Meshy business: MRI and ultrasound evaluation of pelvic floor mesh and slings

MR imaging of benign vulvar lesions: a pictorial essay

Benign vulvar lesions can be difficult to differentiate with few publications on their imaging appearances. While many vulvar lesions may be clinically diagnosed and treated, more are being detected incidentally with the increasing prevalence of magnetic resonance imaging (MRI) of the pelvis. In addition, clinicians may find imaging of benign vulvar lesions helpful for greater anatomical correlation. After reviewing the important MRI sequences for vulvar imaging and the anatomy of the vulva on MRI, this pictorial essay illustrates variety of cystic and solid benign vulvar lesions to familiarize radiologists with their common MRI appearances. Other miscellaneous pelvic lesions that can affect the vulva are also described.

Ultrasound in Female Urinary Incontinence

Urinary incontinence (UI) is a common health condition that may interfere with the quality of life. A comprehensive evaluation of female UI helps with effective and safe treatments. Ultrasound has gained popularity to explore UI recently because it can collect crucial information for treatment planning and counseling. Translabial and introital approaches are commonly and reliably applied to ultrasound. The images can be obtained using two-dimensional and three-dimensional ultrasounds. Ultrasound is the only modality capable of confirming the presence or absence of a mid-urethral sling (MUS) and is able to demonstrate bulking agents as well. Although some of the ultrasound findings may only be incidental or supplementary to the patient's symptoms, ultrasound benefits for investigating the pathophysiology of UI and surgical outcomes of MUS procedures. It is anticipated that standardization in terminology, measurement techniques, and reporting can be established in the near future.

[Radiological imaging following pelvic prolapse surgery]

CLINICAL/METHODICAL ISSUE

Pelvic organ prolapse is a common condition in women, for which both conservative and surgical interventions are available. Knowledge of the different surgical procedures and the materials used is essential for adequate radiological diagnosis after prolapse surgery in order to differentiate potential complications from normal postoperative changes.

STANDARD RADIOLOGICAL METHODS

In the immediate postoperative period, computed tomography (CT) is often the modality of choice for evaluating acute complications such as bleeding or organ injuries. Magnetic resonance imaging (MRI) provides excellent soft tissue contrast and is therefore generally preferred for assessing subacute and chronic complications.

METHODICAL INNOVATIONS

Innovative techniques such as dynamic MRI protocols can improve the radiological assessment after prolapse surgery by enabling the evaluation of organ mobility.

PERFORMANCE

Radiological standard procedures such as computed tomography (CT) and MRI provide detailed and reliable information about the postoperative site and potential complications following prolapse surgery.

ACHIEVEMENTS

Radiological imaging plays an important role in the evaluation of patients after prolapse surgery, particularly when complications are suspected. Accurate radiological diagnosis can guide further appropriate therapeutic measures.

Multimodality Imaging of Anterior Compartment Pelvic Floor Repair

Pelvic organ prolapse (POP) and stress urinary incontinence (SUI) are two common disorders that affect the anterior compartment of the pelvic floor in women. These can be treated conservatively or surgically. Among patients treated surgically, a substantial number present with pain, recurrent POP or SUI, or other conditions that warrant additional interventions. In many of these cases, imaging is key to identifying and characterizing the type of procedure performed, locating synthetic materials that may have been placed, and characterizing complications. Imaging may be particularly helpful when prior surgical records are not available or a comprehensive physical examination is not possible. US and MRI are the most commonly used modalities for such patients, although radiopaque surgical materials may be visible at voiding cystourethrography and CT. The authors summarize commonly used surgical treatment options for patients with SUI and POP, review imaging techniques for evaluation of such patients, and describe the normal imaging appearance and complications of pelvic floor surgical repair procedures in the anterior compartment of the pelvis. ©RSNA, 2023 Quiz questions for this article are available in the supplemental material.

Vaginoscopy With Laser Treatment of Symptomatic Upper Vaginal Mesh Exposure After Prior Mesh Sacrocolpopexy

OBJECTIVE

To describe the technique of vaginoscopy with Holmium:YAG and Thulium laser treatment of upper vaginal mesh exposure after mesh sacrocolpopexy (MSC) as well as evaluate treatment efficacy.

METHODS

Following IRB approval, a chart review of all patients who underwent laser treatment of upper vaginal mesh exposure during vaginoscopy at a single institution between 2013 and 2022 was performed. Demographic information, previous mesh placement history, presenting symptoms, physical examination and vaginoscopy findings, imaging, laser type and settings, operating time, complications, and follow-up including examination and office vaginoscopy findings were extracted from electronic medical records.

RESULTS

Five patients and 6 surgical encounters were identified. All patients had a history of MSC and symptomatic mesh exposure at the vaginal apex, which was tented up and difficult to access by traditional transvaginal mesh excision. Five patients underwent vaginal mesh treatment with laser with no further vaginal mesh exposure on follow-up exam or vaginoscopy. One patient was found to have a small recurrence at 4 months and underwent a second treatment with negative findings on vaginoscopy 7.9 months post-operatively. There were no complications.

