Comparison of magnetic resonance imaging and transvaginal ultrasonography in diagnosing bladder endometriosis

STUDY OBJECTIVE: To take recent progress in magnetic resonance imaging (MRI) into account to determine its accuracy compared with that of transvaginal ultrasonography (TVUS) in diagnosing bladder endometriosis. DESIGN: Retrospective analysis (Canadian Task Force classification II-2). SETTING: University-affiliated hospital. PATIENTS: Twelve women with histologically proved bladder endometriosis. INTERVENTION: Magnetic resonance imaging with body and endocavitary coils and TVUS. MEASUREMENTS AND MAIN RESULTS: Although TVUS was normal in four patients, MRI enabled endometriotic lesions to be detected in all patients. Magnetic resonance imaging with endocavitary coil established the existence of deep infiltration in three patients when muscularis involvement was not visible with the body coil. In seven women MRI determined how far deep posterior endometriotic lesions extended, whereas with TVUS this was impossible to see. Conclusion. MRI had advantages over TVUS in diagnosing small lesions of associated posterior deep endometriotic lesions. The endocavitary coil gave better results than the phased-array coil for diagnosing deep infiltration. These results are important in that they help guide surgical management.     

Obstructive Uropathy and Vesicovaginal Fistula Secondary to a Retained Sex Toy in the Vagina

IntroductionVaginal foreign bodies (FBs) are a rare cause of vesicovaginal, rectovaginal, or urethrovaginal fistulae.AimThe aim of this study was to describe a rare case of vesicovaginal fistula (VVF) and obstructive uropathy and to review the literature.MethodsA case is presented. A comprehensive review of the literature was performed (1948–2013).ResultsA 38‐year‐old woman presenting with sepsis, obstructive uropathy, and severe emaciation was found to have a sex toy retained in her vagina for 10 years. This had caused a VVF and bilateral hydroureteronephrosis. Bilateral nephrostomies were inserted and she underwent cystoscopy and examination under anesthesia (EUA) with retrieval of FB. A left ureteric stricture was demonstrated. Transabdominal VVF repair with omental flap and left ureteric re‐implantation was performed. The VVF recurred, which was successfully re‐repaired transvaginally. Seventy‐six full text articles were reviewed. There were no previously published cases of VVF following vaginal sex toy insertion. There are four cases of obstructive uropathy secondary to a vaginal FB in the literature: three pessaries and one plastic cap. There are 44 cases of VVF secondary to FB: 22 plastic caps (typically from aerosol bottles, inserted for masturbation or contraception) and 5 pessaries. At least nine were in girls aged ≤18 years. Average presentation is 15 months (range 2 months to 35 years) after FB insertion. Most cases were managed with surgical repair; predominantly transvaginal.ConclusionsThis case describes an extremely rare but potentially life‐threatening case of obstructive uropathy caused by a chronically retained sex toy, and adds to the list of potentially rare causes of a VVF and obstructive uropathy. We advocate urinary diversion, staged removal of FB, upper urinary tract imaging, and EUA with VVF repair and/or ureteric reimplantation if required. Transvaginal is the preferred access for FB‐associated VVF repair without concomitant ureteric reimplantation. Donaldson JF, Tait C, Rad M, Walker S, Lam TBL, Abdel‐Fattah M, and Swami SK. Obstructive uropathy and vesicovaginal fistula secondary to a retained sex toy in the vagina. J Sex Med 2014;11:2595–2600.     

Ureteral endometriosis: the role of magnetic resonance imaging

In six women out of 792 who underwent magnetic resonance imaging (MRI) for management of deep infiltrating endometriosis (DIE), ureteral involvement was suspected. Ureteral endometriosis was identified as a hypointense nodule on T2- weighted images and hyperintense foci on T1-weighted images. Magnetic resonance urography detected obstruction and hydronephrosis in half the women. Detection with MRI of periureteral involvement (extrinsic endometriosis) in four women rather than ureteral wall lesions (intrinsic endometriosis) in two women is an original finding from this series. Magnetic resonance imaging features were correlated and matched with intraoperative and pathologic findings. Magnetic resonance imaging is a useful preoperative tool for the diagnosis and assessment of ureteral endometriosis in rare cases when such lesions have been suspected.     

