Rectovaginal Septum Research Articles

Initial Accuracy of and Learning Curve for Transvaginal Ultrasound with Bowel Preparation for Deep Endometriosis in a US Tertiary Care Center

Study ObjectiveTo evaluate the diagnostic accuracy and learning curve of a sonographic mapping protocol for deep endometriosis (DE). DesignRetrospective cohort study (Canadian Task Force classification II-3). SettingTertiary referral center in the United States. Patients117 consecutive patients who presented to our gynecology clinic with complaints of significant noncyclic pelvic pain of at least 6 months' duration, and/or clinical findings concerning for deep endometriosis and who were referred for transvaginal ultrasound with bowel preparation. InterventionsPatients underwent transvaginal ultrasound with bowel-preparation (TVUS-BP) performed by a single radiologist. Findings suspicious for DE were reported and correlated with surgical and histopathological findings. The duration of the examination and number of cases required to achieve proficiency were calculated for positive, equivocal, and negative findings. Measurements and Main ResultsAmong 117 patients (median age, 35 years; range, 19–54 years) referred for TVUS-BP, 113 had complete examinations. Fifty-seven of these 113 patients underwent surgical exploration within 1 year, and DE was identified surgically in 23 of them. DE of the rectosigmoid colon and/or rectovaginal septum was detected with a sensitivity of 94% (95% confidence interval [CI], 70%–100%) and specificity of 100% (95% CI, 91%–100%). DE of the retrocervical region and/or uterosacral ligaments was detected with a sensitivity of 86% (95% CI, 65%–97%) and specificity of 94% (95% CI, 81%–99%). Proficiency, defined by a flattening of the learning curve, was achieved after 70 to 75 scans. The mean duration of the examination was 42 ± 4 minutes initially, but declined to 15 ± 4 minutes once proficiency was achieved. Cases of equivocal or minimal disease demonstrated the greatest decline in examination duration. ConclusionA newly applied TVUS-BP protocol for detection of pelvic DE is highly accurate and required only a modest learning curve to achieve procedural proficiency in a US tertiary referral center where physicians interpret but typically do not perform TVUS exams. Overcoming diagnostic uncertainty regarding minimal or equivocal disease appeared to be an important factor in the initial learning curve. With adequate training, TVUS-BP may be adapted as a primary diagnostic tool for detecting pelvic DE.

MR imaging of endometriosis: Spectrum of disease.

Endometriosis is a common gynecological disorder defined by the presence of endometrial tissue outside the uterus. It is the most common cause of chronic pelvic pain and typically affects the ovaries, uterine ligaments, peritoneum, tubes, rectovaginal septum and bladder. It may, however, be found at various extrapelvic sites, including the perineum, liver, pancreas, lung or even the central nervous system, and in such cases, diagnosis may be quite challenging. Even though definitive diagnosis requires laparoscopy, preoperative identification of endometriosis is important not only to differentiate it from other diseases with similar clinical presentations but also, for accurate presurgical mapping, since complete removal of all endometriotic foci is critical for the effective treatment of the patient's symptoms. Ultrasound is performed initially, but magnetic resonance imaging (MRI) is increasingly being used, particularly when sonographic findings are unclear, when deep pelvic endometriosis is suspected or when surgery is planned, as it provides better contrast resolution and a larger field of view compared to ultrasound. In this article, we will discuss distinctive MRI appearances of endometriotic foci and we will review common and uncommon locations of endometriosis within the body, in an attempt to familiarize radiologists with its wide spectrum of manifestations.

Rectum and bladder spacing in cervical cancer brachytherapy using a novel injectable hydrogel compound

