Accuracy of the ADNEX MR scoring system based on a simplified MRI protocol for the assessment of adnexal masses.

PURPOSE: We aimed to evaluate the ADNEX MR scoring system for the prediction of adnexal mass malignancy, using a simplified magnetic resonance imaging (MRI) protocol. METHODS: In this prospective study, 200 patients with 237 adnexal masses underwent MRI between February 2014 and February 2016 and were followed until February 2017. Two radiologists calculated ADNEX MR scores using an MRI protocol with a simplified dynamic study, not a high temporal resolution study, as originally proposed. Sensitivity, specificity, positive and negative predictive values, likelihood ratios, and the area under the receiver operating characteristic curve were calculated (cutoff for malignancy, score ≥ 4). The reference standard was histopathologic diagnosis or imaging findings during >12 months of follow-up. RESULTS: Of 237 lesions, 79 (33.3%) were malignant. The ADNEX MR scoring system, using a simplified MRI protocol, showed 94.9% (95% confidence interval [CI], 87.5%-98.6%) sensitivity and 97.5% (95% CI, 93.6%-99.3%) specificity in malignancy prediction; it was thus highly accurate, like the original system. The level of interobserver agreement on simplified scoring was high (κ = 0.91). CONCLUSION: In a tertiary cancer center, the ADNEX MR scoring system, even based on a simplified MRI protocol, performed well in the prediction of malignant adnexal masses. This scoring system may enable the standardization of MRI reporting on adnexal masses, thereby improving communication between radiologists and gynecologists.

Neurovascular quantitative study of the uterosacral ligament related to nerve-sparing radical hysterectomy.

OBJECTIVE: To analyze the distribution of autonomic nerves and blood and lymphatic vessels in the uterosacral ligament, elucidate detailed anatomy at a surgical level and provide pathobiological evidence for improvement of nerve-sparing radical hysterectomy. STUDY DESIGN: Surgical samples were collected from 15 patients who underwent radical hysterectomy for early stage cervical cancer (FIGO Ib1-IIa). Twenty-nine fresh specimens were divided into cervical, intermediate and sacral sections, and then subdivided into superficial and deep portions from the middle: the medial surface and lateral surface were also subdivided in order to analyze lymphatic vessels. The numbers of nerve branches in each section or portion of the section were analyzed. The lengths of the uterosacral ligaments were measured and immunohistochemistry staining was studied. Autonomic nerves, blood vessels and lymphatic vessels were quantitatively analyzed using image analysis software and biological stereology. RESULTS: The volume density of sympathetic nerves in the deep portion was significantly higher than in the superficial portion (p<0.05), and the number of nerves was greatest in the cervical section (p<0.05). The volume density of blood vessels was not significantly different between the two portions (p>0.05) or among the three sections (p>0.05), and the volume density of the lymphatic vessels was greater in the medial surface (p<0.05), with most of them in the cervical section (p<0.05). CONCLUSIONS: Our study provides systematic mapping of the location and distribution of autonomic nerve branches, blood vessels and lymphatic vessels in the uterosacral ligament.

Surgical anatomy imaging associated with cervical cancer treatment: A cadaveric study.

The objectives of this study were to visualize the surgical anatomical structures in the female pelvis by computed tomography and to investigate the components of the parametrium for anatomical education, radiological diagnosis, and surgical simulation. We surgically dissected fresh female cadavers maintained in precise surgical anatomic positions and examined the anatomical structures using experimental fine cell detector multislice computed tomography (FDCT) with a slice thickness of 0.3125 mm. In addition, we established a three-dimensional (3D) reconstruction model for precise observation of the surgical anatomy using Materialise's Interactive Medical Image Control System (Mimics). We evaluated two-dimensional (2D) images of the surgical anatomical structures in combination with the 3D reconstruction model. The 3D model was reconstructed from 430 serial axial pelvic CT images of a cadaver. The cardinal ligament, uterosacral ligament, paravesical space, and pararectal space were visualized on the CT images obtained from the surgically dissected part. The parametrium components were clearly distinguished on the surgically dissected side. Based on the information from the dissected side, these components on the undissected side could be distinguished as well. We recognized the parametrium components in the area extirpated during radical hysterectomy. The approach using cadavers, experimental FDCT, and 3D software provided excellent visualization of pelvic structures. High-quality images of surgical anatomical structures provide new insight regarding precise surgical anatomy in the female pelvis. The radiological information has practical usefulness for radiotherapeutic planning and surgical simulation.

