S. Bózsa

Sexual Function after Modified Laparoscopic Vecchietti’s Vaginoplasty

STUDY OBJECTIVE To report on minor modification of laparoscopic Vecchietti vaginoplasty and to examine the quality of sexual life after the operation. DESIGN A retrospective study to examine the role of minor modification during laparoscopic Vecchietti operation to prevent injuries and to evaluate the sexual function of patients with neovagina. SETTING Department of Obstetrics and Gynecology, University of Pécs, Faculty of Medicine, a tertiary supply center in Hungary. PATICIPANTS: Twenty-three adolescents or young adults, ages 16 to 26 with vaginal agenesis (Mayer-Rokitansky-Küster-Hauser syndrome) were operated. Twenty-five sexually active patients with matched age served as controls. INTERVENTIONS Laparoscopic Vecchietti operation was modified with the use of endovaginal ultrasound transducer to visualize the narrow vesico-rectal space. The quality of sexual life 2-11 years after the operation was measured by the Female Sexual Function Index (FSFI). MAIN OUTCOME MEASURES Complications occurring during operations; desire, arousal, orgasm, satisfaction, lubrication, and pain during sexual intercourse. RESULTS The technical modification of the operation, with endovaginal transducer, improved the method. Serious injuries of the bladder or rectum could be avoided. Anatomic and functional results shown by the total FSFI scores did not differ from that of the control group. Desire, arousal, orgasm, and satisfaction of the operated patients were similar to controls; however, patients with neovagina tended to have less lubrication and more pain during sexual intercourse. CONCLUSIONS Laparoscopic Vecchietti operation modified by the use of endovaginal transducer is a safe procedure to create a neovagina, which guarantees good quality of sexual life with high satisfaction for patients.

Assessment of postoperative postvoid residual bladder volume using three-dimensional ultrasound volumetry.

The aim of our prospective study was to assess the concordance between postvoid residual volumes (PVR) of the urinary bladder obtained by two different three-dimensional (3-D) ultrasound (US) volumetric methods (VOCAL and XI VOCAL) and with measurement by the catheter in postoperative patients who have undergone radical hysterectomy. The 3-D sonographic volume-determination of PVR with both methods correlated significantly with the actual amount of PVR by the catheter. The accuracy of both 3-D US volumetric methods was significantly higher under 300 mL of PVR. Bland-Altman plots were generated to examine limits of agreement. Both noninvasive 3-D sonographic methods are appropriate for the correct volume-determination of PVR following radical hysterectomy. Thus, we may avoid routine, albeit often unnecessary, catheterization to measure postoperative residual bladder volumes and subsequently the incidence of lower urinary tract infection may be reduced and better postoperative comfort for patients may be permitted.

OP10.07: The effect of mydriatics on gastric emptying in preterm infants using three-dimensional ultrasound volumetry

Objectives: Amniotic fluid ‘sludge’ (AFS) has been linked to intraamniotic infection, increased rates of spontaneous preterm delivery, PPROM and short interval from ultrasound diagnosis to delivery. This observational pilot study aims to determine if management with broad-spectrum antibiotics and progesterone initiated at diagnosis could delay delivery in patients incidentally found to have extremely premature cervical shortening and the presence of AFS. Methods: From 2008 to 2010, 42 patients were diagnosed with extremely premature cervical shortening (≤ 15 mm) at routine ultrasound between 18–24 weeks’ gestation. Ten patients were excluded because of multiple pregnancy or fetal anomaly. The presence of AFS was identified in 17 of the 32 patients and these women were managed uniformly with bed rest, broad-spectrum antibiotics and progesterone initiated at diagnosis and followed prospectively until delivery. Patients without AFS did not receive antibiotics. Results: Mean gestational (GA) at diagnosis was 21.4 ± 1.9 weeks. The mean GA at delivery was 31.9 ± 6.0 (range 23.0–40.6) for patients without AFS and 35.1 ± 6.9 (range 21.9–41.4) weeks for patients with AFS (P = 0.16). The median delay from ultrasound diagnosis to delivery was 9.8 ± 6.2 (range 1.14–19.0) for patients without AFS and 14.3 ± 6.6 weeks (range 1.9–17.7) for patients with AFS. Conclusions: Though limited by small sample size, it appears that the outcome for women with very premature cervical changes and AFS treated with antibiotics and progesterone does not differ from those women with premature cervical changes without ‘sludge’. Antibiotic and progesterone therapy may improve outcome in these women who have been shown to have a very poor prognosis when treated expectantly or with cerclage. Future studies involving multiple centers are needed to better answer this question.

OP31.01: Duration of time for volume calculation using different slices of the XI VOCAL™ three‐dimensional ultrasound volumetric method in an in vitro setting

birth twice. There were no placental complications and no scar pregnancies. Of the women who had intact scars or small defects in their uterine scar detected by transvaginal ultrasound 2.3% (1/43) suffered uterine dehiscence or uterine rupture in their first delivery after the scan versus 23.1% (3/13) of the women with large defects (P = 0.035). Conclusions: Large defects in the hysterotomy scar after Caesarean detected by transvaginal ultrasound in non-pregnant women increase the risk of uterine rupture or dehiscence in subsequent pregnancy.

