Current applications of transperineal ultrasound in gastroenterology

Sonographic evaluation of a surgically created pouch

This manuscript focuses on a review of the normal and abnormal sonographic appearance of the surgically created pouch as part of an article series on the topic. It includes information regarding sonographic technique, normal anatomy, and commonly encounter diseases and complications.

Neonatal head circumference as a risk factor for obstetric anal sphincter injuries: a systematic review and meta-analysis

OBJECTIVE

Between 53% and 79% of women will sustain some degree of perineal laceration during vaginal delivery. Third- and fourth-degree perineal lacerations are known as obstetric anal sphincter injuries. Timely diagnosis and prompt treatment of obstetric anal sphincter injuries can help to prevent the development of severe consequences like fecal incontinence, urinary incontinence, and rectovaginal fistula. Neonatal head circumference is routinely measured postpartum but is often not mentioned as a risk factor for obstetric anal sphincter injuries in clinical guidelines. Thus far, no review article on the risk factors for obstetric anal sphincter injuries has discussed the role of neonatal head circumference. This study aimed to review and analyze the relationship between head circumference and the occurrence of obstetric anal sphincter injuries among previous studies to conclude whether head circumference should be recognized as an important risk factor.

DATA SOURCES

Through study screening on Google Scholar, PubMed, Scopus, and Science Direct for articles published between 2013 to 2023, followed by assessment of eligibility, this study ended up reviewing 25 studies, 17 of which were included in the meta-analysis.

STUDY ELIGIBILITY CRITERIA

Only studies that reported both the neonatal head circumference and the occurrence of obstetric anal sphincter injuries were included in this review.

METHODS

The included studies were appraised using the Dartmouth Library risk of bias assessment checklist. Qualitative synthesis was based on the study population, findings, adjusted confounding factors, and suggested causative links in each study. Quantitative synthesis was conducted using calculation and pooling of odds ratios and inverse variance using Review Manager 5.4.1.

RESULTS

A statistically significant association between head circumference and obstetric anal sphincter injuries was reported in 21 of 25 studies; 4 studies reported that head circumference was a true independent risk factor. A meta-analysis of the studies that reported neonatal head circumference as a dichotomous categorical variable with a cutoff point of 35±1 cm yielded statistically significant pooled results (odds ratio, 1.92; 95% confidence interval, 1.80-2.04).

CONCLUSION

The risk for obstetric anal sphincter injuries increased as the neonatal head circumference increased-this should be considered in decision-making during labor and postpartum management to attain the best outcome.

New transperineal ultrasound-guided biopsy for men in whom PSA is increasing after Miles' operation

OBJECTIVES

Currently, a prostate biopsy is guided by transrectal ultrasound (US) alone. However, this biopsy cannot be performed in men without an anus. The aim of this study was to show the outcomes of a new transperineal US (TPUS)-guided biopsy technique in patients who underwent Miles' operation.

METHODS

Between April 2009 and March 2022, TPUS-guided biopsy was consecutively conducted in 9 patients (median, 71 years; range, 61-78 years) with high prostate-specific antigen values (22.60 ng/mL; 6.19-69.7 ng/mL). Their anuses were all removed due to rectal cancer. TPUS-guided biopsy was performed according to information on prostate magnetic resonance imaging. The technical success rate, cancer detection rate, and complication rate were recorded. Tumor sizes were compared between benign and cancer groups using an unpaired t-test with Welch's correction.

RESULTS

The new TPUS-guided biopsy was successfully performed in all patients. Cancer was detected in 77.8% (7/9) of the patients. These were all categorized as PI-RADS 5. Among them, the detection rate of significant cancer (Gleason score 7 or higher) was 66.7% (6/9). The median tumor size was 2.4 cm (1.7-3.1 cm). However, two patients were diagnosed with benign tissue with PI-RADS 3 or PI-RADS 4. Their median tumor size was 1.0 cm (0.8-1.2 cm). There was significant difference between the cancer and benign groups (p = 0.037) in terms of tumor size. Neither post-biopsy bleeding nor infections occurred.

