Predicting necrosis in adnexal torsion in women of reproductive age using magnetic resonance imaging.

PURPOSE: To identify the diagnostic performance of magnetic resonance (MR) imaging for patients with adnexal torsion and to develop a predictive model for necrosis related to torsion. METHODS: The institutional ethics committee approved this retrospective study. A total of 56 women with a preoperative pelvic MR scan and a surgical and pathologic diagnosis of adnexal torsion were enrolled from five institutions. Three radiologists reviewed the MR images independently. The kappa value of interrater agreement was assessed. Differences between patients treated with conservative surgery and adnexectomy were evaluated by univariate and multivariate logistic regression analyses. Receiver operating characteristic (ROC) curve analysis was used to assess the ability of the model to predict ovarian necrosis. RESULTS: Fifty-six patients were divided into the conservative surgery group (24/56, 42.9%) or the adnexectomy group (32/56, 57.1%) depending on the surgical outcomes. The radiographic features related to torsion were interpreted by three raters retrospectively with substantial interrater agreement (kappa > 0.60). Older reproductive age and pedicle hemorrhagic infarction were significantly associated with adnexectomy (p < 0.05). At multivariate analysis, pedicle hemorrhagic infarction (odds ratio = 10.476 [95% confidence interval 1.103, 99.504; p = 0.041]) was associated with adnexectomy. Using the predictive model (older reproductive age and pedicle hemorrhagic infarction), a receiver operating characteristic curve was generated with an area under the curve (AUC = 0.870 ± 0.049). CONCLUSION: The presence of pedicle hemorrhagic infarction and older reproductive age can predict necrosis of adnexal torsion and may be used to guide the optimal treatment strategy. KEY POINTS: • Pedicle hemorrhagic infarction and older reproductive age are predictors of necrosis in adnexal torsion in patients of reproductive age (AUC = 0.870 ± 0.049). • Cystic wall thickening, enlarged vascular pedicle, tubal thickening, and uterine deviation are associated with a high risk for adnexal torsion, occurring in more than half of the cases in this study. • MR findings are useful for the definitive diagnosis of adnexal torsion and for the prediction of adnexal necrosis.

Vaginal Repair of Cesarean Section Scar Diverticula Diagnosed in Non-pregnant Women.

STUDY OBJECTIVE: Cesarean section scar diverticulum (CSD) lead to many long-term complications. CSD is more prevalent in patients with a retroflexed uterus than in those with an anteflexed uterus. Therefore, we wanted to estimate the association between flexion of the uterus and the outcome of treatment for CSD treated by vaginal repair. DESIGN: Retrospective cohort study (Canadian Task Force classification II-2). SETTING: University hospital. PATIENTS: A total of 241 women with a CSD were enrolled at the Shanghai First Maternity & Infant Hospital between May 2014 and Oct 2016. INTERVENTIONS: Vaginal excision and suture of CSD. MEASUREMENT AND MAIN RESULTS: A high failure rate was reported in remodeling of the scar by other surgeries in women with retroflexed uteri. Clinical information was obtained from medical records. Because intermenstrual bleeding was a presenting symptom of CSD, duration of menstruation was compared between groups. Patients were required to be followed at 1, 3, and 6 months to record their menstruation situation and to measure the CSD. The thickness of the residual myometrium (TRM) in the retroflexion group was much thinner than that in the anteflexion group before treatment (2.5 ± 1.2 mm vs 2.9 ± 1.1 mm, p < .05). There was no statistical difference in pretreatment menstruation duration between groups (p > .05). The duration of menstruation in the anteflexion group was 8.2 ± 2.1 days and 8.5 ± 2.1 days and in the retroflexion group was 7.6 ± 2.0 days and 7.7 ± 3.1 days at 3 and 6 months after surgery, respectively (p < .05). In all 58.6% of patients (140/239) who had a retroflexed uterus, 60.0% (84/140) reached ≤7 days of menstruation at 6 months after surgery (p < .05). Although about 40% patients still had CSD after repair, menstruation duration and TRM were improved significantly (p < .05). CONCLUSION: We propose that vaginal repair can relieve symptoms and improve TRM for CSD patients, especially for those who have a retroflexed uterus. However, 40% of patients still had a defect postoperatively.

