Exo-anal imaging of the anal sphincter: a comparison between introital and transperineal image acquisition.

INTRODUCTION AND HYPOTHESIS: Three-dimensional exoanal ultrasound imaging of the anal sphincter may be obtained transperineally with a convex probe, or at the introitus with a transvaginal probe. We hypothesised that introital acquisition would yield better quality and more reproducible evaluation. METHODS: We acquired three 3D volumes of the anal sphincter (one transperineal transverse with a 4- to 8-MHz convex probe and two introital with a 5- to 9-MHz probe in transverse and mid-sagittal view) in 20 representative women attending the gynaecology clinic. Each 3D dataset was anonymised and hence blinded for clinical data and for acquisition method. Images were analysed off-line by two expert specifically trained ultrasonographers in a random order to assess image quality, sphincter integrity and sphincteric measurements. We assessed the intra- and interrater agreement by the Cohen's kappa (κ) and by the intraclass correlation coefficient for categorical and continuous variables respectively. RESULTS: The mid-sagittal introital acquisition had most inconclusive images owing to unsatisfactory quality, on which raters agreed (К = 0.80). Subsequently, agreement in the anal sphincter evaluation between transverse introital and transperineal acquisitions was compared. Agreement on internal anal sphincter gap was excellent for both transverse introital (К = 0.87) and transperineal acquisition (К = 0.93). Agreement on external anal sphincter discontinuity was excellent for the transperineal acquisition (К = 0.87) and good for the transverse introital acquisition (К = 0.73). Intra- and interrater agreement of external and internal anal sphincteric measurements were best for transperineal acquisitions. CONCLUSIONS: In our hands, transperineal acquisition with a 4- to 8-MHz probe performed better than introital acquisition with a 5- to 9-MHz probe in the assessment of the anal sphincter complex.

Intraoperative ultrasound visualization of paravertebral anatomy in the retroperitoneal space during lateral lumbar spine surgery.

OBJECTIVE: Lumbar surgery via a lateral approach is a minimally invasive and highly useful procedure. However, care must be taken to avoid its potentially fatal complications of intestinal and vascular injuries. The object of this study was to evaluate the usefulness of intraoperative ultrasound in improving the safety of lateral lumbar spine surgery. METHODS: A transvaginal ultrasound probe was inserted into the operative field, and the intestinal tract, kidney, psoas muscle, and vertebral body were identified using B-mode ultrasound. The aorta, vena cava, common iliac vessels, and lumbar arteries and their associated branches were identified using the color Doppler mode. RESULTS: The study cohort comprised 100 patients who underwent lateral lumbar spine surgery, 92 via a left-sided approach. The intestinal tract and kidney lateral to the psoas muscle on the anatomical approach pathway were visualized in 36 and 26 patients, respectively. A detachment maneuver displaced the intestinal tract and kidneys in an anteroinferior direction, enabling confirmation of the absence of organ tissues above the psoas. In all patients, the major vessels anterior to the vertebral bodies and the lumbar arteries and associated branches in the psoas on the approach path were clearly visualized in the Doppler mode, and their orientation, location, and positional relationship with regard to the vertebral bodies, intervertebral discs, and psoas were determined. CONCLUSIONS: When approaching the lateral side of the lumbar spine in the retroperitoneal space, intraoperative ultrasound allows real-time identification of the blood vessels surrounding the lumbar spine, intestinal tract, and kidney in the approach path and improves the safety of surgery without increasing invasiveness.

Urethral funneling visualized during pelvic floor sonography - analysis of occurrence among urogynecological patients.

OBJECTIVES: There are different diagnostic methods used in women with urinary incontinence symptoms such as: medical history, voiding diary, cough test, pad test, urodynamic testing. None of them is optimal. The aim of this study is to analyze the correlation between urethral funneling visualized during pelvic floor sonography and symptoms of stress urinary incontinence. MATERIAL AND METHODS: We have performed a retrospective analysis of 657 complete datasets of patients who attended our urogynecological clinic for diagnostics. Women with wet overactive bladder were excluded from the analysis. Tests used in our clinic included: standardized interview and questionnaire, clinical exam, cough test. Pelvic floor sonography with a transvaginal probe in women with filled bladder was performed to assess the urethral length and the urethral funneling during maximal Valsalva maneuver. RESULTS: In all patients with clinical SUI symptoms and with a positive cough test the urethral funneling length during Valsalva maneuver was > 50% of urethral length (long urethral funneling). In 83.7% of women without SUI the urethral funneling was absent. In the remaining 16.3% funneling was visible but its relative length was less than 50% of urethral length and urine flow was not observed (short urethral funneling). CONCLUSIONS: Long urethral funneling (> 50% of urethral length) seems to be a characteristic sign for SUI in women. The presence of urethral funneling shorter than 50% of urethral length (short urethral funneling) is not a SUI symptom - it is probably a sign of asymptomatic funneling of bladder neck.