Clinical utility of magnetic resonance imaging and the preoperative identification of low risk endometrial cancer

BACKGROUND: Magnetic resonance imaging (MRI) is reported to offer the best imaging of local disease in endometrial cancer. We audited MRI scans to identify their clinical utility, particularly in the preoperative identification of 'low risk' endometrial cancer (grade one or two endometrioid tumours confined to the inner half of the myometrium). AIM: To correlate histological and MRI findings and to establish our ability to preoperatively identify women with 'low risk' tumours. STUDY DESIGN: A retrospective audit of MRI scans in women with a new diagnosis of endometrial cancer from July 1998 to November 2002. Radiology and pathology reports and surgical staging data were extracted. Independently a team of radiologists reviewed MRI films and the findings were compared to pathology. RESULTS: Thirty-nine patients were included. Only 10% of original reports contained all the clinically relevant information. On review, the sensitivity for the detection of myometrial invasion was 90%, specificity 71%, positive predictive value (PPV) 93% and negative predictive value (NPV) 63%. For the detection of deep invasion, sensitivity was 56%, specificity 77%, PPV 64% and NPV 71%. All women with grade one or two tumours having no invasion or grade one having superficial invasion detected on MRI had pathological 'low risk' disease. CONCLUSIONS: Magnetic resonance imaging scans as reported offered limited clinical benefit. Attention needs to be given to MRI sequencing and reporting protocols. If the review results can be confirmed by prospective studies, MRI offers significant clinical utility in the identification of low risk patients and their surgical treatment planning.     

Clinical examination and dynamic magnetic resonance imaging in vaginal vault prolapse

OBJECTIVE: To estimate the role of dynamic magnetic resonance imaging (MRI) as a diagnostic tool in the evaluation of vaginal apex prolapse in women with previous hysterectomy. METHODS: Clinical examinations were performed on 51 women presenting with symptoms of prolapse. A preoperative dynamic MRI assessment was performed. The mid pubic line was the reference level used for prolapse grading. The parameters of analysis included 1). correlation by compartments of clinical and MRI grading of prolapse, 2). assessment of the accuracy of clinical examination of the middle compartment, and 3). identification of any additional information provided by MRI. All MRI films were analyzed and validated by the same two observers. RESULTS: Analysis of each compartment separately revealed poor correlation between clinical and MRI assessment. Of the 51 cases with clinical vault prolapse, 27 (52.9%) cases were clinically overdiagnosed, 3 (6%) were underdiagnosed, and there was agreement in 21 (41.1%) when compared with MRI findings. Postoperative follow-up of the 18 (85%) patients who underwent colposacropexy after intraoperative assessment revealed the presence of cystocele in 4 (26.6%) occasions and rectocele in 3 (20%), which had been detected on MRI but not confirmed intraoperatively. CONCLUSION: There is poor correlation between clinical and MRI findings when assessing vaginal apex prolapse. Magnetic resonance imaging allows the identification of other prolapsing compartments and may be a complementary diagnostic tool for the diagnosis of complex vaginal apex prolapse.     

Magnetic resonance imaging and pathologic correlation in stage IB cervix cancers

Ten patients with Stage IB cervical carcinoma underwent primary radical surgery within 2 weeks following magnetic resonance imaging (MRI) examination. Underestimation of stromal disease was common on examination under anesthesia (EUA), while MRI correctly estimated tumor volume and degree of stromal invasion in 9 of 10 cases. In six patients, EUA severely underestimated the tumor: stroma ratio, and five of these six underwent postoperative pelvic radiation therapy. Had the true extent of tumor involvement been recognized preoperatively, we probably would have selected either primary radiation or radiation plus extrafascial hysterectomy for these patients. Pathologic correlation revealed that MRI more accurately predicted tumor size and extent of stromal involvement than clinical examination. We believe that magnetic resonance imaging may have a role in treatment planning of patients with Stage IB cervical carcinoma.     

