E. Zupi

Preoperative sonographic features of borderline ovarian tumors

To determine the sonographic findings that distinguish borderline ovarian tumors (BOT) from both benign and invasive malignant tumors, thus allowing conservative treatment and laparoscopic management of these tumors.

Ultrasound‐assisted laparoscopic cryomyolysis: two‐ and three‐dimensional findings before, during and after treatment

To investigate the role of two‐ and three‐dimensional (2D and 3D) ultrasound and power Doppler before, during and after surgery in monitoring the effects of uterine fibroid laparoscopic cryomyolysis.

OC19.04: Sonographic evaluation of posterior deep pelvic endometriosis: endovaginal-, transrectal- and vaginosonography to assess the extension of the disease: Oral communication abstracts

‘‘If only we could see what is really going on in there’’ has been one of reproductive biology’s great wishes. Ultrasonography has provided us with a tool for visualizing many aspects of human reproduction that we could only dream about a few short years ago. One of the most useful aspects of ovarian imaging would be the ability to predict the probability of conception based upon a simple, noninvasive examination. Although this wish is not currently available, it might not be as far from practical application as we might think. The current focus of attention in ovarian imaging in infertility therapy is directed at three distinct areas of inquiry. They are 1) assessment of the ‘‘ovarian reserve’’, 2) prediction of the ovarian response to exogenous superstimulation and 3) correlation of follicle imaging characteristics and oocyte quality. There is no consensus on a test for ovarian reserve that might allow an accurate prediction of the remaining reproductive lifespan for individual women. The methods now vary from the assessment of age and various hormone levels on a standardized day of the menstrual cycle, response to different hormonal challenge tests and estimates of ovarian volume and antral follicle counts. A difficulty with the imaging based portions of these assessments are that the number of antral follicles in the ovaries varies dramatically over the menstrual cycle, we do not yet know how to determine prospectively the ovarian follicular wave pattern that a women may express and that there does yet appear to be a standardized means of determining the number of follicles in different diameter categories. Currently accepted estimates of the number of follicles detectable with ultrasonography for estimation of ovarian reserve range from 8 to 12; however, recent data from detailed studies may be interpreted to mean that 18 to 32 follicles may be anticipated on Day 3.

Reply to the comment on “Deep endometriosis: less is better” by Wattiez et al

We appreciate the letter by Wattiez et al and thank them for their careful review and comments on this important, albeit controversial, subject. We would like to restate why we believe that with “deep infiltrative endometriosis, less is indeed better”. Deep infiltrating endometriosis (DIE) is a complex disease often associated with severe pain, dyspareunia, dysmenorrhea, and occasional bowel and urinary symptoms. Although surgery frequently improves pain symptoms and enhances the chances of pregnancy, it involves complex and advanced surgical skills, not possessed by most gynecologic surgeons, and is associated with potentially disastrous complications. Even in the hands of some of the most skilled gynecologic surgeons, the complication rates associated with the surgical management of DIE are high, and include perforation of the posterior vagina in 13.6%, enterotomy and bowel resection in 6.3%, late bowel perforation and peritonitis in 3%, and ureteral transaction in 0.5% of cases (1). For these patients who experienced life-threatening complications, even when operated by the best gynecologic surgeons, less would have been better. The major point of our editorial was that excisional surgery for DIE is not an option for all gynecologic surgeons, especially for less skilled surgeons in whose hands both the risk of serious complications and rates of disease recurrence may be unacceptably high. We disagree with Wattiez et al that DIE is only a surgical disease. In many cases, medical management of endometriosis adequately suppresses the patient’s symptoms and restores normal quality of life and function, without the risks and expenses of surgery. Finally, like medical therapy, surgery is not always curative, and is often associated with recurrence of symptoms and the need for repeated surgeries (2). The diagnostic criteria mentioned in our editorial (anamnesis, clinical evaluation, and imaging) are necessary in order to better counsel the patient regarding the therapeutic options available to her, including the potential need for a multidisciplinary surgical approach, which may involve bowel, bladder, and extirpative surgery, about which the patient needs to be fully informed before deciding for or against surgery (3, 4). Although Dr. Wattiez and a small number of gynecologic surgeons worldwide may have the skills and surgical privileges to perform bowel and urologic surgeries, few gynecologic surgeons have the skill or the surgical permission to operate on nongynecologic organs. Hence the need for a multidisciplinary surgical approach for DIE, which frequently involves nongynecologic organs. Furthermore, it is not difficult for young general surgeons and urologists to learn the surgical management of endometriosis resection of the bowel, bladder, and ureter. We have known Dr. Wattiez for several decades and admire his excellent and unequalled laparoscopic surgical skill; perhaps in his hands, “better may be best.” But the majority of gynecologic surgeons do not possess his surgical skills, and our editorial was directed at them, reminding them that sometimes “less is better” and to avoid excessive surgical enthusiasm, especially by some young gynecologic surgeons affected by the “me too syndrome.” Such an aggressive surgical approach can be dangerous, not helpful, and frequently harmful. Let us remember our pledge to our patients: “Primum non nocere.” We thank Dr. Wattiez et al for giving us the opportunity to better clarify and expand on our editorial.