Adjustable single incision sling Ajust - the effects of first operations controlled by pelvic floor sonography.

OBJECTIVE: The aim of this study is to evaluate using PFS-TV the mid-term results of our first operative experience with implanting a single incision sling - Ajust™. MATERIAL AND METHODS: One and the same surgeon has operated all the patients with symptoms of stress urinary incontinence. Ajust was the only performed procedure. Postoperative evaluation consisted of: a standardized interview and examination, a cough test and a PFS-TV for evaluation of urinary continence and tape location. PFS-TV was performed under standardized conditions at rest and during maximum Valsalva maneuver. RESULTS: This is a retrospective analysis of data from a total of 31 patients who attended a control visit between the 36th and the 50th month following the operation. Sixteen patients (51.6%) were cured. There were statistically significant differences in urethral mobility (p < 0.0007) and tape-urethra distance (p < 0.002) between cured and not-cured group. The difference in urethral length was not statistically significant. 77.8% of women with a hypermobile urethra was cured in contrast to 15.4% with a normobile urethra. Neither of the groups had a hypomobile urethra patient. There were no significant complications intra- or post-operatively. De novo urgency was observed in 1 patient only. CONCLUSIONS: Implantation of Ajust tape seems to be a safe mode of operative treatment for SUI in women. Our mid-term results suggest that long term effects might be worse compared to retropubic or transobturator tapes, especially at first operative experience with Ajust. Urethral mobility seems to be an important risk factor for treatment failure after Ajust implantation. It seems that patients that may benefit from Ajust most are women with urethral hypomobility but this needs to be verified with a prospective study.

Repeatability and reproducibility of measurements of the suburethral tape location obtained in pelvic floor ultrasound performed with a transvaginal probe.

INTRODUCTION: Implants used to treat patients with urogynecological conditions are well visible in US examination. The position of the suburethral tape (sling) is determined in relation to the urethra or the pubic symphysis. AIM OF THE STUDY: The study was aimed at assessing the accuracy of measurements determining suburethral tape location obtained in pelvic US examination performed with a transvaginal probe. MATERIAL AND METHODS: The analysis covered the results of sonographic measurements obtained according to a standardized technique in women referred for urogynecological diagnostics. Data from a total of 68 patients were used to analyse the repeatability and reproducibility of results obtained on the same day. RESULTS: The intraclass correlation coefficient for the repeatability and reproducibility of the sonographic measurements of suburethral tape location obtained with a transvaginal probe ranged from 0.6665 to 0.9911. The analysis of the measurements confirmed their consistency to be excellent or good. CONCLUSIONS: Excellent and good repeatability and reproducibility of the measurements of the suburethral tape location obtained in a pelvic ultrasound performed with a transvaginal probe confirm the test's validity and usefulness for clinical and academic purposes.

The analysis of repeatability and reproducibility of bladder neck mobility measurements obtained during pelvic floor sonography performed introitally with 2D transvaginal probe.

OBJECTIVES: The aim of the study was the evaluation of repeatability and reproducibility of chosen urethral neck mobility measurements obtained during introital pelvic floor sonography performed with a 2D transvaginal probe. MATERIAL AND METHODS: In order to assess the repeatability and reproducibility, independent measurements on the ultra-sound image were taken by two specialists on 92 female patients at rest and at strain (Valsalva maneuver). 2D ultrasound examination was performed introitally with a transvaginal probe (PFS-TV). The location of the urethral internal orifice was defined with coordinates of two points. Point CI marks the urethral anterior edge visualized on ultrasound as closer to the pubic symphysis. Point CII marks the posterior edge visualized more peripherally from pubic symphysis. RESULTS: Repeatability and reproducibility measurements of point CI location and mobility were good and very good (0.6710-0.9961), while of point CII - were medium, good and very good (0.5738-0.9944). Point CI was clearly visible in all cases. It was not possible to accurately mark point CII in 4.3-17.4% of cases. CONCLUSIONS: The possibility to visualize point CI in every single case with very good and good repeatability and reproduc-ibility of measurements of this point's location and mobility allows the usage of CI point as a universal reference point for evaluation of bladder neck mobility and position during PFS-TV in the clinical practice and for research purposes.