PurposeThe aim of this study was to evaluate injection of a novel hydrogel (TraceIT; Augmenix, Waltham, MA) between the cervix, rectum, and bladder in female cadavers compared with, and in addition to, the current standard of gauze packing, for organ-at-risk sparing in cervical cancer brachytherapy planning. Methods and MaterialsThis brachytherapy cadaver study used T2-weighted MRI and CT imaging to compare three scenarios: (1) gauze packing alone, (2) hydrogel injection placed in the cervical fornices and rectovaginal septum, and (3) gauze packing in conjunction with hydrogel injection. Hydrogel distribution was evaluated. Doses to 2 cm3 volumes (D2cc) for the rectum, bladder, and sigmoid were collected. Statistical significance (p < 0.05) was evaluated using a two-tailed paired t test. ResultsHydrogel was successfully injected to space the bladder and rectum from the cervix in all five cadavers. The spacer was easily identifiable on both CT and MRI. The use of hydrogel in addition to packing resulted in a 22% decrease in rectum D2cc dose (p = 0.02), a 10% decrease in bladder D2cc (p = 0.27), and no change in sigmoid D2cc dose. No difference was observed between hydrogel only vs. gauze packing only. ConclusionsOur results revealed a significant clinically meaningful decrease in rectal D2cc associated with the use of hydrogel in addition to gauze packing—TraceIT hydrogel holds promise as a spacer in cervical cancer therapy.

Transanal Endoscopic Microsurgery for the Treatment of Uncommon Rectal Lesions

IntroductionTransanal endoscopic microsurgery (TEM) was developed as a less aggressive alternative treatment for rectal lesions (mainly adenomas and adenocarcinomas). However, its use for other rectal lesions has become more frequent, trying to reduce the morbidity associated with more invasive techniques. The aim of this study is to describe our experience in the use of TEM in other rectal lesions. MethodsRetrospective and descriptive study including patients operated with TEM (from June 2008 to December 2016) for the treatment of rectal lesions different from adenomas or adenocarcinomas. ResultsAmong the 138 patients treated by TEM in our department, 10 patients were operated on for rectal lesions other than adenomas or adenocarcinomas. Rectal lesions were 3 neuroendocrine tumors, a neuroendocrine tumor metastasis, a rectal stenosis, a cloacogenic polyp, an endometrioma, a retrorrectal tumor, a presacral abscess and a lesion in the rectovaginal septum. Mean operative time was 72min and postoperative stay was 4.2 days. Only one patient needed a reoperation, due to rectal bleeding. ConclusionsTEM could be a useful tool for the treatment of rectal lesions different from adenomas or adenocarcinomas, potentially decreasing the morbidity associated with more aggressive surgical techniques.

Microcirugía endoscópica transanal en el tratamiento de lesiones rectales atípicas

IntroductionTransanal endoscopic microsurgery (TEM) was developed as a less aggressive alternative treatment for rectal lesions (mainly adenomas and adenocarcinomas). However, its use for other rectal lesions has become more frequent, trying to reduce the morbidity associated with more invasive techniques. The aim of this study is to describe our experience in the use of TEM in other rectal lesions. MethodsRetrospective and descriptive study including patients operated with TEM (from June 2008 to December 2016) for the treatment of rectal lesions different from adenomas or adenocarcinomas. ResultsAmong the 138 patients treated by TEM in our department, 10 patients were operated on for rectal lesions other than adenomas or adenocarcinomas. Rectal lesions were 3neuroendocrine tumours, a neuroendocrine tumour metastasis, a rectal stenosis, a cloacogenic polyp, an endometrioma, a retrorrectal tumour, a presacral abscess and a lesion in the rectovaginal septum. Mean operative time was 72min and postoperative stay was 4.2 days. Only one patient needed a reoperation, due to rectal bleeding. ConclusionsTEM could be a useful tool for the treatment of rectal lesions different from adenomas or adenocarcinomas, potentially decreasing the morbidity associated with more aggressive surgical techniques.

The role of MRI in evaluation of recto-sigmoid junction wall endometriosis. A case report

Endometriosis is a condition that occurs due to the presence of endometrial glandular tissue outside the uterine cavity, more frequently at pelvic level affecting ovaries, uterosacral ligament, recto-vaginal septum, sigma or urinary bladder. The diagnosis of endometriosis involves a detailed anamnesis, gynecological examination, imagistic examinations, biochemical investigations, laparoscopy, and histological confirmation. We present herein the case of a 30-year-old patient with severe dysmenorrhea and infertility, diagnosed with profound endometriosis. The patient undergone a magnetic resonance imaging (MRI) pelvic examination with a specific protocol which includes endovaginal and endorectal instillation of gel and involves a scan of the pelvis in three planes (axial, coronal and sagittal) T2-weighted; T2 sequences with inclinations at the level of the uterus, urinary bladder and uterosacral ligaments; T1, T1 Fat Sat sequence unenhanced and post-contrast and T2 sequences post vaginal and rectal instillation of sterile gel. The MRI examination with endovaginal and endorectal instillation of sterile gel has a high specificity and sensitivity in establishing the diagnosis, allowing an accurate evaluation of the various modifications caused by endometriosis and its extent in the wall of pelvic organs. Such an investigation allows an exact preoperative mapping of lesions.

