Three-dimensional ultrasound and three-dimensional power Doppler in the assessment of adnexal masses

Three-dimensional ultrasound is a new, emerging technology that provides additional information for the evaluation of ovarian tumors. Multiplanar and volume-rendering display methods combined with the ability to rotate volume data into standard orientations are essential components of the current and future success of three-dimensional ultrasound.

Increasing knowledge about three-dimensional ultrasound, as well as improved handling allow application of this method to the field of gynecological oncology. The recent development of real-time three-dimensional ultrasound imaging will further advance the clinical applications, particularly in the assessment of pelvic tumors. The introduction of the three-dimensional power Doppler systems may improve the information available on ovarian tumor vascularity and speed up the entire patient management process.     

Neuropelveological assessment of neuropathic pelvic pain

The aim of the present report is to emphasize the importance of taking neurological considerations into account in the diagnostic workup of chronic pelvic pain (CPP) of “unknown origin.” Based on new knowledge of the functional neuroanatomy of the pelvis and recent developments in the treatment of pelvic neuropathies, we incorporated well-known neurologic diagnostic methods into the classical gynecological workup for CPP. “Neuropelveological” assessment of CPP in women requires a detailed gynecological and neurologic history, a classical gynecological workup, and an adapted “gynecological” examination of the pelvic nerves and plexuses. The present report provides guidelines for “neuropelveological” assessment of chronic pelvic pain in clinical practice. It emphasizes the benefits of taking “neurological” considerations into account when diagnosing chronic pelvic pain.     

腹腔镜下自裁Artisyn-Y型网片同时纠正中盆腔及后盆腔缺陷的术式报道

随着腹腔镜技术的发展,其在妇科盆底功能障碍性疾病诊治方面的作用越来越重要,在解决中盆腔和前盆腔缺陷方面效果确切,而对于后盆腔缺陷的腹腔镜诊治较少报道,且通过腹腔镜手术治疗中盆腔缺陷的同时诊治后盆腔缺陷更是鲜有文献描述。对1例盆腔器官脱垂定量分度法(POP-Q)评分:Aa-3,Ba-3,C+2,Ap+3,Bp+3,D+1,考虑子宫脱垂Ⅲ度合并直肠膨出Ⅲ度的患者,重庆市妇幼保健院妇科盆底与肿瘤科针对中盆腔合并后盆腔缺陷的患者设计一种新术式,可在纠正中盆腔缺陷的同时纠正后盆腔缺陷,且能够达到网片平铺、可调等优点,该术式即应用自裁Artisyn-Y型网片固定宫颈和悬吊子宫纠正中盆腔缺陷,同时加固阴道直肠筋膜从而纠正后盆腔缺陷。     

Once-monthly radiotherapy for the palliation of pelvic gynecological malignancy

Twenty-seven patients with advanced pelvic gynecological malignancies were treated using a once-monthly fractionation scheme of 10 Gy to a total dose of 30 Gy to the whole pelvis. This course was well tolerated and provided effective palliation with a minimum of hospitalization. The results obtained suggest this course merits consideration for the palliation of other pelvic malignancies.     

Pelvic exenterations for gynecological malignancies: twenty-year experience at Roswell Park Cancer Institute

The objective of this study is to review the experience with pelvic exenterations for gynecological malignancies at our cancer institute. Charts of 48 women who underwent a pelvic exenteration between January 1980 and December 1999 were reviewed, and several outcomes were analyzed. Majority of patients had received prior radiation therapy. The median survival was 35 months, and the disease-free survival was 32 months. Mortality from the procedure was 4.2%. Early and late postoperative complication rates were 27% and 75%, respectively. Recurrence rate was 60%. Eight patients received intraoperative radiation. Median survival in this group was 11.3 vs 35 months (P = 0.003). Univariate analysis failed to show an association between type of pelvic exenteration, type of fecal and urinary diversion, outcome, need for reoperation, and recurrence. Contemporary pelvic exenterations are associated with a low mortality and a potential for long-term survival in a subset of patients who historically have been given a poor prognosis. In patients with recurrent gynecological cancer confined centrally to the pelvis, pelvic exenteration still remains the choice of therapy as response to chemotherapy to a centrally recurrent tumor in radiated area continues to be poor. Intraoperative radiation in select few patients needs to be further studied.     

