Sonography and radiology of pelvic masses and other maternal disorders

A Safe Laparoscopic Approach for Ovarian Tumors during Pregnancy

Objectives

Surgery for pregnant women with ovarian tumors poses the risk of uterine irritation. We aimed to demonstrate the superiority of our laparoscopic technique over conventional methods and to compare the outcomes of laparoscopy with those of laparotomy for ovarian tumors during pregnancy.

Materials and Methods

This retrospective study included 50 patients undergoing procedures for ovarian tumors during pregnancy at the Tokushima University Hospital between January 2005 and December 2021. We compared surgical outcomes between laparoscopic procedures and laparotomy, along with complications. In addition, we compared the frequency of uterine stimulation with the conventional trocar position to that with the currently used trocar position in laparoscopic surgery.

Results

Forty patients in the laparoscopy group and 10 in the laparotomy group underwent procedures. The laparoscopy group had less bleeding (16.4 ± 28.8 vs. 58 ± 72.2 mL, P < 0.05) and shorter hospital stays (7.6 ± 1.7 vs. 12.8 ± 13.1 days, P < 0.05) compared with those of the laparotomy group. The outcomes showed no significant differences between groups. All laparoscopies and laparotomies were successful and without complications. Furthermore, the current trocar position tended to stimulate the uterus less frequently.

Conclusion

The results suggested that, compared to laparotomy, laparoscopy for ovarian tumors during pregnancy had better outcomes. The trocar position in our technique allows for easy operation of ovarian tumors without interference by forceps or cameras, resulting in minimal irritation of the uterus. Our original laparoscopic method may be safer with superior outcomes over the conventional method.

Subjective assessment of ovarian masses using pattern recognition: the impact of experience on diagnostic performance and interobserver variability

PURPOSE

To compare diagnostic performance and interobserver variability in a group of 36 examiners, with four different levels of experience.

METHODS

Nine junior trainees, eight level I senior trainees, 11 level II senior gynecologists, and eight level III expert sonologists classified 105 ultrasound images of adnexal masses into three subgroups of ovarian lesions (malignancies, functional cysts, and dermoid cysts).

RESULTS

The level III sonologists obtained the best diagnostic results together with the lowest interobserver variability (κ = 0.70, SD = 0.04). They achieved significantly better results in comparison with the junior trainees and also the senior trainees (κ = 0.51, SD = 0.12, p < 0.001; and κ = 0.51, SD = 0.09, p < 0.001). Differences between level III sonologists and the group of level II observers did not reach statistical significance (κ = 0.65, SD = 0.09, p = 0.70). There were no significant differences between senior and junior trainees (p = 1.0) and both groups achieved a significantly poorer diagnostic performance in comparison with the level II observers (p < 0.01 and p < 0.01). For all observers, the largest differences were seen for classifying malignancies, the best results for classifying functional cysts, and the poorest for evaluating dermoid cysts.

CONCLUSIONS

Diagnostic performance of pattern recognition significantly improves with an increasing level of experience, emphasizing the importance of standardized ultrasound training programs with supervision by experts.

Adnexal Masses in Pregnancy: Diagnosis and Management

The widespread use of ultrasound in obstetrics has led to an increase in the diagnosis of asymptomatic adnexal masses in pregnancy. Ultrasound is an accurate and safe method for diagnosing the etiology of an adnexal mass and distinguishing benign from malignant pathology. The management of an adnexal mass in pregnancy is controversial. Historically, it was recommended that any adnexal mass be removed electively in the second trimester to exclude malignancy and prevent complications such as torsion, rupture, and obstruction of labor. More recent recommendations have limited surgical intervention in pregnancy to symptomatic adnexal masses and those that are highly suggestive of malignancy. Surgery in pregnancy is associated with an increased risk of adverse pregnancy outcomes. However, laparoscopy appears to be a safe alternative to laparotomy for benign masses when performed by experienced surgeons.

Learning objectives

To list the differential diagnoses of adnexal masses in pregnancy

To interpret ultrasound images of adnexal masses and distinguish benign from malignant masses

To describe the management options for adnexal masses in pregnancy, including the indications and options for surgical intervention.

Imaging of adnexal masses in pregnancy

OBJECTIVE

To illustrate the imaging appearances of a variety of adnexal masses in pregnancy.

METHODS

Cases of adnexal masses in pregnancy were chosen to illustrate the appearance on ultrasonography and magnetic resonance imaging.

RESULTS

Adnexal masses in pregnancy have a wide spectrum of imaging characteristics and clinical manifestations. Sonography is important in diagnosing, monitoring, and determining the malignant potential of these masses. Common adnexal lesions seen in pregnancy include simple cysts, hemorrhagic cysts, leiomyomas, and hyperstimulated ovaries in patients who have undergone assisted fertility. Uncommon adnexal lesions specific to pregnancy include hyperreactio luteinalis, theca lutein cysts with moles, and luteomas. Adnexal masses associated with pain include ovarian torsion and heterotopic pregnancy. Adnexal lesions that are found incidentally include teratomas, endometriomas, hydrosalpinx, cystadenomas, and cystadenocarcinomas. When the diagnosis of the adnexal mass cannot be made on the basis of sonographic appearance alone, magnetic resonance imaging may help.

CONCLUSIONS

Familiarity with the clinicopathologic and sonographic features of common and uncommon adnexal masses in pregnancy is important for diagnosis and treatment.

Imaging of questionable and unusual pelvic masses

Ultrasonography is usually the initial diagnostic examination performed for evaluating gynaecological conditions and pelvic masses. The authors' experience with 11 "problem cases" and a review of the literature of such enigmas has led to the following recommendations in the following order: a plain radiograph or repeat ultrasound study; ultrasound study with the water enema technique; gastrointestinal examination if the answer is still not apparent, followed by computed tomography or a real-time ultrasound study during a clinical pelvic examination.