may be the only route to the cecum. Similarly, we speculate that the use of the T-fastener system provides adequate additional security and that fecal spillage will not occur in association with percutaneous cecostomy. This systern also allows placement of drainage catheters larger (up to 24-30 F) than previously reported. The importance of large-bore catheters and vigorous mngation has been emphasized in the sungery literature on tube cecostomy (4,6).
Because
of the
of the
fecab
thickness
stream,
are more likely In summary,
and
smaller
to clog. cecal distention
Intraoperative with Transrectal C. Fleischer, S. Burnett, J. Murray, W. Jones
terms:
854.12981 Ultrasound 854.32
Gynecology,
(US) Uterine
#{149}
854.12981
From
guidance neoplasms, US
the
Nashville,
TN
1, 1990;
revision
#{149} Uterine
neoplasms,
US studies,
studies,
Departments
854.12981
March
#{149} Radiology
of Radiology
and Gynecology (A.C.F., Radiation Oncology University Medical Center,
37232-3274.
reprint requests , RSNA, 1990
576
studies, intraoperative.
1990; 176:576-577
(A.C.F.), Obstetrics L.S.B., H.W.J.), and (M.J.M), Vanderbilt
received
(US),
#{149} Uterus,
Radiology
I
US
#{149} Ultrasound
requested 19; accepted
Received
March April
anterior
This
abdominal
insertion, is likely allows
we think to be great-
a direct
6.
anterior
as the larger
im-
7.
U
8.
1.
ly distended
Jackson PP. Baird RM. Cecostomy: an analysisof l02cases. AmJSurg 1967; 114:297-301. Johnson CD, Rice RP, Kelvin FM, Foster WL, Williford ME. The radiologic evaluation of gross cecal distension: emphasis on cecal ileus. AJR 1985; 145:1211-1217. Bode WE, Beart RW, Spencer RJ, CuIp CE, Wolff BC, Taylor BM. Colonoscopic decompression for acute pseudoobstruction of the colon (Ogilvie’s syndrome): report of 22 cases and review of the literature. Am J Surg 1984; 147:243-245. Goldstein SD, Salvati EP, Rubin RJ, Eisenstat TE. Tube cecostomy with cecal extraperitonealization in the management of obstructing left-sided carcinoma of the large intestine. Surg Gynecol Obstet 1986; 162:379-380. Groff W. Colonoscopic decompression and
2.
3.
4.
5.
Intrauterine
9.
10.
11
.
12.
13.
cecum.
Radiology
sonography (TRS) is used extensively for evaluation of the prostate. Its use in women, howeven, has not been fully described, except in a few reports involving a small numben of patients (1,2). We describe the use of TRS for intnaoperative placement of an intrauterine tandem for the purpose of intracavitary radiation thenapy for cervical carcinoma and as guidance for directed dilation and curettage in
complicated
BIPLANE TRANSRECTAL
cases.
Figure
Before
and
Methods
the transnectal
probe
was in-
serted, it was sterilized with a bacteniostatic and vinustatic spray (Sporocidmn International, Rockville, Md). A condom was secured over the probe with rubber bands, and gel was spread on the outer condom surface for adequate coupling. After the probe was in place within the rectum, approximately 30 mL of water was introduced within the condom for adequate transmission. TRS was then performed, initially in the sagittal plane, followed by confirmation in the axial plane (Fig 1). The procedune was observed in real time with both the longitudinally and axially onented transducers contained within a biplanar, 5.0-MHz tnansrectal probe (Toshiba America Ultrasound, Tustin, Cabif).
Representative
Cases
17. Address
old
158:793-
RANSRECTAL
Materials
to A.C.F.
