Diagnostic accuracy of three-dimensional hysterosonography versus hysteroscopy in the evaluation of endometrial pathology in infertile women

Transcription

1 Diagnostic accuracy of three-dimensional hysterosonography versus hysteroscopy in the evaluation of endometrial pathology in infertile women Poster No.: C-2602 Congress: ECR 2013 Type: Scientific Exhibit Authors: L. Torbati, F. Ahmadi, A. Abrishami; Tehran/IR Keywords: Genital / Reproductive system female, Ultrasound, Fluoroscopy, Hysterosalpingography, Diagnostic procedure, Contrast agentother, Hyperplasia / Hypertrophy DOI: /ecr2013/C-2602 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 12

2 Purpose The purpose of this study is To evaluated diagnostic accuracy of three-dimensional (3D) hysterosonography versus diagnostic hysteroscopy in evaluation of endometrial pathologies liable in infertile women. Furthermore, to comparison their preciseness in diagnosis of polyp or hyperplasia by determining their sensitivity and specificity regarding to histological diagnosis of resected endometrial tissue with hysteroscopy as the gold standard.traditionally hysterosalpingography (HSG) and Endovaginalsonography (EVS) are known as the first line investigation tools for diagnosis of uterine pathologies in infertility workup. 3Dhysterosonography and diagnostic hysteroscopy are currently introduced as investigation tools for diagnosis of uterine pathologies as well. HSG and TVS are not sufficient for distinguishing uterine lesions because of their low positive predictive value (PPV) and high negative predictive value (NPV).Diagnostic hysteroscopy is also inadequate for diagnosis of endometrial hyperplasia because of low sensitivity and low positive predictive value (PPV).But 3D hysterosonography is less invasive, cost effective and more available than diagnostic hysteroscopy. Methods and Materials In a cross sectional study one hundred and fourty two infertile woman were investigated by 3D hysterosonography followed by hysteroscopy within one to three months interval in Royan institute. Two experienced radiologists performed 3Dhysterosonography using 3DXI (ACCUVIX XQ,Medison, South Korea) and a 6.5-MHz Endovaginal probe.(figure 1)Hysteroscopy was performed by and experienced gynecologist and biopsy was done in the case of suspicious for polyp or hyperplasia. (Figure 2-4) Endometrial tissue specimens were mostly obtained by dilation and curettage (D&C) and in few cases specimens were obtained by hysteroscopy guided biopsy. In this study 3D extended imaging (3DXI), as a new display modality for 3D ultrasound was employed. It is comprised of Multi-Slice view and oblique view modes and has lots of advantages over conventional methods.(figure 5).for the purpose of performing 3D_SHG the patient underwent a baseline transvaginal sonography(tvs) first,the cervix is exposed with a sterile speculum after that and gently cleaned with betadin,a ballon-tipped silicone urine Foley catheter ( NO.6) is advanced through cervical canal and into lower uterine segment (without any cervical dilatation or application of local anesthetic).the balloon is then distended to 1-2 ml.after that the speculum is exchanged for an endovaginal ultrasound probe which is followed by instillation of 5-20 cc of sterile saline under direct ultrasound guidance till adequate distention of uterine cavity is obtained. Representative transverse and longitudinal images are obtained.the balloon is deflated at the end of procedure to allow for proper sonographic assessment of lower uterine segment. The entire procedure takes only about 6 minutes. Page 2 of 12

3 Three-Dimensional reconstruction helps possibility of access to infinite number of sections in every required plan and permits reproducibility of the measurements which is an efficient method to reduce the examination time helping patients in counter less pain and discomfort. The hysteroscopy was performed using Storz 4mm hyesteroscope (Karl.Storz-Gmbh and co.tttlingen,germany) by expert gynecologist. Distention of the cavity was obtained using a glycin serum. Images for this section: Fig. 1: 6 serial images of more than 250 images taken during sonohysterography. Taking these images which are like CT scan cuts take less than 5 seconds and the whole procedure is about 5 to 10 minutes Page 3 of 12

