Transabdominal Ultrasound Guidance Research Articles

PO0228: Comparison of Transabdominal Ultrasound Guidance versus Magnetic Resonance Image Guided Brachytherapy for Cervical Cancer

PO0228: Comparison of Transabdominal Ultrasound Guidance versus Magnetic Resonance Image Guided Brachytherapy for Cervical Cancer

Combined hysteroscopic Bigatti shaver (IBS) and resectoscope removal of a heterotopic cesarean scar pregnancy in the first trimester

To report a case of heterotopic cesarean scar pregnancy reduction using a combined hysteroscopic integrated Bigatti shaver (IBS) and resectoscope with the preservation of a normal gestational sac in the uterine cavity under simultaneous transabdominal ultrasound guidance. Video article. University-affiliated hospital. A 30-year-old woman, G5P2A2L2, with two previous cesarean deliveries and a history of fertility problems, was admitted with a heterotopic cesarean scar pregnancy at 7+2 gestational weeks. Ultrasound examination showed a dichorionic diamniotic pregnancy. The first gestational sac (1.7 × 1.7 × 0.6 cm) was located in the previous hysterotomy scars, with a thin layer of myometriummeasuring 0.2 cm in thickness and a rich blood supply. The second chorionic sac (2.8 × 2.4 × 1.8 cm) was observed at the uterine fundus. Normal cardiac activity and yolk sacs were observed in both gestational sacs. The couple strongly desired to preserve the intrauterine pregnancy. After Institutional Review Board approval was obtained, a hysteroscopic IBS combined with a bipolar resectoscope was used to remove the heterotopic cesarean scar pregnancy while preserving the intrauterine gestational sac under simultaneous transabdominal ultrasound guidance. The heterotopic cesarean scar pregnancy was completely resected using hysteroscopy, and the gestational sac in the uterine cavity was successfully preserved. Trophoblastic tissue was confirmed using histopathological examination. The patient had an unremarkable postoperative recovery. Subsequent serial ultrasonography confirmed a single ongoing pregnancy with normal growth parameters and a normal placental site. The inability of an IBS to perform coagulation can be offset by its combination with the bipolar resectoscope. Hysteroscopic IBS combined with resectoscope to remove a heterotopic cesarean scar pregnancy offers a short operation time and minimum blood loss. It could be an optimized approach for the management of heterotopic cesarean scar pregnancy in the first trimester when an intrauterine pregnancy needs to be preserved.

Cesarean Scar Pregnancy: Results of Treatment Using a Double-Balloon Cervical Ripening Catheter.

Being considered a life-threatening condition, cesarean scar pregnancy (CSP) leads to loss of fertility, severe bleeding, and even maternal mortality. We intended to assess the effect of double-balloon cervical ripening catheter insertion on CSP termination before nine weeks of gestation. All participants were diagnosed CSP by abdominal and transvaginal ultrasound. The cases were treated with a sterile, double-balloon cervical ripening catheter inserted with real-time transabdominal ultrasound guidance and removed three days later. The control group consisted of patients treated with systemic methotrexate with or without fetal reduction. Thirty-five patients were eligible for double-balloon ripening and 32 for MTX therapy; the treatment in cases failed in five of the patients. Success rate difference between two methods was insignificant (Pearson Chi-square: 0.383, p-value: 0.536). There were significant differences regarding the time to normal menstruation (OR: 1.303) and the thickness of the myometrium after surgery (OR: 4.721), but there was no significant difference in the time resolve of either β-HCG or residue of pregnancy. Double-balloon cervical ripening insertion yields acceptable results for terminating CSP. This strategy does not cause bleeding and even prevents it with its tamponade properties. Additionally, this treatment is minimally invasive simple with low morbidity.

Surgical Management of Intrauterine Adhesions

Intrauterine adhesions, also known as Asherman’s syndrome, can have an impact on both reproductive outcomes and gynaecologic symptoms. Surgical management with hysteroscopic lysis of adhesions is the gold standard for treatment. The following techniques are described in this presentation for cases with severe occlusive cavity and should be performed by experienced surgeons. 1. The use of 3D ultrasound played an important role in the preoperative workup of the patient, it could be used to evaluate the severity of intrauterine adhesion and predict the complexity of the cases. 2. Transabdominal 2D ultrasound guidance can help to delineate the location and extent of the adhesions and reduce the risk of uterine perforation and the formation of false passage. Laparoscopic guidance for severe cases has been advocated for immediate treatment of uterine perforation and minimizing extrauterine trauma. 3. In patients with severe intrauterine adhesion, a “myometrial scoring technique” could be used by bipolar electrode need with score 6 to 8, 4-mm-deep incisions from the fundus to the cervix and a transverse incision at the uterine fundus. Or the “ploughing technique” could be used by scissors, both methods aim to remove the fibrotic tissue, expose any underlying healthy basal endometrial tissue capable of regeneration. It remains to be seen whether “ploughing technique” using cold scissors or a “myometrial scoring technique” by bipolar electrode produces similar or different results, which could only be resolved by RCT in the future. 4. Surgical management offers favourable fertility outcomes and is often successful in restoring menstruation. Endometrial thickness and volume assessed by 3D-TVUS may have important predictive value for pregnancy after hysteroscopic adhesiolysis. 5. Prevention of reformation of adhesions remains challenging and no single method for preventing recurrence has shown superiority.