1986;
794. Haaga JR. Bick RJ, Zollinger RM. CT-guided percutaneous catheter cecostomy. Gastrointest Radiol 1987; 12:166-168. Brown AS, Mueller PR, Ferrucci JT. Controlled percutaneous gastrostomy: nylon Tfastener for fixation of the anterior gastric wall. Radiology 1986; 158:543-545. Cope C. Percutaneous subhepatic cholecystostomy with removable anchor. AJR 1988; 151:1129. Schwartz SI, Storer EH. Principles of surgery. 4th ed. New York: McGraw-Hill, 1984; 1037. Crass JR. Simmons RL, Frick MP, Maile CW. Percutaneous decompression of the colon using CT guidance in Ogilvie syndrome. AJR 1985; 144:475-476.
Procedures
February
12; revision
intubation of the cecum for Ogilvie’s syndrome. Dis Colon Rectum 1983; 26:503-506. Hoffmann J, Jensen HE. Tube cecostomy and staged resection for obstructing carcinoma of the left colon. Dis Colon Rectum 1984; 27:2432. Kukora JS, Dent TL. Colonoscopic decompression of massive nonobstructive cecal dilation. Arch Surg 1977; 112:512-517. Casola C, Withers C, vanSonnenberg E, Herba MJ, Saba RM, Brown RA. Percutaneous cecostomy for decompression of the massive-
References
T
MD MD MD III, MD
the
abdominal approach, as well mediate insertion of catheters than previously described.
Guidance for Sonography’
Transrectal sonography was used for intraoperative guidance in intrauterine tandem placement for intracavitary radiation therapy and in dilation and Curettage procedures. The authors describe the method and three representative cases in which it was applied. It is concluded that the technique may prevent complications such as uterine perforation or bladder injury in tandem placement, and that it can facilitate dilation and curettage in complicated cases. Index
to
by reduced.
to a di-
to surgical or endoscopic When the cecum is sim-
Arthur Lonnie Michael Howard
affixed
wall before catheter the risk of spillage
viscosity catheters
ameter of greater than 10 or 12 cm is a common problem in hospitalized patients and may lead to bowel rupture. Percutaneous cecostomy is an attractive
alternative management.
ply
Case 1.-The patient woman with stage
was “b
a 72-yearsquamous
ly oriented
Diagram
shows
scanning
planes
transducer.
carcinoma of the cervix who had meceived a dose of 4,000 cGy of external irradiation
before
being
admitted
for
tandem and ovoid placement. Initial attempts at sounding the cervical canal were unsuccessful (Fig 2a, 2b). The cenvix had been replaced by a necrotic ulcerative tumor that extended into the upper vagina, night parametnium, and uterosacral ligament. TRS guided initial sounding of the cervix and, after dilation of the cervical canal, final placement of the tandem (Fig 3a, 3b). TRS helped confirm the central location of the tandem in both long and short axes. Case 2.-The patient was a 78-yearold
cell
1.
used for biplanar TRS of the uterus. Since the axially oriented transducer is mounted at the end of the probe, the probe must be withdrawn slightly to obtain a similar area of interest to that depicted with the sagittal-
vulva
woman
and
with
Paget
postmenopausal
disease
of
the
bleeding.
August
1990
The uterus could not be sounded because of cervical stenosis. TRS was used to identify the cervical canal, which was then dilated sufficiently for the dibation and curettage procedure. The uterus was severely retroflexed, and distention of the water-filled condom surrounding the rectal transducer probe afforded some anterior displacement of the uterus, which facilitated subsequent dilation and curettage. Case 3.-The patient was a 72-yearold, extremely obese woman who had undergone three previous conizations of the cervix and had Pap smear results suggestive of adenocarcinoma. TRS was used to guide dilation and curettage (Fig 4a, 4b). a.
b.
Figure
2.
nal and
Transnectal
uterus
in long
US scans
axis (between
a.
Figure show genic
show
echogenic cursors)
interface (a) and
short
arising
from
axis (arrowhead)
the endocervical
ca-
(b).
b.