Central nervous system abnormalities assessed with prenatal magnetic resonance imaging

OBJECTIVE: To determine the frequency at which magnetic resonance imaging (MRI) provides additional information in fetuses with suspected central nervous system (CNS) abnormalities on ultrasound. METHODS: Between May 1, 1996, and March 26, 1999, 83 women with 90 fetuses (including seven sets of live twins) had 91 ultrasonographic and MRI examinations of the fetal CNS. Eight women were studied twice, one for two different indications. If referrals came from outside our institution, a confirmatory sonogram was obtained. Indications for examination were ventriculomegaly (n = 25), suspected neural tube defect (n = 16), arachnoid cyst (n = 12), large cisterna magna (n = 11), and miscellaneous indications (n = 20). RESULTS: Magnetic resonance imaging findings led to changed diagnoses in 26 (40%) of 66 fetuses with abnormal confirmatory sonograms. Magnetic resonance imaging findings not found by ultrasound included partial or complete agenesis of the corpus callosum (n = 11), porencephaly (n = 6), hemorrhage (n = 5), tethered cord (n = 3), cortical gyral abnormality (n = 2), cortical cleft (n = 2), midbrain abnormality (n = 2), and partial or complete agenesis of the septi pellucidi (n = 3), as well as holoprosencephaly, cerebellar hypoplasia, subependymal and cortical tubers, vascular malformation, and vermian cysts (one case each). Abnormalities better delineated by MRI than ultrasound included three cephaloceles, a dural arteriovenous malformation, one distal sacral neural tube defect, and the mass effect of three arachnoid cysts. That information was used to alter patient counseling and at times management. CONCLUSION: When a CNS anomaly is detected by sonography or suspected on ultrasound, MRI findings might lead to altered diagnosis and patient counseling.     

Use of MRI for evaluation of retained uterine fundus mimicking a pelvic mass

Increased use of less invasive hysterectomy techniques requires awareness of the unique potential complications they pose in patients with continued symptoms after surgery. Retained uterine fundus is rare after vaginal hysterectomy; only 2 other cases have been reported in the English literature. Magnetic resonance imaging (MRI) was not used preoperatively in either case. However, imaging evaluation, in particular with MRI because of its superior soft tissue resolution, can be helpful in suggesting the diagnosis. Herein is presented the case of a 40-year-old woman who had undergone vaginal hysterectomy several years previously, but was experiencing abdominal pain. MRI was performed, which revealed a supravesical mass. Visualization at MRI of intact round ligaments arising from the mass favored the diagnosis of retained uterine fundus and confirmed after surgical excision.     

Magnetic resonance imaging of fetuses with intracranial defects

Thirteen women whose fetuses had intracranial defects on ultrasound examination were offered magnetic resonance imaging (MRI) without charge. All fetuses were paralyzed with pancuronium before the study, which lasted approximately 1 hour. With the mother in the left lateral decubitus position to minimize transmitted maternal aortic pulsation, T1-weighted images were obtained using a Picker 0.5-tesla superconductive unit. Magnetic resonance imaging provided excellent detail of intracranial anatomy in all cases. In four of the 13 fetuses, the MRI diagnosis differed from that of ultrasound and ultimately proved correct. In another three, MRI added greatly to the ultrasound diagnosis by delineating intracranial anatomy more precisely. In the remaining six cases, MRI confirmed the ultrasound impression. For circumstances in which the ultrasound diagnosis is unclear or antenatal intervention might require exact knowledge of anatomical detail, the additional information provided by MRI may justify its cost.     

