Revisión pictográfica de las anomalías de los conductos de Müller por resonancia magnética / Pictographic review of Müllerian duct anomalies by magnetic resonance imaging

Las anomalías útero-vaginales o müllerianas son un grupo de patologías congénitas que se originan por un defecto del desarrollo, fusión o canalización de los conductos de Müller en la etapa embrionaria, excepcionalmente pueden deberse a una alteración adquirida. La mayoría se diagnostica en forma tardía, como resultado de estudios de infertilidad o complicaciones obstétricas tempranas o tardías. La resonancia magnética (RM) es un examen no invasivo, que no utiliza radiación ionizante, con una alta resolución de contraste, que permite la evaluación multiplanar de las malformaciones müllerianas, permitiendo su aproximación diagnóstica y caracterización, complementando otras técnicas de imágenes como la histerosalpingografía y la ecografía ginecológica. El radiólogo debe estar familiarizado con las alteraciones anatómicas de los genitales femeninos y su representación en RM permitiendo un diagnóstico diferencial apropiado, oportuno y en consecuencia, un tratamiento adecuado. Este artículo describe los hallazgos en este grupo de malformaciones según la clasificación de la American Fertility Society, la más utilizada en la literatura actual.

The uterus-vaginal or Müllerian anomalies are a group of congenital diseases that are caused by a developmental defect, merger or channeling of Müllerian ducts in the embryonic stage, exceptionally may be due to an acquired disorder. Most belatedly diagnosed as a result of studies of infertility or early or late obstetric complications. Magnetic resonance imaging (MRI) is a noninvasive test that does not use ionizing radiation, with high contrast resolution, which allows multiplanar evaluation of Müllerian malformations, allowing its diagnostic approach and characterization, complementing other imaging techniques such as hysterosalpingography and gynecological ultrasound. The radiologist should be familiar with the anatomical abnormalities of the female genitalia and its representation in MRI, allowing an appropriate and timely differential diagnosis, and consequently, an appropriate treatment.

Desfecho reprodutivo após septoplastia histeroscópica: estudo retrospectivo / Reproductive outcomes after hysteroscopic septoplasty: a retrospective study

OBJETIVO: Avaliar os resultados reprodutivos após septoplastia histeroscópica. MÉTODOS: Estudo retrospetivo observacional por meio de análise dos registos clínicos de 28 mulheres com antecedentes de infertilidade ou de abortos recorrentes, submetidas à septoplastia histeroscópica. Para a avaliação do desfecho reprodutivo foram consultados os registos informáticos dos Cuidados de Saúde Primários e do nosso Centro Hospitalar, no período compreendido entre a septoplastia e a primeira gravidez ou o presente. Os outcomes primários foram a taxa de gravidez, de recém-nascidos e de abortos após septoplastia. O septo uterino foi diagnosticado por ecografia 2D ou 3D e classificado de acordo com a classificação da American Fertility Society. A septoplastia foi realizada na fase folicular do ciclo menstrual, com recurso da energia monopolar, bipolar e/ou microtesoura. Os programas Microsoft Excel e SPSS versão 17 foram utilizados para comparação do desfecho reprodutivo prévio e posterior à septoplastia. Foi utilizado o teste exato de Fisher, considerando significado estatístico quando p<0,05. RESULTADOS: Foi realizada septoplastia histeroscópica em 20 doentes (72%) com infertilidade secundária e 8 (28%) com infertilidade primária, tendo sido necessária segunda intervenção para remoção completa do septo em 5 casos (18%). Ocorreu um caso perfuração uterina minor. Após septoplastia histeroscópica, 64% das mulheres engravidaram, obtendo-se uma taxa de nados vivos de 48%; gravidez tubária de 4%; e 19% das doentes tiveram abortos espontâneos. CONCLUSÕES: Os resultados do presente estudo estão de acordo com o descrito na literatura, tendo-se obtido uma melhoria significativa dos desfechos reprodutivos, com uma redução da taxa de aborto espontâneo de cinco vezes após a septoplastia histeroscópica. .