CONCLUSIONS

New TPUS-guided biopsy technique may contribute to detecting large PI-RADS 5 prostate cancer in men after Miles' operation.

Obstetric anal sphincter injuries (OASIS): using transperineal ultrasound (TPUS) for detecting, visualizing and monitoring the healing process

Purpose

The aim of this study was to examine whether OASIS, and its extent, can be confirmed or excluded using transperineal ultrasound (TPUS). A further objective of this study was to monitor the healing process over a period of 6 months and to establish a connection between the sonographic appearance of obstetric anal sphincter injury (OASIS) and anal incontinence.

Materials and methods

In this retrospective clinical study, women with OASIS who gave birth between March 2014 and August 2019 were enrolled. All the patients underwent TPUS 3 days and 6 months after delivery. A GE E8 Voluson ultrasound system with a 3.5–5 MHz ultrasound probe was used. The ultrasound images showed a third-degree injury, with the measurement of the width of the tear and its extent (superficial, partial, complete, EAS and IAS involvement). A positive contraction effect, a sign of sufficient contraction, was documented. Six months after delivery, a sonographic assessment of the healing (healed, scar or still fully present) was performed. A Wexner score was obtained from each patient. The patients’ medical histories, including age, parity, episiotomy and child’s weight, were added.

Results

Thirty-one of the 55 recruited patients were included in the statistical evaluation. Three patients were excluded from the statistical evaluation because OASIS was excluded on TPUS 3 days after delivery. One patient underwent revision surgery for anal incontinence and an inadequately repaired anal sphincter injury, as shown sonographic assessment, 9 days after delivery. Twenty patients were excluded for other reasons. The results suggest that a tear that appears smaller (in mm) after 3 days implies better healing after 6 months. This effect was statistically significant, with a significance level of alpha = 5% (p = 0.0328). Regarding anal incontinence, women who received an episiotomy had fewer anal incontinence symptoms after 6 months. The effect of episiotomy was statistically significant, with a significance level of alpha = 5% (p = 0.0367).

Conclusion

TPUS is an accessible, non-invasive method for detecting, quantifying, following-up and monitoring OASIS in patients with third-degree perineal tears. The width, as obtained by sonography, is important with regard to the healing of OASIS. A mediolateral episiotomy seems to prevent anal incontinence after 6 months.

Literature review of the outcome of and methods used to improve transperineal repair of rectocele

BACKGROUND

Rectocele is commonly seen in parous women and sometimes associated with symptoms of obstructed defecation syndrome (ODS).

AIM

To assess the current literature in regard to the outcome of the classical transperineal repair (TPR) of rectocele and its technical modifications.

METHODS

An organized literature search for studies that assessed the outcome of TPR of rectocele was performed. PubMed/Medline and Google Scholar were queried in the period of January 1991 through December 2020. The main outcome measures were improvement in ODS symptoms, improvement in sexual functions and continence, changes in manometric parameters, and quality of life.

RESULTS

After screening of 306 studies, 24 articles were found eligible for inclusion to the review. Nine studies (301 patients) assessed the classical TPR of rectocele. The median rate of postoperative improvement in ODS symptoms was 72.7% (range, 45.8%-83.3%) and reduction in rectocele size ranged from 41.4%-95.0%. Modifications of the classical repair entailed omission of levatorplasty, addition of implant, concomitant lateral internal sphincterotomy, changing the direction of plication of rectovaginal septum, and site-specific repair.

CONCLUSION

The transperineal repair of rectocele is associated with satisfactory, yet variable, improvement in ODS symptoms with parallel increase in quality-of-life score. Several modifications of the classical TPR were described. These modifications include omission of levatorplasty, insertion of implants, performing lateral sphincterotomy, changing the direction of classical plication, and site-specific repair. The indications for these modifications are not yet fully clear and need further prospective studies to help tailor the technique to rectocele patients.

