Which patients benefit from a 3D reconstructed coronal view of the uterus added to standard routine 2D pelvic sonography? AJR Am J Roentgenol. 2008;190:626-629. [PMID: 18287431 DOI: 10.2214/ajr.07.2632]

How to do a 3D uterus ultrasound?

Three-dimensional (3D) ultrasound is an invaluable tool in the detection and evaluation of many uterine anomalies and improves upon the traditional approach of two-dimensional (2D) ultrasonography. We aim to describe an easy way of assessing the uterine coronal plane using the basic three-dimensional ultrasound in everyday gynecological practice.

Diode Laser Hysteroscopic Metroplasty for Dysmorphic Uterus: a Pilot Study

This paper aims to study the efficacy and safety of diode laser hysteroscopic metroplasty for dysmorphic uterus and the impact on reproductive outcomes. This is a retrospective, single-center pilot study with prospective follow-up. The study was performed at a university-affiliated, tertiary hospital. From February 2018 to February 2020, all nulliparous women with a 3D ultrasound diagnosis of T-shaped or Y-shaped dysmorphic uterus and diagnosis of infertility, recurrent implantation failure, or recurrent pregnancy losses were referred for hysteroscopic metroplasty. Diode laser hysteroscopic metroplasty was performed under general anesthesia in an ambulatory setting. Main outcome measures included operative time, complications, hysteroscopic appearance of the cavity in a follow-up hysteroscopy, and reproductive outcomes in terms of pregnancy and live birth. A total of 25 infertile women with mean duration of infertility of 56.6 ± 36.1 months underwent hysteroscopic metroplasty. No complications were reported, and subsequent 3D ultrasound and follow-up hysteroscopic appearance were satisfactory in all cases. Maximum follow-up was 32 months (mean ± standard deviation 11.5 ± 9.2 months). Fifteen nulliparous women returned for fertility treatments in our institute, among whom nine conceived (60% pregnancy rate). The rate of deliveries and ongoing pregnancies (pregnancies beyond 24 weeks of gestation) was 78% (7/9), with six successful liveborn deliveries at 36-38 weeks and one ongoing pregnancy. One had spontaneous abortion at week 19 and one had a spontaneous abortion at week 7. Hysteroscopic metroplasty in an ambulatory setting, using diode laser, is a safe and effective procedure, improving reproductive outcomes in cases of T-shaped or Y-shaped uterus.

Three-Dimensional Coronal Plane of the Uterus: A Critical View for Diagnostic Accuracy

Two-dimensional transvaginal and transabdominal ultrasound (US) examinations are the suggested methods for examining the uterus. Three-dimensional (3D) US, which is not compulsory by society guidelines, provides additional uterine views, reassuring users of pathologic conditions not evident on customary sagittal and transverse views. The 3D coronal plane is rarely seen by 2-dimensional US transducers, let alone in extremely retroverted or axial uteri. Ultrasound machines nowadays feature 3D US capability. Our experience is that the coronal uterine view is a problem solver, helping diagnostic abilities of pelvic imaging. We advocate its liberal use and its acquisition in every pelvic scan. In this Pictorial Essay we present examples to demonstrate its use.

Endometrial Volume Measured by VOCAL Compared to Office Hysteroscopy for Diagnosis of Endometrial Polyps in Premenopausal Women with Abnormal Uterine Bleeding

The aim is to compare hysteroscopy, two-dimensional transvaginal ultrasound (2D TVUS), and three-dimensional (3D) Virtual Organ Computer-aided AnaLysis™ (VOCAL) to detect endometrial polyps (EPs) in premenopausal women with abnormal uterine bleeding (AUB). This prospective study was done at Ain Shams Maternity Hospital, Egypt, from March 5, 2015, to December 30, 2015, enrolling 118 premenopausal women with AUB. 2D TVUS, 3D VOCAL, and hysteroscopy were done. 109 patients reached final analysis. 36 women (33%) were diagnosed with EP by 2D TVUS. 50 (45.9%) had EP by hysteroscopy. Endometrial thickness was 10.1 mm by 2D TVUS and endometrial volume was 4.92 mL by VOCAL in women with EP by hysteroscopy compared to 9.9 mm and 3.50 mL in women with no EP, respectively (P = 0.223; P = 0.06). 2D TVUS has sensitivity, specificity, and positive and negative predictive values of 54%, 84.7%, 75%, and 68.5%, respectively. Endometrial thickness of >7.5 mm has sensitivity, specificity, positive and negative predictive values, and overall accuracy of 82%, 37.3%, 52.6%, 71%, and 57.8%, respectively. Endometrial volume of >1.2 mL has sensitivity, specificity, positive and negative predictive values, and overall accuracy of 90%, 42.4%, 57%, 83.3%, and 64.2%, respectively. 3D VOCAL may be used as a noninvasive method for the diagnosis of EP in premenopausal women with AUB.

