Although a small number of patients with migrated IUCDs will present with acute symptoms necessitating urgent surgery, most will be relatively asymptomatic, and therefore undergo planned surgery. Despite most cases being asymptomatic, the current guidance is that all misplaced IUCDs should be surgically removed.11
We undertook this review with the aim of providing a comprehensive evaluation of the current evidence for those faced with this situation in their clinical practice. In particular, we aimed to determine whether laparoscopic surgery was an appropriate approach and to determine an approximate rate of conversion to open surgery. To our knowledge, this is the first systematic review to address this issue and provides the most comprehensive review of the current evidence.
This review revealed that the majority (93.0%) of reported cases were attempted laparoscopically; however 22.5% of these were converted to open procedures. The overall rate of open surgery was found to vary according to the site of the misplaced IUCD. The patients with an IUCD that was related to both abdominal and pelvic organs had the highest rate of open surgery at 57.1%, compared with a rate of just 12.9% in those related to only pelvic organs and 40.0% in those related to only abdominal organs. These rates are likely to reflect the complexity of the surgery required to remove the IUCDs; because the majority of those located in the pelvis were “free” and not fixed to pelvic organs, it is not surprising that the rate of conversion was lowest among these cases.
A discussion regarding the risk of conversion to open surgery is an important part of the consent process for any laparoscopic surgery. This review provides surgeons with an approximate rate of conversion; however, it should be quoted with caution. The reported cases span the period from 1971 to 2010, during which significant advances in laparoscopic surgery have occurred. The inclusion of earlier cases may have led to the rate of conversion being falsely elevated. In addition, a review of case reports and retrospective case series will suffer significantly from publication bias, with novel and interesting cases, as well as those perceived to have been “successful” (ie, not converted) being preferentially published. However, despite these limitations, this report represents the best available evidence regarding the rate of conversion.
Very few complications were reported. Just 2 major complications were reported across the 129 cases included. This small number may also represent data likely to have suffered from publication bias, as in suppressed mention of those cases with complications. Additionally, there were 11 cases about which no comment on postoperative recovery was made. Despite these concerns, a laparoscopic approach appears to be safe, and would therefore be appropriate for this group of young patients, for whom cosmesis may be an important consideration. The infrequent number of complications and the age of this patient group studied indicate this surgery may be undertaken in an outpatient setting.
We did not evaluate the preoperative imaging used in each case. However, the site of the IUCD appears to influence the risk of conversion and the potential need for additional intraoperative procedures, such as cystoscopy and proctoscopy. Therefore, accurately locating the IUCD, with appropriate imaging, would ensure that the required equipment and specialists were present, as well as further informing the consent process.
In summary, the results of this systematic review support the use of laparoscopic surgery for the elective removal of migrated IUCDs from within the peritoneal cavity. With complications rarely being reported, it is also likely that the procedure could appropriately be undertaken in an outpatient setting. The intraoperative use of adjunct technology (such as cystoscopy) and the rate of open surgery are both influenced by the site of the IUCD; it is therefore advised that the device is accurately localized preoperatively.