3D in 3D in GynGynUltrasound:Ultrasound: The Basics and ... · 3D in 3D in GynGynUltrasound:Ultrasound: The Basics and Applications WILLIAM W. BROWN, III, MD Director, Ambulatory

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3D in 3D in GynGyn Ultrasound:Ultrasound:The Basics and ApplicationsThe Basics and Applications

WILLIAM W. BROWN, III, MDWILLIAM W. BROWN, III, MDDirector, Ambulatory Ob/Director, Ambulatory Ob/GynGyn and Ultrasoundand Ultrasound

Denver Health Medical CenterDenver Health Medical Center

Associate ProfessorAssociate Professor, Dept. Ob/, Dept. Ob/GynGyn

University of Colorado School of MedicineUniversity of Colorado School of Medicine

Conflict of Interest DisclosureConflict of Interest Disclosure

Consultant—Philips Ultrasound

Learning ObjectivesLearning Objectives

BBehavioral objective: ehavioral objective: –– Incorporate 3Incorporate 3--dimensional pelvic ultrasound dimensional pelvic ultrasound

into practice where there are clear benefits to into practice where there are clear benefits to the technology the technology

Content:Content:–– The “ZThe “Z--technique” and the midtechnique” and the mid--coronal plane coronal plane

of the uterusof the uterus

–– Formatting Formatting –– MPR, rendered, inversion and MPR, rendered, inversion and tomographic views tomographic views

–– Technical tips to expand practiceTechnical tips to expand practice

33--D Ultrasound in GYND Ultrasound in GYN

Areas of clear benefit– Uterus and endometrium

• Müllerian uterine anomalies (CUA)

• IUD location/managementIUD location/management

• Sub-mucous myomas

• 3D sonohysterography (SIS)

• Essure micro-inserts

• Intrauterine adhesions (Asherman’s)

33--D Ultrasound in GYND Ultrasound in GYN

Areas of clear benefit– Fallopian tube

• Cornual/interstitial pregnancy

• HydrosalpinxHydrosalpinx

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22--Dimensional ImagingDimensional Imaging

Limitations – Scanning planes – two

• Sagittal

H i t l• Horizontal

– Bony structures of the pelvis reduce vaginal probe mobility

33--D Imaging D Imaging Orthogonal Planes

Th l f d t iPlane 3

The volume of data is displayed as three orthogonal planes at 90°to each other

Plane 1

33--D DisplayD DisplayWhat does it mean?

Acquisition view

90° toPlane 1

90° to bothPlanes 1&2

3-D Imaging Multi-planar (MPR) Views

Three MPR views displayed

Ability to

Plane 1 (A) Plane 2 (B)

Ability to – Slice through the

planes sequentially or rotate any plane

– Reconstruct the MPR views in different planes

Plane 3 (C)

3-D Imaging Rendered Volume

2-Dimensional Imaging3-Dimensional ImagingUterusUterus

Sagittal TransverseCoronalCoronal

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“Volume Data Set” Manipulation“Volume Data Set” ManipulationMultiMulti--Planar Reconstruction, RenderingPlanar Reconstruction, Rendering

33--D Ultrasound in GYND Ultrasound in GYNUterus and EndometriumUterus and Endometrium

Z-Technique1 for mid-coronal view – Board certified physicians already practicing

2-D TVS

1Abuhamad A. JUM 2006;25:607

– No prior exposure to post-processing 3-D volume data sets

– Mean time required to display the C-plane was 47.7 seconds

– Easy to learn!

Congenital Uterine Congenital Uterine AnomaliesAnomalies Congenital Uterine AnomaliesCongenital Uterine AnomaliesAccuracy Accuracy

3-D ultrasound as effective as MRI, but less costly and faster– Raga, F. Fertil Steril 1996;65:523

• 42 patients, infertility, LS and HS confirmation

• 11/12 correct anomaly diagnosis

• 41/42 correct external configuration of the uterus

– Kupesic S. J Ultrasound Med 1998;17:631• 420 patients, infertility or RPL, 278 septate uterus

• LS and HS confirmation

• Sensitivity 98.4%, specificity 100%

Congenital Uterine AnomaliesCongenital Uterine Anomalies

Septate


Septate

4


Septate


Arcuate


< 1 cm

Arcuate


T-Shaped

Congenital Uterine AnomaliesCongenital Uterine AnomaliesTechnical Tips Technical Tips

With TVS, consider late luteal phase timing– Sonohysterography (SIS) helpful, not mandatory

Uterine size/architecture may require moreUterine size/architecture may require more than one automated sweep or a handheld sweep– Alternative: horizontal plane of acquisition

Separate 3D imaging of the cervix

IUDIUD

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IUDIUD

Improved accuracy for IUD identification and positioning– Bonilla-Musoles F. J Clin Ultrasound 1996;

24:263 26724:263-267• 2D vs. 3D assessment of IUD location

• 2D: 10/66 either misidentified location/position or not seen

• 3D: all IUDs accurately identified—confirmed by hysteroscopy (HS)

IUDIUD

Ideal means to image myometrial side arm penetration– Benacerraf B. Ultrasound Obstet Gynecol

2009;34:110-115• 16.8% of 167 pts showed side arm penetration into

the myometrium and this finding only detected on 3-D coronal view of the uterus

• Higher proportion (75%) of pts with abnormal IUD location had pain or bleeding than those with normal IUD location (34.5%)

• 20/21 symptomatic pts with abnormal IUD location improved after removal

IUDIUD

Benacerraf B. Obstet Gynecol 2010;116:305-10

IUDIUD

Shipp T. J Ultrasound Med 2010;29:1453-6

IUDIUD

32 mm

Mirena® Paraguard®

36 mm

Skyla®

IUDIUD

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IUDIUD IUDIUD

IUDIUDTechnical Tips Technical Tips

Consider 3D sweep on all patients with IUD in-situ presenting for ultrasound

Rendered/slab/thick slice view may improveRendered/slab/thick slice view may improve contrast and detection of myometrial penetration

Should ‘best practice’ mean a 3D ultrasound before/after IUD insertion?

