Imaging and Treatment of Complications of Abdominal and Pelvic Mesh Repair.

Surgical mesh is used most frequently for tension-free repair of abdominal wall hernias in adults, because the rate of hernia recurrence is lower with mesh than with primary soft-tissue repair. Since the introduction of polypropylene mesh in the middle of the 20th century, many mesh materials and configurations for specific surgical procedures have been developed. In addition to abdominal wall hernia repair, mesh may be used for repair of diaphragmatic hernias, urinary incontinence in women (female slings), genitourinary prolapse (vaginal mesh and sacrocolpopexy), rectal prolapse (rectopexy), and postprostatectomy male urinary incontinence (male slings). General mesh repair complications include chronic pain; fluid collections such as seromas, hematomas, and abscesses; adhesions that may lead to intestinal blockage; erosion into solid or hollow viscera including enterocutaneous fistulizing disease; and mesh failure characterized by mesh shrinkage, detachment, and migration with repair malfunction. Several mesh complications are often diagnosed with imaging, primarily with CT and less frequently with MRI and US, despite variable mesh visibility at imaging. This article reviews the common surgical mesh applications in the abdomen and pelvis, discusses imaging of mesh repair complications, and provides complication treatment highlights.©RSNA, 2020.

CT Colonography: Improving Interpretive Skill by Avoiding Pitfalls.

An earlier incorrect version of this article appeared online. This article was corrected on December 20, 2019.

What Is the Appropriate Use of Renal Sonography in an Inner-City Population With New-Onset Acute Kidney Injury?

OBJECTIVES: We aimed to determine the prevalence of hydronephrosis in patients who underwent renal sonography for new-onset acute kidney injury (AKI) and to identify clinical factors predictive of hydronephrosis. In patients with hydronephrosis, we sought to investigate how routine renal sonography affects patient treatment, including performance of interventional procedures. METHODS: A retrospective chart review identified 274 adults with AKI who underwent renal sonography at an urban teaching hospital from January through July 2011. The prevalence of hydronephrosis was determined. Electronic medical records were reviewed for comorbidities, including risk factors for hydronephrosis such as a pelvic mass, prior renal or pelvic surgery, and neurogenic bladder, and for subsequent interventions and outcomes. RESULTS: Sonography showed hydronephrosis in 28 patients (10%); 5 (18%) had subsequent interventions. In a multivariable logistic regression model with the outcome being hydronephrosis, all considered risk factors (pelvic mass, prior renal or pelvic surgery, and neurogenic bladder) were significantly associated with hydronephrosis (odds ratio, 6.4; 95% confidence interval, 2.7-15.4; P < .001) when adjusting for age and diabetes mellitus. Diabetes had a negative predictive value for hydronephrosis. No diabetic patients younger than 85 years and without clinical risk factors had hydronephrosis. CONCLUSIONS: Hydronephrosis is infrequently seen on sonograms in hospitalized patients with AKI who lack risk factors for urinary tract obstruction. Deferral of sonography pending a trial of medical treatment is safe and will reduce medical costs. Adoption of clinical guidelines to assess patients' risk levels for hydronephrosis is critical to avoid unnecessary imaging.

Adrenal cysts: natural history by long-term imaging follow-up.

OBJECTIVE: The purpose of this article is to determine the natural history of adrenal cysts on the basis of long-term imaging follow-up. MATERIALS AND METHODS: This retrospective study included patients with adrenal cysts who had at least 12 months of imaging follow-up (1993-2010). Medical records were reviewed. Two radiologists reviewed imaging examinations in consensus and recorded wall thickness (thin, ≤ 3 mm; thick, > 3 mm), septations, and calcification. CT attenuation value, MRI signal intensity, the presence or absence of enhancement, and typical sonographic features were used to confirm fluid content of the lesions. Cyst wall enhancement was recorded (thin, ≤ 3 mm and smooth; thick, > 3 mm). Cyst diameter on the initial and most remote follow-up examinations was compared. The Wilcoxon matched-pairs signed rank test was applied to assess statistically significant differences in size and CT attenuation on follow-up examinations. RESULTS: Twenty patients with unilateral adrenal cysts (seven male and 13 female patients; mean age, 44 years; range, 10-75 years) had a mean imaging follow-up period of 64 months (range, 12-198 months). CT, MRI, and ultrasound examinations were obtained in 19, 11, and 13 patients, respectively. Cysts were diagnosed by lack of enhancement on CT or MRI in 12 patients, typical sonographic features in three patients, and combination of CT and sonographic or MRI features in five patients. Signal intensities typical for fluid were found on all MRI examinations, attenuations of less than 20 HU on 17 of 19 (89%) CT examinations, and features of either simple or mildly complicated cysts on all sonograms. Thin walls, wall calcifications, and thin septations were found in 20 (100%), 12 (60%), and four (20%) lesions, respectively. During the follow-up of 20 lesions, the median cyst diameter increased by 26.0% (interquartile range, 6.8-68.4%) in 12 (60%) patients, decreased by 32.9% (interquartile range, 7.1-42.8%) in six (30%) patients, and was unchanged in two (10%) patients. The median baseline CT attenuation values did not significantly change on follow-up CT examinations (p = 0.72). No patient developed a complication of adrenal cyst. Four patients had histologically confirmed benign adrenal cysts. CONCLUSION: Interval enlargement of an adrenal cyst is frequent and as an isolated finding does not indicate malignancy or presence of a complication. However, some adrenal cysts may decrease or remain stable in size over time.