Endometrial Stromal Sarcoma Arising from Endometriosis

The malignant transformation of endometriosis is a very uncommon event but can occur in 0.7% to 1% of all cases. Any histological type of tumor found in the endometrium might also occur in endometriosis. Most malignant tumors that originate from endometriosis are endometrioid adenocarcinomas and also clear-cell type carcinomas. On the other hand, sarcomas, especially endometrial stromal sarcoma (ESS), are extremely unusual representing 12% of all cases. ESS is an uncommon neoplasm and accounts for 0.2% of the uterine malignances. Malignant tumors arising from endometriosis can derive from the uterine wall as well as from extra-uterine sites. The most frequent extrauterine location is the ovary (78.7%), followed by the pelvic peritoneum (5.7%), the rectovaginal septum (4.3%), the colon (4.3%) and the vagina (2%), representing the majority of extragonadal sites. ESSs arising from the extrauterine and extraovarian endometriosis sites in the absence of a primary uterine lesion are extremely rare and the treatment options are not clear. Surgical debulking seems to be the best treatment. Adjuvant therapy, such as radiation, hormonal therapy and chemotherapy are not yet proven to be effective. Molecular target therapy could be a future possibility of treatment. A systematic review of English Medical Literature about incidence, treatment and prognosis of extrauterine ESS arising from endometriosis foci was performed. The selected articles on which this review is based are the following: 9 literature reviews, 8 retrospective studies, 7 case series, 1 prospective trial and 11 case reports.

Laparoscopic Sacral Colpopexy: The “6-Points” Technique

Study ObjectiveTo illustrate laparoscopic sacral colpopexy for pelvic organ prolapse, a new method using a simplified mesh fixation technique, with only 6 fixing points. DesignStep-by-step explanation of the surgery using video (educative video). The video was approved by the local institutional review board. SettingUniversity Hospital of Strasbourg, France (Canadian Task Force Classification III). PatientsWomen with multicompartment prolapse. InterventionWe first dissected the promontorium and vertically incise the posterior parietal peritoneum on the right pelvic sidewall up the pouch of Douglas. We then dissect the rectovaginal septum up to the anal cap, laterally exposing the puborectalis muscle on each side. Middle rectal vessels can be coagulated and cut without increasing the risk of digestive disorders (especially constipation), but it is preferable to conserve them if the space is sufficient for suture. Then, we dissect the vesicovaginal space and realized the subtotal hysterectomy. Finally, we realized the fastening of the anterior and posterior meshes. The particularity is that we performed only 6 points for fixing the meshes: 1 on the puborectalis muscle on each side without tension (to reduce the risk of mesh contracture, dyspareunia, and chronic pelvic pain), 1 for the fixing of the anterior mesh on the anterior vaginal wall at the level of the bladder neck, and 1 on each side of the cervix for the reconstitution of the pericervical ring gathering together the anterior mesh, the pubocervical fascia, and the insertion of the uterosacral ligament at the level of the cervix and the posterior mesh. The sixth stitch fastened 1 of 2 meshes to the anterior paravertebral ligament at the level of the sacral promontory. We finished with the peritonization. Main ResultsThe duration of surgery lasts approximately 120 minutes in well-experienced hands. Based on our experience the 6-point technique was relatively simple (few laparoscopic stiches) with few operative difficulties and was also associated with a low rate of reintervention. ConclusionSurgical management of middle compartment prolapse could be performed quickly and efficiently under laparoscopy with the “6-points” technique.