基于磁共振成像的女性盆底肌群数字化三维模型构建

目的探讨利用磁共振(MRI)原始数据集构建女性盆底肌群数字化三维模型的方法及意义。方法选取2010年10月至2011年9月在南方医科大学南方医院因各类妇科疾病行盆腔MRI检查的患者20例,对其行高分辨薄层轴位扫描。将采集的Dicom3.0原始数据集导入Mimics10.01软件中行女性盆底肌群的三维重建。结果成功构建了女性盆底肌群的数字化三维模型,该模型表面光滑、层次分明、形态逼真,可以进行任意角度旋转以便观察盆底肌群的形态及其空间毗邻结构。利用软件测量工具还能够对肌肉形态进行定量研究。结论女性盆底肌群数字化三维模型是研究女性盆底肌群的好方法,具有广阔的应用前景。     

盆腔器官廓清术在复发宫颈癌治疗中的价值

盆腔器官廓清术（盆廓术）为中央型盆腔复发的宫颈癌患者提供了再次治愈的机会。姑息性盆廓术对部分周围型复发患者也可以起到减轻症状和改善生活质量的作用。满意的手术切缘是影响盆廓术疗效和患者预后的最重要因素。术前需要根据患者的临床表现、妇科检查、影像学检查进行重点评估,并综合患者既往治疗情况、一般机体状态、患者心理、术中探查情况等综合考虑,筛选合适病例,并选择合理的手术方式和入路,才能使复发宫颈癌患者从盆廓术中获益。     

Sonographic diagnosis of cervical incompetence for prevention and management

Cervical shortening, as seen by transvaginal sonography increased concentrations of maternal salivary estriol, inflammatory cytokines in amniotic fluid, and fetal fibronectin expression in cervicovaginal mucus are all detected weeks to months before a preterm birth, providing evidence that spontaneous preterm birth is the result of a long-term process, with varying clinical manifestations and dynamics and a dilated cervix as the common terminal pathway.

Routine pelvic examination has not been shown to be predictive of preterm labor. The examination of the cervix by transvaginal sonography is more objective and has been shown to be superior to the digital examination in estimating the risk of premature birth. Thereby, the sonographic structure of the cervix (length, funneling) determines, more than any other clinical findings, the interval to the delivery.

During normal pregnancy, the pregnant woman spends part of her time in an upright position. Therefore, we have established longitudinal sonographic criteria, separate for twin and singleton pregnancies, in supine and upright positions. Up to now, we have found that the funneling in an upright position -in combination with cervicovaginal fibronectin -is the most significant sonographic parameter to predict prematurity.

In risk populations, we emphasize longitudinal examinations by transvaginal sonography to increase the chance to recognize symptoms in a reversible instead of an irreversible phase and to evaluate whether maternal postural challenge assists in predicting patients at risk for premature delivery. Transvaginal sonography is of assistance to indicate and follow any management to prevent preterm birth. Clinical trials of interventions (e.g. lifestyle changes, tocolytic treatment, different types of cerclage or vaginal pessaries), based on transvaginal sonographic findings combined with biochemical examinations (cultures, interleukins, fibronectin), are urgently needed.     