PURPOSE: To assess the reproductive outcomes after hysteroscopic septoplasty. METHODS: A retrospective observational study was performed with analysis of the medical records of 28 women with infertility or recurrent abortions undergoing hysteroscopic septoplasty. To evaluate reproductive outcomes we consulted the medical records of our hospital and of primary health care units between septoplasty and the present or first pregnancy. Primary outcomes were pregnancy rate, newborns, and abortions after septoplasty. Uterine septum was diagnosed by 2D or 3D ultrasound and classified according to the American Fertility Society. All procedures were performed in the follicular phase of the menstrual cycle using monopolar or bipolar energy and/or microscissors. To compare the reproductive outcomes before and after septoplasty we used Microsoft Excel and SPSS version 17. Fisher's exact test was considered statistically significant if p<0.05. RESULTS: Hysteroscopic septoplasty was performed in 20 patients (72%) with secondary infertility and in 8 patients (28%) with primary infertility. The septum was incompletely removed during the first hysteroscopy in 5 cases (18%), which required a second surgery. One case was complicated with minor uterine perforation. After hysteroscopic septoplasty, 64% of women became pregnant and 48% live neonates were delivered; 4% of the patients had a tubal pregnancy; and 19% had miscarriages. CONCLUSIONS: The results of this study are consistent with those described in the literature. Patients obtained a significant improvement of reproductive outcomes with a fivefold reduction in miscarriage rate after hysteroscopic septoplasty. .

Síndrome de Mayer-Rokitansky-Kuster-Hauser (SMRKH): relato de caso / Syndrome Mayer-Rokitansky-Kuster-Hauser (SMRKH): case report

Relata-se o caso clínico de paciente feminino, 46 anos de idade, que procurou, há 21 anos, atendimento médico, após várias tentativas frustradas de engravidar. Não havia levado em consideração que sua menarca não tinha acontecido, o que ocorreu talvez à sua pouca informação. Trata-se da síndrome de Mayer-Rokitansky-Kuster-Hauser. A obtenção do diagnóstico exigiu intensa propedêutica, como ultrassonografia abdominal total e pélvica endovaginal, laparotomia exploradora e urografia excretora. Não há consenso quanto ao melhor acesso terapêutico. A paciente não foi submetida a qualquer das formas terapêuticas.

We report a case of female patient, 46 years old, who began to seek medical attention at age 25, after several failed attempts to become pregnant. Still did not take into account that her menarche had not occurred. This fact is perhaps due to little information about the patient. This is the syndrome of Mayer-Rokitansky-Kuster- Hauser. Obtaining the required extensive diagnostic workup, as USG total abdominal + pelvic endovaginal, laparotomy and intravenous urography. Currently there is no consensus on the best therapeutic access. The patient was not subjected to any form of treatment.

Comparison of Transvaginal Ultrasonography with Hysterosonography as a Screening Method in Patients with Abnormal Uterine Bleeding

OBJECTIVE: To assess the utility of hysterosonography (HS) as a screening method in patients with abnormal uterine bleeding. MATERIALS AND METHODS: We retrospectively reviewed transvaginal ultrasonography (TVS) and HS for 105 patients whose diagnosis was confirmed pathologically. All 105 patients were initially evaluated on the same day with both TVS and HS. On TVS and HS examination, endometrial cavitary lesions were classified as diffuse hyperplasia, endometrial polyp, endometrial cancer, uterine synechia and submucosal leiomyoma. Hysteroscopy with biopsy (n=35), curettage (n=60) or hysterectomy (n=10) was performed, and the results of TVS and HS examination were correlated with the pathological findings. RESULTS: The sensitivity and specificity were 79.0% and 45.8% for TVS, and 95.1% and 83.3% for HS, respectively. The positive and negative predictive values were 83.0% and 39.3% for TVS, and 95.1% and 83.3% for HS, respectively. Twenty-seven showed a discrepancy between the TVS and HS, and eight cases showed a discrepancy between HS and the pathologic diagnosis. CONCLUSION: TVS is a sensitive method to evaluate the endometrial cavitary lesions, but it often does not provide the physician with sufficient diagnostic information. With its higher sensitivities, specificities and positive and negative predictive values, HS can be better used than TVS in evaluating those patients with abnormal uterine bleeding.

