Title 5.G- 2020 - IMAGENES - PISO PELVICO. Clinical applications of pelvic floor imaging. Chernyak, V._ Bleier, J_.pdf ✅

Vol.:(0123456789) 1 3 Abdominal Radiology https://doi.org/10.1007/s00261-021-03017-8 PERSPECTIVE FROM THE SAR Clinical applications of pelvic foor imaging: opinion statement endorsed by the society of abdominal radiology (SAR), American Urological Association (AUA), and American Urogynecologic Society (AUGS) Victoria Chernyak1 · Joshua Bleier2 · Mariya Kobi1 · Ian Paquette3 · Milana Flusberg4 · Philippe Zimmern5 · Larissa V. Rodriguez6 · Phyllis Glanc7 · Suzanne Palmer8 · Luz Maria Rodriguez9 · Marsha K. Guess10 · Milena M. Weinstein11 · Roopa Ram12 · Kedar Jambhekar12 · Gaurav Khatri13 Received: 19 November 2020 / Revised: 21 February 2021 / Accepted: 25 February 2021 © The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature 2021 Abstract Pelvic foor dysfunction is prevalent, with multifactorial causes and variable clinical presentations. Accurate diagnosis and assessment of the involved structures commonly requires a multidisciplinary approach. Imaging is often complementary to clinical assessment, and the most commonly used modalities for pelvic foor imaging include fuoroscopic defecography, magnetic resonance defecography, and pelvic foor ultrasound. This collaboration opinion paper was developed by repre- sentatives from multiple specialties involved in care of patients with pelvic foor dysfunction (radiologists, urogynecolo- gists, urologists, and colorectal surgeons). Here, we discuss the utility of imaging techniques in various clinical scenarios, highlighting the perspectives of referring physicians. The fnal draft was endorsed by the Society of Abdominal Radiology (SAR), American Urogynecologic Society (AUGS), and the American Urological Association (AUA). Introduction Pelvic foor dysfunction is a broad term encompassing mul- tiple clinical conditions which may involve any combination of pelvic organs: the urinary bladder (urinary incontinence, voiding dysfunction), uterus, and vagina (sexual dysfunc- tion, vulvodynia, dyspareunia), rectum (fecal incontinence and disorders of defecation), and various degrees of pelvic organ prolapse. The symptoms vary in severity and depend on the organs involved. Patients may present with pelvic * Victoria Chernyak [email protected] 1 SAR DFP, Department of Radiology, Montefore Medical Center, The Bronx, USA 2 Department of Colorectal Surgery, University of Pennsylvania, Rockville, MD, USA 3 Division of Colon and Rectal Surgery, University of Cincinnati, Cincinnati, USA 4 SAR DFP, Department of Radiology, Westchester Medical Center (Valhalla, NY), Valhalla, USA 5 AUA, Department of Urology, University of Texas Southwestern Medical Center, Dallas, USA 6 AUA, Departments of Urology and Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA 7 SAR DFP, Department of Radiology, University of Toronto, Toronto, USA 8 SAR DFP, Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, USA 9 Walter National Military Medical Center (WRNMMC), Department of Surgery and National Cancer Institute, Division of Cancer Prevention (DCP), Gastrointestinal & Other Cancers Research Group, SSO and AACR, Bethesda, USA 10 University of Colorado Denver School of Medicine, Aurora, CO, USA 11 Massachusetts General Hospital Pelvic Floor Disorders Center, Boston, MA, USA 12 Department of Radiology, SAR DFP, University of Arkansas for Medical Sciences, Little Rock, USA 13 Department of Radiology, SAR DFP, University of Texas Southwestern Medical Center, Dallas, USA

Abdominal Radiology 1 3 or when patient’s symptoms are not explained by the MRD fndings. A major disadvantage of FD is the use of ionizing radiation. It should be noted that radiation exposure can be minimized with the use of pulsed fuoroscopy. Additional limitations of FD include the inability to directly visual- ize pelvic foor soft tissue anatomy, limited availability and expense of the specialized radiolucent commode required for the examination, and greater patient inconvenience due con- trast instillation into the urinary bladder, vagina, and rectum by three separate catheterizations in order to visualize those structures. In addition, oral contrast may be administered two hours prior to the onset of the study to improve the diagnosis of enteroceles, making this the longest total patient preparation time requirement of any of the pelvic foor imag- ing techniques. Finally, fewer physicians are comfortable performing and interpreting FD as a result of increased uti- lization of MRD over the past 2 decades. MR defecography MRD has evolved as one of the essential imaging tech- niques for pelvic foor