Response to letter to the editor

I want to thank Drs. Sapienza, Ludwig, and Baiocchi for their thoughtful letter regarding our article relating to uterine perforation ( ). I do agree that the results of the study suggest that uterine perforation is not generally a reason to avoid proceeding with a brachytherapy implant. The results of the study do note that ultrasound guidance was not associated with an improvement in the incidence of uterine perforation. This is in contrast to multiple studies, including a study I published, suggesting that a uterine tandem should never be placed without guidance ( , , , − ). The authors correctly point out that we did not evaluate the risk of uterine perforation with or without the use of ultrasound guidance in relationship to changes in procedures – specifically the discontinuation of the use of a smit sleeve. The patients that had 1–2 implants had a statistically higher rate of perforations compared to 5−6 implants (p = 0.009). In general, the 5−6 implants were associated with the use of a smit sleeve. I agree with the suggestion that the terminology could be better refined to report the precise timing that the image was performed, using subcategories of "real-time image guided" (if the US image is obtained simultaneously with the progression of the tandem through the cervix) and "real time image-assisted" (if the US image was done only in time points immediately before and/or after insertion to provide anatomic information and confirmation of the placement). We currently use real-time ultrasound image guidance with all our implants.