Effectiveness of treating menorrhagia using microwave endometrial ablation at a frequency of 2.45 GHz.

Microwave endometrial ablation (MEA) is a minimally invasive treatment for menorrhagia. It has been covered by the national insurance in Japan since April 2012, and its demand has been increasing as the importance of women's health has advanced in society. To examine the efficacy of MEA as a treatment option for menorrhagia. In this study, we retrospectively analyzed 76 patients who underwent MEA between January 2016 and March 2020 in our department. MEA was performed in the lithotomy position, under general anesthesia, and with transabdominal ultrasound guidance, including the entire endometrial circumference while confirming endometrial coagulation. The Microtaze AFM-712 and the Sounding Applicator CSA-40CBL-1006200C were used for MEA, and the endometrium was ablated using a Microtaze output of 70 W and coagulation energization time of 50 s per cycle. The visual analog scale (VAS) was used to evaluate menorrhagia, menstrual pain, and treatment satisfaction. Additionally, the hemoglobin (Hb) levels before and after MEA and associated complications were investigated. The average age of the patients was 44.8 ± 4.0 years. While 14 patients had functional menorrhagia, 62 had organic menorrhagia, of whom 14 had endometrial polyps, 40 had uterine fibroids, and 8 had adenomyosis. The VAS score before MEA and 3 and 6 mo after the procedure were 10, 1.3 ± 1.3, and 1.3 ± 1.3, respectively, for menorrhagia and 10, 1.3 ± 1.8, and 1.3 ± 1.8, respectively, for menstrual pain, both showing improvements (P < 0.001). The MEA Hb level significantly improved from 9.2 ± 4.2 g/dL before MEA to 13.4 ± 1.2 g/dL after MEA (P = 0.003). Treatment satisfaction was high, with a VAS score of 9.6 ± 0.7. Endometritis was observed in one patient after surgery and was treated with antibiotics. MEA is a safe and effective treatment for menorrhagia.

Hysteroscopic removal of a heterotopic cervical pregnancy to preserve a patient’s intrauterine sac

To introduce a case of removing the heterotopic cervical pregnancy while preserving the normal gestational sac in the uterine cavity by hysteroscopic surgery under ultrasound guidance. Video description of the case and surgical procedure. Hospital affiliated to university. A 35-year-old woman, G7P1A5L1, was admitted with a heterotopic cervical pregnancy 21 days after IVF-ET (the corrected gestational age was 5+2 weeks). The serum β-hCG level was 24,530.00 mIU/ml at the corrected gestational age of 5+3 weeks. The ultrasound examination on the day of admission showed that there was a gestational sac in the cervical canal (1.5×0.8×0.5 cm, yolk sac visible) and another sac in the intrauterine cavity (1.2×1.2×1.1 cm, yolk sac visible). The pregnant woman and her partner strongly urged the removal of the cervical gestational sac and continuing the intrauterine pregnancy to term. After the Institutional Review Board (IRB) approval was obtained, hysteroscopic surgery with bipolar resectoscope and transabdominal ultrasound guidance was used to resect the heterotopic cervical pregnancy while preserving the intrauterine gestational sac. The heterotopic cervical pregnancy was completely resected by hysteroscopy, and the normal gestational sac in the uterine cavity was successfully preserved. Ultrasound-guided hysteroscopic surgery allowed us to successfully preserve the intrauterine pregnancy while removing the cervical pregnancy completely. During the operation, the dilation pressure and the flow rate of the dilation fluid was kept as low as possible to avoid excessive intrauterine pressure and excessive dilation fluid entering the intrauterine cavity, which could have had adverse effects on the intrauterine pregnancy sac. No surgical-related or anesthesia-related complications occurred. The pathological results confirmed placental villi and decidual tissue. The One-month follow-up ultrasonography showed a live single intrauterine pregnancy with cardiac activity. Hysteroscopic removal of a heterotopic cervical pregnancy under ultrasound guidance can be safely performed while successfully preserving an ongoing intrauterine pregnancy.

