Echographie en saline infusion (SIS) of Hydrosonografie Symposium GYNECHO VVOG 24 mei 2007 M. Dhont UZ-Gent Ter Elst, Edegem 24 mei, 2007

Historiek en Terminologie Nannini et.al. 1981: echohysteroscopy Parsons en Lense 1993: sonohysterography Hysterosonography Saline hysterosonography Saline sonohysterography Saline infusion sonohysterography (SIS) Saline infusion ultrasonography Ultrasonohysterography Hydrosonografie Ter Elst, Edegem 24 mei, 2007

Techniek van de hydrosonografie Transvaginale echografie Ontsmetten vagina en portio Insertie flexibele catheter of balloncatheter (bij openstaand ostium) Inspuiten fysiologisch water tot distensie van het cavum uteri Ter Elst, Edegem 24 mei, 2007

Two ways to perform a sonohysterography : with or without a balloon, with on the right the balloon visible in the lower part of the uterine cavity. NEXT Ter Elst, Edegem 24 mei, 2007

Materiaal voor hydrosonografie Speculum Ontsmetting Catheter Mülly zuigcatheter CH 6, 53 cm, - 0,19 € Paediatrische Foleysonde CH 6 - 8,16 € Fysiologisch water - 2,00 € Spuit van 20 cc of 60 cc Prestatienummer: TVS (469593) 21.80 € Hydrosonografie (431410) 27,64 € Ter Elst, Edegem 24 mei, 2007

Indicaties hydrosonografie Onduidelijke visualisatie van het cavum uteri Verdikt endometrium Abnormaal uterien bloedverlies Monitoring behandeling met tamoxifen Endocavitaire afwijkingen Placentaire resten endometriumpoliep submuceuze myomata Infertiliteit Asherman syndroom Invasiediepte endometriumcarcinoom Ter Elst, Edegem 24 mei, 2007

Betere visualisatie van het cavum uteri A seemingly uniformly thickened endometrium is confirmed on SIS. In this patient with active bloodloss TVS does not attribute much to the diagnosis, while SIS shows several bloodclots in the cavity. NEXT Ter Elst, Edegem 24 mei, 2007

Exploratie verdikt endometrium In this patient TVS already gives a strong suspicion of a polyp. This diagnosis is easily confirmed on SIS, and operative hysterocopy is performed. NEXT Ter Elst, Edegem 24 mei, 2007

Exploratie defectbeeld op hysterosalpingografie Ter Elst, Edegem 24 mei, 2007

Saline contrast hysterosonography in abnormal uterine bleeding: a systematic review and meta-analysis De Kroon et al, BJOG 2003; 110: 938 Assessment of diagnostic accuracy of SIS in abnormal bleeding 24 studies, including 2.227 procedures Results Sensitivity 95% Specificity 88% Likelihood ratios: 8,23 and 0,06 Conclusion SIS is an accurate method for evaluation of the uterine cavity in case of abnormal uterine bleeding Feasibility is high (premenopausal (95%) > postmenopausal (85%) SIS can become the standard diagnostic procedure in women with abnormal uterine bleeding Ter Elst, Edegem 24 mei, 2007

Postmenopauzaal bloedverlies Ter Elst, Edegem 24 mei, 2007

Postmenopauzaal bloedverlies TVS can not differentiate between a hyperplastic endometrium or a polyp, while on SIS a polypoid mass arising from the anterior wall can be easily identified. It proved to be a carcinoma. NEXT Ter Elst, Edegem 24 mei, 2007

Endometriumcarcinoom Ter Elst, Edegem 24 mei, 2007

Hyperplasie vs poliep Ter Elst, Edegem 24 mei, 2007

A systematic review of transvaginal ultrasonography, sonohysterography and hysteroscopy for the investigation of abnormal uterine bleeding in premenopausal women Farquhar et al (Cochrane Menstrual disorders and Subfertility Group) Acta Obstet Gynecol Scand 2003; 82: 493 19 studies which met the stuy criteria (reference standard of histopathology) Both sonohysterography and diagnostic hysteroscpy have excellent diagnostic accuracy for diagnosing submucous fibroids Due to heterogeneity of the studies, pooled likelihood ratios were not available for the detection of endometrial hyperplasia or carcinoma Transvaginal sonography followed by sonohysterography if TVS is suggestive of intrauterine abnormalities should be further investigated Ter Elst, Edegem 24 mei, 2007

Saline infusion sonography and office hysteroscopy to asses endometrial morbidity associated with tamoxifen intake Garuti et al, Gynecologic <Oncology 2002; 86: 323 66 asymptomatische postmenopausale vrouwen onder tamoxifen en endometrium > 4mm op TVS Procedure SIS Hysteroscopie en endometriumbiopsie Diagnoses Cystische atrofie (33%) Poliep (15%) Hyperplasie (10,5%) Submuceus myoom (3%) Conclusie: de diagnostische accuraatheid van ambulante hysteroscopie is hoger dan die van SIS bij asymptomatische patiënten onder tamoxifen Ter Elst, Edegem 24 mei, 2007

Verdikt endometrium onder Tamoxifen Ter Elst, Edegem 24 mei, 2007

Een poliep of een myoom? Ter Elst, Edegem 24 mei, 2007

Ter Elst, Edegem 24 mei, 2007

Cost-effectiveness of transvaginal and saline infused sonography in the evaluation of menorrhagia Dijkhuizen et al, Int J Gynecol&Obstet 2003; 83:45 Decision analysis comparing the percentage of patients successfully treated and cost of different evaluation strategies Hormonal treatment without investigation Balloon ablation without investigation TVS and therpeutic hysteroscopy Diagnostic and therapeutic hysteroscopy SIS for all patients was superior over immediate diagnostic hysteroscopy Conclusion: SIS is recommended as the procedure of first choice in the work-up of women with menorrhagia Ter Elst, Edegem 24 mei, 2007

Preoperative assessmenrt of submucous myomas Leone et al, Fertil Steril, 2003; 79: 998 Ter Elst, Edegem 24 mei, 2007

Side effects and complications of sonohysterosalpingography Dessole et al, Fertil Steril 2003; 80:620 1.153 procedures in pre- and postmenopausal women Indications: uterine bleeding, thick endometrium, infertility, mullerian abnormalities, Asherman syndrome Feasability: 93% Side effects Moderate pain and/or vasovagal reaction : 8,8% Fever and/or peritonitis (0,95%) Ter Elst, Edegem 24 mei, 2007

Hydrosonografie: conclusies Aanvulling van de TVS in geval van: Verdikt endometrium Onvoldoende visualisatie van het endometrium Endocavitaire afwijkingen Primaire indicatie bij Menorragie en abnormaal uterien bloedverlies Pre-operatieve evaluatie van een submuceus myoom Andere indicaties: infertiliteit, endometriumcarcinoom, Asherman syndroom, congenitale uterusafwijkingen.. Nog onvoldoende evidentie Veilig, eenvoudig, goedkoop en betrouwbaar Nog ondergewaardeerd!! Ter Elst, Edegem 24 mei, 2007