Performance of MRI for the detection of anterior pelvic endometriotic lesions.

OBJECTIVE: To study the performance of MRI for the detection of anterior pelvic endometriotic lesions. MATERIALS AND METHODS: We carried out a retrospective, single site, case-controlled study of patients who underwent surgery for endometriosis between March 2005 and December 2013. Laparoscopy was used to obtain the reference diagnosis of the endometriotic lesions. We age-matched patients with anterior endometriosis with those with isolated posterior endometriosis for reference. All of the pre-therapeutic MRI data were anonymized and blindly reread by two radiologists (junior and senior) twice. They assessed the overall presence of anterior lesions, those of the inter-vesicouterine space, the detrusor, the uterus, and posterior lesions. For each site, we calculated the sensitivity (Se) and specificity (Sp) for each reading compared to the reference, as well as the inter- and intra-operator variability using the Kappa coefficient (K) with its 95% confidence interval (95% CI). RESULTS: During the study period, 256 patients underwent surgery for endometriosis: 22 presented with anterior endometriosis at surgery, and had had pre-preoperative imagery. We included 22 controls who had an isolated posterior lesion. For the overall detection of anterior lesions, the two radiologists had an identical Se of 77.3% (95% CI; 54.6-92.2). The Sp was 100% (95% CI; 82.4-100) for the junior, and 89.5% (95% CI; 66.9-98.7) for the senior radiologist. The area under the ROC curve was 0.89 (95% CI; 0.80-0.98) for the junior and 0.81 (95% CI; 0.68-0.93) for the senior radiologist. The intra-operator variability was low with almost perfect reproducibility for the overall detection of anterior lesions; k=0.90 (95% CI; 0.77-1) for the junior and k=0.85 (95% CI; 0.70-1) for the senior radiologist. For the various anterior sites, the junior radiologist had k values between 0.60 and 1, whereas those of the senior radiologist were between 0.87 and 1. For inter-operator reproducibility, there was modest agreement between the two radiologists, k=0.46 (95% CI; 0.19-0.73), for the overall detection of anterior lesions; k varied between 0.43 and 0.61, depending on the site. CONCLUSION: Our results show that the characterization of anterior lesions by MRI is specific, but not very sensitive, with only moderate inter-operator reproducibility depending on the site. MRI can be used to diagnose anterior lesions, but cannot replace laparoscopy.

Value of Round Ligament Artery Embolization in the Management of Postpartum Hemorrhage.

PURPOSE: To evaluate the feasibility and efficacy of embolization of the round ligament arteries in the management of postpartum hemorrhage. MATERIALS AND METHODS: Eleven women (mean age, 31 y) underwent round ligament artery because of persistent or recurrent hemorrhage after initial uterine or internal iliac artery embolization. RESULTS: A total of 16 round ligament arteries were embolized. The round ligament artery arose from the inferior epigastric artery in 11 cases (69%) and directly from the external iliac artery in 5 (31%). Embolization was performed with calibrated microspheres in 7 women (63%) and gelatin sponge pledgets in 4 (37%). Coils were used in addition to gelatin sponge pledgets in 3 patients. Hemostasis was achieved in 10 patients (91%), and 1 required additional conservative surgery. The mean hemoglobin level before embolization was 7.2 g/dL ± 1 and increased significantly on day 1 after embolization (10.3 g/dL ± 1.0; P < .05). No procedure-related complication was reported. The mean hospital stay was 5.6 days ± 2. Two patients had further pregnancies 13 and 14 months after embolization. CONCLUSIONS: Selective embolization of the round ligament artery is a safe and effective treatment for obstetric hemorrhage. It should be considered in cases of persistent or recurrent bleeding after initial uterine or internal iliac artery embolization.

Fertility after uterine artery embolization for symptomatic multiple fibroids with no other infertility factors.