4 Fig. 2: Sagital image of 3D SHG which outlines a sessile anterior wall polyp Page 4 of 12

5 Fig. 3: 3D reconstructed image which shows 2 pedunculate polyps Page 5 of 12

6 Fig. 4: Focal thickening of endometrium due to endometrial polyp and diffuse thickening of endometrium due to endometrial hyperplasia proved during hysteroscopy and its histopathologic evaluation. Page 6 of 12

7 Fig. 5: Coronal reconstructed image shows thick echogenic bands due to uterine synechia which reassure us of the diagnosis already proved by sagital images Page 7 of 12

8 Fig. 6: short film of SHG. The endometrial cavity is filled by saline and the normal endometrium is outlined Page 8 of 12

9 Fig. 7: T2 sub mucosal fibroid is out lines by saline in this SHG Page 9 of 12

10 Fig. 8: In conventional TVS a thickened endometrial line is evident. After infusion of saline during 3D SHG the outlines of a polyp become apparent. Page 10 of 12

11 Results SHG hysteroscopy Polyp or Hyperplasia Sub mucosal myoma 7 7 Adhesion 6 6 Normal or congenital anomalies Total the results of SHG and hysteroscopy 142 hysterosonograms were reviewed in 142 infertile women [24-47 years, Mean 33.3±0.55]. 3Dhysterosonography had 95% sensitivity and 88% specifity for the diagnosis of endometrial pathologies leading to infertility. Of these 142 patients 100 had either one of the three pathologies and 42 were found to be either normal or having other pathologies leading to infertility such as congenital anomalies; while hysteroscopy could diagnose 7 more patients than sonohystergraphy,the results where the same for adhesions and submucosal myomas. Sensitivity 3D SHG 95.3 SHG diagnostic accuracy Specifity PPV NPV Conclusion 3D hysterosonography had the same diagnostic accuracy for detection of endometrial pathologies leading to infertility regarding to hysteroscopy as the gold standard.3d hysterosonography and diagnostic hysteroscopy both had exactly the same diagnostic accuracy for detection of endometrial polyps versus hyperplasia regarding histopathology as the gold standard. 3D sonohysterpgraphy allows for accurate assessment of intrauterine pathologies in infertile women and so can be a substitute for diagnostic hysteroscopy which is more Page 11 of 12

12 invasive. Hystrosonography is a simple, feasible, time efficient, cost benefit method for diagnosis of intrauterine lesions and so can be a substitute for diagnostic Hysteroscopy which is more invasive as the first line investigation tool for infertility. References Moty Pansky, MD, Michal Feingold, MD, Ron Sagi, MD, Arie Herman, MD, David Schneider, MD, and Reuvit Halperin, phd, MD: Diagnostic Hysteroscopy as a Primary Tool in a Basic Infertility Workup, JSLS Apr-Jun; 10(2): Brown SE, Coddington CC, Schnorr J, Toner JP, Gibbons W, Oehninger S : Evaluation of outpatient hysteroscopy, saline infusion hysterosonography and hysterosalpingography in infertile women: a prospective, randomized study. Fertil Steril. 2000; 74: Luo XM, Yang YM, Shi Q. Hunan Yi Ke Da Xue, Xue Bao :Hysterosalpingography combined with hysteroscopy-laporoscopy in diagnosing female infertility Aug; 28(4):421-3 Personal Information DR Firouzeh Ahmadi : Department of Reproductive Imaging, Reproductive Biomedicine Center, Royan Institute for Reproductive Biomedicine, ACECR, Tehran - Iran, <f_ahmadi@royaninstitute.org> Dr Leila Torbati : Tehran University of medical science,imam khomeini hospital,medical Imagng Center(MIC),Tehran-Iran, <lili.torbati@gmail.com> Dr Alireza Abrishami : Tehran University of medical science,imam khomeini hospital,medical Imagng Center(MIC),Tehran-Iran,<abr.alireza@yahoo.com> Page 12 of 12