P-748 Fertility and anatomical outcome following hysteroscopic adhesiolysis of intrauterine adhesions classified according to symptoms, imaging findings and hysteroscopic appearance of the uterine cavity

Abstract Study question To classify patients with dense intrauterine adhesions based on clinical characteristics as well as, ultrasound, hysterosalpingography (HSG) and hysteroscopy findings into different prognostic groups. Summary answer We have defined a prognostic model to classify patients with dense intrauterine adhesions which could easily be implemented in patient counseling and management. What is known already Intrauterine adhesions are a major cause of hypo-amenorrhea and failure to conceive. A universally agreed classification to categorize intrauterine adhesions is paramount to provide individualized counseling and care. Previous efforts for categorization suffer from limitations such as variable assessment of anatomical outcomes, application of different techniques, pooling of results of different operators and lack of long-term follow-up. Many experts have voiced a call for a prognosis-oriented classification system. An ideal classification model should consider clinical characteristics, findings from imaging techniques (including ultrasound and HSG) together with hysteroscopic appearance of the uterine cavity and demonstrate a high predictive value. Study design, size, duration This is a retrospective analysis of 281 patients treated for intrauterine adhesions by a single operator (B.U.) between 2010 and 2021. Lysis of adhesions was affected in 479 office hysteroscopy procedures using the Versapoint bipolar cutting electrode under transabdominal ultrasound guidance. 227 patients were followed for at least 15 months after the last surgical procedure. Patients were classified into five categories (Class I to V) according to their symptoms, ultrasound, HSG and hysteroscopy findings. Participants/materials, setting, methods Clinical data and operative findings were reviewed from patient files and video recordings. The number of hysteroscopic interventions needed to restore the cavity and the reproductive outcome in women who were desirous for pregnancy were recorded. Predictive power of the model was assessed using the live birth rate as the primary and rate of cavity restoration and number of interventions as the second outcome parameters. Groups were compared using ANOVA, ROC and regression analyses. Main results and the role of chance Adhesions were classified as class I in 43 (15.3%), class II in 72 (25.6%), class III in 57 (20.3%), class IV in 82 (29.2%) and class V in 27 (9.6%) patients. They were due to previous curettages of pregnancies (79,7%) or retained products of gestation (3.9%), prior uterine surgery (6.8%), prior hysteroscopy of inappropriate technique (6.8%) and tuberculosis (2.8%). The cavity was septate in 12 and unicornuate in 2 patients. The mean age of the study group was 29.8 ± 3.7 (20-40). Age was not related with the severity of adhesions (p = 0.335). While the majority of patients with curettage-related adhesions were classified as Class II, uterine surgery, iatrogenic and tuberculosis related adhesions were higher in severity. The number of hysteroscopic adhesiolysis procedures (from 1.0 ± 02. to 2.3 ± 0.5) needed for optimal restoration of the cavity was directly related and the rate of full restoration (from 100% - 18.5%) was indirectly related with the severity of adhesions according to the proposed classification (p = 0.0001 for both). The live birth rates were 54.3%, 45%, 31.7%, 21% and 12.5% for patients in Class I to V, respectively (p = 0.0001). The proposed classification was fairly predictive (AUC: 0.654, 95%CI: 0.582-0.727) for live birth. Limitations, reasons for caution This is a retrospective analysis of consecutive patients with intrauterine adhesions in routine practice. The follow-up for reproductive outcome is limited. The study is hospital-based and single-center. Thus, the predictive value of the proposed classification needs to be validated in an external data set preferably in a prospective series. Wider implications of the findings In patients with intrauterine adhesions, a classification system based on patient symptoms, imaging findings and hysteroscopic appearance of the uterine cavity reliably predicts the postoperative outcome in terms of the extent of anatomical restoration of the uterine cavity and pregnancy and live birth rates. Trial registration number Not applicable

Evaluation of a photodynamic therapy agent using a canine prostate cancer model.