Characterization of colorectal symptoms in women with vesicovaginal fistulas

ObjectiveTo characterize colorectal symptoms in women with a history of an obstetric vesicovaginal fistula (VVF).MethodsPatients under evaluation with a VVF during two 2-week surgical service trips to Evangel Hospital VVF Center in Jos, Nigeria, in 2010 were assessed for symptoms of fecal incontinence (FI) using the Vaizey and Colorectal-Anal Impact (CRAIQ) questionnaires. Women with rectovaginal fistulas were excluded. Each participant's impression of overall health was assessed using a visual analog scale (VAS) from 0 (poor) to 15 (excellent). A study nurse translated questionnaires into native languages.ResultsThe mean age of the 83 women included was 29 years. Three women (3.6%) reported FI and 42 (50.6%) reported constipation. All of the women with FI reported that it affected their quality of life on the CRAIQ. Average VAS score was 10.8 overall and 6.8 for women with FI.ConclusionIn this population of women with VVF but no rectovaginal fistulas, we found a low prevalence of fecal incontinence and a high prevalence of constipation. Despite significant pelvic floor trauma resulting in VVF, the majority of patients appeared to have an intact bowel continence mechanism.     

Magnetic resonance imaging (MRI) of the pelvis in the diagnosis of cervical carcinoma -- review

Magnetic resonance imaging (MRI) is an accepted imaging method for diagnosing cervical cancer staging before therapy and for recurrent cervical carcinoma. This review article describes the usefulness and the limits of MRI in the diagnosis of cervical cancer. Typical manifestations are illustrated with sample images.     

Gynecological surgery caused vesicovaginal fistula managed by Latzko operation

ObjectiveIn developed countries, vesicovaginal fistula (VVF) is a rare complication after gynecological surgery. In this report, the Latzko procedure was used to repair VVF to evaluate its safety and efficacy.Materials and MethodsBetween 1991 and 2009, cases in which VVF developed after various gynecological surgeries and repaired using the Latzko procedure were included. The cause of VVF and outcome after Latzko procedure were reported. The previous published reports regarding Latzko procedure were also listed and compared. The median follow-up period was 8 years.ResultsSix cases of VVF were documented in this period. All fistulas were simple type with a fistular size of less than 2 cm. In three of six cases, fistulas developed after a hysterectomy for carcinoma in situ of cervix. Of those remaining, one case developed after staging an operation for endometrial adenocarcinoma, while the other two cases occurred after hysterectomy for myoma. Five cases were repaired successfully. One case had postoperative complications such as fever and urinary tract infection. Intraoperative blood loss and hospital stay were minimal. There was no recurrence of VVF postoperatively among successful cases during the follow-up period.ConclusionAdequate exposure of the fistular site is a key point to a successful repair. The Latzko method is a minimal access procedure for VVF repair. This technique may be considered a first-line treatment of VV fistula.     

MRI of intestinal endometriosis

Endometriosis is a common gynecological condition of unknown etiology, which mainly affects women of reproductive age. The commonest site of gastrointestinal endometriosis is the rectosigmoid colon. Involvement of the sigmoid, cecum, appendix, and small bowel are less common, but one third of rectosigmoid endometriosis is associated with right-sided extra-pelvic bowel endometriosis. Intestinal endometriosis represents one of the most severe forms of deep endometriosis (DE).Magnetic resonance imaging (MRI) is recommended as a second-line technique in the preoperative workup of DE, especially for gastrointestinal endometriosis. An optimal MRI protocol is required for a complete mapping of endometriotic lesions. MRI could be used as a triage test in the diagnosis of rectosigmoid colon endometriosis. Magnetic resonance enterography should be additionally performed requiring a specific additional MRI protocol for the evaluation of multicentric intestinal endometriotic lesions.Except other imaging techniques, the aim of this chapter is to expose indications for MRI, technical requirements, patient preparation, MRI protocols, and criteria for the diagnosis of intestinal endometriosis.     