Transvaginal and transperineal ultrasound follow-up after laparoscopic correction of uterine retrodisplacement in women with posterior deep infiltrating endometriosis.

BACKGROUND: Retrodisplacement of the uterus (retroflexion and/or retroversion) may be associated with pelvic pain symptoms and posterior deep infiltrating endometriosis (DIE). Previous studies in symptomatic women with retrodisplacement of the uterus showed the efficacy of hysteropexy in terms of pain symptoms improvement. AIM: To evaluate sonographic, clinical and surgical outcomes of a hysteropexy technique MATERIALS AND METHODS: Laparoscopic round ligament plication and tilting of the uterine fundus in women with uterine retrodisplacement and posterior deep infiltrating endometriosis was performed. Forty-two symptomatic women were enrolled and the sonographic data of each (angle of uterine version and uterine flexion, uterine mobility) was assessed before and after surgery with transvaginal and transperineal approaches. Women were also evaluated at 1, 6 and 12 months after surgery for pain symptoms with a numerical rating scale (dysmenorrhoea, dyspareunia and chronic pelvic pain), intraoperative data and surgical complications. RESULTS: The additional mean operative time of hysteropexy procedure was 8 ± 3 min. At early follow-up both the uterine angles were significantly (P < 0.001) reduced. At 12-month follow-up, seven patients (16.7%) presented a retroverted uterus, while 12 (28.6%) presented a retroflexed uterus; the sliding sign remained negative in four patients (9.5%). A significant improvement of symptoms (P < 0.001) was observed during the follow-up. CONCLUSION: Laparoscopic hysteropexy appears as an effective additional surgical procedure, which can temporarily correct the uterine position in order to reduce the risk of postoperative adhesions.

New Laparoscopic Technique of Hysteropexy for Uterine Retrodisplacement: Bologna Technique.

STUDY OBJECTIVE: To show a new laparoscopic technique of hysteropexy for uterine retrodisplacement (retroversion and/or retroflexion). DESIGN: Narrated step-by-step explanation of the Bologna hysteropexy technique using descriptive text and an educational video. SETTING: Tertiary referred center of minimally invasive gynecology, Sant'Orsola Hospital, Bologna University. INTERVENTIONS: The Bologna hysteropexy is proposed as an additional procedure after surgical laparoscopic interventions for benign gynecologic disease. The technique consists of 2 semicontinuous absorbable sutures (Biosyn monofilament no. 1 [Covidien, Mansfield, MA] with 2/3 inch diameter needle, 36 mm) suspending the uterus to the anterior abdominal wall, through the plication and shortening of round ligaments. A knot is tied intracorporeally between the 2 free ends of the semicontinuous sutures, drawing a V shape figure and resulting in uterine ventrosuspension. CONCLUSION: The Bologna technique hysteropexy is simple and quick to perform. It is effective in suspending the uterus in anteverted and anteflexed positions at 6-month ultrasound follow-up. No perioperative complications were recorded. It can be done with a standard surgical suture-passer and does not add additional cost to surgery. Furthermore, an absorbable suture is desirable for fertile women.

Isthmocele in a retroflexed uterus: a report of an unrecognized case.

The term "isthmocele" refers to a niche on the anterior wall of the uterine isthmus or of the cervical canal at the site of a previous cesarean delivery scar. Such anatomic defect can cause many gynecologic sequelae that only recently have being identified and described. Hysteroscopy is commonly considered the gold standard for the diagnosis and also for the treatment, at least in the case of defects of small size. The authors described the case of a 37-year-old woman who underwent a cesarean section (CS) seven years before, with a long lasting history of menstrual irregularities, and pelvic pain increasing during menstruation at the hypogastric level. Magnetic resonance imaging (MRI) showed an exceptionally large isthmocele on the anterior wall of a retroflexed uterus which was otherwise misinterpreted as the uterine cavity filled with menstrual blood during a previous hysteroscopy (HSC). Although exceptional, this case highlights the possibility that a large sized isthmocele in a retroflexed uterus could be misinterpreted as the uterine cavity filled by menstrual blood at HSC. In this case MRI definitely clarified the diagnosis.

Anteverted retroflexed uterus: a common consequence of cesarean delivery.