Functional and anatomic comparison of 2 versus 3 suture placement for uterosacral ligament suspension: a cadaver study.

OBJECTIVE: The objective of the study was to compare the vaginal apex pullout distance using 2 vs 3 suspension sutures during transvaginal uterosacral ligament suspension (USLS) and to describe relationships to ipsilateral ureter and nerve structures. STUDY DESIGN: Eight fresh-frozen female cadavers were studied. After hysterectomy, a transvaginal USLS was performed with placement of 3 suspension sutures per side. The 2 most distal sutures on each ligament were tied. A screw-and-washer attachment was secured in the middle of the vaginal cuff and tied to a pulley system with surgical filament. Distal traction was applied with sequentially increasing weight loads. Distal migration of the vaginal apex from baseline with each weight load was recorded. The most proximal suspension suture was tied and the procedure repeated. Horizontal distances between each USLS suture to the ipsilateral ureter were measured. Three discrete points were marked on sacral nerves S1-S3, and the shortest distance between each point and each ipsilateral USLS suture was measured. Descriptive statistics and repeated-measures analysis of variance were performed. RESULTS: Application of each load resulted in greater migration distances for the 2 suture configuration when compared with 3 sutures (P < .05). Differences were greatest for the 3 kg load (mean ± SEM, 2.0 ± 0.2 vs 1.5 ± 0.1 cm, respectively). Distances to ipsilateral ureter between the 2 most cranial sutures were comparable (P > .05). The most cranial USLS suture was closest to sacral nerves S1-S3. CONCLUSION: In this cadaveric study, 3 USLS sutures provided more support to the vaginal apex than 2 sutures, although the absolute difference may not be clinically significant. The most cranial suture had the smallest distances to sacral nerves S1-S3.

Phenotypic characterization by high-resolution three-dimensional magnetic resonance imaging evidences differential effects of embryo genotype on intrauterine growth retardation in NOS3-deficient mice.

The Nos3-knockout mouse, deficient for endothelial constitutive nitric oxide synthase (NOS3), is affected by a reduction in the number and weight of the embryos and constitutes a good model for some features of preeclampsia and intrauterine growth retardation (IUGR). Deficiencies in conceptus growth and survival may result from factors inherent in the embryo itself or from deficiencies in uterine function. In the current study, we aimed to determine the effects of embryonic genotype independently of maternal genotype, which can affect uterine environment. Therefore, by using magnetic resonance imaging (MRI), we characterized the phenotypes of NOS3-defective (Nos3(-/-); n = 6), normal wild-type (Nos3(+/+); n = 5), and heterozygous (Nos3(+/-); n = 16) mouse fetuses. All of them were littermates obtained by breeding heterozygous mice (Nos3(+/-)); therefore, the maternal genotype was the same for all the fetuses. At Day 13.5 (i.e., Theiler stage TS 21-22), females were anesthetized and scanned with three-dimensional MRI. Analysis of the different measurements of the embryos and the gestational annexes showed no significant differences between Nos3(+/+) and Nos3(+/-); however, there was a trend toward larger sizes in Nos3(+/+), and values in Nos3(-/-) were significantly smaller than in Nos3(+/+) and Nos3(+/-). The reduction in the crown-rump length of Nos3(-/-) reached 12% when compared to Nos3(+/+) (P < 0.05); the effect was higher for head measurements (16% for occipito-snout length and biparietal diameter, P < 0.05 for both) and trunk diameter (17%, P < 0.05). Overall, the maximum area of fetuses in longitudinal planes decreased 27% (P < 0.05) when comparing Nos3(-/-) to wild-type Nos3(+/+). Finally, Nos3(-/-) showed a reduction of 29% in the maximum thickness of the placenta, which may be related to the appearance of IUGR due to compromised nutritional delivery to the fetus.

Three-dimensional reconstruction of the uterine vascular supply through vascular casting and thin slice computed tomography scanning.

