Radiogenic risks from hysterosalpingography

Hysterosalpingography: a step up for dose reduction

AIM

To evaluate the efficiency of last image capture in interpreting a hysterosalpingogram (HSG) when compared to conventional spot views; to confirm its validity in showing pathology; to establish its use as the preferred method; and to decrease the radiation dose to the patient.

MATERIALS AND METHODS

The study population consisted of women aged ≥18 years. A standard technique was performed including additional five last image capture after each spot view. Every patient had two stacks of images, one with the exposure film and one with the last image capture. The images were interpreted separately (high-dose versus low-dose) and blindly by two radiologists with different levels of training assessing for uterine abnormalities, fallopian tube abnormalities, peritoneal spillage, and incidental findings. Inter-reading variability was calculated using Kohen's kappa.

RESULTS

Discrepancies between exposure film and last image capture were detected in only a minority of cases for all variables. Except for the presence of strictures, there was at least substantial agreement between the readers and almost perfect agreement regarding peritoneal spillage and fallopian tube patency, both on exposure film and last image capture.

CONCLUSION

Reduction in radiation dose without compromising the diagnostic efficacy of HSG is mandatory. If the study is of sufficient quality and deemed negative on last image capture, conventional spot view can be avoided. If further detail is required, standard spot views can still be obtained. Using last image capture instead of spot films has the potential to reduce the overall radiation dose by up to 78%.

The Impact of Preconceptional Hysterosalpingography with Oil-based Contrast on Maternal and Neonatal Iodine Status

The objective of this study is to investigate the impact of preconceptional exposure to oil-based iodinated contrast in the hysterosalpingography (HSG) on pregnant women and their offspring's iodine status, thyroid function, and the outcomes of pregnancy. A cross-sectional evaluation of iodine status was performed on pregnant women with the preconceptional experience of ethiodized-oil HSG. For those found to have iodine excess (with serum iodine concentration (SIC) > 92 μg/L), a prospective follow-up was conducted until termination of the pregnancy or 1 week postpartum. Among 70 of 425 pregnant women with preconceptional ethiodized-oil HSG, iodine excess was initially confirmed in 38 (54.3%), with an elevated SIC (294.00 μg/L [142.00, 123.20]) and urinary iodine-to-creatinine ratio (UI/Cr) (830.00 μg/g Cr [437.50, 255.30]), both higher than the normative data (P = 0.000, P = 0.000). Subsequent follow-up in pregnancy showed a downward trend in both SIC and UI/Cr. Thirty-four women delivered healthy neonates at full term, though the other 4 cases of premature birth, abnormal fetal karyotype, spontaneous abortion, and neonatal cardiac defect were reported. After delivery, the iodine concentration in maternal breast milk and neonatal urine was 584.50 μg/L [328.50, 1507.50] and 424.00 μg/L [277.00, 657.50], respectively, both higher than normative data (P = 0.001, P = 0.015). For thyroid evaluation, 25 cases (65.79%) of clinical or subclinical hypothyroidism and 2 cases (5.26%) of thyrotoxicosis were confirmed in women with iodine excess. Neither goiter nor thyroid dysfunction was detected in any offspring. Preconceptional exposure to oil-based contrast in HSG might exert a far-reaching impact on maternal and offspring iodine status, and tend to result in increased risk of maternal thyroid dysfunction.

Conversion factors for effective dose and organ doses with the air Kerma area product in hysterosalpingography

Histerosalpingography (HSG) remains the dominant diagnostic tool for investigation of infertility in women. Conversion factors used to estimate effective (E) and organ doses (H_T) from air Kerma area product (KAP) are needed to estimate patient doses in HSG, performed with state-of-the-art fluoroscopic X-ray systems with digital detectors. In this study, estimates of E and H_T for six critical organs/tissues, were derived on an individual basis in 120 HSG procedures and in 1410 irradiation events, performed on two X-ray systems from information available through the radiation dose structured report using Monte Carlo methods. Mean values of E and H_ovaries were1.0 ± 0.9 mSv and 5.6 ± 5.4 mGy. E/KAP conversion factors of 0.13; 0.18; 0.28 and 0.35 mSv Gy^-1cm^-2 were established for irradiation events with a Cu filtration of 0.0; 0.1; 0.4 and 0.9 mm. A high agreement was obtained between E estimated through Monte Carlo methods and E/KAP conversion factors accounting separately for the different modes of fluoroscopy and the radiography component of HSG, with a systematic error of 0 mSv and lower/upper limits of agreement of -0.6 and 0.5 mSv. On the contrary, the use of a single coefficient of conversion did not provide accurate estimates of E, showing a bias of -0.4 mSv and lower and upper limits of agreement of -1.9 and 1.2 mSv. An algorithm for the estimation of effective and organ doses from KAP has been established in HSG procedures depending on the Cu filtration in the X-ray irradiation events.