Three-dimensional imaging of the uterus: The value of the coronal plane

Advent in three-dimensional (3D) imaging technology has seen 3D ultrasound establish itself as a useful adjunct complementary to traditional two-dimensional imaging of the female pelvis. This advantage largely arises from its ability to reconstruct the coronal plane of the uterus, which allows further delineation of many gynecological disorders. 3D imaging of the uterus is now the preferred imaging modality for assessing congenital uterine anomalies and intrauterine device localization. Newer indications include the diagnosis of adenomyosis. It can also add invaluable information to delineate other endometrial and myometrial pathology such as fibroids and endometrial polyps.

Minimally invasive surgical options for congenital and acquired uterine factors associated with recurrent pregnancy loss

Recurrent pregnancy loss (RPL) is defined as two or more failed clinical pregnancies before 20 weeks' gestation and may be caused by genetic, endocrinologic, anatomic and immunologic abnormalities. Anatomic uterine anomalies include congenital malformations (bicornuate, didelphic, septate and unicornuate uteri) and acquired defects (fibroids, adenomas, adhesions and polyps). Women with septate and bicornuate uteri, intrauterine adhesions, and some adenomas and fibroids are at increased risk of RPL. Data support surgical treatment of all of these lesions except bicornuate uteri. The role of polyps in RPL is unclear. Minimally invasive options for surgical correction of intrauterine lesions include hysteroscopy, laparoscopy with and without robotic assistance and minilaparotomy.

The current status of three-dimensional ultrasonography in gynaecology

Ultrasonography (US) is the most recent cross-sectional imaging modality to acquire three-dimensional (3D) capabilities. The reconstruction of volumetric US data for multiplanar display took a significantly longer time to develop in comparison with computed tomography and magnetic resonance imaging. The current equipment for 3D-US is capable of producing high-resolution images in three different planes, including real-time surface-rendered images. The use of 3D-US in gynaecology was accelerated through the development of the endovaginal volume transducer, which allows the automated acquisition of volumetric US data. Although initially considered an adjunct to two-dimensional US, 3D-US is now the imaging modality of choice for the assessment of Müllerian duct anomalies and the location of intrauterine devices.

Role of Three-Dimensional Ultrasound in Gynecology

Three-dimensional ultrasound (3D USG) is a fast-evolving imaging technique that holds a great potential for use in gynecology. Its sensitivity and specificity is reported to be close to 100 % for diagnosing congenital uterine anomalies, comparable with those of magnetic resonance imaging (MRI) and laparoscopy. With 3D USG, a coronal view of the uterus can be obtained, clearly outlining the external contour of the uterus and providing accurate information about the shape of the cavity. Although 3D USG may not perform well in thin endometria, combining it with saline infusion sonography (SIS) overcomes this problem. Research shows that 3D USG is more sensitive and specific than two-dimensional ultrasound (2D USG) in defining and mapping uterine lesions, such as fibroids, adenomyosis, and intrauterine synechia. In cases of suspected malignancy, 3D USG is mainly used in the initial evaluation of patients. Measuring various indices and mapping vascular architecture with 3D power Doppler have been proposed for evaluating adnexal masses. Although some studies raised hope, no consensus is reached about its use, success, and limitations. In urogynecology, translabial 3D USG is proved to be a valuable tool, as it provides instant access to the axial plane, which clearly depicts the relationship of the vagina, urethra, rectum, and the muscular pelvic floor. Studies report no significant differences between translabial 3D USG and MRI measurements for evaluation of the pelvic floor. In conclusion, adding 3D USG to routine gynecological workup can be beneficial for clinicians, as it provides fast and accurate results in a relatively cost-effective setting.

Practical applications of 3D sonography in gynecologic imaging

Volume imaging in the pelvis has been well demonstrated to be an extremely useful technique, largely based on its ability to reconstruct the coronal plane of the uterus that usually cannot be visualized using traditional 2-dimensional (2D) imaging. As a result, this technique is now a part of the standard pelvic ultrasound protocol in many institutions. A variety of valuable applications of 3D sonography in the pelvis are discussed in this article.