Assessment of the Depth and Extent of Myometrial Invasion in Uterine Adenomyosis Using MRI

PURPOSE: To determine the detection rate of MRI in the diagnosis of adenomyosis and ascertain the accuracy of MRI in assessing the extent and depth of the myometrial invasion. MATERIALS AND METHODS: By retrospective analysis of MR images of the pelvis in 65 pathologically proven cases of uterine adenomyosis, we investigated the detection rate and differences of in the detection rate when this was based on (a) the extent, and (b) the depth of myometrial invasion. The condition was classified as diffuse or focal according to the extent of invasion, and mild, moderate, or severe according to its depth. RESULTS: Pathologically, there were 35 cases of focal adenomyosis (53.8%), and 30 of diffuse adenomyosis (46.2%). Among patients with the focal variety of this condition, 12 cases were mild, 14 were mild, 14 were moderate, and nine were severe, while among those with the diffuse variety, two were mild, ten were moderate and 18 were severe. A total of 48 cases (73.8%) were detected on MR images; the detection rate of focal adenomyosis was 60.0% (21/35) and that of diffuse adenomyosis was 90.0% (27/30). The detection rates of mild, moderate, and severe adenomyosis were 42.9%(6/14), 79.2%(19/24), and 85.2% (23/27), respectively. Among the 48 cases detected on MR images, the pathologic and MR findings were consistent with regard to both the extent and depth of myometrial invasion in 26(54.2%). For diffuse adenomyosis, the consistency rate was higher than for the focal variety (81.5%, 22/27; compared with 19%, 4/21). The extent of myometrial invasion was correctly evaluated in 32 cases (66.7%); the consistency rate for the diffuse form was higher than for the focal form [96.3% (26/27), compared with 28.6% (6/21)]. In 42 cases (87.5%), the depth of invasion was correctly evaluated, though differences in this depth were not significant. CONCLUSION: MR imaging was a useful imaging modality in the diagnosis of uterine adenomyosis. With regard to the extant of mymetrial invasion, the detection rate was higher among cases of the diffuse form than of the focal form, and with regard to depth, the rate was higher among moderate and severe cases than among mild ones. These findings may be useful for preoperative diagnosis based on clinical symptoms, and provide important yardstick for decisions as to whether hysterectony should be replaced by an alternative therapy.

CT and MR Imaging Findings of Cystic Adenomyosis of the Uterus: Report of Three Cases

Adenomyosis of the uterus is a relatively common gynecologic disease characterized by the presence of ectopic endometrial glands and stroma within the myometrium. Small cystic spaces (not larger than several mil-limeters) are invariably present, and these are filled with blood. Extensive hemorrhagic cystic adenomyosis,however, is rare, and there have been very few radiologic reports of this condition. We describe the CT and MRI features of three cases of histologically confirmed huge cystic adenomyosis.

Differential Diagnosis of Bicornuate and Septate Uterus : Is Comparison of Septal Signal Intensity on MR Image Useful?

PURPOSE: To evaluate the usefulness of comparison of the signal intensity of uterine septum in the differential diagnosis of bicornuate and septate uterus on magnetic resonance (MR) imaging. MATERIALS AND METHODS: Preoperative MR imaging findings of surgically proven 5 bicornuate and 6 septate uteri were retrospectively analyzed. Because preoperative differential diagnosis of both was possible in all cases in terms of the intercornual distance, external contour of uterine fundus, and divergent angle of two uterine cavities, these criteria were excluded in this study. The signal intensity of uterine septum in patients with bicornuate and septate uterus was analyzed on T1-weighted and fast spin echo T2-weighted images obtained in the axial and coronal planes, using a 1.5-T MR scanner. The signal intensity of uterine septum especially on T2-weighted images was compared with that of myometrium or junctional zone. RESULTS: The signal intensity of uterine septum in patients with bicornuate uterus (n=5) and septate uterus (n=6) was similar to that of myometrium in all cases on T1-weighted images. The septum of bicornuate uterus (n=5) on fast spin echo T2-weighted images was isointense with myometrium in three and hypointense in two cases. The uterine septum of septate uterus (n=6) on T2-weighted images was isointense with myometrium in two, hypointense in two, and isointense with or more hypointense than junctional zone in two cases. No patient showed different signal intensity between upper and lower uterine septum. CONCLUSION: Because the MR signal intensity of the uterine septum in bicornuate or septate uterus is variable, it should not be used alone in the differential diagnosis of them. In these clinically important differentiation, therefore, comprehensive analysis of MR findings in terms of the external contour of uterine fundus, intercornual distance, divergent angle of two uterine cavities, in addition to the signal intensity of the uterine septum, should be considered.