EFSUMB Recommendations for Gastrointestinal Ultrasound Part 3: Endorectal, Endoanal and Perineal Ultrasound

This article represents part 3 of the EFSUMB Recommendations and Guidelines for Gastrointestinal Ultrasound (GIUS). It provides an overview of the examination techniques recommended by experts in the field of endorectal/endoanal ultrasound (ERUS/EAUS), as well as perineal ultrasound (PNUS). The most important indications are rectal tumors and inflammatory diseases like fistula and abscesses in patients with or without inflammatory bowel disease (IBD). PNUS sometimes is more flexible and convenient compared to ERUS. However, the technique of ERUS is quite well established, especially for the staging of rectal cancer. EAUS also gained ground in the evaluation of perianal diseases like fistulas, abscesses and incontinence. For the staging of perirectal tumors, the use of PNUS in addition to conventional ERUS could be recommended. For the staging of anal carcinomas, PNUS can be a good option because of the higher resolution. Both ERUS and PNUS are considered excellent guidance methods for invasive interventions, such as the drainage of fluids or targeted biopsy of tissue lesions. For abscess detection and evaluation, contrast-enhanced ultrasound (CEUS) also helps in therapy planning.

Transperineal Sonography of Anal Mass Status Post Total Colectomy: A Case Report

Transperineal sonography is a diagnostic tool for imaging the pelvic floor and lower pelvis. Because of the higher spatial resolution of pelvic sonography compared with other cross-sectional imaging techniques, transperineal sonography can provide detailed visualization of the lower pelvic organs, including the urethra, vagina, and anorectum. This case report describes the use of transperineal sonography for evaluation of an indeterminate lower pelvic process seen on computed tomography in a 53-year-old woman with progressive pelvic pain, dysuria, and dyspareunia. Because of severe dyspareunia, the patient declined transvaginal sonography. Transperineal sonography provided diagnostic imaging of the anal mass causing these symptoms.

Expert consensus document: Advances in the evaluation of anorectal function

Faecal incontinence and evacuation disorders are common, impair quality of life and incur substantial economic costs worldwide. As symptoms alone are poor predictors of underlying pathophysiology and aetiology, diagnostic tests of anorectal function could facilitate patient management in those cases that are refractory to conservative therapies. In the past decade, several major technological advances have improved our understanding of anorectal structure, coordination and sensorimotor function. This Consensus Statement provides the reader with an appraisal of the current indications, study performance characteristics, clinical utility, strengths and limitations of the most widely available tests of anorectal structure (ultrasonography and MRI) and function (anorectal manometry, neurophysiological investigations, rectal distension techniques and tests of evacuation, including defecography). Additionally, this article provides our consensus on the clinical relevance of these tests.

Rectocele plication: description of a novel surgical technique and review of clinical results

INTRODUCTION AND HYPOTHESIS

A rectocele is the bulging of the anterior rectal wall into the posterior vaginal compartment. The route of surgical repair can be transvaginal, transrectal or abdominal. The aim of this retrospective study is to describe a novel transvaginal surgical procedure and investigate the associated subjective and objective clinical outcomes.

METHODS

Database records were retrieved for all women who underwent a rectocele plication for the period from January 2010 until December 2015 in a referral urogynecology unit with a minimum follow-up period of 12 months. This transvaginal technique entails a plication of the anterior rectal wall by suturing of the rectal muscularis layer. Clinical findings and quality of life (QOL) metrics were evaluated and reported on.

RESULTS

One hundred thirty-nine women met the initial inclusion criteria with full data available for 123. The presenting symptoms included a vaginal bulge in 73 (52.5%), overactive bladder (OAB) in 73 (52.5%), obstructed defecation (OD) in 49 (35.3%) and anal incontinence (AI) in 35 (25.2%). The majority of women (n = 72, 51.8%) had stage 3-4 posterior prolapse. The mean follow-up period was 27 ± 15 months. The postoperative symptoms were significantly improved for all, except AI (p = 0.43). There was a significant improvement in posterior prolapse (p < 0.001) with the majority of women noted to have a stage 0 or 1 (n = 109; 88.6%) posterior prolapse at follow-up.

CONCLUSIONS

The rectocele plication is a novel surgical technique with good subjective and objective clinical outcomes in the medium term.