Male dogs can develop spontaneous prostate cancer, which is similar physiologically to human disease. Recently, Tweedle and coworkers have developed an orthotopic canine prostate model allowing implanted tumors and therapeutic agents to be tested in a more translational large animal model. We used the canine model to evaluate prostate-specific membrane antigen (PSMA)-targeted gold nanoparticles as a theranostic approach for fluorescence (FL) imaging and photodynamic therapy (PDT) of early stage prostate cancer. Dogs (four in total) were immunosuppressed with a cyclosporine-based immunosuppressant regimen and their prostate glands were injected with Ace-1-hPSMA cells using transabdominal ultrasound (US) guidance. Intraprostatic tumors grew in 4-5 weeks and were monitored by ultrasound (US). When tumors reached an appropriate size, dogs were injected intravenously (iv) with PSMA-targeted nano agents (AuNPs-Pc158) and underwent surgery 24 h later to expose the prostate tumors for FL imaging and PDT. Ex vivo FL imaging and histopathological studies were performed to confirm PDT efficacy. All dogs had tumor growth in the prostate gland as revealed by US. Twenty-four hours after injection of PSMA-targeted nano agents (AuNPs-Pc158), the tumors were imaged using a Curadel FL imaging device. While normal prostate tissue had minimal fluorescent signal, the prostate tumors had significantly increased FL. PDT wasactivated by irradiating specific fluorescent tumor areas with laser light (672 nm). PDT bleached the FL signal, while fluorescent signals from the other unexposed tumor tissues were unaffected. Histological analysis of tumors and adjacent prostate revealed that PDT damaged the irradiated areas to a depth of 1-2 mms with the presence of necrosis, hemorrhage, secondary inflammation, and occasional focal thrombosis. The nonirradiated areas showed no visible damages by PDT. We have successfully established a PSMA-expressing canine orthotopic prostate tumor model and used the model to evaluate the PSMA-targeted nano agents (AuNPs-Pc158) in the application of FL imaging and PDT. It was demonstrated that the nano agents allowed visualization of the cancer cells and enabled their destruction when they were irradiated with a specific wavelength of light.

Does Ultrasound Guidance Provide Pain Relief During Intrauterine Contraceptive Device Insertion? A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

To evaluate ultrasound guidance effect in pain relief during intrauterine device (IUD) insertion. Four different databases were searched from inception till June 2022. We selected randomized controlled trials (RCTs) that compared transabdominal ultrasound guidance versus traditional non-guided IUD insertion among women undergoing IUD placement for contraception. We used Revman software during performing our meta-analysis. Our primary outcome was the pain score during IUD insertion as evaluated by the Visual Analog Scale (VAS). Our secondary outcomes were the procedure insertion time, satisfaction, and incidences of complications and misplaced IUDs. Seven RCTs were retrieved with a total number of 1267 patients. There was a significant reduction in the VAS pain score during IUD insertion among the ultrasound-guided group (MD=-1.91, 95% CI [-3.08, -0.73], P=.001). The procedure insertion time was significantly shorter within the ultrasound guidance group compared with the control group (MD=-1.35, 95% CI [-1.81, -0.88], P < .001). Moreover, more women were significantly satisfied with the procedure among the ultrasound-guided group (P < .001). In addition, ultrasound-guided IUD insertion was linked to significant decline in incidences of complications and misplaced IUDs. Ultrasound guidance can be used as a modified technique during IUD insertion as it decreases pain, procedure time, and rates of complications and misplaced IUDs with better patient satisfaction.

Trophoblastic microcirculation occlusion as an adjunct to electric vacuum aspiration for the treatment of endogenous cesarean scar pregnancy