Diagnostic and clinical value of 3D gel installation sonohysterography in addition to 2D gel installation sonohysterography in the assessment of intrauterine abnormalities

OBJECTIVE

To study the diagnostic value of three-dimensional gel instillation sonography (3D GIS) in addition to two-dimensional (2D) GIS in the assessment of intrauterine abnormalities. Secondly, the clinical value of 3D GIS in the planning for hysteroscopic procedures was evaluated.

STUDY DESIGN

A prospective cohort study was performed from 2008 till 2010. All women with a suspected intrauterine abnormality on 2D GIS suitable for hysteroscopic resection or with recurrent postmenstrual bleeding were planned for a hysteroscopic procedure. Diagnostic accuracy tests were calculated for the detection of fibroids and polyps with both histology and hysteroscopy as the reference standard. For the assessment of type and size of fibroids hysteroscopy was used as the reference standard. We compared the planning for type of hysteroscopy based on 2D GIS findings with the combined 2D-3D GIS findings.

RESULTS

In total 110 patients were analysed. In comparison to histology, addition of 3D GIS did not change sensitivity or specificity substantially in the discrimination between fibroids and polyps. In comparison to hysteroscopy, sensitivity increased for detecting fibroids and polyps, without major interference with the specificity. Despite an improved accuracy after the addition of 3D GIS, the planning for hysteroscopic procedures did not improve substantially.

CONCLUSION

In daily practice, the addition of 3D GIS to 2D GIS improved the accuracy for the detection of polyps and fibroids compared to hysteroscopy, but only marginally improved the planning of hysteroscopic procedures, and therefore the clinical relevance seems to be limited.

ACR appropriateness criteria(®) on abnormal vaginal bleeding

In evaluating a woman with abnormal vaginal bleeding, imaging cannot replace definitive histologic diagnosis but often plays an important role in screening, characterization of structural abnormalities, and directing appropriate patient care. Transvaginal ultrasound (TVUS) is generally the initial imaging modality of choice, with endometrial thickness a well-established predictor of endometrial disease in postmenopausal women. Endometrial thickness measurements of ≤5 mm and ≤4 mm have been advocated as appropriate upper threshold values to reasonably exclude endometrial carcinoma in postmenopausal women with vaginal bleeding; however, the best upper threshold endometrial thickness in the asymptomatic postmenopausal patient remains a subject of debate. Endometrial thickness in a premenopausal patient is a less reliable indicator of endometrial pathology since this may vary widely depending on the phase of menstrual cycle, and an upper threshold value for normal has not been well-established. Transabdominal ultrasound is generally an adjunct to TVUS and is most helpful when TVUS is not feasible or there is poor visualization of the endometrium. Hysterosonography may also allow for better delineation of both the endometrium and focal abnormalities in the endometrial cavity, leading to hysteroscopically directed biopsy or resection. Color and pulsed Doppler may provide additional characterization of a focal endometrial abnormality by demonstrating vascularity. MRI may also serve as an important problem-solving tool if the endometrium cannot be visualized on TVUS and hysterosonography is not possible, as well as for pretreatment planning of patients with suspected endometrial carcinoma. CT is generally not warranted for the evaluation of patients with abnormal bleeding, and an abnormal endometrium incidentally detected on CT should be further evaluated with TVUS.

The width of the uterine cavity is narrower in patients with an embedded intrauterine device (IUD) compared to a normally positioned IUD

OBJECTIVE

The purpose of this study was to determine whether women with intrauterine devices (IUDs) embedded in the myometrium or cervix have a narrower fundal transverse endometrial diameter as seen on 3-dimensional (3D) sonography compared to women whose IUDs are in a normal location.

METHODS

A sonographer blinded to the study hypothesis retrospectively evaluated the 3D images and reconstructed coronal views of the uterine cavity in 172 consecutive women who had an IUD in the uterus. The width of the endometrial cavity at the fundus of the uterus was measured transversely on the rendered coronal sonogram using the calipers on a picture archiving and communications system. The measurements obtained from women who had nonembedded IUDs were compared to those with embedded IUDs.

RESULTS

Measurement of the width of the endometrial cavity at the fundus was successfully performed in 132 patients with nonembedded IUDs and 29 with embedded IUDs. The mean ± SD values of the fundal uterine cavity for the nonembedded and embedded IUDs were 32 ± 1.0 and 25 ± 0.8 mm, [corrected] respectively (P = .0003).