3. Tnansrectal US scans after placement of tandem, in long axis (a) and short the central position of the tandem. The metal in the tandem produces a highly interface with distal reverberation (arrow).
axis (b), echo-
Discussion Because it does not interfere with manipulation of the cervix and vagina, TRS can be used mntraoperatively for a variety of gynecobogic procedures (1). In case 1, it was used to ensure intrauterine placement of the tandem used in cesium irradiation for cervical carcinoma. We previously reported the utility of this technique for placement of surgicab sutures in a patient who had undergone three previous conization procedunes of the cervix (1). Others have meported its use in evaluation of tumor recurrence (2). We believe that the transrectal approach is beneficial in a variety of gynecobogic procedures such as removal of intrauterine devices and guided dilation and curettage, since it provides real-time visualization of the cervical canal and uterine cavity while allowing room for simultaneous mntravagmnab or intrauterine manipulation. To visualize this area adequately with TRS, the smallest-angle retractors should be used and held along the lateral aspect of the vagina. The use of TRS for intracavitary tandem placement may prevent complications such as uterine perforation or bladder injury (3). Similarly, its use during dilation and curettage can facilitate the procedure, particularly in uteri that are severely anteor metroflexed and in those with cervical stenosis. U
References 1.
2.
a.
b.
Figure
4. TRS before (a) and during (b) dilation and curettage of an anteflexed, parous The markedly anteflexed uterus can be recognized by the vertically oriented endometnium (straight arrow). A maximally distended condom around the transnectal probe assisted in straightening the uterus so that the curette (curved arrow) could be more easily passed into the endometrial lumen. uterus.
Volume
176
#{149} Number
2
3.
Fleischer A, Lombardi 5, Kepple D. Transrectal sonography for guidance during cerclage. J Ultrasound Med 1989; 8:589-590. Squillaci E. Saizani MC, Grandinetti ML, et al. Recurrence of ovarian and uterine neoplasms: diagnosis with transrectal US. Radiology 1988; 169:355-358. Rossmann MD, Koprowski C. Lewis C, Amendola BE, Gonick P. Bladder puncture from Fletcher-Suit tandem applicator: diagnosis by pelvic ultrasound. J Ultrasound Med 1989; 8:403-405.
Radiology
#{149} 577
Because
of the
of the
fecab
thickness
stream,
are more likely In summary,
and
smaller
to clog. cecal distention
Intraoperative with Transrectal C. Fleischer, S. Burnett, J. Murray, W. Jones
terms:
854.12981 Ultrasound 854.32
Gynecology,
(US) Uterine
#{149}
854.12981
From
guidance neoplasms, US
the
Nashville,
TN
1, 1990;
revision
#{149} Uterine
neoplasms,
US studies,
studies,
Departments
854.12981
March
#{149} Radiology
of Radiology
and Gynecology (A.C.F., Radiation Oncology University Medical Center,
37232-3274.
reprint requests , RSNA, 1990
576
studies, intraoperative.
1990; 176:576-577
(A.C.F.), Obstetrics L.S.B., H.W.J.), and (M.J.M), Vanderbilt
received
(US),
#{149} Uterus,
Radiology
I
US
#{149} Ultrasound
requested 19; accepted
Received
March April
anterior
This
abdominal
insertion, is likely allows
we think to be great-
a direct
6.
anterior
as the larger
im-
7.
U
8.
1.
ly distended
Jackson PP. Baird RM. Cecostomy: an analysisof l02cases. AmJSurg 1967; 114:297-301. Johnson CD, Rice RP, Kelvin FM, Foster WL, Williford ME. The radiologic evaluation of gross cecal distension: emphasis on cecal ileus. AJR 1985; 145:1211-1217. Bode WE, Beart RW, Spencer RJ, CuIp CE, Wolff BC, Taylor BM. Colonoscopic decompression for acute pseudoobstruction of the colon (Ogilvie’s syndrome): report of 22 cases and review of the literature. Am J Surg 1984; 147:243-245. Goldstein SD, Salvati EP, Rubin RJ, Eisenstat TE. Tube cecostomy with cecal extraperitonealization in the management of obstructing left-sided carcinoma of the large intestine. Surg Gynecol Obstet 1986; 162:379-380. Groff W. Colonoscopic decompression and
2.
