武功密笈

小黃藏書

1. Imaging of the Upper Urinary Tract

Hydronephrosis, renal stones, renal parenchyma

Obstructive and non-obstructive hydroureters – Doppler ultrasound

Completer visualization of ureter – retroperitoneal course and bowel contents

Genitourinary anomalies: aplasia, hypoplasia, horseshoe kidney, confirmed by radiology.

2. Sonographic Measurement of Bladder Volumes

Not reliable for bladder volumes < 50 ml

1. TAS: = H x W x D x 0.7 (error 21%)
2. TVS: = 5.9 x H x D – 14.6

1. Sonographic Urethrocystography and Genuilne Stress Incontinence

GSI: 1. Anatomic alterations

2. Type of surgery

1. Surgical results and postop complications
2. Techniques: (depends on the availability of the ultrasound probe)

1. Endosonographic: vaginal, rectal
2. External: perineal, introital, transabdominal

1. Results

1. quantative:

1. retrovesical angle β
2. position of int urethral orifice: two methods

Key landmark: pubic bone and central line of symphysis

1. qualitative:

1. bladder neck funneling
2. position and motility of urethra and bladder base

6. Vaginal Ultrasound:

a. alternative to videocystourethrography

b. inc in MUP, FUL, PTR, if probe inserted 2 cm into the vagina

7. Rectal ultrasound

8. Perineal and Introital Sonography, not alter anatomic relationship, not affected by straining, can be used in severe genitourinary prolapse.

1. Perineal: transducer on the perineum, Kohorn 1986, linear-array or curved-array scanner
2. Introital: transducer just between the labia minora underneath the external urethral orifice, Koelbl 1989, vaginal sector scanner
3. Unstable bladder: wavelike bladder contraction + bladder neck opening
4. Inadequate emptying after overzealous urethropexy
5. Uncoordinated emptying in DSD
6. Successful colposuspension: more atnerior, although not necessarily more elevated of urethrovesical junction.

1. Ultrasound and the Pelvic Floor: evaluation of pelvic floor function

1. extent of displacment, movement of intrapelvic structures by FROZEN pictures at rest and at maximal effort.
2. Study results:

1. Bladder neck significantly elevated after pelvic floor trailning,
2. Dec in pelvic floor contraction power 1 wk after delivery, and recover 6 wks after delivery

1. Demonstrating the vagina, the rectum, the anorectal angle and various pathological conditions such as enterocele, rectocele or enterorectocele – different compartmental defects; limiting factor: extensive pelvic floor relaxation

1. Ultrasound in the Assessment of Bladder Wall Displacement and Infiltration

1. Vaginal ultrasound:

1. Mobility of bladder wall against the vaginal ultrasound probe in the region of the anterior vaginal fornix à exclude infiltration
2. Accuracy: sono: 95%; CT: 76%; cystoscopy: 86%; MRI: 80%

1. Cystosonography:

1. rotation scanner with a range of 360 ^o, 6 MHz, introduced via a 24 Fr resectoscope, preceded by cystoscopy (avoiding inadverting bleeding from urethral stricture or bladder tumors)
2. detect edema and/or tumor invasion of the bladder mucosa ß à tumor spread
3. deep layer of bladder mucosa ß à cystoscopy: superficial changes
4. biopsy under direct ultrasound control

1. intraurethral Ultrasound (IUUS)

1. 20 MHz
2. urinary incontinence (sphincter itself):

Kirschner-Hermanns et al:

1. negative correlation between the external urethral sphincter (area and circumference) ß à grade of incontinence
2. In no pateitnts with normal urinary continence was the sphincter reduced in size

1. urethral diverticula

1. identification of the size and orientation
2. the extent of periurethral inflammatiion
3. diverticular thickness
4. the distance between the diverticular wall and urethral lumen
5. 3 D Ultrasound:

Khullar et al: 5 MHz:

1. All women with urethral sphincter incontinence has a continuous hypoechoic area from the bladder neck to the urethral meatus
2. Severe GSI had breaks in the continuous circle of the rhabdosphincter, replaced by hyperechoic areas—damage to urethral sphincter

A. Diagnosis: relevant structures of the female pelvis

1. enterocele is detectable
2. upright position—measurred in a physiologic way
3. dynamic assessment, provocation tests, for research and quantification for quality control
4. German Association of Urogynecology:

1. Reference: pubic bone, central line and inferior border
2. Two different ways:

1). Creighton: pubourethral line, the distance and the angle between central line

2). Schaer et al: xy coordination system: central line and its perpendicular line at the lower border of symphysis

1. Funneling by Echovist (Ultrasound contrast medium)
2. Urge incontinenc: Khullar et al, bladder wall thickness > 5mm, a sensitive screen method for DI (without outflow obstruction)
3. + UD à functinal anatomy of the urethrovesical junction

B. Therapy

1. hypermobile urethra à Burch or Cowan procedure
2. immobile urethra with low intraurethral resting pressure à sling, injection
3. biofeedback tool for pelvic floor re-education

An excellent imaging modality for many pelvic structures of interest to urogynecologist

1. Different Scanning Approaches – clinical Value

1. external (perineal or introital) ß à endoacvitary (transvagial or transrectal)
2. not used for d/d of urinary incontinence,
3. with UD data à select the appropriate surgical technique by including the topographical situation: vertical, rotational descent or fixed bladder neck
4. Urethrovesical angle and vertical distance of the internal urethral meatus to the lower brim of the symphysis bone correlated significantly with the clinical degree of urinary incontinence.

1. Visualization of Pelvic Floor Muscles

1. Movements of intrapelvic structures during pelvic floor muscle contraction physiologically: more cranial rather than a ventral direction when the attachment of the urethra by the pubourethral ligaments and the puborectalis sling are intact
2. Coughing results in fast and caudally oriented movement
3. Extent of displacment à degree of insufficiency of the urethrovaginal attachments or their active fixation
4. Parametes for clinical and research purpose:

1. frozen images
2. videotaping

1. Rhabdosphincter, smaller in GSI
2. Helpful in pelvic floor training programs:

1. by identifying the static and functional disturbance;
2. by easy visualization of the movement and action of the different muscle groups and organs to the patient, thus having potential as a biofeedback method for pelvic floor re-education;
3. by objective comparison of changes before and after pelvic floor exercises;
4. in the future measurement of muscle thickness and other parameters;

1. Doppler Imaging

1. Thickness and length
2. Echoguiding of a needle: injection and EMG
3. Urethral pulse: a hyperechogenic beat localized near the intraurethral catheter at the spot where the sphincter sheath is thickest
4. Submucous vascular plexus: arteriovenous anastomoses, 1/3 of urethral pressure
5. Blood flow measurements within the bladder wall are reduced at volumes > 30 ml
6. Color Doppler ureteric jet: the distance of the ureteric jet origin from the midline correlated with vesicoureteric reflux
7. Blood flow in the fundus of the bladder in patients with DI and in young women

1. Summary and Outlook

1. advantage: no ionizing radiation used
2. more detailed information about the urethra and periurethral tissues by 3D and

intraluminal high-frequency ultrasound

3. color Doppler:

1. the effect of menopausal changes on the submucous plexus
2. identifying DI: blood flow in the fundus of the bladder