Pelvic exenteration without external urinary or fecal diversion in gynecological cancer patients

In 1993, the authors introduced an orthotopic bladder replacement technique in the treatment of gynecological cancer patients. In this series, they report their long-term experience with orthotopic urinary reconstruction in case of primary- and radiotherapy-treated recurrent gynecological malignancies. Between 1993 and 2003, in 29 patients orthotopic ileocecal ascending colon reservoirs (Budapest pouch) were created. Twenty-one of the 29 patients received radiotherapy prior to their operation. In 12 out of these 29 cases, the fecal stream was reconstructed with the use of low rectal anastomosis. Two patients (6.9%) died in the perioperative period. Orthotopic reconstruction of the lower urinary system was successful in 77% of the cases. Success rate was 68% in the irradiated cohort of patients. All orthotopic bladder replacement patients voided voluntarily at the time of their follow-up, without the need of self-catheterization, and 23.5% of them complained of some degree of daytime incontinence and 47% of nighttime incontinence. Low rectal anastomosis reconstruction of the fecal stream was successful in all but one case. Our present experience demonstrated that anterior and total supralevator pelvic exenteration in patients with gynecological malignancies is feasible with orthotopic reconstruction of the lower urinary tract.     

Closed suction drainage versus no drainage following pelvic lymphadenectomy for gynecological malignancies

Abstract. Bafna UD, Umadevi K, Savitha M. Closed suction drainage versus no drainage following pelvic lymphadenectomy for gynecological malignancies.
The present study was undertaken in the Department of Gynecologic Oncology, Kidwai Memorial Institute of Oncology, Bangalore between October 1998 and July 1999. One hundred and forty three consecutive patients with various gynecological malignancies undergoing pelvic ± aorto-caval lymphadenectomy as part of definitive surgical procedures, were analyzed. Sixty nine patients had closed suction retroperitoneal pelvic drainage (Group A) and 74 patients had no suction drainage and no pelvic reperitonealization (Group B). The mean postoperative hospitalization was 10 days in both groups. Six patients in Group A and four patients in Group B developed paralytic ileus which responded to conservative line of management. Five patients in Group A and two patients in Group B developed lymphocysts ( P > 0.05). The present study demonstrates that closed suction retroperitoneal pelvic drainage following pelvic + aorto-caval lymphadenectomy confers no advantage over no drainage & no pelvic reperitonealization. The partial closure of pelvic peritoneum with no drainage was associated with increased lymphocyst formation (7/25 cases, 28%) during the period immediately before this modified study was undertaken.     

磁共振成像盆底三维重建的方法及意义

磁共振成像(MRI)盆底三维重建可以了解盆底解剖,协助盆底缺陷诊断。目前,MRI盆底三维重建的内容包括骨盆、盆腔器官、盆底肌肉、韧带等,是研究盆底的最新方法。笔者对年轻未育、足月单胎妊娠晚期、广泛性全子宫切除术后、盆腔器官脱垂(pelvic organ prolapse,POP)患者的盆底研究发现,通过运用该方法可以直观观察不同状态的女性盆底、了解盆底的解剖状况并反映功能异常,可协助诊断盆底功能障碍性疾病,是较超声更为直观先进的方法。但盆底三维重建技术基于较为昂贵的MRI检查数据,且该技术的掌握相对困难,因而适合科学研究,临床推广有一定难度。     

Gallstones and uterine fibroids

In a series published in 1961, an unusual frequency of hysterectomies for uterine leiomyomas (fibroids) was reported in women with gallstones. The purpose of this study was to confirm the association between gallstones and uterine leiomyomas with a patient control study and to investigate its physiopathologic basis comparing the cholesterol saturation of bile in women with gallstones, in women with leiomyomas but no gallstones and in those in the control group with no gallstones or leiomyomas. Patients admitted to the surgical department have, routinely, echography of the gallbladder before and manual exploration of the pelvic floor during surgical intervention. For the first part of the study, we collected information concerning the diagnosis of leiomyomas from the operating room registers and about the diagnosis of gallstones from the clinical records. In 1982, 42 of 139 women operated upon consecutively for gallstones and five of 69 operated upon for other diseases of the gastrointestinal tract had leiomyomas, a statistically significant difference (chi-square test, p less than 0.001). This difference persisted stratifying women with gallstones and those in the control group for age. In the second part of the study, we examined the bile collected at duodenal drainage after gallbladder stimulation with cholecystokinin, in 11 young women with radiolucent gallstones (echography and cholecystography), in ten women with leiomyomas (gynecologic examination and pelvic echography) but no gallstones (echography) and in 11 women with no leiomyomas (gynecologic examination or pelvic echography) or gallstones (echography). Cholesterol, phospholipids and total bile acids in the biliary tract were analyzed with standardized enzymatic methods. The cholesterol saturation index of the biliary tract was higher in patients with leiomyomas than in those in the control group (Wilcoxon rank sum test, p less than 0.01) and similar to that of women with radiolucent gallstones. These data suggest that gallstones and leiomyomas are associated diseases, probably sharing a common cause.     