3.
4.
5.
Intrauterine
9.
10.
11
.
12.
13.
cecum.
Radiology
sonography (TRS) is used extensively for evaluation of the prostate. Its use in women, howeven, has not been fully described, except in a few reports involving a small numben of patients (1,2). We describe the use of TRS for intnaoperative placement of an intrauterine tandem for the purpose of intracavitary radiation thenapy for cervical carcinoma and as guidance for directed dilation and curettage in
complicated
BIPLANE TRANSRECTAL
cases.
Figure
Before
and
Methods
the transnectal
probe
was in-
serted, it was sterilized with a bacteniostatic and vinustatic spray (Sporocidmn International, Rockville, Md). A condom was secured over the probe with rubber bands, and gel was spread on the outer condom surface for adequate coupling. After the probe was in place within the rectum, approximately 30 mL of water was introduced within the condom for adequate transmission. TRS was then performed, initially in the sagittal plane, followed by confirmation in the axial plane (Fig 1). The procedune was observed in real time with both the longitudinally and axially onented transducers contained within a biplanar, 5.0-MHz tnansrectal probe (Toshiba America Ultrasound, Tustin, Cabif).
Representative
Cases
17. Address
old
158:793-
RANSRECTAL
Materials
to A.C.F.
1986;
794. Haaga JR. Bick RJ, Zollinger RM. CT-guided percutaneous catheter cecostomy. Gastrointest Radiol 1987; 12:166-168. Brown AS, Mueller PR, Ferrucci JT. Controlled percutaneous gastrostomy: nylon Tfastener for fixation of the anterior gastric wall. Radiology 1986; 158:543-545. Cope C. Percutaneous subhepatic cholecystostomy with removable anchor. AJR 1988; 151:1129. Schwartz SI, Storer EH. Principles of surgery. 4th ed. New York: McGraw-Hill, 1984; 1037. Crass JR. Simmons RL, Frick MP, Maile CW. Percutaneous decompression of the colon using CT guidance in Ogilvie syndrome. AJR 1985; 144:475-476.
Procedures
February
12; revision
intubation of the cecum for Ogilvie’s syndrome. Dis Colon Rectum 1983; 26:503-506. Hoffmann J, Jensen HE. Tube cecostomy and staged resection for obstructing carcinoma of the left colon. Dis Colon Rectum 1984; 27:2432. Kukora JS, Dent TL. Colonoscopic decompression of massive nonobstructive cecal dilation. Arch Surg 1977; 112:512-517. Casola C, Withers C, vanSonnenberg E, Herba MJ, Saba RM, Brown RA. Percutaneous cecostomy for decompression of the massive-
References
T
MD MD MD III, MD
the
abdominal approach, as well mediate insertion of catheters than previously described.
Guidance for Sonography’
Transrectal sonography was used for intraoperative guidance in intrauterine tandem placement for intracavitary radiation therapy and in dilation and Curettage procedures. The authors describe the method and three representative cases in which it was applied. It is concluded that the technique may prevent complications such as uterine perforation or bladder injury in tandem placement, and that it can facilitate dilation and curettage in complicated cases. Index
to
by reduced.
to a di-
to surgical or endoscopic When the cecum is sim-
Arthur Lonnie Michael Howard
affixed
wall before catheter the risk of spillage
viscosity catheters
ameter of greater than 10 or 12 cm is a common problem in hospitalized patients and may lead to bowel rupture. Percutaneous cecostomy is an attractive
alternative management.
ply
Case 1.-The patient woman with stage
was “b
a 72-yearsquamous
ly oriented
Diagram
shows
scanning
planes
transducer.