To describe a simple adjunct treatment option, trophoblastic microcirculation occlusion (TMO), which could change subsequent high-risk electric vacuum aspiration in patients with an endogenous cesarean scar pregnancy (CSP) into a routine conventional surgical procedure. Electric vacuum aspiration for the treatment of CSP may be associated with several significant complications, including hemorrhage and tissue remnants. Consequently, a second intervention, such as uterine artery embolization, resectoscopy, or methotrexate, may be required, thus complicating the surgical treatment of CSP. We demonstrate the principle and detailed technique of TMO treatment using animations, video clips, and slides. The study was approved by the institutional review board of Hangzhou Women's Hospital. Tertiary maternity hospital. The video shows a 30-year-old woman with a 5-week endogenous CSP. The procedural steps were repeated in another 6 patients suffering from endogenous CSP (Table1). Written informed consent was obtained from each patient. In patients with a CSP, the syncytiotrophoblastic cells erode the helicine arteries in the inner uterine myometrium. The cytotrophoblastic cells extend as villi tissue into the syncytiotrophoblast. Maternal blood enters the intervillous space between the cytotrophoblast and syncytiotrophoblast. The syncytiotrophoblast, cytotrophoblast, and intervillous space constitute the trophoblastic microcirculation, which subsequently becomes the main blood supply to the gestational sac (Fig.1). During TMO treatment, the trophoblastic microcirculation is identified by contrast-enhanced ultrasound with the cubital vein injected with sulfur hexafluoride microbubbles (Bracco, Switzerland). A 21-gauge needle (200 mm long) was punctured vaginally into the uterine myometrium surrounding the syncytiotrophoblast at 3 different points, and a total of 8 mL sclerosant was injected directly to seal the trophoblastic microcirculation. Complete compression of the helicine arteries for trophoblastic blood supply is the key to TMO treatment (Fig.2, see video interpretation for detailed information). A repeat contrast-enhanced ultrasound was performed after injection to confirm a significant reduction of blood flow in the trophoblast. An electric vacuum aspiration was performed 24 hours after TMO treatment to remove the products of conception completely. Surgical safety was enhanced by deep sedation and concurrent transabdominal ultrasound guidance. The levels of β-human chorionic gonadotropin (β-hCG) were measured weekly until a nonpregnant level was achieved. A follow-up ultrasound then was performed to confirm that the treatment was complete. The clinical value and feasibility of TMO treatment as an adjunct before high-risk electric vacuum aspiration for the management of endogenous CSP. The TMO treatment was performed successfully in all 7 patients; the clinical outcomes are presented in Table2. The TMO treatment significantly reduced the risk of hemorrhage during electric vacuum aspiration. No complications were detected perioperatively. Patients were discharged on day 1 postoperatively. Follow-up ultrasound, performed when the levels of β-hCG had fallen to normal, failed to identify any remnants of the uterine corpus. One patient achieved an intrauterine pregnancy 7 months postoperatively and gave birth to a live baby at 39 weeks of gestation via repeat cesarean section. No cesarean scar dehiscence was observed. Surgical abortion of an endogenous CSP, with a high risk of intraoperative hemorrhage, can be performed with minimal blood loss in a single electric vacuum aspiration when assisted by TMO treatment. This technique provides good results in terms of bleeding reduction that are comparable to those in conventional patients. The TMO treatment can be accomplished via ultrasound-guided needle puncture, a technique that is available widely in the practice of reproductive medicine with a reduced need for consumable resources. The use of a simple adjunct treatment option, TMO, expands the indications of electric vacuum aspiration. This sequential treatment allows for completion of clinical management without the need for uterine artery embolization, resectoscopy, or methotrexate, thus simplifying the originally complicated form of surgical treatment for CSP.

Intramyometrial Pregnancy

Study Objective Hysteroscopic management of Extra cavitary ectopic pregnancy. Design Case presentation. Setting Operative Hysteroscopy using 1.8 mm 30degree telescope with operative sheath and hand instruments without electrocautery Patients or Participants single case study. Interventions Operative Hysteroscopy at low pressure of 8 mm Hg under trans abdominal ultrasound guidance. Measurements and Main Results A second para patient was referred to our tertiary center with failed attempt to perform dilatation and evacuation for a missed abortion. They did not find and product of conception in curettage specimen. At our center on 3d transvaginal ultrasound we diagnosed it to be an intra myometrial pregnancy. Under trans abdominal ultrasound guidance with full urinary bladder we decided to remove band of fibrotic adhesion near fundus with cold Scissors to release intra myometrial pregnancy in endometrial cavity. It was followed by suction with disposable cannula under trans abdominal ultrasound guidance for ensure complete evacuation. Integrity of fundal myometrium was checked at the end of the procedure. More than 1 cm myometrial thickness was present above ectopic gestation site. Conclusion Hysteroscopy under sonography guidance is safe management option for such complicated intramyometrial ectopic pregnancy. Hysteroscopic management of Extra cavitary ectopic pregnancy. Case presentation. Operative Hysteroscopy using 1.8 mm 30degree telescope with operative sheath and hand instruments without electrocautery single case study. Operative Hysteroscopy at low pressure of 8 mm Hg under trans abdominal ultrasound guidance. A second para patient was referred to our tertiary center with failed attempt to perform dilatation and evacuation for a missed abortion. They did not find and product of conception in curettage specimen. At our center on 3d transvaginal ultrasound we diagnosed it to be an intra myometrial pregnancy. Under trans abdominal ultrasound guidance with full urinary bladder we decided to remove band of fibrotic adhesion near fundus with cold Scissors to release intra myometrial pregnancy in endometrial cavity. It was followed by suction with disposable cannula under trans abdominal ultrasound guidance for ensure complete evacuation. Integrity of fundal myometrium was checked at the end of the procedure. More than 1 cm myometrial thickness was present above ectopic gestation site. Hysteroscopy under sonography guidance is safe management option for such complicated intramyometrial ectopic pregnancy.