Surgical repair of complex rectovaginal fistulas: Report of two cases

A rectovaginal fistula (RVF) is an abnormal communication between the rectum and the vagina. In girls, the main etiologies are iatrogenic (correction of anorrectal malformations and Hirschsprung disease) and traumatic (sexual abuse and foreign bodies). Multiple surgical approaches have been described for the treatment of this pathology, having the posterior sagital approach, in pediatric population, the one with best results. However the complex RVF (epithelialized long length communications, located at the upper third of the rectovaginal septum, diameters > 2.5 cm, and recurrent and those secondary to pelvic radiation) have poor results when are treated with conventional techniques; they require the removal of peripheral fibrous tissue and replacement by healthy tissue with adequate arterial supply, preserving the anal canal and, in consequence, fecal continence. This work describes our experience in the repair of two pediatric patients with complex rectovaginal fistulas using a combination of two colorectal surgical techniques: the posterior sagital approach and transanal pull-trough (Swenson technique) with the complete resolution of the fistulas, allowing the stomas closure and keeping fecal continence.

Digital rectal examination in the evaluation of rectovaginal septal defects.

The objective was to evaluate the diagnostic potential of digital rectal examination in the identification of a true rectocele. This is a retrospective observational study utilising 187 archived data sets of women presenting with lower urinary tract symptoms and/or pelvic organ prolapse between August 2012 and November 2013. Evaluation included a standardised interview, ICS-POPQ, rectal examination and 4D translabial ultrasound. The main outcome measure was the diagnosis of rectocele by digital rectal palpation on Valsalva manoeuvre. This diagnosis correlated with the sonographic diagnosis of rectocele to determine agreement between digital examination and ultrasound findings. Complete data sets were available for 180 participants. On imaging, the mean position of the rectal ampulla was 11.07 (-36.3 to 44.3) mm below the symphysis pubis; 42.8% (77) had a rectocele of a depth of ≥10mm. On palpation, a rectocele was detected in 60 women (33%). Agreement between palpation and imaging was observed in 77%; the kappa was 0.52 (CI 0.39-0.65). On receiver operator characteristic analysis, the area under the curve was 0.854 for the relationship between rectocele pocket depth and the detection of rectocele on palpation. Moderate agreement was found between digital rectal examination for rectocele and translabial ultrasound findings of a "true rectocele". Digital rectal examination may be used to identify these defects in clinical practice. Extending the clinical examination of prolapse to include rectal examination to palpate defects in the rectovaginal septum may reduce the need for defecatory proctograms for the assessment of obstructive defecation and may help triage patients in the management of posterior compartment prolapse.

Ultrasound Imaging for Ovarian and Deep Infiltrating Endometriosis

The main challenges of imaging for endometriosis are the detection of nonovarian disease and the evaluation of the extension of the disease into pelvic structures. Transvaginal ultrasonography (TVS) has been proposed as the first-line imaging technique because it allows extensive exploration of the pelvis. The "typical" endometrioma is a unilocular cyst with homogeneous low-level echogenicity (ground glass echogenicity) of the cyst fluid. The use of color Doppler helps avoid classifying malignancies as endometriomas, defining the presence of vascular flow in papillations. The real-time dynamic TVS examination of adhesions and pouch of Douglas (POD) obliteration, using the sliding sign technique, seems to be useful in the identification of women at increased risk for bowel endometriosis. Transvaginal ultrasound allows an accurate assessment of the vagina, particularly the areas of the posterior and lateral vaginal fornixes, the retrocervical area with torus uterinum and uterosacral ligaments, and the rectovaginal septum. The slightly filled bladder permits an evaluation of the bladder walls and the presence of endometriotic nodules which appear as hypoechoic linear or spherical lesions bulging toward the lumen, involving the serosa, muscularis, or (sub)mucosa of the bladder. Deep nodules of the rectum appear as hypoechoic lesions, linear or nodular retroperitoneal thickening with irregular borders, penetrating into the intestinal wall distorting its normal structure with the presence of few vessels observed with power Doppler evaluation. Adenomyosis can be observed with the two-dimensional (2D) TVS showing the typical myometrial features and 3D evaluation of the junctional zone. Although the sensitivity and specificity of TVS in the prediction of deeply infiltrating endometriosis and adenomyosis is high, their assessment by TVS is difficult and needs a great expertise.