It was the objective of this study to construct a model of the uterine vascular supply through vascular casting and thin slice computed tomography scanning. This will provide a teaching aide for the understanding of uterine artery embolization (UAE) procedures, as well as normal uterine and ovarian arterial anatomy. Using 20% chlorinated poly vinyl chloride, we infused and cast a set of a normal uterus, vagina and bilateral adnexa through the uterine artery and ovarian artery. After thin slice CT scanning, we obtained the three-dimensional (3D) reconstruction by maximum intensity projection (MIP) and surface-shaded display (SSD), and then observed its figure and characteristics. A model of the uterine vascular supply can be successfully reconstructed by vascular casting and thin slice CT scanning. The 3D reconstruction offers a clear view of the course of the uterine artery and its blood supply distribution. It has two major branches: The intramuscular uterine branch and the cervicovaginal branch (1). Blood supply is generally unilateral, with communicating branches between the two sides and possible anastomoses between the arterial blood supply of the uterus and the ovaries. The major blood supply of the cervix comes from the cervicovaginal branch of the uterine artery, while the vaginal arterial supply derives directly from the internal iliac artery. The CT technique allows real-time 360 degrees rotation and changes in model for in-depth study of the vascular network and its adjacent tissues. It is possible to construct an in vitro uterine arterial network by vascular casting and CT scanning, which can provide unique insight into the female genitourinary system arterial network. Based on this, we can create reconstructions as well as models for different diseases such as leiomyomata, adenomyosis, and endometrial cancer. These models will provide morphological evidence to the interventional therapy and UAE teaching in Obstetrics and Gynecology.

Ultrasonography of reproductive structures and hormonal correlates of follicular development in female American alligators, Alligator mississippiensis, in southwest Louisiana.

Ultrasonography has been used effectively to study reproduction in a variety of reptile species, but its application to crocodilians has been relatively limited. We present results from a study testing the efficacy of using ultrasonography to monitor reproduction in the American alligator, Alligator mississippiensis. Ultrasound results were then compared with plasma hormone levels. A total of 124 females were examined during March, April, May, and early June (2001-2003). Ultrasound results were validated on a series of reproductive females (n=14) necropsied for other studies. Previtellogenic follicles, vitellogenic follicles, recently shelled eggs, fully developed well-calcified eggs, and atretic follicles were readily discernible with ultrasound in mature females. Reproductive structures were observed in 57 females of which 43 were actively reproductive, while 14 were non-reproductive, but contained large atretic follicles from prior years. Oviducts were discernible in females with eggs. Ovarian state was also correlated with hormone levels. These results are in agreement with previous studies that showed that 50% or less of the adult female alligator population is reproductively active in a given year. Ultrasonography can be used to make an accurate assessment of reproductive condition in wild alligator populations.

Magnetic resonance imaging of benign adnexal disease.

Magnetic resonance imaging (MRI) plays an important role in localizing and characterizing pelvic masses, particularly adnexal masses. The multiplanar capability of MRI helps to locate an abnormality outside the ovary and facilitate the exclusion of malignancy. Its superior soft-tissue contrast features help to diagnose specific benign masses, including teratoma, endometrioma, and ovarian fibroma. In addition, cystic ovarian neoplastic lesions can be further characterized as benign versus malignant, particularly after gadolinium administration. An approach to adnexal evaluation using MRI is discussed based on these features.

The connections of lymphatic vessels draining female reproductive organs with lymphnodes in the pig.

The connections of lymphatic vessels leaving the reproductive organs (ovary, oviduct, uterine horn, corpus and cervix, and vagina) with lymphnodes (normal and hemal) located in the uterine broad ligament and paraaortal regions were examined in the cyclic and immature pigs. To visualize the lymph pathways, the lymphatic lumen was filling with varicoloured microfil and/or ink-gelatin mass introduced all the way down to appearance in several nodes. This study revealed that lymphatics emanating from the uterine horn, corpus and the anterior part of the cervix demarcated large a lymphatic area in the porcine broad ligament. From the caudal portion of the cervix and vagina 2-3 lymphatics were found to emerge running near walls of these organs and connecting with large complex nodes, and 2-3 lymphatics reaching the plica urogenitalis. Generally, the lymphatic vessels leaving the porcine reproductive organs were connected by collector lymphangions with 3-5 normal-, 0-3 hemal- and one large composed nodes all found between the distal vascular subovarian plexus and the uterine artery as well as with 9-27 normal and 3-9 hemal nodes in the paraaortal region.

Normal adnexa uteri specimens: anatomic basis of MR imaging features.