Abscess of the piriformis muscle in a 14-year old boy - a transrectal drainage method under transabdominal ultrasound guidance

IntroductionSciatica is a common reason for a medical consultation throughout the population. Piriformis pyomyositis is a rare cause of these symptoms. Its probable etiology is transient bacteraemia co-existing temporarily with a muscle injury.AimThe aim of the study is to present a method for treating a piriformis muscle abscess with transabdominal ultrasound-guided transrectal drainage.Case studyA 14-year old boy, previously healthy, was admitted with symptoms of sciatica that appeared after intense physical exertion. Laboratory tests revealed elevated inflammatory parameters and positive blood culture results indicating Staphylococcus aureus. Antibiotic therapy was implemented. MRI of the small pelvis revealed a forming abscess of the right piriformis muscle. On day 6 of the antibiotic therapy, in the absence of improvement, it was decided to perform transrectal drainage under ultrasound guidance. Clinical improvement was achieved, and the inflammatory parameters decreased.Results and discussionCo-existence of sciatica symptoms and signs of an inflammatory condition should prompt the consideration of piriformis pyomyositis. The mainstay of treatment for piriformis pyomyositis is antibiotic therapy. The abscess formation reduces its effectiveness, which necessitates surgical intervention. The authors present the application of transrectal drainage under transabdominal ultrasound guidance as the shortest route of abscess evacuation.ConclusionsTransrectal drainage of piriformis pyomyositis is an effective and safe method. Concomitant use of ultrasound scans reduces the patient’s exposure to ionising radiation. However, the widespread use of this method requires more in-depth research and broadened experience.

Hysteroscopic management of a "hernia-like" uterine myoma within the uterine cavity

To introduce a case of a uterus "hernia-like" myoma within the uterine cavity that was successfully treated with hysteroscopy. Step-by-step explanation of the case and surgical procedure using a video and slides. The Medical Ethics Committee of Women and Children's Hospital of Chongqing Medical University approved the study and decided for this video to be exempt from formal approval, and informed consent was obtained from the patient. Hospital. A 37-year-old woman, gravida 1, para 1, with a history of secondary infertility for 2 years and heavy menstrual bleeding for 7 months, which eventually resulted in anemia, was diagnosed with a type 1 (International Federation of Gynecology and Obstetrics leiomyoma subclassification system) myoma approximately 4 cm in diameter using ultrasonography. Her hemoglobin level was 8.6 g/dL (11.5-15.0 g/dL), red blood cell count was 3.6 ×10-12/L (3.8-5.1 ×10-12/L), and hematocrit was 26.7% (35%-45%). Hysteroscopic myomectomy with bipolar resectoscope and transabdominal ultrasound guidance was used to resect the hernia-like myoma. Blunt dissection combined with oxytocin (20 U I.V.) and uterine dilation pressure reduction was used to induce the hernial content (myoma) protrusion into the uterine cavity. The hernia-like myoma was completely resected by hysteroscopy, and all symptoms disappeared. The hernia-like myoma was successfully and completely resected by hysteroscopy. The operative time was 37 minutes. No surgical-related or anesthesia-related complications occurred. During the follow-up period, the patient had regular menstrual cycles without hypermenorrhea, and her anemia had improved. The 5-month follow-up ultrasound examination and hysteroscopy revealed that the uterine cavity had recovered well. The patient conceived 7 months after the procedure and delivered at term (39 weeks 1 day) via cesarean section. A hernia-like myoma covered with endometrium is a degenerative myoma that herniates into the myometrium and forms a hernia sac-like defect. Hysteroscopy is an effective and feasible method for treating hernia-like myoma.

A comparative study of transabdominal and transvaginal ultrasound guidance on consequences of embryo transfer at Mahdiyeh hospital of Tehran in 2020: An RCT.

Background Infertility is an important problem that affects many couples worldwide. Assisted reproductive technology (ART) helps infertile couples to have offspring. One of the critical parts of ART is embryo transfer (ET).ObjectiveTo compare the effect of transvaginal and transabdominal ultrasonography-guided ET on ART outcomes.Materials and MethodsIn this randomized clinical trial study, 90 women who were candidates for in vitro fertilization (IVF) referred to Mahdiyeh hospital of Tehran, Iran during the yr 2020 were randomly divided into two groups (n = 45/each) of transvaginal and transabdominal ultrasonography-guided ET. The embryos were transferred two-three days after oocyte retrieval. The patient pain, duration and difficulty of the procedure, three-dimensional vision quality and successful pregnancy rate were measured.ResultsIn this study, 63.2% of the 45 women who underwent IVF under the guidance of the transvaginal guidance and 36.8% of the 45 women who underwent IVF under the transabdominal guidance had a successful pregnancy, which was not significantly different (p = 0.19). Also, based on other results there was no difference between the two groups in terms of patient pain (p = 0.53), duration (p 0.50), difficulty of procedures (p 0.50) and ultrasonography vision; however, the three-dimensional vision quality in the transvaginal ultrasonography was better than that in the transabdominal ultrasonography (p 0.01).ConclusionOverall, the ART outcomes in the transvaginal and transabdominal ultrasonography-guided ET were similar, so we suggest that physicians evaluate the patient's situation, the hospital equipment, and their ability before selecting the type of ultrasonography.

