Comment on: Delayed intestinal perforation and vertebral osteomyelitis after high-intensity focused ultrasound treatment for uterine leiomyoma.

We read with interest the article by Hwang et al. [1] which reported a case of delayed intestinal perforation, uterine perforation with recto-uterine fistula and vertebral osteomyelitis 29 days after high-intensity focused ultrasound (HIFU) treatment for uterine leiomyoma. This article reminds physicians that while HIFU is increasingly being considered an effective and safe option for treatment of uterine leiomyomas [234], often for women who wish uterine preservation, potentially serious complications can occur.

Recently, we have also encountered a woman with adenomyosis who presented with intestinal perforation 8 days after HIFU [5]. Consistent with the findings from Hwang et al.'s case [1] together with 2 other cases reported by Chen et al. [6] (presented at 10 and 20 days following HIFU), this delayed presentation appears to be quite indicative of intestinal damage following HIFU. We speculate that tissue ablation at a temperature of only 56℃–90℃ from HIFU results in a subtle and delayed intestinal damage, which may not even be obvious on imaging studies [5]. We stress the importance of physician's alertness of this delayed presentation for early recognition and timely management of intestinal injury following HIFU treatment.

Furthermore, prevention of such occurrence is equally important. This patient reported by Hwang et al. [1] had multiple previous abdominal surgeries including myomectomy, appendectomy and caesarean section; clearly at risk of extensive pelvic adhesions. In many centers, including ours, patients with known or suspected extensive pelvic adhesions, or bowel adherent to the uterus or abdominal wall, such as a history of major abdominal or pelvic surgery, pelvic inflammatory disease, or pelvic endometriosis, are generally considered contraindications for HIFU treatment [234]. This case illustrates the importance of proper patient selection when considering HIFU for uterine leiomyomas or adenomyosis, as a simple and effective means to avoid complications arising from this treatment modality.