MyomasMyomas

MyomasMyomas MyomasMyomas

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3D SIS vs. 2D SIS 3D SIS vs. 2D SIS(Compared to Hysteroscopy)

HS Abnormal NormalSIS

Abnormal 19 3Abnormal 19 3Normal 1 22

3D-SISAbnormal 19 0Normal 1 25

de Kroon et al. J Ultrasound Med 2004; 23: 1433-1440

3D SIS vs. 2D SIS

Procedure time and patient comfort– Shortens procedure time and improves

patient satisfaction/comfort1

Weinraub Z. Ultrasound Obstet Gynecol 1996;8:277-282

Essure

Adhesions Fallopian TubeFallopian Tube

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Fallopian TubeFallopian TubeInterstitial Ectopic

Izquierdo, L. J Clin Ultrasound 2003;31:484-7

Malinowski A. Fertil Steril 2006;86:e1711-4

Tulandi T. Obstet Gynecol 2004;103:47-50

Fallopian Fallopian TubeTubeHydrosalpinxHydrosalpinx

Fallopian Fallopian TubeTubeInversion Rendering

Timor-Tritsch I. JUM 2005;24:681-88

ResearchResearchInfertility/ARTInfertility/ART

Infertility/ART

Cancer– Uterine

– Cervix

– Ovarian

Incontinence/pelvic floor– Vaginal, transperineal, endoanal

3D Ultrasound Limitations3D Ultrasound Limitations

“What you see is what you get”

Technology cost

Sonographer and physician learning curve

Decreased spatial resolution, especially outside of the plane of acquisition

Entire organ may not be in view with a single sweep and may require 2-3 volumes

Work flow changes in the ultrasound unit

SummarySummary

Short acquisition time for the test

Images may be manipulated in any plane

Multiple formats can be customized di t f d t taccording to preference and structure

under evaluation (e.g., MPR, rendered, thick slice/slab, tomographic display, etc)

Increase efficiency and patient satisfaction (3-D SIS)

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SummarySummary

“Doable” learning curve for data manipulation

Several areas within Gynecology where this technology has moved from thethis technology has moved from the research bench into clinical practice

The ongoing areas of research predict further expanded clinical uses for this imaging modality in the future

Case ExamplesCase ExamplesCase a p esCase a p es

Case #1Case #1

24 y/o, G0– LMP ~ 6 weeks prior; no contraception

– 2 day hx of moderately severe pelvic cramping and light vaginal bleedingcramping and light vaginal bleeding

– PMH, PSH – unremarkable– Physical exam

• 36° F, HR 84, RR 16, 134/83• Abdomen: non-tender, soft

– Laboratory• WBC 8.4, Hct 45%, A positive• UPT +, hCG 3183

Case #1Case #1 Case #1Case #1

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Ultrasound dx: – Left cornual pregnancy



Ultrasound dx: eccentrically located “angular” IUP

Interstitial pregnancy

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Case Case #2#2

17 y/o, G0– LMP ~ 2 weeks prior– Sudden, progressive, severe pain mostly L-

sided; seen 1 day prior at another hospital– Nausea, emesis, intolerant of oral analgesics– Menarche age 13 x 28 days x 4 days– PMH, PSH, ROS negative– Physical exam

• VSS; Abd – non-surgical; Pelvic – tender, no mass

– Laboratory• WBC 8.7, Hct 34%, UPT negative

Case Case #2#2

Hospital course– Report of outside ultrasound: possible

bicornuate uterus with normal right horn and a left horn “full of blood and debris”. Plan was for uterine evacuation if necessary.

– Treatment: IV anti-emetics and narcotic analgesics, non-steroidal analgesics, IV fluid hydration

– Imaging performed

Case Case #2#2 Case Case #2#2

Case Case #2#2 Case Case #2#2

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Case Case #2#2

Hospital course– Relapsing 10/10 pain, nausea, vomiting

– Surgery: laparoscopy with resection of left non-communicating functional uterine horn and leftcommunicating functional uterine horn and left salpingectomy

Case Case #2#2

Case Case #2#2 Case #3Case #3

31 y/o presented to PCP for annual exam. Only complaint = daily, mild, non-lateralizing pelvic discomfortpelvic discomfort.

IUD of unknown type placed elsewhere 3 years prior. Strings not visible on pelvic examination.

Patient desired IUD removal and fertility.


Brown W. The Female Patient 2011;36:37-39

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Case #3Case #3

Brown W. The Female Patient 2011;36:37-39

Case #3Case #3

Case #4Case #4

29 y/o, G5 P4, desiring sterilization– Essure tubal micro-inserts placed bilaterally

• “scar tissue at left ostea”scar tissue at left ostea

– HSG performed 3.5 mos later• Patient c/o chronic LLQ pain since procedure and

admitted significant discomfort during the procedure with placement of the left device only

Case #4Case #4


Documents

3D in 3D in GynGynUltrasound:Ultrasound: The Basics and ... · 3D in 3D in GynGynUltrasound:Ultrasound: The Basics and Applications WILLIAM W. BROWN, III, MD Director, Ambulatory