OBJECTIVE: The purpose of this study was to determine in a sequential unselected sample of nonpregnant women whether an anteverted retroflexed uterine position develops after cesarean delivery and to see whether the amount of myometrial thinning related to cesarean delivery affects the development of an anteverted retroflexed uterine position. MATERIALS AND METHODS: Images from 641 consecutive transvaginal ultrasound examinations performed between 2008 and 2011 in which a uterus was present were reviewed and archived. The series was analyzed in three groups: patients who underwent cesarean delivery, patients who were parous but had not undergone cesarean delivery, and patients who were nulliparous. The uterine axis was categorized as anteverted, anteverted and anteflexed, retroverted, retroverted and retroflexed, anteverted and retroflexed, retroverted and anteflexed, and axial, that is, in the same axis as the vagina. RESULTS: An anteverted retroflexed uterine position was found in 27% of women after cesarean delivery. It was rare when no cesarean section had been performed, being found in 1% of those women, and was not seen in nulliparous women. CONCLUSION: An anteverted retroflexed uterine position is a common consequence of cesarean delivery but is rarely seen in other parous women.

[Anterior dislocation of a Incarcerated Retroverted Uterus at 21 weeks of amenorrhea : Case Report. ]. / Luxation antérieure d'un utérus rétroversé incarcéré à 21 semaines d'aménorrhée : à propos d'un cas.

BACKGROUND: An incarcerated uterus refers to the retroversion of a pregnant uterus within the pelvis due to the absence of a forward tilt at the end of the first trimester. An incarcerated uterus that is overlooked or only discovered perpartum can cause severe obstetrical complications. Several authors have shared their experience with uterine incarceration management at 12, 14, and 16 weeks of amenorrhea. CASE: Our report concerns a case of uterine incarceration management at 21 weeks of amenorrhea, achieved by way of a specific anesthesia protocol and the positioning of the patient, which allowed the disimpaction of the uterus with the help of external maneuvers. No recurrence was observed. CONCLUSION: Uterine incarceration management is possible beyond 16 weeks of amenorrhea.

Background: An incarcerated uterus refers to the retroversion of a pregnant uterus within the pelvis due to the absence of a forward tilt at the end of the first trimester. An incarcerated uterus that is overlooked or only discovered perpartum can cause severe obstetrical complications. Several authors have shared their experience with uterine incarceration management at 12, 14, and 16 weeks of amenorrhea. Case: Our report concerns a case of uterine incarceration management at 21 weeks of amenorrhea, achieved by way of a specific anesthesia protocol and the positioning of the patient, which allowed the disimpaction of the uterus with the help of external maneuvers. No recurrence was observed. Conclusion: Uterine incarceration management is possible beyond 16 weeks of amenorrhea.

Imaging and video of late preterm delivery by midline laparotomy due to incarcerated uterus: A case report and literature review of a rare but morbid condition.

Incarcerated gravid uterus (IGU) is a rare and serious obstetric complication. IGU is defined as the entrapment of the gravid uterus between the pubic symphysis and the sacral promontory. The incidence of IGU is 1 in 3000-10 000 cases. IGU is associated with significant obstetric complications, including preterm labor, intrauterine fetal death, growth restriction, renal failure, uterine ischemia/rupture and thrombosis. Here, we present the case of a primigravida with urinary retention at 14 weeks. On transabdominal ultrasound at 19+5/7 weeks the cervix was difficult to visualize, and the anterior uterine wall appeared thickened. The bladder was elongated superior to the uterus and the placenta was low-lying. Initially the patient was managed with intermittent self-catheterization, and subsequently indwelling catheterization was required from 22 weeks. At 30 weeks, the patient was transferred to a tertiary center and magnetic resonance imaging (MRI) was preformed due to challenging visualization of the cervix on ultrasound and the patient's continued symptoms of constipation and recurrent urinary infections. The MRI found a retroflexed gravid uterus, with vagina and endocervix displaced anteriorly and compressed by the gravid uterus. The findings were consistent with an incarcerated uterus. The patient subsequently had positive urinary cultures for Pseudomonas and rising creatinine. Given the obstructive uropathy and associated morbidity and mortality, a plan for elective pre-term delivery at 33+6/7 weeks was made. Delivery was by midline laparotomy, normal anatomy was restored after manual evacuation of the fundus from below the sacral promontory, and an uncomplicated lower segment transverse uterine cesarean section was performed.

Uterine retroversion and gluteal transposition flap for postoperative perineal evisceration after extralevator abdominoperineal resection.

