Comparison of Virtual Ultrasonographic Hysteroscopy with Conventional Hysteroscopy in the Workup of Patients Who Are Infertile

STUDY OBJECTIVE

To compare the tolerability and diagnostic accuracy of virtual ultrasonographic hysteroscopy (VUH) with that of conventional diagnostic outpatient hysteroscopy in the workup of patients who are infertile.

DESIGN

A single-center, retrospective cohort study.

SETTING

Department of Obstetrics and Gynecology, Gynecologic Oncology, and Minimally Invasive Pelvic Surgery Unit of Sacred Heart Hospital Don Calabria in Negrar, Italy.

PATIENTS

A total of 120 consecutive women who underwent hysterosalpingosonography and subsequent VUH and conventional hysteroscopy for infertility evaluation were included. The inclusion criterion was infertility for at least 1 year, with evaluation in the early or intermediate follicular phase of the menstrual cycle.

INTERVENTIONS

After the placement of an intracervical catheter, a Ringer Lactate solution was injected into the uterine cavity and fallopian tubes, and a 3D volume was obtained. The ultrasound volume acquired was successively elaborated offline, and a VUH was performed. Subsequently, a variable amount of air was introduced into the uterine cavity, and the patency of the salpinges was evaluated.

MEASUREMENTS AND MAIN RESULTS

The VUH findings were compared with those of conventional hysteroscopy performed in the subsequent month. For the detection of endometrial pathology in the overall pool, the sensitivity and specificity of VUH in comparison with conventional hysteroscopy were 100% (95% confidence interval [CI], 84.6%-100%) and 100% (95% CI, 96.3%-100%), respectively. For the detection of uterine cavity pathology and uterine malformations in the overall pool, the sensitivities of VUH were 80% (95% CI, 28.4%-99.5%) and 100% (95% CI, 75.3%-100%), respectively, with specificities of 100% (95% CI, 96.8%-100%) and 100% (95% CI, 96.6%-100%), respectively, when compared with conventional hysteroscopy. The positive predictive values for endometrial pathology, uterine cavity alterations, and uterine malformations were 100% (95% CI, 84.6%-100%), 100% (95% CI, 39.8%-100%), and 100% (95% CI, 75.3%-100%), respectively, with a receiver operating characteristic area of 100%, 90% (95% CI, 70%-100%), and 100%, respectively. There were no cases of severe vasovagal reactions or other complications. Most patients (67%, 81 of 120 women) described the examination as "less painful than expected," 25% (30 of 120 women) "just as expected," and only 7% (9 of 120 women) as "more painful than expected."

CONCLUSION

VUH was well tolerated and showed a high accuracy (100%) in the study of the uterine cavity when compared with conventional hysteroscopy.

Transvaginal sonography for preoperative assessment of deep endometriosis

PURPOSE

To determinate transvaginal scan (TVS) accuracy in the preoperative evaluation of deep endometriosis in a large cohort of patients with subsequent laparoscopic assessment.

METHODS

A retrospective study was performed in a tertiary referral center for endometriosis. Transvaginal scan reports were retrieved from an electronic database of all patients who underwent laparoscopy for pelvic pain or infertility in 2009. The accuracy of TVS was assessed for 10 different sites of pelvic endometriosis.

RESULTS

Four hundred twenty women were included in the study. Sensitivity and specificity of TVS were 61% and 99%, respectively, for bladder endometriosis, 52% and 96% for endometriosis of rectovaginal septum, 65% and 99% for rectum endometriosis, and 69% and 98% for endometriosis of the sigmoid colon.

CONCLUSIONS

TVS appears to be useful for the detection of endometriosis located in the bladder and involving the sigmoid colon, the rectovaginal septum, and the rectum.

Endometriosis of the abdominal wall: ultrasonographic and Doppler characteristics

OBJECTIVES

To describe the sonographic and clinical features of abdominal wall endometriosis (AWE), a frequently misdiagnosed condition.

METHODS

This was a retrospective study of 21 consecutive women with pathologically proven endometriosis of the abdominal wall. Ultrasonographic and Doppler examinations were performed, before surgery, with a high-frequency linear transducer. The clinical data and the results of the sonographic examinations were reviewed and described.

RESULTS

At ultrasound, all the nodules appeared as discrete solid masses that were less echogenic than the surrounding hyperechoic fat. The nodules had a median diameter of 20 (range, 5-50) mm and in 18/21 (86%) cases the nodules had a round/oval shape. In eight of 21 (38%) women the AWE was located at the umbilicus, in six of 21 (29%) it was between the transverse suprapubic line and the umbilicus, in five of 21 (24%) it was found along the scar of a previous Cesarean section and in two of 21 (9%) it was in the right inguinal canal. The content was homogeneously hypoechoic in 12/21 (57%) women and inhomogeneous in the other nine (43%). The outer borders were invariably ill defined. Scarce blood vessels were found by power Doppler. Cyclic or continuous spontaneous pain at the level of the AWE was present in 19/21 (91%) cases, and two (9%) patients were asymptomatic.