Hysterosalpingography in endometriosis: performance and interpretation

Endometriosis is often seen and sometimes initially diagnosed on hysterosalpingography (HSG), an imaging exam routinely performed on patients with infertility. Here we discuss the role of HSG in the evaluation of patients with infertility with a focus on patients with endometriosis. The HSG technique, including patient preparation as well as potential risks and complications, is detailed. Imaging findings in patients with endometriosis are illustrated and a template for exam reporting is presented. Common imaging pitfalls are described with examples.

Assessment of Patient Absorbed Radiation Dose during Hysterosalpingography: A Pilot Study in Southwest Nigeria

BACKGROUND

Hysterosalpingography (HSG) is an indispensable tool for diagnosing infertility in females. The procedure exposes female reproductive organs to ionizing radiation as the genitals are irradiated during the process. Investigating patient absorbed dose during the procedures is essential for effective radiological protection of the patient.

OBJECTIVE

This study aims to investigate the radiation dose received by patient during HSG examination in the study environment in order to enhance optimization of procedures and the associated dose, thereby minimizing radiation risks.

MATERIAL AND METHODS

The prospective pilot study, was conducted in four tertiary healthcare institutions in Southwest Nigeria. Thermoluminescence dosimeter (TLD 100) was used to determine the Entrance Surface Dose (ESD) of 80 patients presented for HSG investigation. The corresponding effective dose, ovary, uterus and urinary bladder doses were evaluated using PCXMC software.

RESULTS

The mean entrance surface doses (ESD) obtained from the four centers were 18.58±6.31 mGy, 15.18±2.27 mGy, 17.44±3.43 mGy and 34.24±11.98 mGy for SW1, SW2, SW3 and SW4 centers, respectively. The corresponding mean of effective doses were 1.54±0.63 mSv, 1.24±0.28 mSv, 1.41±0.30 mSv and 2.53±0.94 mSv for SW1, SW2, SW3 and SW4 centers, respectively. The resulting mean doses to the ovary, urinary bladder and uterus were also presented.

CONCLUSION

The results obtained in general are comparable with international standards. It was, however, recommended that study centers with high doses should conduct dose audit in order to enhance patient safety.

Role of Interventional Procedures in Obstetrics and Gynecology

Radiological guided intervention techniques are discussed in obstetric and gynecologic patients. Fallopian tube recanalization, postpartum hemorrhage control, techniques of treating uterine leiomyomas, pelvic congestion treatment, and the use of percutaneous and transvaginal ultrasonography-guided aspirations and biopsy are covered. These techniques use basic radiological interventional skills and show how they are adapted for use in the female pelvis.

Hysterosalpingo-contrast-sonography vs. magnetic resonance-hysterosalpingography for diagnosing fallopian tubal patency: A systematic review and meta-analysis

PURPOSE

To compare hysterosalpingo-contrast-sonography (HyCoSy) and magnetic resonance-hysterosalpingography (MR-HSG) in the diagnosis of fallopian tubal patency.

MATERIALS AND METHODS

The databases of PubMed, Embase, and the Cochrane Library were searched for records up to November 30, 2019. Studies involved in the diagnostic detection of HyCoSy or MR-HSG for fallopian tubal patency using conventional HSG or laparoscopy as the reference test were included. Data was analyzed by meta-analysis. We compared sensitivity, specificity, positive and negative likelihood ratios (PLR and NLR), diagnostic odds ratio (DOR), and summary receiver operating characteristic (sROC) plots of both HyCoSy and MR-HSG. Quality was assessed using the QUADAS-2 tool.

RESULTS

The analysis included 24 articles involving 1340 patients. HyCoSy was studied in 17 studies, and MR-HSG was studied in seven studies. For HyCoSy in diagnosis of fallopian tubal patency, pooled sensitivity was 89 % (95 % confidence interval [CI], 87 %-91 %), and specificity was 93 % (95 % CI, 91 %-94 %). For MR-HSG in diagnosis of fallopian tubal patency, pooled sensitivity was 100 % (95 % CI, 98 %-100 %), and specificity was 82 % (95 % CI, 74 %-89 %). The sROC showed similar diagnostic accuracy for MR-HSG and HyCoSy. 3D/4D HyCoSy with ultrasound microbubbles had equal sensitivity (95 % vs. 100 %, P = 0.186) and significantly higher specificity (94 % vs. 82 %, P = 0.005) compared with MR-HSG.