Transvaginal six-arm mesh OPUR in women with apical pelvic organ prolapse - analysis of short-term results, pelvic floor ultrasound evaluation.

OBJECTIVES: Analysis of feasibility, efficacy and short-term results after six-arm transvaginal mesh OPUR implantation in women with apical prolapse. MATERIAL AND METHODS: The same surgeon operated all of 39 women using mesh OPUR. Preoperatively patients had a standardized interview and clinical examination. Intraoperative and postoperative complications were analyzed. Postoperative evaluation included standardized interview, clinical examination and standardized pelvic floor ultrasound performed with 2D transvaginal probe and 4D abdominal probe. RESULTS: There was no complication that needed operative intervention. Hematomas in 3 patients resolved spontaneously. Transient voiding difficulties which lasted less than 7 days were observed in 5 patients. No erosion was observed. Comparison of pre- and postoperative results in 34 women revealed that in all 3 compartments improvement in POP-Q scale was statistically significant (p < 0.0000). One patient with malposition and rolled up mesh needed re-operation. During PFS-TV in 94.1% of patients urethra was normobile or hypermobile. In all of the patients urethral end of the mesh was positioned far enough from the middle part of the urethra (ultrasound) to implant suburethral sling without risk of collision. Sexually active women did not inform of any important discomfort or pain during intercourse. CONCLUSIONS: It seems that six-arm OPUR mesh, if implanted under strict surgical rules, gives low risk of complications and high chance to successfully reduce POP symptoms in short term after the operation. It seems that OPUR mesh should not have negative influence on the results after anti-incontinence suburethral sling.

The effectiveness of a pre-pubic four-arm NAZCA-TC mesh in treating cystocele and stress urinary incontinence simultaneously - results controlled with a pelvic floor ultrasound. A preliminary study.

OBJECTIVES: It is controversial whether pelvic organ prolapse and stress urinary incontinence (SUI) should be treated simultaneously with a single surgery or separately with two procedures. The pre-pubic four-arm NAZCA-TC® mesh was invented to treat cystocele and SUI with a single procedure. The objective of this study is to analyze short-term results after the implantation of NAZCA-TC mesh. MATERIAL AND METHODS: A total of 18 women underwent the evaluation of results of mesh implantation within a 24 to 36 months follow-up. Pre-operatively, patients were examined under standardized conditions. Postoperatively we analyzed the following: standardized interview and examination as well as pelvic floor ultrasound: 2D with a transvaginal probe and 4D with an abdominal probe. RESULTS: There was one case of intraoperative bladder damage noticed and repaired followed with NAZCA implantation. In 2 cases vaginal erosion was found that healed successfully after re-operation. In 3 cases hematomas were observed but resolved spontaneously. After the surgery there was a statistically significant improvement of prolapse in anterior (p < 0.0003) and in central (p < 0.001) compartment. Six women (33.3%) had no stress urinary incontinence symptoms during the control visit but we did not find a statistically significant improvement in SUI symptoms after the procedure. We recorded no case of hypomobile urethra after the surgery. The mesh covered > 50% of the urethral length in all of the patients. CONCLUSIONS: Mid-term results showed that implantation of NAZCA TC mesh allows to achieve statistically significant im-provement in reducing cystocele coexisting with enterocele in over 65% of patients. A complete cure from stress urinary incontinence was confirmed in 1/3 of patients. NAZCA-TC covered more than 50% of the urethral length, which can possibly have a negative influence on the effectiveness of the suburethral tape.

Incidence of human papillomavirus contamination of transvaginal probes in Japan and possible contamination prevention strategy.

PURPOSE: To clarify the present status of human papillomavirus (HPV) contamination of transvaginal probes in Japan and propose a preventive method. METHODS: This study was performed at three institutes: a tertiary center, secondary hospital, and primary facility. To identify contamination rates, probes were disinfected and covered with probe covers and condoms; the cover was changed for each patient. The probes were tested for HPV, and those with HPV detected were analyzed to identify the type of HPV. Next, nurses put on new gloves before covering the probe for each patient, and the probes were similarly tested for HPV. RESULTS: A total of 120 probes were tested, and HPV was detected from a total of five probes, a contamination rate of 4.2 % (5/120). HPV was detected in all three institutes. Importantly, high-risk HPV, i.e., HPV-52, 56, and 59, was detected. After the "glove change strategy" was implemented, HPV was not detected on any of 150 probes tested at any of the three institutions. CONCLUSIONS: In Japan, the HPV contamination rate of vaginal probes in routine practice was 4.2 %. There was no HPV contamination of probes after changing the gloves for cover exchange for each patient. This strategy may prevent HPV probe contamination.