


Brachytherapy; Cervical cancer; Gynecological cancer; Image-guided insertion; Meta-analysis; Uterine perforation

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