Diagnostic accuracy of laparoscopy,magnetic resonance imaging,and histopathologic examination for the detection of endometriosis

OBJECTIVE: To evaluate the utility of fat-suppressed magnetic resonance imaging (MRI) in the diagnosis of endometriosis. DESIGN: A prospective clinical trial. SETTING: A government research hospital. PATIENT(S): Forty-eight women with pelvic pain. INTERVENTION(S): Magnetic resonance imaging followed by surgical excision and pathologic diagnosis of endometriosis. MAIN OUTCOME MEASURE(S): Presence and extent of endometriosis suggested by preoperative MRIs compared with surgical inspection and biopsy. RESULT(S): A preoperative MRI in 46 women detected fewer endometriosis lesions than histopathology or laparoscopy (78 vs. 101 vs. 150). Few MRI lesions correlated with those identified by laparoscopy (50 of 150) or pathology (38 of 101). Of 42 women with surgically diagnosed endometriosis, 28 had at least one corresponding abnormality on MRI, 5 had abnormalities that didn't correlate with surgical findings, and 9 had normal MRIs. The sensitivity of MRI in detecting biopsy-proven endometriosis for any woman was 69% (25 of 36), and the specificity was 75%. CONCLUSION(S): Although MRI identifies fewer areas of endometriosis than seen at surgery, it suggested endometriosis in 75% of those with at least mild disease. Only 67% of lesions identified at surgery contained histologic evidence of endometriosis.     

Magnetic resonance imaging in Mayer-Rokitansky-Küster-Hauser syndrome

Six girls with suspected Rokitansky syndrome underwent magnetic resonance imaging (MRI) and then sonography and laparoscopy to confirm the clinical diagnosis and define the precise characteristics of the malformation. The uterus was missing in all; four had müllerian rudiments in place of the uterus, which were cavitary in two as shown by sonography and in one by MRI. Both ovaries were present in all cases, normally located in four and extrapelvic in two; they were correctly identified by MRI in all cases and by sonography in four. Partially canalized vaginal rudiments were recognized by MRI in two girls and by sonography in one. One patient had unilateral renal agenesis, demonstrated by both MRI and sonography. Magnetic resonance imaging was more precise than laparoscopy and sonography in defining the anatomical characteristics of Rokitansky syndrome, and is less invasive and expensive than laparoscopy.     

Magnetic Resonance Imaging of Female Prostate Pathology

IntroductionThe female prostate (paraurethral glands) is a well-known, yet poorly understood, anatomic structure. Imaging studies of the female prostate, its physiology, and pathologies are still highly controversial.AimTo study the anatomy of the female prostate with contemporary magnetic resonance imaging (MRI) techniques and correlate these findings to clinical features.Main Outcome MeasuresFemale prostate pathologic anatomy on MRI.MethodsWomen with clinical signs of function (or dysfunction) of paraurethral glands have been examined with 1.5 or 3 Tesla MRI and urethroscopy.ResultsSeven women aged 17 to 62 years (median 40 years) have been prospectively included into the study. Clinically, one of the seven women reported ejaculation at orgasm, whereas three women presented with occasional secretions independent of sexual stimulation. In two women, paraurethral glands have been randomly found on MRI that has been performed in the diagnostic workup of other diseases. One woman presented with swelling of the external urethral meatus at puberty. In this woman, a paraurethral gland has been found, besides the erectile tissue at the external meatus. Two women reported lower urinary tract symptoms (LUTS) with mainly urethral symptoms (recurrent infections in one and paraurethral stones in the other). On MRI, paraurethral glands could be visualized in six of the seven patients. There was no relation between glandular volume and ejaculation status. In cases where glands or related pathologies could be found on physical examination, there was a clear correlation with MRI anatomy.ConclusionsMRI has the potential to become the standard imaging modality for female prostate pathology. Exact visualization of this highly variable structure is possible by tailored MRI protocols. This tool can aid in understanding an individual woman's symptoms related to paraurethral glands with an impact on her sexual life. Wimpissinger F, Tscherney R, and Stackl W. Magnetic resonance imaging of female prostate pathology. J Sex Med 2009;6:1704–1711.     