OC10.01: Rectal deep endometriosis: transrectal approach with transvaginal probe to assess the infiltration of rectal mucosa

Objectives: Pulsed tissue Doppler is a technique to record fetal myocardial wall movements with extremely high temporal resolution. Applicable measurements of cardiac performance indexes as TD-Tei Index or mechanical atrioventricular conduction times require knowledge of the exact length of cardiac time intervals as short as 30–50 ms. This requires meticulously fine tuning of the ultrasound parameters and high performance ultrasound equipment.The effect of two different ultrasound machines used to record fetal cardiac tissue Doppler traces on the results was analysed. Methods: Fetal cardiac tissue Doppler traces where obtained on 176 patients, who attended our institute for routine ultrasound scanning for fetal abnormalities or routine assessment of fetal growth. Ultrasound equipment used was either: Philips IU22, vision 2009 (P) or General Electrics E8, BT08 (G). Td-Tei index, the corresponding z-scores, medians and variance where compared. Results: Mean TD-Tei Index was 0.597 (P) and 0.587 (G) variance of TD-Tei Index was 0.009 and 0.008 mean Z-score of TD-Tei Index was 0.167 and −0.115 variance of Z-score of TD-Tei Index was 0.984 and 0.826 mean isovolaemic contraction time was 50.54 and 51.17 variance of isovolaemic contraction time was 116.4 and 109.3 mean isovolaemic relaxation time was 48.28 and 52.12 variance of isovolaemic relaxation time was 70.68 and 93.54 Conclusions: There where only minor differences in the means for fetal cardiac time intervals and their corresponding indices. In the variance of parameters measured with the two different ultrasound systems there were also no significant differences. The used equipment in our setup did not influence the results.

OC11.04: Three dimensional evaluation of adenomyosis: correlation of sonographic findings to histology

Methods: Observational cohort study of 804 patients. Two consecutive cohorts of 402 women undergoing SIS or GIS at the department Bleeding Clinic were included. Patients characteristics, ultrasound features, technical failure rates and final diagnosis (based on endometrial sampling, hysteroscopy and/or surgery) were compared. Pathology was defined as hyperplasia, polyps, intracavity myomas and carcinoma. Results: Mean age was 50.7 years (SD 12) and 50.2 years (SD 11.6) in the SIS and GIS group (NS). In the SIS group 12.7% were nulliparous and 53% premenopausal versus 17.4% and 57.2% in the GIS group (NS). Technical failure rate was 5.0% for SIS versus 1.9% for GIS (difference between proportions 0.03; CI [0.0054-0.0588]). Failure due to inadequate distension was 1.5% versus 0.3% for SIS and GIS (difference between proportions 0.01; CI [−0.02 0.03]). Pathology was diagnosed in 180 (49%) patients of the SIS group versus 147 (40.2%) of the GIS group (difference between proportions 0.09; CI [0.02-0.16]). The LR+ and LR− of a lesion during contrast sonography was 4.03 and 0.28 for SIS and 3.9 and 0.19 for GIS, respectively (NS). The sensitivity was 77.8% and 85.0%, respectively (NS). The negative predictive value was 79.1% for SIS and 88.6% for GIS (difference between proportions 0.095; CI [0.02-0.17]). Conclusions: The technical failure rate, partly due to unstable filling of the uterine cavity and transcervical backflow, was less for GIS. The diagnostic accuracy of GIS was comparable with SIS. We conclude that GIS is a feasible and accurate alternative for SIS in the evaluation of periand postmenopausal women with abnormal bleeding.