Primary vaginal leiomyosarcoma, a rare tumour: case report and review

Primary vaginal leiomyosarcomas (pvLMS) are rare, recurrent tumours accounting for ca. 2% of all vaginal cancers. The etiology is still unknown, the prognosis is poor and there is no consensus guideline on its management. Diagnosis is usually made during the 5th decade due to the presence of a vaginal mass or nodule [1-2]. Current medical literature reports about 200 cases (PubMed®); only 3 studies have considered the ultrastructure [2-4]. Herein a pvLMS is presented and discussed. A nodular, 25 x 23 x 28 mm-mass, infiltrating the urethra but not the rectovaginal septum, was widely excised from the superior vaginal wall of a 58-year-old previously hysterectomized woman. Macroscopic images and MRI were performed. Iliac lymph nodes and HMB-45 were negative. The sample was fixed and prepared for light microscopy, transmission (TEM) and scanning (SEM) electron microscopy. Semithin sections showed a storiform pattern of spindle shaped cells with blunt-ended nuclei. Cells arranged in interwoven fascicles within a dense and richly vascularised stroma (neoangiogenesis). Some atypic mitotic figures and focal necrosis were seen. SEM evidenced a dense collagenous stroma with numerous microvessels. TEM showed neoplastic and pleomorphic cells with complex cytoplasm projections containing paranuclear crowds of dilated mitochondria, free ribosomes and a well-developed rough endoplasmic reticulum. Nuclei were large, mostly hyperchromatic, usually indented, with prominent nucleoli and nucleolonema. The dense intercellular space contained dense bundles of collagen fibers. A high and reactive endothelium lined blood vessels. After 4 follow-ups, the patient is fine and without recurrence. Best outcomes occur when the tumour is small, localized, and can be removed surgically with wide, clear margins, as it was for this case. As there are different kinds of LMS, biopsy followed by immunohistochemistry and electron microscopy still represents a good diagnostic choice.

Diagnosis of endometriotic lesions by sonovaginography with ultrasound gel.

The aim of the study was to evaluate the diagnostic ability of sonovaginography (SVG) with ultrasound gel inpatients with endometriosis. We conducted a multicentre prospective study, which included 193patients with symptoms highly suggestive for endometriosis. All patients were investigated by transvaginal sonography andSVG with gel and afterwards underwent laparoscopic surgery. For each category of endometriotic lesions investigated, wecalculated and compared the sensitivity, specificity, positive predictive value and negative predictive value of the imagisticinvestigations used. In the case of endometriotic lesions of the uterosacral ligaments, SVG with gel had a sensitivityof 78.5% and a specificity of 96% (p=ns). The lesions of the vagina and rectovaginal septum were diagnosed with a sensitivityof 79%, respectively 94% (p=ns), obtaining a specificity of 99%, respectively of 97% (p=0.007). The lesions of the Douglaspouch were identified with a sensitivity of 81% (p=0.015), and those of the rectosigmoid with a 94% sensitivity (p=0.010). Weobtained lower sensitivity (67%) in detecting the lesions of the urinary bladder (p=ns). SGV with ultrasound gelrepresents a useful investigation tool for the evaluation of endometriotic lesions in the posterior pelvic compartment.

Prosthetic materials for treating posterior vaginal wall prolapse and rectocele - own experience.

This report describes results of posterior vaginal wall prolapse and rectocele treatment performing tension free reconstruction method with polypropylene mesh implantation. In years 2001 to 20015, 71 female patients in age of 42-82 years were surgically treated. Besides difficult emptying they complained of feeling of heaviness in the pelvis (38%) and dyspareunia (16.9%). Defecography and magnetic resonance proved the presence of rectocele in 84.5%, enterocele in 38%, descending perineum in 28.2%, genital organ prolapse in 23.9%, and rectal prolapse in 22.5% cases. 37 patients with defects of low location have undergone implantation of prosthetic material from vaginal approach. In cases of high location and genital organ prolapse abdominal approach was done. Permanent reconstruction of the rectovaginal septum has been achieved in 70 patients (98%). Symptoms of dyschesia, pelvic plain, heavy straining were persisted in 4 patients (10.3%). 3 cases of mash erosions were diagnosed. One patient was reoperated. Among 6 other patients who needed futher surgical treatment only one was reoperated because of vaginal prolapse. 81.7% of patients was satisfied with their treatment. Using prosthetic materials in pelvic floor defects treatment is characterized by high efficacy and low complication percentage.

