What is your approach to uterine perforation during the time of brachytherapy implant for cervical cancer?

First off, I think uterine perforations occur a lot more frequently and easily than we previously accounted for. I learned how to perform brachytherapy using purely orthogonal X-rays, with dosing and dwell position times based on measured distances from the applicators, and all of the focus was placed on obtaining "perfect geometry." Not to say these techniques and planning concepts are not valuable, but it is very easy to obtain perfect geometry while the tandem is not in the uterus. Historically, published rates of uterine perforation were often very low, eg. in the 3-4% range; but, as I have personally transitioned my clinic to CT-based planning, I have witnessed quite a bit of more variation in tandem placement, and this seems to be ech...

I agree with most of @Dr. First Last's comments. The most important point is that a tandem should never be loaded if any portion of it is in the peritoneal cavity. A loaded tandem in the peritoneal cavity will almost always lead to a bowel perforation, which is frequently fatal.

There are many tricks that can be used to successfully sound the uterus. I agree that close pre-procedure examination of available imaging gives important information about the size of the uterus and location of the canal. We also now perform all of our cases under ultrasound guidance, which can help a great deal. In some cases, a tenaculum on the cervix can be helpful. If the vagina is narrow, I typically remove the speculum/retractors from the vagina after the tip...