dysfunction assessment [13–15]. It can simultaneously and non-invasively evaluate all pelvic foor compartments, and provide not only functional, but also anatomic information about muscles and ligaments with superior soft tissue contrast resolution, without use of ion- izing radiation, and with minimal patient discomfort [16, 17]. While anterior and middle (apical) compartment dys- function can be accurately diagnosed clinically, MRD may help diferentiate various types of posterior compartment pathology such as enteroceles, sigmoidoceles, peritoneoce- les, rectoceles, levator herniation and rectal intussusceptions and prolapse [18–21]. MRD is most commonly performed in the supine position in a standard 1.5T or 3T scanner. While upright open-bore scanners provide accurate assessment in a physiologic sitting position, the availability of such scanners is limited [22]. Although the supine position is not physiologic, MRD in the supine position and MRD in the sitting position demonstrate similar detection rates of clinically signifcant pelvic foor abnormalities [23]. While one study had shown that supine MRD may underestimate the degree of pelvic foor descent compared with clinical examination and FD performed in a sitting position, this study assessed only strain images, and did not include defecatory phase [12], and it is known that strain images underestimate the frequency and severity of pelvic foor abnormalities as compared with defecation images [24]. Endorectal contrast (e.g., ultrasound gel) is usually instilled to facilitate defecation, and to improve detection of pelvic organ prolapse and rectal intussusception [25]. The most important sequences in pelvic foor assessment with MRD are the dynamic portions of the study, consisting of imaging during a cycle of rest, squeeze, strain, and defeca- tion. The dynamic sequences are most commonly acquired using a steady-state-free precession sequence (BTFE/ FIESTA/trueFISP) in a mid-sagittal plane which includes the anorectal junction. Dynamic imaging during actual defecation is preferred over straining, when possible, and should be repeated several times to ensure adequate strain and defecation [17, 26]. As mentioned earlier, one of the strengths of MRI is its ability to provide high resolution images of the pelvic foor anatomic structures. MR can also be helpful in the evaluation of pelvic synthetic mesh implants, urethral bulk- ing agents, urethral slings, vaginal mesh, in particular for regions that are not optimally seen on pelvic foor ultra- sound, such as the superior aspect of vaginal mesh implants or the retropubic component of mid-urethral slings [27–29]. Inconsistencies in the literature regarding performance of MRD in various clinical scenarios are likely attributable to wide diferences in techniques, including patient positioning, choice of whether to use a defecation phase or only strain, and variation in applied reference lines/landmarks. Clinical exam describes prolapse in relation to the position of the hymen. This is in contrast to MRD, which most frequently uses the pubococcygeal line (PCL), marking the level of the pelvic foor, as a reference point. The hymenal position can be approximated on MRD by use of an alternate refer- ence line, the midpubic line (MPL) [30]. However, a recent literature review demonstrated no single reference line per- formed better for diagnosis of pelvic organ prolapse [16]. Additionally, a follow-up study on MRD showed the PCL to be the most reliable reference line with the highest intra- and interobserver reliability [31]. Therefore, it is reasonable to use the PCL in interpretation of MRD, with the understand- ing that imaging is providing complementary information and not acting as a replacement for clinical exam. Pelvic foor ultrasound Pelvic foor ultrasound is ofered in approximately 11% of radiology practices with pelvic foor imaging programs [32]. There are various techniques for ultrasound (US) of the pelvic foor, including translabial or transperineal, trans- vaginal, and endorectal/transrectal. Of these techniques, the most commonly performed technique employs a translabial or transperineal approach using a mid-frequency convex transducer, applied to the perineum. Translabial ultrasound is an emerging modality for the investigation of functional anatomy of the pelvic foor which can provide dynamic visu- alization of all three compartments [33, 34]. Images can be obtained as cine-loops at rest and during dynamic maneuvers such as strain or pelvic foor contractions. Recent advances in software capabilities permit rapid acquisition of data vol- umes which can be reviewed of-line and permit multiplanar,