OP31.05: The accuracy and validity of the XI VOCAL™ three‐dimensional ultrasound volumetric measurement using an in vitro model

Objectives: To compare the pre-surgical ability of a multivariate predictive algorithm combining CA 125, HE4 and menopausal status (ROMA) vs. ultrasound (US) imaging performed by an experienced examiner, for estimation of the risk of malignancy in patients with adnexal masses. Methods: Prospective multi-center, double blind, clinical trial enrolling patients presenting with adnexal masses and candidate for surgical treatment. Blood samples for HE4 and CA 125 measurements and US were performed within 30 days prior to surgery. Masses were classified by US according to IOTA criteria: the examiner classified each mass as certainly or probably benign, difficult to classify, or probably or certainly malignant. A separate self impression of presumed histological diagnosis was given. Separate logistic regression algorithms for preand post-menopausal women were utilized to categorize patients into low and high risk group for ovarian cancer (ROMA). Outcome measures were sensitivity (Sens), specificity (Spec), positive predictive value (PPV) and negative predictive value (NPV) of ROMA, CA 125 and HE4 and US in discriminating adnexal masses. Results: To date 51 patients entered in the study. At final pathology there were 23 malignancies, 3 borderline tumors and 25 benign diseases. The different tests performed as follow: US (Sens 100%, Spec 89.3%, PPV 88.9%, NPV 100%), ROMA (Sens 91.3%, Spec 89.7%, PPV 87.5%, NPV 92.9%), HE4 (Sens 91.3%, Spec 89.3%, PPV 87.5%, NPV 92.6%), CA 125 (Sens 90.7%, Spec 57.1%, PPV 64.7%, NPV 88.9%. Conclusions: The algorithm ROMA has a similar accuracy in discriminating adnexal masses compared to HE4 and superior to CA 125 alone. US expertise opinion remains superior. Combination of biomarkers could offer an improvement in the preoperative triage of adnexal masses to centers of excellence.

OP39.11: The significance of prenatal detection of fetal growth restriction by the assessment of fetal limb-volume using XI VOCAL™ three-dimensional ultrasound volumetry

Objectives: Placental insufficiency and fetal growth restriction may lead to fetal hypoxia and acidemia, which result in fetal cardiac injury. The aim was to compare the levels of fetal cardiac troponin T (cTnT) at birth according to fetal gender in pregnancies complicated by placental insufficiency before 34 weeks gestation. Methods: Between March 2007 and Feb 2010, 45 singleton pregnancies with placental insufficiency characterized by abnormal umbilical artery Doppler were prospectively studied. All the patients delivered by Cesarean section and the Doppler exams were performed at the same day. Immediately after delivery, UA blood samples were obtained for fetal cTNT measurements. Fetal cardiac injury was characterized by abnormal level of fetal cTnT at birth (>=0.10 ng/mL). Results: Fetal cardiac TnT at birth was significantly higher in the group of male fetuses (n = 20, 44.4%) when compared with female fetuses (mean = 0.137, SD = 0.095 ng/mL vs. mean = 0.082, SD = 0.077 ng/mL, P = 0.041). In the group of male fetuses, Doppler results of ductus venosus (DV) showed values of DV PIV > 1.0 in 14 cases (70%), and in the group of female fetuses 12 cases (48%, P = 0.237). Conclusions: Fetal gender was associated with cTnT level at birth in pregnancies complicated by placental insufficiency before 34th weeks gestation. The fetal cardiac compromise and cardiac injury may be influenced by fetal gender, suggesting differences in the cardiovascular response to fetal hypoxia.

P27.07: Intrauterine intrafunicular treatment of nonimmune hydrops fetalis caused by fetal cardiomyopathia

Congenital cystic adenomatoid malformation (CCAM) is a rare lesion of the developing fetal lung consisting of increased cell proliferation in the bronchial structures with lack of differentiation of the alveoli. The incidence is estimated to be 13 : 100,000. The mortality rate for fetuses hydrops before 30 weeks has been reported from 66–100%. Case: A 26-year-old, G2, C1, was referred at 30 weeks with the diagnosis of hydrops. Ultrasound examination showed a 62 × 31 × 30 mm echogenic mass in the left lung, consistent with CCAM type III. Severe right mediastinal shift and fetal hydrops characterized by ascites, subcutaneous edema, pleural and pericardial effusion. Doppler studies showed tricuspid regurgitation. After extensive counseling, the patient agreed to FST with 3% Polidocanol and she gave informed consent. Institutional approval was obtained. Under ultrasound guidance, a 22-gauge needle was directed to the left fetal lung and 1 ml of Polidocanol was successfully injected into the CCAM. There was a significant left mediastinal shift. The fetus exhibited a normal heart rate following the procedure. Follow-up ultrasounds showed complete resolution of the hydrops within twelve days of the procedure. Lung mass remained same size. The patient was delivered by cesarean section at 39 weeks. A male infant was delivered, weighing 2,800 gr Apgar 7–8. After birth the infant developed respiratory distress and intubation was required and he was transferred to the NICU. The baby died 4 days later because of pulmonary hypertension.