Leiomyoma at an Unusual Site: A Case Report

Uterine leiomyomas are one of the most common tumors found in women of reproductive age. Leiomyoma is usually derived from uterine smooth muscle but sometimes it may arise from an unusual site, have rarely been reported in this age group.In this present case, vaginal fibroid caused clinical dilema. Here, we report the rare case of a leiomyoma in a 27-years married, nuliparous lady; presented with dyspareunea and rectal pain treated by myomectomy. The treatment of the symptomatic fibroid is either myomectomy or hysterectomy1. A liomyoma was located in rectovaginal septum and , at the junction middle and lower one third of vagina and above the anal canal, separate from the uterus. Histopathological examination confirmed as a case of leiomyoma.Bangladesh J Obstet Gynaecol, 2013; Vol. 28(1) : 44-46

Meta-Analysis and Systematic Review to Determine the Optimum Imaging Modality for the Detection of Deep Infiltrative Endometriosis in the Rectovaginal Septum

Meta-Analysis and Systematic Review to Determine the Optimum Imaging Modality for the Detection of Deep Infiltrative Endometriosis in the Rectovaginal Septum

The Intraoperative Imaging of the Recto-Vaginal Septum Using a Dual Array Transrectal / Transvaginal Ultrasound Probe: A Novel Aid to Promote Intraoperative Safety and Accuracy

The Intraoperative Imaging of the Recto-Vaginal Septum Using a Dual Array Transrectal / Transvaginal Ultrasound Probe: A Novel Aid to Promote Intraoperative Safety and Accuracy

P15.01: Meta‐analysis and systematic review to determine the optimum imaging modality for the detection of rectovaginal septum deep infiltrative endometriosis

P15.01: Meta‐analysis and systematic review to determine the optimum imaging modality for the detection of rectovaginal septum deep infiltrative endometriosis

A novel technique of introducing the mesh at the distal dissection while performing laparoscopic ventral rectopexy

Laparoscopic ventral rectopexy (LVR) is considered an effective treatment for rectal prolapse and/or rectoanal intussusception. After the dissection of the rectovaginal septum down to the pelvic floor, a strip of mesh is introduced and should be secured as distally as possible. We have developed a novel technique of introducing the mesh at the distal dissection. A nylon thread with straight needle was passed through the posterior wall of vagina at the distal extent of the dissection, which was caught in the abdominal cavity and fixed at the end of the mesh extracorporeally. The mesh was then introduced, pulled toward the pelvic floor and settled at the pierced site by the perineal operator. Sixty-eight female patients underwent LVR using this technique. There were no intra-operative and postoperative mesh-related complications. The mean distance from the vaginal ostium to the point of passing a nylon thread through the posterior wall of the vagina was 2cm. Postoperative proctography showed the anatomical correction in 47 of the 48 patients who were examined. The surgeon can confirm that the mesh is introduced and secured at the distal dissection by using this technique while performing LVR.

Laparoscopic Treatment of a Retroduodenopancreatic Endometriotic Cyst Observed Postpartum.

Endometriosis occurs in 5%-10% of fertile women, usually in the pelvic region, such as the ovaries, uterine ligaments, pelvic peritoneum, and rectovaginal septum. A mesenteric endometriotic cyst is an exceptional observation and difficult to diagnose preoperatively. We report a case of a large mesenteric endometriotic cyst treated by laparoscopy. A 21-year-old Caucasian woman was admitted as an emergency to our Academic Hospital on the 30th day postpartum for abdominal pain and a palpable epigastric mass. A CT scan revealed a mass measuring 7.5 × 5.5 cm showing a fluid content, located below the pancreas. A preoperative diagnosis of mesenteric cyst was made and confirmed by MRI. A dissection of the mass from the inferior vena cava, pancreas, and duodenum was achieved by a laparoscopic approach. During the blunt dissection, avoiding any spillage, the cyst was aspirated to preserve a safe cleavage plane with the lower third of the duodenum showing tenacious adhesions to the mass. Histology revealed an endometriotic cyst of the mesenterium. To our knowledge, this is the first case reported in the literature of laparoscopic treatment of a retroduodenopancreatic endometriotic cyst observed postpartum. In dedicated centers, laparoscopic management could be the gold standard.