MR Imaging of Asherman's Syndrome in Patients With and Without Uterine Anomalies: Comparison withHysterosalpingography

PURPOSE: To assess the role of MR imaging in the detection of Asherman's syndrome, especially whenthis is associated with a congenital uterine anomaly. MATERIALS AND METHODS: MR images were obtained in thesemicoronal plane parallel to the long axis of the uterus in 11 patients. Dilatation and curettage involving thein-sertion of an intrauterine device was performed in all patients, and transabdominal metroplasty was performedin four with uterine anomaly. MR imaging findings we r e compared with those of hyste rosalpingograhy in all patients and compared with sur-gical findings in four. RESULTS: The MR findings of uterine synechiademonstrated in nine of 11 patients were focal thickening of the uterine junctional zone (n=2), hypointense fociin the en-dometrium (n=1), or both these findings (n=6). Seven of the 11 patients had associat-ed uterineanomalies, which were demonstrated in all seven by MR imaging. In four of the seven, HSG failed to demonstratethese anomalies. CONCLUSION: MR imaging satisfactorily demonstrated intrauterine lesions in nine of 11 patientswith Asherman's syndrome, and was especially helpful in demonstrating associated uterine anomalies.

Intrauterine Filling Defects on Hysterosalpingography Correlation with Hysteroscopic Findings

PURPOSE: To describe various hysterosalpingographic (HSG) findings of intrauterine lesions, and to determinethe correlation of these with their hysteroscopic findings. MATERIALS AND METHODS: This study involved 100patients who during a 23-month period underwent both HSG and hysteroscopic examinations. The HSG findings werecategorized as intrauterine adhesion, endometrial polyp, myoma, or 'other', and were correlated with hysteroscopicfindings and histologic diagnoses. RESULTS: Diagnoses based on HSG findings were intrauterine adhesions (n=80),endometrial polyps (n=8), myomas (n=10) and 'other' (n=2). The hysteroscopic diagnoses of these patients wereintrauterine adhesions (n=68), endometrial polyps (n=11), myomas (n=4), and 'other' (n=17). HSG and hysteroscopicdiagnoses were consistent 72 patients (72%). CONCLUSION: Lesions presenting as filling defects on HSG sometimesshow nonspecific or overlapping findings and the normal uterus may produce defects of this kind which mimicklesions.

MR Imaging of Focal Cervical Edema Mimicking Carcinoma: A Case Report

We describe the MR findings in a patient with stage-I carcinoma confined to the posterior lip of the uterinecervix, a "mass-like", separate, localized area of edema developed in the anterior lip. preoperative MR imagingcould not distinguish edema from tumor, through MR imaging of the surgical specimen edema from tumor on accountof the higher signal intensity of the former. Histopathologic correlation is illustrated.

Uterine Didelphys with Blind Hemivagina, Hematocolpos, Ipsilateral Renal Agenesis (UD-BHRA) and BilateralOvarian Tumors: A Case Report

Uterine didelphys is a congenital malformation characterized by the presence of two separated hemiuteri andhemivaginas, due to lack of midfusion of the Mullerian ducts. We report a case of UD-BHRA(uterine didelphys withblind hemivagina and ipsilateral renal agenesis), a rare type of uterine didelphys charaterized by symptomaticunilateral hematocolpos due to blind hemivagina after menarche and ipsilateral renal agenesis. The MRI findings in22-year-old woman with bilateral ovarian tumors demonstrated two separated uterine horns and cervical and vaginalcanals, with left hematocolpos and left renal agenesis.

MR Findings of Mayer-Rokitansky-Kuster-Hauser Syndrome: Two Cases Report

Magnetic resonance imaging (MRI) was used to study Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome in two 21-year-old women. In one case MRI revealed that fluid filled an area of the uterus measuring about 4 x 4cm, but that the ovaeies were normal ; in the other case, a rudimentary uterus and normal ovaries were seen. MRI is useful both in the planning of surgical management and in evaluating the details of pelvic anatomy and uterine morphologic characteristics.