CONCLUSIONS

HyCoSy and MR-HSG showed similar overall diagnostic performance for diagnosing fallopian tubal patency. 3D/4D HyCoSy with ultrasound microbubbles could significantly improve the diagnostic specificity of HyCoSy.

Is there a link between preoperative fluoroscopic cough stress testing and synthetic midurethral tape outcome?

OBJECTIVES

The primary aim of our study was to assess the utility of fluoroscopic cough stress testing as a predictor of synthetic midurethral tape (MUT) outcome. The secondary aim was to examine whether baseline demographics, clinical symptoms and urodynamic variables could predict MUT success.

STUDY DESIGN

We carried out a retrospective study including women with stress urinary incontinence (SUI) who underwent retropubic MUT in a tertiary referral urogynaecology unit. We excluded cases where concurrent pelvic organ prolapse surgery was performed. Patients were subdivided into groups based on the pre-operative fluoroscopic cough stress testing, using Blaivas and Versi classifications. Subjective outcome was evaluated at 6 weeks based on self-reported SUI in the symptom domain of the King's Health Questionnaire. Logistic regression models were used to identify predictors of treatment success.

RESULTS

143 patients were included in the study. Blaivas and Versi classifications were not useful in predicting subjective success (p=0.44 and p=0.40, respectively). Baseline demographics, clinical and other urodynamic variables failed to predict subjective outcome.

CONCLUSIONS

Fluoroscopic cough stress testing is not a useful predictor of MUT outcome. No preoperative variables have been found to predict MUT success.

Subsequent Cancer Risk of Women Receiving Hysterosalpingography: A Nationwide Population-Based Retrospective Cohort Study

The objective of this study was to estimate the subsequent cancer risk of women after receiving hysterosalpingography (HSG) by conducting a nationwide retrospective cohort study. We identified a study cohort of 4,371 patients who had had a HSG examination and a comparison cohort of 17,484 women without HSG examination between 1998 and 2005. Both cohorts were followed up with until the end of 2010 to measure the incidence of cancer. The risk of developing cancer for patients with HSG was assessed using the Cox proportional hazard model. In the multivariate analyses, the HSG cohort did not have a significantly greater risk of cancer (Hazard Ratio [HR] = 1.02, 95% CI = 0.79-1.31) than the non-HSG cohort. The HR was highest for genital cancer (HR = 1.32, 95% CI = 0.77-2.25), followed by urinary system cancer (HR = 1.11, 95% CI = 0.23-5.40), and abdominal cancer not involving the GU system (HR = 1.04, 95% CI = 0.53-2.03), all of which were non-significant elevations. The cancer incidence rates, especially that for urinary system cancer, were increased in the HSG cohort, but the increase in cancer incidence was small and not statistically significant.

Estimation of effective dose during hystrosalpingography procedures in certain hospitals in Sudan

The aims of this study were to measure the patients' entrance surface air kerma doses (ESAK), effective doses and to compare practices between different hospitals in Sudan. ESAK were measured for patient using calibrated thermo luminance dosimeters (TLDs, GR200A). Effective doses were estimated using National radiological Protection Board (NRPB) software. This study was conducted in five radiological departments: Two Teaching Hospitals (A and D), two private hospitals (B and C) and one University Hospital (E). The mean ESAK was 20.1mGy, 28.9mGy, 13.6mGy, 17.5mGy, 35.7mGy for hospitals A, B, C, D, and E, respectively. The mean effective dose was 2.4mSv, 3.5mSv, 1.6mSv, 2.1mSv and 4.3mSv in the same order. The study showed wide variations in the ESDs with three of the hospitals having values above the internationally reported values.

Pain during Fallopian-tube patency testing by hysterosalpingo-foam sonography

OBJECTIVES

To evaluate perception of pain during Fallopian-tube patency testing by hysterosalpingo-foam sonography (HyFoSy).

METHODS

In this cross-sectional study, 216 consecutive women presenting at a university fertility clinic for HyFoSy examination were included. Patients were instructed to take ibuprofen 1 hour before the procedure. Immediately after the procedure, patients filled in a questionnaire concerning discomfort or pain experienced during the process, including a visual analog scale (VAS) score for perception of pain.