CONCLUSIONS

Hypoechoic round/oval nodules with ill-defined borders and a hyperechoic rim should raise the suspicion of abdominal wall endometriosis, even in patients with no history of endometriosis or previous laparotomic surgery. Pressing the ultrasound probe against the nodule should reinforce a suspected diagnosis because of the pain it induces.

Proposal for a systematic preoperative assessment of pelvic endometriosis

AIM

Severe endometriosis represents one of the most challenging clinical and surgical cases in gynecology. Preoperative assessment of the extension of the disease is of key relevance to opt for medical or surgical therapy and, sometimes, to plan a multidisciplinary approach.

METHODS

A systematic diagnostic approach is proposed and evaluated in a tertiary referral centre. It is based on an initial clinical evaluation and a second level ultrasound of the pelvis. Further exams, whenever required, have to be aimed at demonstrating specific involvements of organs other than ovaries and peritoneum such as bowel, urinary tract and nerves.

RESULTS

The application of the proposed protocol has led to a reduction of the number of non-radical surgical procedures due to incomplete consent associated with missed diagnosis over the years (P<0.001).

CONCLUSION

Our findings support the efficacy of a systematic diagnostic approach to endometriosis. This allows a correct planning of therapy with a multidisciplinary approach when necessary.

Four-dimensional and Doppler sonography in the diagnosis and surveillance of a true cord knot

Prenatal diagnosis of a true knot of the umbilical cord is often an incidental observation at ultrasound with a difficult differential diagnosis between true and false knots. Furthermore, little is known about the optimal management of these cases. We report the importance of color Doppler and four-dimensional ultrasound for the differential diagnosis in the case of true cord knot and the role of Doppler flow velocimetry in the management of that case.

Preoperative diagnosis of 221 consecutive ovarian masses: scoring system and expert evaluation

OBJECTIVE

The aim of our work was to assess the diagnostic accuracy of a scoring system versus subjective assessment of the risk of malignancy of pelvic masses achieved by gynecologist/sonologists in the preoperative triage of a busy gynecology department.

METHODS

One hundred and eighty-two consecutive patients who underwent surgical removal of ovarian neoplasms were examined. In 39 patients pelvic masses were bilateral. The total number of neoplasms analyzed in this series was 221. Lesions were examined and scored according to the sonographic characteristics. Gynecologist/sonologists also recorded a subjective evaluation of the adnexal masses defining them as "probably benign", and "suspicious/probably malignant". Preoperative ultrasound risk assessment was compared to the final pathologic report and diagnostic accuracy was calculated. CA125 was obtained in all patients and its independent and combined accuracy was calculated.

RESULTS

The sensitivity of the scoring system and subjective evaluation was 86% and 95% respectively, specificity was 79% and 91% with a positive predictive value of 41% and 53%. The frequency of positive diagnoses for CA125 was 44% due to the high prevalence of endometrosis in this series (48%). In premenopausal patients (75%) the specificity was 93% and 89% for scoring and subjective evaluation, respectively. The combined use of morphological scoring and CA125 achieved higher specificity and positive predictive values both for the whole series and in premenopausal patients.

CONCLUSIONS

These results confirmed that the experience of gynecological surgeons with ultrasound skills, outperforms the morphological indexing assessment of ovarian masses. Nonetheless an easy sonographic descriptive scoring system is not significantly lower in accuracy than the expertise achieved by gynecologists with sonographic skills.

LOWER-LIMB LENGTHENING IN SHORT STATURE

We assessed peripheral nerve function during and after lower-limb lengthening by callotasis in 14 patients with short stature, using motor conduction studies.

Four patients with short stature of varying aetiology showed unilateral and one showed bilateral weakness of foot dorsiflexion. Both clinical and electrophysiological abnormalities consistent with involvement of the peroneal nerve were observed early after starting tibial callotasis. There was some progressive electro-physiological improvement despite continued bone distraction, but two patients with Turner’s syndrome had incomplete recovery. A greater percentage increase in tibial length did not correspond to a higher rate of peroneal nerve palsy. The function of the posterior leg muscles and the conduction velocity of the posterior tibial nerve were normal throughout the monitoring period.

The F-wave response showed a longer latency at the end of the bone distraction than in basal conditions; this is probably related to the slowing of conduction throughout the entire length of the nerve.

Lower-limb lengthening in short stature. An electrophysiological and clinical assessment of peripheral nerve function

We assessed peripheral nerve function during and after lower-limb lengthening by callotasis in 14 patients with short stature, using motor conduction studies. Four patients with short stature of varying aetiology showed unilateral and one showed bilateral weakness of foot dorsiflexion. Both clinical and electrophysiological abnormalities consistent with involvement of the peroneal nerve were observed early after starting tibial callotasis. There was some progressive electrophysiological improvement despite continued bone distraction, but two patients with Turner's syndrome had incomplete recovery. A greater percentage increase in tibial length did not correspond to a higher rate of peroneal nerve palsy. The function of the posterior leg muscles and the conduction velocity of the posterior tibial nerve were normal throughout the monitoring period. The F-wave response showed a longer latency at the end of the bone distraction than in basal conditions; this is probably related to the slowing of conduction throughout the entire length of the nerve.