Anal squamous cell carcinoma (ASCC) is the most common histological subtype of malignant tumor affecting the anal canal. Chemoradiotherapy (CRT) is the first-line treatment in nearly all cases, ensuring complete clinical response in up to 80% of patients. Abdominoperineal resection (APR) is typically reserved as salvage therapy in those patients with persistent or recurrent tumor after CRT. In locally advanced tumors, an extralevator abdominoperineal excision (ELAPE), which entails excision of the anal canal and levator muscles, might be indicated to obtain negative resection margins. In this setting, the combination of highly irradiated tissue and large surgical defect increases the risk of developing postoperative perineal wound complications. One of the most dreadful complications is perineal evisceration (PE), which requires immediate surgical treatment to avoid irreversibile organ damage. Different techniques have been described to prevent perineal complications after ELAPE, although none of them have reached consensus. In this technical note, we present a case of PE after ELAPE performed for a recurrent ASCC. Perineal evisceration was approached by combining a uterine retroversion with a gluteal transposition flap to obtain wound healing and reinforcement of the pelvic floor at once, when a mesh placement is not recommended.

The incarcerated uterus: a review of MRI and ultrasound imaging appearances.

OBJECTIVE: The objective of this article is to review the MRI and ultrasound appearances of incarcerated uterus. CONCLUSION: Incarcerated uterus is a rare but serious complication of pregnancy in which the gravid uterus becomes trapped in the posterior pelvis. Characteristic MRI and ultrasound imaging features enable definitive diagnosis of incarcerated uterus, which reduces risks of complications that can lead to maternal and fetal morbidity and mortality.

Accuracy of Transvaginal Ultrasonographic Diagnosis of Retroflexed Uterus in Endometriosis, with Magnetic Resonance Imaging as Reference.

BACKGROUND: Accurate diagnosis of retroflexed uterus in daily practice is essential because this condition is related to pelvic pain and deep endometriosis. Uterine flexion can be measured by transvaginal ultrasonography (TVUS), a cost-effective primary test, but the accuracy required for diagnosing retroflexed uterus is unclear. This study assessed the accuracy of TVUS for diagnosis of retroflexed uterus in patients with endometriosis and compared it with that of magnetic resonance imaging (MRI) -the gold standard for measuring the uterine axis. METHODS: The study included 123 patients who underwent endometriosis surgery in our department between 2012 and 2017. Uterine flexion angles were measured by retrospectively examining TVUS and MRI images, and the correlation was analyzed. Analysis of anteverted and retroverted uterine subgroups identified aspects of diagnosing uterine flexion with TVUS. RESULTS: Uterine flexion angles on TVUS were strongly positively correlated (r = 0.86) with MRI results. Additionally, TVUS yielded no false-positive diagnoses and 28 false-negative diagnoses of retroflexion. All false-negative diagnoses occurred in patients with anteverted retroflexed uteruses. CONCLUSIONS: TVUS was generally accurate for measuring uterine flexion angle, as indicated by its strong correlation with MRI. Misdiagnosis of anteverted retroflexed uterus was a limitation of using TVUS for retroflexion diagnosis.

Significance of pelvic magnetic resonance imaging in preoperative diagnosis of incarcerated retroverted gravid uterus with a large anterior leiomyoma: a case report.

BACKGROUND: Incarceration of the gravid uterus is a rare but serious complication of pregnancy. The often required cesarean section is technically complicated, and preoperative planning is critical. An important initial surgical step is to lift the fundus out of the pelvis prior to creating the hysterotomy in order to facilitate adequate visualization of the pelvic anatomy. CASE: A 38-year-old primigravida with uterine incarceration from a large anterior leiomyoma underwent cesarean delivery at 29 weeks' gestation. In this case, a failure of the fundal height to increase was not appreciated as the anterior leiomyoma was palpated to represent the fundus. Intraoperatively the uterus was unable to be repositioned because of the leiomyoma. However, the surgery did proceed smoothly primarily due to the highly detailed images obtained on pelvic magnetic resonance imaging. CONCLUSION: Although uterine incarceration is rare, knowledge of this condition is important. Magnetic resonance imaging is a useful tool in that it enables the detailed evaluation of the pelvic anatomy in cases with suspected uterine incarceration.