RESULTS

The median VAS score for perception of pain during transvaginal ultrasound examination and during HyFoSy examination was 1.5 (95% CI, 1.2-1.7) and 3.6 (95% CI, 3.0-4.0), respectively. One-third of women reported that the level of discomfort or pain during HyFoSy examination was similar to that during the preceding transvaginal ultrasound examination and 48% of women considered HyFoSy examination to be neutral/unpleasant, but not painful. There was an inverse association between both patients' age and parity and the pain experienced.

CONCLUSIONS

HyFoSy examination is tolerated well and allows for reliable tubal patency testing without exposing the patient to ionizing radiation in an outpatient setting with a low technical failure rate.

Rate of detection of unsuspected pregnancies after implementation of mandatory point-of-care urine pregnancy testing prior to hysterosalpingography

PURPOSE

The aim of this study was to determine the rate of detection of unsuspected pregnancies after the implementation of mandatory point-of-care urine pregnancy testing before hysterosalpingography (HSG).

METHODS

At the authors' institution, HSGs are scheduled to occur during days 8 to 12 of the menstrual cycle. Upon arrival in the radiology department, all women undergo point-of-care urine pregnancy testing before HSG (at a cost of $1.25 per test). Urine pregnancy test results were retrospectively reviewed.

RESULTS

Four hundred ten women (mean age, 25.9 years; range, 22-50 years) underwent point-of-care urine pregnancy testing before HSG between October 2010 and July 2012. Study indications were infertility evaluation (90.7% [372 of 410]) and tubal patency assessment after placement of tubal occlusive devices (9.3% [38 of 410]). Two positive urine pregnancy test results (0.5%) were recorded. One positive result was deemed a false-positive because the patient had received an intramuscular injection of β-human chorionic gonadotropin before the scheduled HSG, and follow-up laboratory testing showed declining β-human chorionic gonadotropin levels. The second positive result was a true-positive, and the patient was determined to be 4.5 weeks pregnant on the date of the scheduled HSG.

CONCLUSIONS

One of 410 women presenting for HSG was found to have an unsuspected early pregnancy, which was detected with a point-of-care urine pregnancy test. Consideration should be given to routine pregnancy testing of women before HSG because scheduling on the basis of menstrual cycle dates can be unreliable.

ICRP Publication 117. Radiological protection in fluoroscopically guided procedures performed outside the imaging department

An increasing number of medical specialists are using fluoroscopy outside imaging departments, but there has been general neglect of radiological protection coverage of fluoroscopy machines used outside imaging departments. Lack of radiological protection training of those working with fluoroscopy outside imaging departments can increase the radiation risk to workers and patients. Procedures such as endovascular aneurysm repair, renal angioplasty, iliac angioplasty, ureteric stent placement, therapeutic endoscopic retrograde cholangio-pancreatography,and bile duct stenting and drainage have the potential to impart skin doses exceeding Gy. Although tissue reactions among patients and workers from fluoroscopy procedures have, to date, only been reported in interventional radiology and cardiology,the level of fluoroscopy use outside imaging departments creates potential for such injuries.A brief account of the health effects of ionising radiation and protection principles is presented in Section 2. Section 3 deals with general aspects of the protection of workers and patients that are common to all, whereas specific aspects are covered in Section 4 for vascular surgery, urology, orthopaedic surgery, obstetrics and gynaecology,gastroenterology and hepatobiliary system, and anaesthetics and pain management.Although sentinel lymph node biopsy involves the use of radio-isotopic methods rather than fluoroscopy, performance of this procedure in operating theatres is covered in this report as it is unlikely that this topic will be addressed in another ICRP publication in coming years. Information on radiation dose levels to patients and workers, and dose management is presented for each speciality.

Hysterosalpingography using a flat panel unit: evaluation and optimization of ovarian radiation dose

PURPOSE

The aim of the present study was the evaluation and optimization of radiation dose to the ovaries (D) in hysterosalpingography (HSG).

METHODS

The study included a phantom study and a clinical one. In the phantom study, we evaluated imaging results for different geometrical setups and irradiation conditions. In the clinical study, 34 women were assigned into three different fluoroscopy modes and D was estimated with direct cervical TLD measurements.