Sonographic determination of gestational age

Objective.To review current evidence regarding sonographic determination of gestational age.

Methods.We reviewed current and available data to evaluate optimal methods of gestational age determination.

Results.First trimester estimates of gestational age based on crown-rump length and second trimester estimates of gestational age based on composite biometry are very accurate with an absolute error of less than 5 days in the first trimester and 7 days in the second trimester in most cases.

Conclusion.Ultrasound is an accurate and useful modality for assessment of gestational age in the first and second trimester of pregnancy and, as a routine part of prenatal care, can greatly impact obstetric management and improve antepartum care.     

Explosive growth of uterine leiomyomas and carcinologic ovarian risk in a non-menopausal patient with BRCA1-BRCA2 mutation treated by tamoxifen

OBJECTIVE: To report the case of significant growth of a myoma in a premenopausal woman with a suspicion of BRCA1 and BRCA2 mutation, treated by tamoxifen for a hormonodependent breast cancer and to point out the carcinologic ovarian risks with a mutation BRCA1-BRCA2 in this context. Case. Four months after surgical treatment, chemotherapy and the beginning of tamoxifen, an explosive growth of the abdomen justified pelvic echography and laparoscopy confirming the diagnosis of uterine myoma. A polymyomectomy by laparotomy was performed. CONCLUSION: Use of tamoxifen in premenopausal woman with subjacent gynecological pathologies, whether BRCA1-BRCA2 mutation is present or not can prove to be delicate. A regular clinical and echographic monitoring is necessary.     

Fetal biometry and fetal weight estimation: JSUM standardization

From the clinical point of view, it is very important to standardize methods of fetal growth evaluation. The standardization committee of fetal measurement of the Japanese Society of Ultrasound in Medicine (JSUM) announced the recommended standard procedure for fetal biometry, calculation of estimated fetal weight (EFW) and their evaluation method. In short, the abdominal circumference (AC) by the ellipse-tracing method should be the standard for the fetal abdominal measurement and the EFW should be calculated by the following formula:

EFW = 1.07 × BPD. + 0.30 × AC × FL,

where BPD is the biparietal diameter and FL the femur length.     

子宫内膜异位症不孕与盆腔内环境及表观遗传学的关系

子宫内膜异位症（内异症）是一种妇科常见病,不孕是其主要临床表现之一。内异症不孕是多因素共同作用的结果。目前认为,内异症不孕的发生与盆腔内环境的改变密切相关,腹腔液中的多种细胞因子和自由基可能参与其中。另外,异常的表观遗传调控可能与内异症不孕的发生有关。     

Presentación tardía de lesión ureteral secundaria a cirugía laparoscópica

We present the case of a 32-year-old woman who presented to the emergency service complaining of abdominal distension 2 months after laparoscopically-assisted right oophorectomy for pelvic endometriosis. Ultrasound examination revealed abundant ascitic fluid. Fine-needle aspiration biopsy suggested the fluid to be urine. Computed tomography scan of the abdomen and pelvis showed a retroperitoneal fistula with contrast leak and secondary massive ascites.Ureteroperitoneal fistula with secondary ascites is a rare complication in gynecological laparoscopic practice but can cause serious morbidity. Management depends on the timing of diagnosis, etiology, the length and location of the injury, and the patient's clinical status.     