The transvaginal probe as a uterine manipulator: a new technique to simplify transabdominal chorionic villus sampling in cases with difficult access to the trophoblast.

OBJECTIVES: To evaluate the efficacy of using the transvaginal probe to manipulate the uterus and change the position of the trophoblast, and to simplify access to the chorionic villus under difficult conditions. METHODS: One thousand five hundred and thirty-nine procedures were performed in our centre in 1524 pregnant women from September 2006 to September 2009. In 90 of these, a difficult access to the trophoblast was observed and uterine manipulation under continuous ultrasound guidance with a double needle technique, was applied to obtain the sample. Of these, 86 samples were taken from singleton pregnancies and 4 from two bichorionic twin pregnancies RESULTS: One thousand five hundred and thirty-nine transabdominal chorionic villus sampling (TA-CVS) procedures were conducted on 1524 pregnant women. As many as 1449 were performed without manipulation with the transvaginal probe and in 90 cases the manipulation was carried out. In 89 cases, access to the trophoblast was difficult and the uterus was manipulated, which enabled an adequate TA-CVS to be performed with a single aspiration. In one case, TA-CVS was not performed due to significant pelvic pain in a patient with a fixed, retroflexed uterus and a previous history of endometriosis. CONCLUSIONS: Uterine manipulation with the transvaginal probe may be a useful solution in cases where TA-CVS is limited by difficult access to the trophoblast.

Efficacy of well-planned management in patients with incarcerated gravid uterus: A case series and literature review.

OBJECTIVE: Incarcerated gravid uterus is a condition in which uterine myoma and intraperitoneal adhesion lead to persistent uterine retroversion. Accurate diagnosis before cesarean section is crucial so that the procedure can be planned with regard to the spatial relationship between the uterine incision and other organs. This study investigated the effects of well-planned management on the outcome of cesarean sections. MATERIALS AND METHODS: Four patients with incarcerated gravid uterus who received well-planned management and preoperative magnetic resonance imaging were compared with three unexpected patients who were operated without preoperative diagnosis. RESULTS: In the preoperatively diagnosed group, compared with the non-preoperatively diagnosed group, the frequency of cervical canal damage tended to be lower (0% vs. 100%), blood loss tended to be less (1171 ± 290 mL vs. 2000 ± 300 mL), and surgery duration tended to be shorter (82 ± 17 min vs. 147 ± 84 min). None of the preoperatively diagnosed cases required allogeneic blood transfusion, and no organ damage was observed. CONCLUSION: The early detection of a suspected incarcerated uterus, and a thorough understanding of diagnostic methods and the use of preoperative magnetic resonance imaging and ultrasonography facilitate the safe performance of a cesarean section.

The value of ultrasound guidance during IUD insertion in women with RVF uterus: A randomized controlled trial.

OBJECTIVE: The study objective is to evaluate the benefits of using ultrasound guidance during insertion of Intrauterine device IUD in women with retroverted flexed RVF uteri. STUDY DESIGN: A randomized controlled trial conducted on 400 women with RVF uteri eligible for IUD insertion. They were randomly divided into 2 groups. Group 1 underwent IUD insertion under ultrasound guidance while in group 2 no ultrasound guidance was used. The primary outcome measure was the(Visual Analogue Scale) VAS pain score reported by the women during insertion. Other outcome included easiness of insertion, the procedure time and occurrence of complications as nausea, vomiting, abdominal cramps, failure of insertion, uterine perforation and bleeding. RESULTS: The VAS pain score was significantly lower (2.36 ± 1.77 vs. 4.74 ± 2.35, p < 0.001), the insertion was much easier (score 4.0 ± 0.9 vs. 2.5 ± 1.27, p < 0.001) and the time needed for the procedure was significantly shorter (5.82 ± 2.56 vs. 9.4 ± 4.99 min, p < 0.001) in women within the ultrasound guided group when compared to control group. The total rate of complications was significantly lower (6 vs. 16 %, p 0.001) especially bleeding (2 vs. 9%, p = 0.002), abdominal cramps (10.5 vs. 28 %, p 0.012) and failure of the procedure (0 vs. 3%, p = 005) in ultrasound guided group women when compared to control. CONCLUSION: Insertion of Intrauterine device IUD under ultrasound guidance in women with Retroverted flexed RVF uterus easier and less painful than the blind standard technique.