CONCLUSION

Vaginoscopy using a rigid cystoscope and laser treatment of upper vaginal mesh exposure using a Holmium:YAG or Thulium laser is a safe and quick method which led to definitive symptom resolution.

Complications of Mesh Sacrocolpopexy and Rectopexy: Imaging Review

Sacrocolpopexy and rectopexy are commonly used surgical options for treatment of patients with pelvic organ and rectal prolapse, respectively. These procedures involve surgical fixation of the vaginal vault or the rectum to the sacral promontory with mesh material and can be performed independently of each other or in a combined fashion and by using an open abdominal approach or laparoscopy with or without robotic assistance. Radiologists can be particularly helpful in cases where patients' surgical histories are unclear by identifying normal sacrocolpopexy or rectopexy mesh material and any associated complications. Acute complications such as bleeding or urinary tract injury or stricture are generally evaluated with CT. More chronic complications such as mesh extrusion or exposure with or without fistulization to surrounding structures are generally evaluated with MRI. Other complications can have a variable time of onset after surgery. Patients with suspected bowel obstruction are generally evaluated with CT. Those with suspected infection, abscess formation, and discitis or osteomyelitis may be evaluated with MRI, although CT evaluation may be appropriate in certain scenarios. The authors review the sacrocolpopexy and rectopexy surgical techniques, discuss appropriate imaging protocols for evaluation of patients with suspected complications, and illustrate the normal appearance and common complications of these procedures. ^© RSNA, 2023 Quiz questions for this article are available in the supplemental material.

Knowledge mapping and visualization analysis of pelvic organ prolapse repair with mesh from 2001 to 2021

Aims: In recent decades, extensive attention has been paid to the application of mesh to repair pelvic floor defects. However, a large body of related literature has not been system summarized. The purpose of this study is to summarize and visualize the literature on pelvic organ prolapse (POP) repair with mesh using bibliometrics. Methods: Medical literature regarding POP repair with mesh were searched and obtained in the Web of Science™ Core (WoSCC) database from 2001 to 2021. Microsoft Excel 2020, CiteSpace and VOSviewer were used to conduct the bibliometric and knowledge-map analysis. Results: In the past 20 years, a total of 2,550 articles and reviews have been published in 35 journals, and the published and cited results show a growing trend. Cosson M and International Urogynecology Journal were the authors and journals with the highest output, respectively. The United States, France and the United Kingdom are among the top three countries/organizations in relevant publications in worldwide. 584 key words in the literature are divided into 8 clusters, which are mainly related to prolapse type, risk factors, surgical methods, imaging, quality of life and bioengineering. Using clinical research and tissue engineering technology to reduce mesh complications is the current hot spot in this field. Conclusion: Reasonable application of mesh and avoiding mesh complications are still the most concerned topics in POP research. Although clinical research, surgical improvement, biological mesh and bioengineering technology have shown promising results, it is still urgent to carry out clinical transformation application research.

Clinical applications of pelvic floor imaging: opinion statement endorsed by the society of abdominal radiology (SAR), American Urological Association (AUA), and American Urogynecologic Society (AUGS)

Pelvic floor dysfunction is prevalent, with multifactorial causes and variable clinical presentations. Accurate diagnosis and assessment of the involved structures commonly requires a multidisciplinary approach. Imaging is often complementary to clinical assessment, and the most commonly used modalities for pelvic floor imaging include fluoroscopic defecography, magnetic resonance defecography, and pelvic floor ultrasound. This collaboration opinion paper was developed by representatives from multiple specialties involved in care of patients with pelvic floor dysfunction (radiologists, urogynecologists, urologists, and colorectal surgeons). Here, we discuss the utility of imaging techniques in various clinical scenarios, highlighting the perspectives of referring physicians. The final draft was endorsed by the Society of Abdominal Radiology (SAR), American Urogynecologic Society (AUGS), and the American Urological Association (AUA).

Pelvic floor ultrasound: when, why, and how?

Pelvic floor disorders are a significant medical issue, reportedly affecting nearly one in four women in the United States. Nonetheless, until the last decade, there has been relatively limited imaging research into this highly prevalent disorder. The three major imaging modalities utilized to assess pelvic floor function are ultrasound, MRI and fluoroscopy. Pelvic floor ultrasound is a rapidly emerging technique which takes advantage of the widespread availability of ultrasound, the non-invasive and relatively inexpensive approach and the incorporation of real-time imaging and software advances which permit 3-D volume imaging. Pelvic floor ultrasound provides the opportunity to optimize patient counseling and enhance pre-operative planning by providing an anatomic and functional roadmap for the referring clinician. We recommend the consideration of pelvic floor ultrasound, as described here, as an addition to the imaging armamentarium available to physicians and surgeons serving this patient population.