Ultrasound tissue characterization with the gray level histogram width of the B-mode

Objectives. We investigated fetal lung immaturity, fetal brain periventricular echodensity (PVE) and other problems related to changes in fetal tissue by non-invasive ultrasound tissue characterization, using a commonly available real-time B-mode ultrasound machine.

Methods. Histograms of a region of interest (ROI) were displayed on a B-mode screen. The base length of a histogram divided by the full gray-scale length gave the gray level histogram width (GLHW); this value is insensitive to changes in B-mode model, device gain or image depth. Any variation in the magnitude of GLHW in high-contrast images was easily corrected. Fetal lung immaturity was suspected when the fetal lung GLHW was less than that of normal fetal lung and fetal liver after 30 weeks of pregnancy. The GLHW values of fetal brain PVE were also compared to those of normal fetal brain.

Results. GLHW values were compared between the “mature fetal lung” and the “immature fetal lung” groups, as determined by the stable microbubble test: the former had 5 or more microbubbles per 1 mm² of aspirated and shaken amniotic fluid on microscopic observation, while the latter had less than 5. The sensitivity and specificity of the GLHW criterion in predicting lung immaturity were 89% and 79%, respectively, when the GLHW was less than 31%, and less than that for fetal liver. The GLHW of fetal brain PVE was significantly higher than that of normal fetal brain. The GLHW was also high in various obstetrical abnormalities and in the case of malignant gynecological masses.

Conclusion. The GLHW of B-mode images from simple real-time ultrasound imaging machines is useful for the characterization of fetal tissue.     

Echogenic intracardiac focus: A review of the literature

Objective. The objective was to review the existing literature on the echogenic intracardiac focus (EIF) with an emphasis on its association with fetal aneuploidy.

Methods. A thorough bibliographic search was performed using the terms echogenic intracardiac focus and golf-ball sign.

Results. The incidence of EIF in 19 studies was about 2.4%, varying from 0.17% to 20.34%. EIF varies in different ethnic groups and can be as high as 15-30% in Asian populations. It is usually isolated and located in the left ventricle. Pathological studies have shown that EIF is caused by increased mineralization of the papillary muscles. EIF is associated with Down's syndrome but its sensitivity and positive predictive value are low.

Conclusions. The identification of an EIF is an indication to perform a detailed and accurate examination for other major or “soft” sonographic findings-markers of aneuploidy.     

Pelvic floor dysfunction,and effects of pregnancy and mode of delivery on pelvic floor

Pelvic floor dysfunction (PFD), although seems to be simple, is a complex process that develops secondary to multifactorial factors. The incidence of PFD is increasing with increasing life expectancy. PFD is a term that refers to a broad range of clinical scenarios, including lower urinary tract excretory and defecation disorders, such as urinary and anal incontinence, overactive bladder, and pelvic organ prolapse, as well as sexual disorders. It is a financial burden on the health care system and disrupts women's quality of life. Strategies applied to decrease PFD are focused on the course of pregnancy, mode and management of delivery, and pelvic exercise methods. Many studies in the literature define traumatic birth, usage of forceps, length of the second stage of delivery, and sphincter damage as modifiable risk factors for PFD. Maternal age, fetal position, and fetal head circumference are nonmodifiable risk factors. Although numerous studies show that vaginal delivery affects pelvic floor structures and their functions in a negative way, there is not enough scientific evidence to recommend elective cesarean delivery in order to prevent development of PFD. PFD is a heterogeneous pathological condition, and the effects of pregnancy, vaginal delivery, cesarean delivery, and possible risk factors of PFD may be different from each other. Observational studies have identified certain obstetrical exposures as risk factors for pelvic floor disorders. These factors often coexist; therefore, the isolated effects of these variables on the pelvic floor are difficult to study. The routine use of episiotomy for many years in order to prevent PFD is not recommended anymore; episiotomy should be used in selected cases, and the mediolateral procedures should be used if needed.