CONCLUSIONS

Patients with embedded IUDs have a smaller fundal endometrial cavity diameter compared to those with normally placed IUDs as documented using 3D rendering of the uterus. Whether preprocedural 3D sonography for women who are IUD candidates would be useful deserves further study.

Imaging of endometrial pathology

The normal endometrium changes regularly with the menstrual cycle and atrophies after menopause. It is important to be aware of the normal spectrum of endometrial appearances at imaging to accurately detect and diagnose pathologic conditions. This article reviews imaging features of the normal and abnormal endometrium, and conditions which may mimic endometrial pathology. Emphasis will be on ultrasound with sonohysterography and magnetic resonance imaging as these are the imaging modalities of choice for evaluation of the endometrium. The complementary role of hysterosalpingography, computed tomography, and 18-fluorodeoxyglucose-positron emission tomography will also be discussed.

Incorporating 3D Multiplanar Reconstructed Images for Endovaginal Endometrial Assessment

A study was undertaken to evaluate the use of 3D multiplanar reconstructed (MPR) images to reduce the scan time for endovaginal studies, thereby potentially reducing sonographer strain and possibly improving patient workflow. The scope of the study was limited to evaluation of the endometrium. A group of 42 patients with dysfunctional uterine bleeding was selected for the study. After initial transabdominal examination on each patient, an endovaginal study of the endometrium was performed using 3D data collection; this was followed by a complete conventional 2D endovaginal scan. The scan times and endometrial measurements for 3D and 2D methods were compared. Staff members were interviewed for feedback on the experience and for future protocol recommendations.

Sonography of the pelvis in patients with primary amenorrhea

Duplex/color Doppler sonography (US) is the imaging modality of choice for the evaluation of patients with primary amenorrhea. Careful correlation with clinical history, physical examination and laboratory findings significantly narrows the diagnostic possibilities thus allowing for a more precise diagnosis. This article discusses the wide gamut of etiologies of primary amenorrhea, the US appearance of pathologic processes that result in primary amenorrhea, and helps the reader understand when additional higher tech imaging is indicated.

Three-dimensional ultrasound detection of abnormally located intrauterine contraceptive devices which are a source of pelvic pain and abnormal bleeding

OBJECTIVE

To determine whether intrauterine contraceptive devices (IUDs) that are located abnormally within the myometrium or cervix cause a higher incidence of pelvic pain and abnormal bleeding compared with normally positioned devices.

METHODS

Over a period of 9 months, all patients with an IUD presenting at our unit for two-dimensional pelvic ultrasound underwent a three-dimensional (3D) volume reconstruction of the coronal view, to visualize the entire IUD within the cavity. The IUD was deemed malpositioned if any part extended past the cavity, into the myometrium or cervix. The indications for ultrasound were recorded at presentation for the exam. The presenting symptoms of patients with an abnormally located IUD were compared with those with normally positioned ones.

RESULTS

Among 167 consecutive patients with an IUD evaluated using the 3D reconstructed coronal view, 28 (16.8%) had an IUD with side arms abnormally located within the myometrium. The abnormal positioning of the IUD arms was only detected using the 3D coronal view. A higher proportion of patients with an abnormally located IUD presented with bleeding (35.7%) or pain (39.3%) compared with those with normally positioned IUDs (15.1% with bleeding and 19.4% with pain) (P = 0.02 and 0.03, respectively). Seventy-five percent of patients with an abnormally located IUD presented with bleeding or pain compared with 34.5% of those whose IUD was normally placed (P = 0.0001). Twenty of 21 patients with an abnormally located IUD presenting with pelvic pain or bleeding reported improvement in their symptoms after IUD removal.

CONCLUSION

A 3D coronal view of the uterus is useful in the visualization of IUDs. The coronal view showing the entire device and its position within the uterus may help in identifying the cause of pelvic pain and bleeding in patients with an embedded IUD.

Imaging of endometrial pathology

The normal endometrium changes regularly with the menstrual cycle and atrophies after menopause. It is important to be aware of the normal spectrum of endometrial appearances at imaging to accurately detect and diagnose pathologic conditions. This article reviews imaging features of the normal and abnormal endometrium, and conditions which may mimic endometrial pathology. Emphasis will be on ultrasound with sonohysterography and magnetic resonance imaging as these are the imaging modalities of choice for evaluation of the endometrium. The complementary role of hysterosalpingography, computed tomography, and 18-fluorodeoxyglucose-positron emission tomography will also be discussed.