Epiphyseal distraction. Hemichondrodiatasis

Hemichondrodiatasis is a technique of closed, gradual, asymmetric distraction of the growth plate to correct angular deformities in growing children. This report describes the technique and the results achieved in 35 operated lower extremity segments, 14 involving the femur and 21 involving the tibia. The best results were achieved in posttraumatic deformities when the bone bridge occupied less than 20%-30% of the epiphyseal plate. The procedure is best performed toward the end of growth, or earlier if a progressive deformity exceeds 15 degrees - 20 degrees.

Epiphyseal distraction. Chondrodiatasis

Chondrodiatasis is a limb-lengthening technique involving slow, controlled, symmetric epiphyseal distraction. The clinical and histological differences between this technique and distraction epiphysiolysis are described. Results are given for the elongation of 170 bone segments in 75 children (41 with limb-length discrepancies and 34 with achondroplasia). All patients were operated upon while the growth plate was still open with maximum bone maturation corresponding to Risser 2.

Lengthening of the lower limbs in achondroplastic patients. A comparative study of four techniques

We report our experience of lengthening by over 30% a total of 117 lower limbs in achondroplastic patients. We have compared four methods: transverse osteotomy, oblique osteotomy, callotasis of the shaft and chondrodiatasis of the epiphysis. Chrondrodiatasis of the femur and callotasis of the tibia are the techniques which gave fewest complications.

Limb lengthening by diaphyseal corticotomy, callus distraction, and dynamic axial fixation. An experimental study in the ovine femur

Limb lengthening of the left femur was performed in 12 sheep, 7-8 months of age. After weakening of the cortex by drill holes, a controlled fracture was created in the diaphysis. The bone segments were fixed in reduced position using a unilateral external fixation device. The fixator was left in neutral position for 10 days postoperatively when lengthening started. By means of daily distraction at a rate of 1.0 mm once a day for 3 weeks, an average lengthening of 1.9 cm (11.9%) was obtained. Two weeks after distraction had been discontinued, distinct callus bridging of the lengthening zone was confirmed radiographically in all animals. At this time the rigid state of fixation was converted to a system allowing axial compression by loading in half the animals. The other half of the animals served as controls with the fixator remaining unchanged. The external device was left on until 5 weeks after the end of distraction. At this time the animals were killed. Both femora of all animals were tested mechanically in torsion. The average ultimate torsional strength of the elongated femur compared with control was 71% in the group with dynamic axial fixation and 65% in the control group. No significant difference in relative strength of the tested bones in the two groups was found. We conclude that intermittent axial compression by loading during consolidation had no significant effect on the bone-healing process evaluated by radiography and mechanical testing.

Limb lengthening by callus distraction (callotasis)

Callotasis is a new technique of limb lengthening involving slow distraction of the callus formed in response to a proximal submetaphyseal corticotomy. Using a dynamic axial fixator with telescoping capabilities, distraction begins after 2 weeks. When the required length is attained, the fixator is held in the rigid mode until radiographic evidence of callus is observed. The locking screw is then released, and dynamic axial loading is instituted to promote corticalization. One hundred bony segments have been lengthened; 50 patients had limb length inequality, and 23 had achondroplasia. The mean lengthening achieved was 22% (maximum, 58%). There were 14 complications (14%).

Chondrodiatasis-controlled symmetrical distraction of the epiphyseal plate. Limb lengthening in children

We describe a technique for slow, progressive, symmetrical distraction of the growth plate using a lightweight dynamic axial fixation system. Results are given for the elongation of 40 bony segments in children with limb-length discrepancies and 60 segments in children with achondroplasia or hypochondroplasia. Increases in limb length of up to 36% were obtained in non-achondroplastic and up to 64.5% in achondroplastic patients. There were no nerve or vascular lesions or bony infections and no case required a bone graft. Pin-track complications occurred in only 1.5%.

Limb lengthening by distraction of the epiphyseal plate. A comparison of two techniques in the rabbit

We have compared, in rabbits, two techniques of limb lengthening by distraction of the epiphyseal plate using a unilateral external fixation frame. In all cases, 14 mm of symmetrical lengthening without deviation was achieved. With rapid distraction at rates of 1 mm per day (distractional epiphyseolysis) separation of the epiphysis from the metaphysis occurred by day 7, and by day 70 almost complete ossification of the cartilage and the elongated segment was evident. In contrast, slow distraction at 0.25 mm every 12 hours (chondrodiatasis) produced hyperplasia of growth cartilage without any evidence of detachment at 28 days, the end of the distraction period. By day 70 the epiphyseal plate had returned to normal thickness with normal cellular morphology, while the lengthened segment was occupied by ossified tissue. The significance of these findings is discussed.