PURPOSE: To elucidate the anatomic basis for the magnetic resonance (MR) imaging features of normal ovaries and fallopian tubes and causes for varied MR appearances. MATERIALS AND METHODS: MR imaging of 24 surgical specimens of ovary and adnexa uteri in the fresh state from 15 patients was performed before histopathologic processing. T1-weighted spin-echo and T2-weighted fast spin-echo images were obtained. MR imaging findings related to the zonal anatomy of the ovary, functional cysts, and fallopian tubes were correlated with findings at histopathologic examination. RESULTS: Ovaries in premenopausal women showed differentiation between the ovarian cortex and the ovarian medulla on T2-weighted images and in histopathologic sections. Ovaries in postmenopausal women were more homogeneous because of replacement of the medulla with stromal proliferation and corpora albicantia. Functional cysts of the ovary had low-signal-intensity rims on T2-weighted images, which corresponded to the theca and stromal reaction around the cyst. The signal intensity of normal fallopian tubes was intermediate on T2-weighted images and that of muscularis was low. CONCLUSION: Typical patterns of MR appearance of the ovary and functional cysts correlate with the regional histopathologic anatomy of the ovary. T2-weighted imaging of the ovary revealed cyst walls, corpora lutea, and ovarian medulla.

An anatomical approach to oophorectomy during vaginal hysterectomy.

Oophorectomy is not always performed at the time of vaginal hysterectomy because of technical difficulties encountered in visualizing the ovaries and clamping and ligating the infundibulopelvic ligament. After uterine removal, a method that simplifies the approach involves separating the round ligament along the avascular space from the fallopian tube and ovary, then ligating the infundibulopelvic ligament separately from the round ligament, rather than clamping and ligating the infundibulopelvic and round ligaments together.

Magnetic resonance imaging of benign adnexal conditions.

Magnetic resonance imaging can be used to demonstrate a variety of benign adnexal diseases. However, the real utility and efficacy of MR imaging in benign pelvic disease has not been investigated thoroughly. This is the challenge for future research. Presently, particularly in light of changes in the health care system, it is incumbent upon radiologists, gynecologists, and other clinicians to determine what additional information MR imaging will add to the diagnostic evaluation already completed before performing MR imaging. One must ask several questions. Will MR imaging provide additional information? Will that information affect care and treatment of the patient? Will the treatment be beneficial to the care of the patient? Will the patient agree to the management? Many times these questions are not asked. And if asked, the answers are unknown or under investigation. However, using one's best clinical judgment and armed with the knowledge at hand, if answers to the above questions are yes, then MR imaging may prove useful.

[The interrelation of interhemispheric functional brain asymmetry and the morphofunctional asymmetries of the female reproductive system in in its comparative evolutionary aspect]. / Vzaimosviaz' funktsional'noi mezhpolusharnoi asimmetrii mozga i morfofunktsional'nykh asimmetrii sistemy zhenskoi reproduktsii v sravnitel'no-évoliutsionnom aspekte.

In experiments carried out in female rats it has been established that there is a connection between morphological asymmetry of uterine horns and adnexa and orientation of encephalic interhemispheric asymmetry (EIHA). Unilateral adnexectomy and ablation of one of the uterine horns resulted in modifications of EIHA, which increased during pregnancy in the remaining horn. Comparative analysis of experimental results and the data obtained during examination of pregnant women (such as interconnections of the placentation side with gestational dominant and initial orientation of the lateral phenotype) suggests an important role of asymmetry of the visceral part of female reproductive system in the formation of EIHA in onto- and phylogenesis. Possible mechanisms of self-organization of the polar functional systems are discussed under evolutionary aspect.

Value of a postvoid scan during adnexal sonography.

The position of the uterus and ovaries can be affected by the degree of bladder filling. A postvoid scan may bring into view ovarian pathologic conditions not previously discerned.

Pulsion enterocele: review of functional anatomy of the pelvic floor.

Pulsion enterocele has a well-deserved reputation as a difficult surgical problem; the multiplicity of suggested solutions attests to this. Until the functional anatomy of the pelvic floor is better understood, particularly the specific anatomic defects involved, planning of a rational surgical attack will remain elusive. Both the pelvic cellular tissues and the levator ani complex are involved in the genesis of the condition, and both require correction during any surgical procedure. The supporting effect of the levator complex and the positioning effect of the cellular tissues must be restored.

Gray scale ultrasound in adnexal thickening: correlation with laparoscopy.

A retrospective comparison between ultrasound and subsequent laparoscopy was made in 70 female patients to evaluate the sonographic features of minimal pelvic disease (in particular, adnexal thickening). The overall accuracy of sonography as compared with laparoscopy was 75 percent (53 of 70), with a true positive rate of 72 percent (40 of 51) and a true negative rate of 68 percent (13 of 19). In this study the concept of clinical or sonographic adnexal thickening did not correlate with observations at laparoscopy. Of the 7 patients diagnosed by ultrasound as having adnexal thickening, only 1 had pelvic inflammatory disease, whereas the other 6 showed no abnormalities at laparoscopy.