OP05.01: Three‐dimensional Coded Contrast Imaging: a new ultrasound approach to evaluate tubal patency

recruitment was completed. Multiplanar mode was used for volume reconstruction by 2 examiners who did not know the 2D NT measurements. 3D NT values in each position (random or neutral) were compared to those obtained with 2D ultrasound. We compared percentages of concordance between 2D and 3D using Fisher’s exact test. According to inter-observer variability described in the literature, we accepted a variation between NT of 0.40 mm. Then, we determined the Spearman correlation coefficients between 2D and 3D for the 2 examiners for each fetal position. Results: The concordance between 2D and 3D was superior when the acquisition was made in ‘‘neutral position’’ compared to ‘‘random position’’; 87% versus 77.7% for the first examiner (P = 0.25) and 97% versus 66.7% for the second one (P < 0.05). When the acquisition was made in ‘‘neutral position’’, correlation coefficients between 2D and 3D were 0.75 and 0.56 for the two examiners versus 0.43 and 0.46 for ‘‘random position’’. Conclusions: In order to obtain valid 3D NT measurements, we found 3D volume acquisition to be more reliable when fetus is in neutral midsagittal position. However, further investigation with larger sample of patients, is needed before 3D NT measurement is included in a first trimester Down syndrome screening program.

OC023: Sonographic evaluation of deep pelvic endometriosis: Endovaginal‐, transrectal‐ and vaginosonography to assess the extension of the disease

S. Guerriero1, L. Savelli2, F. P. G. Leone3, A. A. Lissoni4, A. C. Testa5, T. Bourne6, L. Valentin7, D. Timmerman8, C. Van Holsbeke9 1Department of Obstetrics and Gynaecology, University of Cagliari, Cagliari, Italy, 2Reproductive Medicine Unit, Department of Obstetrics and Gynecology, Bologna, Italy, 3DSC L. Sacco, Università di Milano, Milan, Italy, 4Clinica Ostetrica e Ginecologica, Ospedale S. Gerardo, Università di Milano Bicocca, Monza, Italy, 5Instituto di Clinica Ostetrica e Ginecologica, Universita Cattolica del Sacro Cuore, Rome, Italy, 6Department of Obstetrics and Gynecology, St George’s Hospital, London, United Kingdom, 7Department of Obstetrics and Gynecology, Malmö University Hospital, Lund University, Malmö, Sweden, 8University Hospitals Leuven, Leuven, Belgium, 9Ziekenhuis Oost-Limburg, Genk, Belgium

OC181: Characterising borderline tumours of the ovary

Objective: To investigate the natural history and outcome of fetal cystic adenomatoid malformation (CCAM) of the lung diagnosed by routine ultrasound scanning at 18–23 weeks’ gestation. Patients and Methods: This was a retrospective study of all cases of fetal CCAM of the lung diagnosed at 18–23 weeks of gestation. All cases were referred to a tertiary centre for further management. A computer search was made to identify all referred cases, and the records of these patients were examined to determine the pregnancy outcome. Results: In a four year period, 32 cases of fetal CCAM were referred for further management. At presentation, all the cases were noted to be unilateral CCAMs and the majority (75%) were microcystic in nature. The CCAMs were complicated by varying degrees of mediastinal shift (81.2%), hydrops fetalis (12.5%) and polyhydramnios (12.5%). During the course of the pregnancy, the lung lesion was seen to reduce in size or resolve spontaneously in 75% of cases without any prenatal intervention (including resolution of hydrops in three cases). One pregnancy was terminated for persisting hydrops fetalis and another resulted in a late neonatal death from complications of neonatal cardiac surgery to an associated aortic coarctation. Conclusion: The outcome of antenatally detected CCAM is much better than previously reported even when complicated by hydrops fetalis at presentation. The latter seems to be related to the high spontaneous regression rate of this tumour. Despite the antenatal resolution of CCAMs on ultrasound, postnatal followup is recommended in view of the long-term complications of this malformation.

OC103: Laparoscopic cryomyolysis: 2D and 3D sonographic and color flow Doppler appearance before, during and after treatment of uterine fibroids

This complication occurs mainly in women (3%) over the age of 45. From an economical point of view, embolization is a valuable alternative to surgery mainly because of a shorter hospital stay and faster recovery. A sufficient number of fibroid embolizations have been carried out and the results published to date strongly indicate that this is a viable alternative to hysterectomy and multiple myomectomy for symptomatic women.