Diagnostic performance of endoscopic ultrasound-guided tissue acquisition of splenic lesions: systematic review with pooled analysis.

BackgroundFocal splenic lesions are usually incidentally discovered on radiological assessments. Although percutaneous tissue acquisition (TA) under trans-abdominal ultrasound guidance is a well-established technique for obtaining cyto-histological diagnosis of focal splenic lesions, endoscopic ultrasound (EUS)-guided TA has been described in several studies, reporting different safety and outcomes. The aim was to assess the pooled safety, adequacy, and accuracy of EUS-TA of splenic lesions.MethodsA comprehensive review of available evidence was conducted at the end of November 2021. All studies including more than five patients and reporting about the safety, adequacy, and accuracy of EUS-TA of the spleen were included.ResultsSix studies (62 patients) were identified; all studies have been conducted using fine-needle aspiration (FNA) needles. Pooled specimen adequacy and accuracy of EUS-TA for spleen characterization were 92.8% [95% confidence interval (CI), 86.3%–99.3%] and 88.2% (95% CI, 79.3%–97.1%), respectively. The pooled incidence of adverse events (six studies, 62 patients) was 4.7% (95% CI, 0.4%–9.7%).ConclusionEUS-FNA of the spleen is a safe technique with high diagnostic adequacy and accuracy. The EUS-guided approach could be considered a valid alternative to the percutaneous approach for spleen TA.

THE EFFECT OF TRANSABDOMINAL ULTRASOUND-GUIDED TRANSJUGULAR PORTAL VENOUS PUNCTURE ON RADIATION EXPOSURE IN THE ESTABLISHMENT OF A TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT

Objective: The study's objective is to assess the technical and clinical results of the transjugular intrahepatic portosystemic shunt (TIPS) procedure carried out under additional transabdominal ultrasound guidance. Methods: We evaluated the radiation dosage for all TIPS performed with transabdominal ultrasound guidance for PV puncture over a four-year period (n=212, with 210 successfully completed and data available for 206); fluoroscopy time, dose area product (DAP), and skin dose were recorded. Results: The mean fluoroscopy time was 12 minutes and 9 seconds (SD, 14 minutes and 38 seconds), the mean DAP was 40.3 ± 73.1 Gy.cm2, and the mean skin dosage was 404.3 ± 464.8 mGy. Conclusion: Our findings show that ultrasound-guided PV puncture yields fluoroscopy times and radiation doses that are significantly lower than the sole published dose reference limits.

Fertility-sparing management of a suspicion of leiomyosarcoma: avoiding hysterectomy by performing transcervical myoma biopsy

To describe the fertility-sparing management of an atypical uterine myoma.Step-by-step video explanation of transcervical biopsy using transabdominal ultrasound guidance, highlighting tips and tricks. Patient consent was obtained before the publication of the case.University hospital.A 32-year-old nulliparous woman with a history of dysmenorrhea was found to have an atypical myoma FIGO 6, with suspicion of leiomyosarcoma on magnetic resonance imaging.A transcervical biopsy of an atypical myoma was done under transabdominal ultrasound guidance. A myomectomy by a minimally invasive approach was performed without morcellation.Feasibility of transcervical biopsy and correlation with definitive anatomopathological diagnosis.The patient was under general anesthesia. A hysteroscopy confirmed the normal appearance of the uterine cavity with no direct access to the myoma. Four core biopsies were performed with a 16-gauge needle transcervically under ultrasound guidance. The preliminary diagnosis of cellular leiomyoma allowed a fertility-sparing surgery. Myomectomy and surgical treatment of endometriosis were performed secondarily. This patient had a successful recovery, and the diagnosis of benign cellular leiomyoma was confirmed on the surgical specimen.The current video highlights the safety and feasibility of transcervical ultrasound-guided core biopsy in patients with atypical uterine fibroids.

Technical and Medium-Term Clinical Outcomes of Transjugular Intrahepatic Portosystemic Shunt with Fluoroscopy and Additional Trans-abdominal Ultrasound Guidance.