Staging of cervical cancer: comparison between magnetic resonance imaging, computed tomography and pelvic examination under anesthesia.

A prospective study was undertaken to compare magnetic resonance imaging (MRI) with computed tomography (CT) and examination under anesthesia (EUA) in staging cervical carcinoma, with special emphasis on parametrial status. Twenty patients with carcinoma of the cervix, in whom the extent of the disease was surgically confirmed, were analyzed by MRI, CT and EUA. The tumor size estimated by MRI correlated well (r = 0.79, p < 0.001) with those obtained by histopathologic measurement of the surgical specimen. Neither clinical examination nor CT could precisely estimate tumor size. The overall accuracy rate of MRI in staging carcinoma of the cervix was 75%, compared with 32% for CT staging and 55% for clinical staging. The accuracy rate of these modalities for parametrial status was 90% for MRI, 55% for CT and 82.5% for EUA. MRI accurately excluded all 20 patients with pelvic side wall, bladder and rectal involvement. In conclusion, MRI is superior to CT and EUA in assessment of the parametrium (90% vs 55% vs 82.5%, p < 0.005). From MRI, tumor size can be estimated precisely. Although a larger scale study comparing MRI and CT is needed to determine their roles, both should help in the diagnosis and selection of proper treatment for cervical carcinoma. Our preliminary report agrees with previous reports that MRI is promising and indispensable. MRI should be routinely used in conjunction with clinical staging to determine appropriate therapy in patients with cervical carcinoma.     

Differential diagnosis of adnexal masses: risk of malignancy index, ultrasonography, magnetic resonance imaging, and radioimmunoscintigraphy

A risk of malignancy index (RMI), based on menopausal status, ultrasound (US) findings, and serum CA125, has previously been described and validated in the primary evaluation of women with adnexal masses and is widely used in selective referral of women from local cancer units to specialized cancer centers. Additional imaging modalities could be useful for further characterization of adnexal masses in this group of women. A prospective cohort study was conducted of 196 women with an adnexal mass referred to a teaching hospital for diagnosis and management. Follow-up data was obtained for 180 women; 119 women had benign and 61 women malignant adnexal masses. The sensitivity and specificity of specialist US, magnetic resonance imaging (MRI), radioimmunoscintigraphy (RS), and the RMI were determined. We identified a subgroup of women with RMI values of 25-1000 where the value of further specialist imaging was evaluated. Sensitivity and specificity for specialist US were 100% and 57%, for MRI 92% and 86%, and for RS 76% and 87%, respectively. Analysis of 123 patients managed sequentially, using RMI cutoff values of > or =25 and <1000 and then US and MRI provided a sensitivity of 94% and a specificity of 90%. Using this RMI cutoff followed by specialist US and MRI, as opposed to the traditional RMI cutoff value of 250, can increase the proportion of patients with cancer appropriately referred in to a cancer center, with no change in the proportion of patients with benign disease being managed in a local unit.     

Céphalées brutales du post-partum : à propos de deux cas et revue de PRES !

We report two cases of Posterior Reversible Encephalopathy Syndrome (PRES) in the postpartum period. Sudden initial headache, impairment of consciousness and visual disturbance associated with arterial hypertension were reported in the two cases. Only the first woman had seizures. These neurologic symptoms were compatibled with eclampsia and PRES. Magnetic resonance imaging (MRI) established the diagnosis of PRES. These two cases illustrate the value of MRI to make diagnosis and prognosis of any sudden postpartum headache. This diagnosis shouldn??t be ignored by obstetricians because peripartum is a risky period. Prognosis is good if a symptomatic treatment is initiated early.