P27.06: Successful intrauterine medical treatment of nonimmune hydrops fetalis caused by fetal tachyarrhythmia

Congenital cystic adenomatoid malformation (CCAM) is a rare lesion of the developing fetal lung consisting of increased cell proliferation in the bronchial structures with lack of differentiation of the alveoli. The incidence is estimated to be 13 : 100,000. The mortality rate for fetuses hydrops before 30 weeks has been reported from 66–100%. Case: A 26-year-old, G2, C1, was referred at 30 weeks with the diagnosis of hydrops. Ultrasound examination showed a 62 × 31 × 30 mm echogenic mass in the left lung, consistent with CCAM type III. Severe right mediastinal shift and fetal hydrops characterized by ascites, subcutaneous edema, pleural and pericardial effusion. Doppler studies showed tricuspid regurgitation. After extensive counseling, the patient agreed to FST with 3% Polidocanol and she gave informed consent. Institutional approval was obtained. Under ultrasound guidance, a 22-gauge needle was directed to the left fetal lung and 1 ml of Polidocanol was successfully injected into the CCAM. There was a significant left mediastinal shift. The fetus exhibited a normal heart rate following the procedure. Follow-up ultrasounds showed complete resolution of the hydrops within twelve days of the procedure. Lung mass remained same size. The patient was delivered by cesarean section at 39 weeks. A male infant was delivered, weighing 2,800 gr Apgar 7–8. After birth the infant developed respiratory distress and intubation was required and he was transferred to the NICU. The baby died 4 days later because of pulmonary hypertension.

OP16.02: The reproducibility of the XI VOCAL™ three-dimensional sonographic volumetry in the measurement of irregular-shape objects

Objectives: The purpose of this presentation is to describe the use of 3D volume-slice in prenatal diagnosis. Conventional 3D multislice allows simultaneous display of multiple sequential parallel planes while in 3D volume slice it is multiple sequential 3D or 4D rendered volumes that are simultaneous displayed on the screen. The render line offset distance between sequential images can be set from a minimum of 1 mm to a maximum of 5 mm and each volume displayed on the monitor can be rendered separately. In other words up to 7 volumes can be rendered using different algorithms and visualized side by side at the same time. Methods: Volume data were acquired prospectively from the mid-sagittal plane of the fetal spine and face in 15 fetuses at the second and third trimester. All volumes were acquired with Accuvix V20 (Medison) using 4–8 MHz transabdominal curved array mechanically driven probe. Results: The following information was able to be obtained from all volumes obtained (Number of ribs, anterior vertebral bodies, both nasal bones, the metopic suture) Conclusion: 3D volume-slice is a promising new tool in the visualization and analysis of fetal bony structures.

P13.07: In-vivo validation of the XI VOCAL™ three-dimensional sonographic volumetry with the assessment of urinary retention after radical hysterectomy

Objective: Postoperative urinary retention may develop after radical gynecologic operations. Dysfunction of the urinary bladder may cause urinary retention and increases the incidence of urinary tract infection. Sonographic (US) assessment of the postvoid residual volume (PRV) of the bladder is a non-invasive, reproducible method. Methods: The authors report on a 6-month prospective study of patients with cervical cancer who have undergone radical abdominal hysterectomy (n = 17) at the Department of Obstetrics and Gynecology, University of Pécs. They estimated the amount of postoperative PRV with two methods of three-dimensional (3D) US volumetry (VOCAL and XI VOCAL, n = 35) and with exact measurement of the PRV by the catheter. The authors compared the feasibility and accuracy of the two US-methods in in-vivo organvolume estimation and first validated the XI VOCAL method in an in-vivo setting. Results: Three-dimensional US volume determination of postoperative PRV with the application of the VOCAL and XI VOCAL methods correlated significantly with the actual amount of the PRV measured by catheterization (correlation coefficient 0.985 for VOCAL and 0.990 for XI VOCAL, respectively, p < 0.001). If the amount of PRV did not exceed 350 mls, the accuracy of the XI VOCAL method was superior to that of the VOCAL (correlation coefficient 0.980 for VOCAL and 0.994 for XI VOCAL, respectively, p < 0.001). Using a cutoff value of PRV ≥ 100 mls to eliminate the necessity of catheterization, both 3D-US methods had a specificity, sensitivity, positive and negative predictive values of 100%, respectively. Conclusions: In case of postoperative urinary retention following radical hysterectomy both non-invasive 3D-US methods are appropriate for the correct volume determination of PRV. Thus we may decrease the number of unnecessary urinary bladder catheterization, reduce the incidence of iatrogenic urinary tract infection, and permit a better postoperative comfort for patients.