carcinoma of the cervix who had meceived a dose of 4,000 cGy of external irradiation
before
being
admitted
for
tandem and ovoid placement. Initial attempts at sounding the cervical canal were unsuccessful (Fig 2a, 2b). The cenvix had been replaced by a necrotic ulcerative tumor that extended into the upper vagina, night parametnium, and uterosacral ligament. TRS guided initial sounding of the cervix and, after dilation of the cervical canal, final placement of the tandem (Fig 3a, 3b). TRS helped confirm the central location of the tandem in both long and short axes. Case 2.-The patient was a 78-yearold
cell
1.
used for biplanar TRS of the uterus. Since the axially oriented transducer is mounted at the end of the probe, the probe must be withdrawn slightly to obtain a similar area of interest to that depicted with the sagittal-
vulva
woman
and
with
Paget
postmenopausal
disease
of
the
bleeding.
August
1990
The uterus could not be sounded because of cervical stenosis. TRS was used to identify the cervical canal, which was then dilated sufficiently for the dibation and curettage procedure. The uterus was severely retroflexed, and distention of the water-filled condom surrounding the rectal transducer probe afforded some anterior displacement of the uterus, which facilitated subsequent dilation and curettage. Case 3.-The patient was a 72-yearold, extremely obese woman who had undergone three previous conizations of the cervix and had Pap smear results suggestive of adenocarcinoma. TRS was used to guide dilation and curettage (Fig 4a, 4b). a.
b.
Figure
2.
nal and
Transnectal
uterus
in long
US scans
axis (between
a.
Figure show genic
show
echogenic cursors)
interface (a) and
short
arising
from
axis (arrowhead)
the endocervical
ca-
(b).
b.
3. Tnansrectal US scans after placement of tandem, in long axis (a) and short the central position of the tandem. The metal in the tandem produces a highly interface with distal reverberation (arrow).
axis (b), echo-
Discussion Because it does not interfere with manipulation of the cervix and vagina, TRS can be used mntraoperatively for a variety of gynecobogic procedures (1). In case 1, it was used to ensure intrauterine placement of the tandem used in cesium irradiation for cervical carcinoma. We previously reported the utility of this technique for placement of surgicab sutures in a patient who had undergone three previous conization procedunes of the cervix (1). Others have meported its use in evaluation of tumor recurrence (2). We believe that the transrectal approach is beneficial in a variety of gynecobogic procedures such as removal of intrauterine devices and guided dilation and curettage, since it provides real-time visualization of the cervical canal and uterine cavity while allowing room for simultaneous mntravagmnab or intrauterine manipulation. To visualize this area adequately with TRS, the smallest-angle retractors should be used and held along the lateral aspect of the vagina. The use of TRS for intracavitary tandem placement may prevent complications such as uterine perforation or bladder injury (3). Similarly, its use during dilation and curettage can facilitate the procedure, particularly in uteri that are severely anteor metroflexed and in those with cervical stenosis. U
References 1.
2.
a.
b.
Figure
4. TRS before (a) and during (b) dilation and curettage of an anteflexed, parous The markedly anteflexed uterus can be recognized by the vertically oriented endometnium (straight arrow). A maximally distended condom around the transnectal probe assisted in straightening the uterus so that the curette (curved arrow) could be more easily passed into the endometrial lumen. uterus.
Volume
176
#{149} Number
2
3.
Fleischer A, Lombardi 5, Kepple D. Transrectal sonography for guidance during cerclage. J Ultrasound Med 1989; 8:589-590. Squillaci E. Saizani MC, Grandinetti ML, et al. Recurrence of ovarian and uterine neoplasms: diagnosis with transrectal US. Radiology 1988; 169:355-358. Rossmann MD, Koprowski C. Lewis C, Amendola BE, Gonick P. Bladder puncture from Fletcher-Suit tandem applicator: diagnosis by pelvic ultrasound. J Ultrasound Med 1989; 8:403-405.
Radiology
#{149} 577