OBJECTIVES: To evaluate the fertility of women eligible for surgical multiple myomectomy, but who carefully elected a fertility-sparing uterine artery embolization (UAE). METHODS: Non-comparative open-label trial, on women ≤40 years, presenting with multiple symptomatic fibroids (at least 3, ≥3 cm), immediate pregnancy wish, and no associated infertility factor. Women had a bilateral limited UAE using tris-acryl gelatin microspheres ≥500 µm. Fertility, ovarian reserve, uterus and fibroid sizes, and quality of life questionnaires (UFS-QoL) were prospectively followed. RESULTS: Fifteen patients, aged 34.8 years (95%CI 32.2-37.5, median 36.0, q1-q3 29.4-39.5) were included from November 2008 to May 2012. During the year following UAE, 9 women actively attempting to conceive experienced 5 live-births (intention-to-treat fertility rate 33.3%, 95%CI 11.8%-61.6%). Markers of ovarian reserve remained stable. The symptoms score was reduced by 66% (95%CI 48%-85%) and the quality of life score was improved by 112% (95%CI 21%-204%). Uterine volume was reduced by 38% (95%CI 24%-52%). Women were followed for 43.1 months (95%CI 32.4-53.9), 10 live-births occurred in 8 patients, and 5 patients required secondary surgeries for fibroids. CONCLUSION: Women without associated infertility factors demonstrated an encouraging capacity to deliver after UAE. Further randomized controlled trials comparing UAE and myomectomy are warranted. KEY POINTS: • Women without infertility factors showed an encouraging delivery rate after UAE. • For women choosing UAE over abdominal myomectomy, childbearing may not be impaired. • Data are insufficient to definitively recommend UAE as comparable to myomectomy. • Further randomized trials comparing fertility after UAE or myomectomy are warranted.

External validation of the MR imaging scoring system for the management of adnexal masses.

OBJECTIVE: To investigate the prognostic value of ADNEX Magnetic Resonance Imaging Scoring in the preoperative management of adnexal masses. STUDY DESIGN: We performed a retrospective study on patients who underwent surgery for an adnexal mass, with prior exploration by Magnetic Resonance Imaging (MRI), at the Gynecology Department of the Poissy Teaching Hospital between May 2012 and August 2014. MRI data were retrospectively read by radiologists, without knowledge of the histology, and classified according to the criteria of the ADNEX MR score. The radiological presumption of benign or malignant mass was compared with the final histological diagnosis. We calculated the sensitivity, specificity, positive and negative likelihood ratios and ROC curve of the ADNEX MR score with their 95% confidence intervals (95%CI). RESULTS: One-hundred-and-forty-eight patients were included in the study of which 24 had malignant or borderline ovarian tumors. The proportion of malignant or borderline ovarian tumors in each class of the ADNEX MR score in our study was: ADNEX I: 0% (95%CI, 0-8); ADNEX II: 1.7% (95%CI, 0.04-8.9); ADNEX III: 7.7% (95%CI, 0.2-36); ADNEX IV: 57.1% (95%CI, 34.2-78.8) and ADNEX V: 100% (95%CI, 69.2-100). Thus, for an ADNEX MR score greater than or equal to 4, the sensitivity was 91.7% (95%CI, 73-99) and the specificity 92.7% (95%CI, 86.7-96.6) for the diagnosis of a malignant or borderline ovarian tumor. The area under the ROC curve was 0.92 (95% CI%, 0.86-0.98). CONCLUSIONS: MRI, coupled with the use of the ADNEX MR scoring system, can accurately classify adnexal masses into low-risk (ADNEX MR score <4) or high-risk (ADNEX MR score ≥4) group, thereby allowing for appropriate preoperative counseling and planning for surgery.

Transverse colon diverticulitis simulating inguinal hernia strangulation: a first report.

BACKGROUND: Strangulation is the most serious complication of inguinal hernia. Diverticulitis, a common condition, is usually localized in the left colon. The association of complicated inguinal hernia and diverticulitis is rare. METHODS: We report the case of a 73-year-old male patient who presented with a suspicion of strangulated inguinal hernia. RESULTS: CT and operative findings showed transverse colon diverticulitis lodged in an incarcerated inguinal hernia without signs of strangulation. Surgical hernia repair was undertaken while the treatment of diverticulitis was conservative. Follow-up was uneventful. CONCLUSION: This is a first report of documented transverse colon diverticulitis simulating inguinal hernia strangulation.