Colostomy on CT and fluoroscopy: What the radiologist needs to know.

Colostomies are commonly created in conjunction with colorectal surgery performed for both malignant and benign indications. Familiarity with the different types of colostomies and their normal imaging appearance will improve radiologic detection and characterization of colostomy complications. The radiologist plays a large role in assessment of colostomy patients either via fluoroscopic technique or multidetector computed tomography (CT) in order to help identify ostomy complications or to aid the surgeon prior to colostomy reversal. In this article, we will review: (1) the types of colostomies and indications for their creation; (2) the proper radiographic technique of ostomy evaluation; and (3) the potential complications of colostomies and their imaging manifestations.

Laparoscopic sleeve gastrectomy: Everything the radiologist needs to know.

Obesity has become an epidemic in the United States, and bariatric surgery is being increasingly performed for its management. There has been an increased number of laparoscopic sleeve gastrectomies performed for the treatment of morbid obesity due to its efficacy and lower complication rate compared to other bariatric surgical techniques. The authors discuss the surgical technique, review the imaging of normal and complicated sleeve gastrectomy, and highlight radiographic pitfalls.

Improving diagnosis of atraumatic splenic lesions, Part III: malignant lesions.

Focal atraumatic splenic lesions often pose a diagnostic challenge on cross-sectional imaging. They can be categorized based on etiology, as nonneoplastic, benign neoplastic, and malignant neoplastic (discussed in Part III) lesions, or on prevalence, as common, uncommon, and rare lesions. Familiarity with pertinent clinical parameters, etiology, pathology, prevalence, and ancillary features such as splenomegaly, concomitant hepatic involvement, and extrasplenic findings, in addition to knowledge of imaging spectra of the lesions, can improve diagnostic confidence. Consideration of these factors together can arm the radiologist with the necessary tools to render a more confident diagnosis and thus better aid management.

Improving diagnosis of atraumatic splenic lesions, part II: benign neoplasms/nonneoplastic mass-like lesions.

Focal atraumatic splenic lesions often pose a diagnostic challenge on cross-sectional imaging. They can be categorized based on etiology as nonneoplastic, benign neoplastic (discussed in Part II), and malignant neoplastic lesions or on prevalence as common, uncommon, and rare lesions. Familiarity with pertinent clinical parameters, etiology, pathology, prevalence and ancillary features such as splenomegaly, concomitant hepatic involvement, and extrasplenic findings, in addition to knowledge of imaging spectra of the lesions, can improve diagnostic confidence. Consideration of these factors together can arm the radiologist with the necessary tools to render a more confident diagnosis and, thus, better aid management.

Hollow organ abdominal ischemia, part II: clinical features, etiology, imaging findings and management.

Acute hollow organ ischemia commonly presents with acute pain prompting radiologic evaluation and almost always requires urgent treatment. Despite different risk factors and anatomic differences, ischemia is commonly due to low flow states but can also be due to arterial and venous occlusion. Radiologic diagnosis is critical as many present with nonspecific symptoms. Contrast-enhanced computed tomography (CT) is the modality of choice. Magnetic resonance imaging (MRI) is preferred in suspected appendicitis in pregnant patients and is superior in biliary necrosis. This article provides a pictorial review of the CT/MRI features of hollow abdominal organ ischemia while highlighting key clinical features, pathogenesis, and management.

Improving diagnosis of atraumatic splenic lesions, part I: nonneoplastic lesions.

Focal atraumatic splenic lesions often pose a diagnostic challenge on cross-sectional imaging. They can be categorized based on etiology as nonneoplastic (reviewed in Part I), benign neoplastic, and malignant neoplastic lesions. Lesions can also be characterized based on prevalence as common, uncommon, and rare. Familiarity with pertinent clinical parameters, etiology, pathology, prevalence, and ancillary features such as splenomegaly, concomitant hepatic involvement, and extrasplenic findings, in addition to knowledge of imaging spectra of these lesions, can improve diagnostic confidence. Since the nonneoplastic lesions are usually easily recognized, it is critical that the radiologist identifies them avoiding unnecessary work up.

Pearls and pitfalls in first-trimester obstetric sonography.

Ultrasound is the primary imaging modality used in the evaluation of first-trimester vaginal bleeding and pelvic pain. This article will summarize the ultrasound findings in normal first-trimester pregnancy, failed pregnancy, ectopic pregnancy, subchorionic hemorrhage, retained products of conception, and gestational trophoblastic disease. Mastery of the spectrum of sonographic findings in the normal and abnormal first-trimester pregnancy allows the radiologist to make accurate diagnoses and helps to appropriately guide patient management.

Multimodality imaging of normal hepatic transplant vasculature and graft vascular complications.

Orthotopic liver transplantation is an important treatment option for patients with end-stage liver disease. Advances in surgical technique, along with improvements in organ preservation and immunosuppression have improved patient outcomes. Post-operative complications, however, can limit this success. Ultrasound is the primary imaging modality for evaluation of hepatic transplants, providing real-time information about vascular flow in the graft. Graft vascular complications are not uncommon, and their prompt recognition is crucial to allow for timely graft salvage. A multimodality approach including CT angiography, MRI, or conventional angiography may be necessary in cases of complex transplant vascular anatomy or when sonography and Doppler are inconclusive to diagnose the etiologies of these complications. The purpose of this article is to familiarize radiologists with the normal post-transplant vascular anatomy and the imaging appearances of the major vascular complications that may occur within the hepatic artery, portal vein, and venous outflow tract, with an emphasis on ultrasound.