Background and Objective The aim of the study is to evaluate the technical and clinical outcomes of transjugular intrahepatic portosystemic shunt (TIPS) performed with additional transabdominal ultrasound guidance. Material and Methods Patients who underwent TIPS between January 2004 to January 2020 in our center were studied. Technical, hemodynamic, angiographic, and clinical outcome were recorded up to 1 year of follow-up. Results TIPS was attempted in 162 patients (median [range] age 37[3–69] years; 105 were males and 57 were females; Etiology: Budd-Chiari syndrome [BCS] 91, cirrhosis 65, symptomatic acute portal venous thrombosis [PVT] 3, veno-occlusive disease [VOD] 2, congenital portosystemic shunt [CPSS] 1) during the study period. Indication for TIPS was refractory ascites in 135 patients (BCS 86, cirrhosis 49) and variceal bleed in 21 patients (BCS 5, cirrhosis 16). Technical success was seen in 161 of the 162 (99.4%) patients. The tract was created from hepatic vein in 55 patients and inferior vena cava (IVC) in 106 patients. Complications within 1 week post TIPS were seen in 29 of the 162 (18%) patients, of whom one developed unexplained arrhythmia and hypotension and died. Of the patients with available follow-up, clinical success was noted in 120 (81%), while 14 (9%) patients had partial nonresponse and six (4%) had complete nonresponse. Eight (5%) patients died during the follow-up period. Conclusion The technical success of TIPS creation with additional transabdominal ultrasound guidance is very high with low peri-procedural complication rate. It has enabled the inclusion of a wider spectrum of cases like acute PVT and obliterated hepatic veins which were otherwise considered contraindications.

Radiation-Free Transabdominal Ultrasound-Guided Endoscopic Biliary Stenting in Pregnant Women with Choledocholithiasis

Background: Hepatobiliary disorders are common problems during pregnancy, causing significant morbidity and mortality in both mother and fetus. Biliary pancreatitis and cholangitis are common sequelae that warrant urgent endoscopic interventions. However, fetal radiation exposure is a major concern during endoscopic retrograde cholangiopancreatography (ERCP). Fetal malformation, preterm labor, and intrauterine fetal death are the recognized complications of ERCP. Objectives: To evaluate the application of transabdominal ultrasound (US) guidance in endoscopic biliary stenting as a substitute for fluoroscopy and contrast injection. Patients and Methods: In this study, we reviewed the data of ten pregnant patients, who had undergone endoscopic biliary stenting under US guidance without fluoroscopy between January 2018 and October 2020. An abdominal US examination was performed to confirm that the guide wire and the stent were placed inside the common bile duct (CBD) without fluoroscopy. The CBD clearance was postponed until after delivery. Results: The mean gestational age was 12 weeks (range: 5 - 33 weeks), and the mean maternal age was 23 years (range: 19 - 33 years). All procedures were performed successfully, with biochemical and clinical improvements after endoscopy. In none of the patients, maternal or fetal complications were reported after endoscopy or at birth. Also, no cases of post-endoscopic pancreatitis were documented. Conclusion: Based on the present findings, abdominal US guidance in endoscopic biliary stenting can be a safe and effective approach.

Ultrasound-guided portal vein puncture during Transjugular Intrahepatic Portosystemic Shunt: Technique and experience of a quaternary liver transplant hospital.

Portal hypertension (PH) is associated with complications including refractory ascites and variceal haemorrhage and can be treated endovascularly with a Transjugular Intrahepatic Portosystemic Shunt (TIPS). Portal vein puncture during TIPS using real-time transabdominal ultrasound guidance is one of many portal vein puncture techniques and is seldom used compared with other methods. The purpose of this manuscript is to describe this technique and its associated procedural outcomes at a quaternary liver transplant hospital. Clinical data of all patients who underwent ultrasound-guided TIPS at our institution between 1 January 2009 and 1 January 2019 were retrospectively obtained from electronic medical records and reviewed. Patient demographics, indications, procedural outcomes and complications were recorded. Forty-four ultrasound-guided TIPS procedures were performed during the study period. The most common indication for TIPS was refractory ascites (n = 26; 57%) and variceal haemorrhage (n = 12; 26%). Technical success rate was 100%. No intraprocedural complications occurred. Periprocedural complication rate was 35% (n = 16) with encephalopathy (n = 8; 17%) and sepsis (n = 5; 11%) the most common. One patient with sepsis died. No other TIPS-related deaths occurred. Median fluoroscopy time, contrast volume, air kerma and dose area product values for all procedures were 35 minutes (IQR 24-51), 100 ml (IQR 70-160), 0.95 Gy (IQR 0.50-1.53) and 127 Gycm2 (IQR 68.75-206), respectively. Transabdominal ultrasound-guided portal vein puncture during TIPS is safe and technically feasible. When compared to fluoroscopically guided methods, it is associated with lower intraprocedural complication rates, fluoroscopy times, contrast volumes and radiation doses in our experience. Radiation doses, FTs and contrast volumes were also considerably lower than recommended limits.