RESULTS

In the phantom study, we used a source-to-image-distance (SID) of 110 cm and a field diagonal of 48 cm, and thus decreased air KERMA rate (KR) by 19% and 70%, respectively, for beam filtration: 4 mm Al and 0.9 mm Cu (Low dose). The least radiation exposure was accomplished by using the 3.75 pps fluoroscopy mode in conjunction with beam filtration: Low dose. In the clinical study, D normalized to 50 s of fluoroscopy time with a 3.75 pps fluoroscopy mode reached a value of 0.45 ± 0.04 mGy. Observers' evaluation of diagnostic image quality did not significantly differ for the three different modes of acquisition that were compared.

CONCLUSIONS

Digital spot radiographs could be omitted in modern flat panel systems during HSG. Fluoroscopy image acquisitions in a modern flat panel unit at 3.75 pps and a beam filtration of 4 mm Al and 0.9 mm Cu demonstrate acceptable image quality with an average D equal to 0.45 mGy. This value is lower compared to the studied literature. For these reasons, the proposed method may be recommended for routine HSG examination in order to limit radiation exposure to the ovaries.

Cancer incidence risks to patients due to hysterosalpingography

Cancer incidence estimates and dosimetry of 120 patients undergoing hysterosalpingography (HSG) without screening at five rural hospitals and with screening using image intensifier-TV at an urban hospital have been studied. Free in air kerma measurements were taken for patient dosimetry. Using PCXMC version 1.5, organ and effective doses to patients were estimated. Incidence of cancer of the ovary, colon, bladder and uterus due to radiation exposure were estimated using biological effects of ionising radiation committee VII excess relative risk models. The effective dose to patients was estimated to be 0.20 ± 0.03 mSv and 0.06 ± 0.01 mSv for procedures with and without screening, respectively. The average number of exposures for both procedures, 2.5, and screening time of 48.1 s were recorded. Screening time contributed majority of the patient doses due to HSG; therefore, it should be optimised as much as possible. Of all the cancers considered, the incidence of cancer of the bladder for patients undergoing HSG procedures is more probable.

Selective visualization of the Fallopian tube with magnetic resonance imaging

At present, X-ray hysterosalpingography is used commonly as a screening method for testing Fallopian tube patency, but the results are often unreliable due to mucous plugs or muscular contractions. Selective catheterization of the tubes under X-ray control is feasible, but is rarely used due to exposure of young individuals aiming for pregnancy to a high ionizing dose. Here, a case is described of a patient whose Fallopian tubes were selectively catheterized and visualized three-dimensionally under contrast-enhanced magnetic resonance imaging (MRI) guidance using a high-viscous gadoteric acid solution (Dotarem). In this patient, bilateral peritubal adhesions caused a blockage of the fimbrial part of the tube leading to transuterine spilling of tubal fluid. Laparoscopy followed by bilateral salpingectomy was then performed, which confirmed the three-dimensional MRI images, and the excised specimens were examined histologically. The advantages of this novel technique include the avoidance of ionizing damage to the gonads and the potential for development of more elaborate interventional methods, such as ballooning and stenting. It is intended to develop contrast MRI further, both for improved non-invasive visualization and for manipulative technology of the Fallopian tubes.

Radiation exposure during standing voiding cystourethrography in women

OBJECTIVES

To calculate the total radiation exposure and effective organ doses from standard protocol voiding cystourethrography (VCUG).

METHODS

A prospective series of consecutive, non-neurogenic women underwent a standardized VCUG protocol by the same technologist using a Siemens Sireskop Fluorospot radiographic/fluoroscopic unit. Only studies that followed the protocol were included. The effective dose was calculated using a commercially available dose-modeling program (PCXMC, version 1.5) for risk assessment.

RESULTS

A total of 119 studies in 118 women (mean age 60 +/- 13 years, range 30 to 93) were included. Only 15 patients (13%) were premenopausal with in situ reproductive organs. The mean number of images and fluoroscopic time per study was 12.8 +/- 1.4 (lateral images 7.5 +/- 1.3) and 35.8 +/- 11.2 seconds, respectively. The mean effective dose for a single VCUG study was calculated to be 4.3 mSv, of which 26% was from fluoroscopy (1.1 mSv). The dose to the gonads accounted for 50% of the total effective organ dose. Using whole population radiologic risk factors, the total risk detriment, cancer and hereditary, was about 3 per 10,000 patients or a 99.997% chance of no detriment incurred from the study. The genetic and malignant risks were reduced in this cohort of patients, who were older, with most (87%) having no reproductive potential.

CONCLUSIONS

Using a standard protocol for adult women, a VCUG study is associated with an acceptable radiation risk.