Transvaginal Ultrasound None Guided Pelvic Procedures Tara Morgan, - - PowerPoint PPT Presentation

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Transvaginal Ultrasound None Guided Pelvic Procedures Tara Morgan, - - PowerPoint PPT Presentation

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10/28/2016 Disclosures Transvaginal Ultrasound None Guided Pelvic Procedures Tara Morgan, MD Assistant Professor of Radiology University of California San Francisco tara.morgan@ucsf.edu Pelvic masses and fluid collections are The

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10/28/2016 1

Transvaginal Ultrasound Guided Pelvic Procedures

Tara Morgan, MD Assistant Professor of Radiology University of California San Francisco tara.morgan@ucsf.edu

Disclosures

  • None

Pelvic masses and fluid collections are

  • ften deep and/or surrounded by bowel

The vaginal cuff is an additional “window” into the peritoneum

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10/28/2016 2

Bladder

Transabdominal vs. Transvaginal Procedures Types

  • Biopsy
  • Aspiration
  • Therapeutic Injection

Patient Selection

  • Planning is imperative
  • Diagnostic pelvic ultrasound prior to

procedure

  • Complication rate is very low
  • Usually given conscious sedation

Technique

  • Disposable

endocavity needle guide

  • Accepts up to

16-18G needle

  • Predictable

location of the needle on the image

programonline.civco.com

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10/28/2016 3

Biopsies

  • Access to the cervix, uterus, vagina,

posterior bladder, adnexa, parametrial/cul-de-sac

  • Indeterminate masses
  • Suspected cancer recurrence
  • Fine needle aspiration vs. core biopsy

Biopsy Case 1

63 year old history mullerian adenosarcoma

Biopsy

Case 1

Biopsy

Case 1

VC

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10/28/2016 4

Biopsy

Case 1

Biopsy

Case 1

Recurrent Mullerian Adenosarcoma

Biopsy Case 2

36 year old, ovarian cancer

Biopsy

Case 2

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10/28/2016 5

Biopsy Case 3

56 yo history of serous ovarian cancer

Biopsy

Case 3

High grade carcinoma

T1 T2 fat sat T1 post contrast fat sat

Biopsy Case 4

22 year old female with pelvic pain, referred for mass

Biopsy

Case 4

T2 T1 post contrast fat sat

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Biopsy

Case 4

Biopsy

Case 4

Case 4

Bladder Paraganglioma

Biopsy Case 5

64 yo pancreatic ca 7 years prior

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Biopsy Case 5

Metastatic pancreatic cancer

Drainage/Aspiration

  • Abscess (gyn vs. non-gyn)
  • Hemorrhage
  • Ovarian/Peritoneal inclusion cyst
  • Serous/Mucinous Neoplasm
  • Diagnostic versus symptomatic
  • Adjunct or alternative to surgery

Aspiration Case 1

44 yo fever and pelvic pain

Aspiration

Case 1

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Aspiration Case 1

Post

Aspiration Case 2

24 year old, prior TOA and endometriosis

T2 T1 fat sat post contrast

Aspiration

Case 2

Aspiration

Case 2

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10/28/2016 9

Aspiration Case 2

Recurrence required drain placement

Aspiration Case 3

55 yo history of vaginal cancer

PET/CT

Aspiration

Case 3

Aspiration

Case 3

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10/28/2016 10

Aspiration Case 3

Post

R squamous cell, L benign

Therapeutic Injection

  • Intra-amniotic injection for ectopic

pregnancy

  • Treatment of AVM, fistula

Therapeutic Injection Case 1

C-Section Ectopic

Transvaginal Methotrexate Injection

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10/28/2016 11

Therapeutic Injection Case 2

23 yo old, s/p D&C and uterine septum removal, AVF ++bleeding

T1 post contrast fat sat

Therapeutic Injection

Case 2

Therapeutic Injection

Case 2

Therapeutic Injection

Case 2

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Therapeutic Injection

Case 2

Arteriogram of the uterus

Therapeutic Injection

Case 2

T1 post contrast fat sat

Pitfalls

  • Poor screening tool
  • Prior radiation/scar tissue
  • Pelvic ascites
  • Technical factors

– Soft masses/collections – Bladder prolapse – Introduction of air BL

Pitfall Case 1

23 year old RLQ pain

T1 post contrast fat sat T2

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10/28/2016 13

Pitfall

Case 1

Pitfall Case 1 Soft Mass Pitfall Case 2

Pelvic Ascites/Fine Cystic Mass

Pitfall Case 3

40 year old with hx cervical cancer, ?infection vs recurrence

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10/28/2016 14

Pitfall

Case 3

Pitfall Case 3

2 months later

Pitfall Case 3

Missed Recurrence

Conclusion

  • Transvaginal ultrasound is a great

method to access deep pelvic lesions

  • Procedures include biopsy, aspiration,

and therapeutic injection

  • Some technical limitations can occur
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1) Transvaginal ultrasound has which advantage over CT?

  • A. Better screening/surveillance for

metastatic disease

  • B. Larger field of view
  • C. Superior resolution of pelvic

structures

  • D. Better visualization of bone
  • E. Better visualization through gas

filled structures

B e t t e r s c r e e n i n g / s u r v e i l l . . . L a r g e r f i e l d

  • f

v i e w S u p e r i

  • r

r e s

  • l

u t i

  • n
  • f

p e . . . B e t t e r v i s u a l i z a t i

  • n
  • f

b

  • n

e B e t t e r v i s u a l i z a t i

  • n

t h r

  • .

. .

0% 0% 3% 0% 97%

Ultrasound

Pyosalpinx

2) What finding may compromise safety of a transvaginal ultrasound guided biopsy?

  • A. Prior hysterectomy
  • B. Empty bladder
  • C. Pelvic Infection
  • D. Pelvic Ascites
  • E. EPrior radiation

P r i

  • r

h y s t e r e c t

  • m

y E m p t y b l a d d e r P e l v i c I n f e c t i

  • n

P e l v i c A s c i t e s E P r i

  • r

r a d i a t i

  • n

1% 3% 34% 59% 3%

3) How could this lesion best be sampled for diagnosis?

  • A) Transvaginally

with ultrasound

  • B) Ultrasound

guided percutaneous

  • C) CT guided

percutaneous

  • D) No safe access

with CT or ultrasound

  • E) Cystic and can not

be sampled

33 yo with hx of ovarian cancer

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10/28/2016 16

Percutaneous Approach

Transabdominal US Vaginal Cuff

Transvaginal

Recurrent low serous carcinoma

Tara.morgan@ucsf.edu