Ultrasound in Low-Invasive Imaging Guided Management of Small Pelvic Cystic Masses - SD

Introduction

Hello, I'm Ari Radiologist from Georgia.

My talk is about low in ultrasound and low invasive management of small pel cystic masses, small pel cystic masses.

More and more these problems are managed using low invasive treatment.

We performed low invasive treatment under imaging guidance to two bo n abscesses post-surgery cystic infected masses, GY post the GYN and rectal surgery, ORN, para para cysts, prosthetic abscesses, and few cases of para proctitis.

Types of Low Invasive Treatments

What kind of low invasive treatment might be performed? It's aspiration rinsing to tub bo rrn abscesses or vari cyst, prosthetic abscesses, para proctitis and drainage procedures, which were performed to two Bo Rrn abscesses and post-surgery infected cystic messes.

Imaging Guidance Techniques

Imaging guidance techniques, which might be used for this Purpose is ultrasound, combination of ultrasound and fluoroscopy CT guidance. And MRI guidance, MRI guidance requires non-magnetic instrumentation and we have experience using ultrasound. Combination of ultrasound and CT guidance.

Treatment procedures are performed using percutaneous approaches for this purpose. We can use ultrasound, combination of ultrasound and fluoroscopy, CT and MR guidance and endo cavity approach, which might be used when we perform ultrasound guidance and combination of ultrasound and fluoroscopy guidance.

Endo cavity approaches means vaginal and rectal approach, Ultrasound or ct.

Comparison of Guidance Modalities

What if we compare these two modalities for low invasive treatment guidance? First of all, we should mention the low, very well known advantages, general advantages of ultrasound, like real time technique. This is non-invasive, no ionizing. We are not dealing with ionizing radiation. We have possibility of needle aiming, a guide guidance. We have possibility of real time vessel imaging, possibility of combination with other modalities, and at last it's cost saving technique.

But when we are talking about the small pelvis area, first of all, and the most important advantage, which should be mentioned, is possibility of endo cavity approach. That is why in our material, we have only three cases performed under CT guidance. And all the rest cases we do under flu x-ray and ultrasound and combination of ultrasound fluoroscopy guidance.

CT Guidance Methodology

When we are talking about possibility on a methodology of CT guidance, I can, I'd like to show you some example of this, which is another area, thoracic area, which is much more complicated and dangerous for puncture.

Patient in this case, the target is posterior mediastinal mass. So what we do using CT guidance for low invasive procedure, first of all, we identify the lesion, then we can do CT angio to identify the major vessels in order to avoid the vessel damage. Then we put the markers on the skin to choose appropriately the exactly the puncture side. We insert the needle in a certain depths and make the control to make sure that the direction is adequate. If it's not, you can withdraw the needle and correct, like you see here. Then we insert needle reaching the target. And finally in this, the, in this case, the target was posterior mediastinal lymph node for biopsy. We are in the target. This is the methodology which is used in any I, including small pelvis.

Equipment for Ultrasound and Combined Guidance

Also here we see equipment, which we use for ultrasound and combined ultrasound fluoroscopy guidance. This is ultrasound machine, very small c-arm unit with operation table, which is of course radiolucent and can move during the procedure from ultrasound to x-ray area ultrasound probes with needle guide capabilities, which are used for these purposes.

This is convex probe for peroneal approach with needle guide, which has different adapters which accept different diameter needles and endo cavity probe with needle guide, which accepts 18 gauge needle.

Devices and Tools

Very simple device for aspiration rinsing. We see here different diameter needles We use starting from 22 gauge shiba needle to eight to 14 gauge quite thick needle and syringe with connector for aspiration device for one step drainage contains of stiffening canula with internal steel IT and catheter, drainage catheter.

We more prefer to use catheters with a need fixation thread, which does not require the fixation to the skin except it's especially important when we do endo cavity procedures.

Devices for draining using drainage using guidewire technique consists of puncture needle, which use we use usually 18 gauge needle, which accepts guidewire 0 35 or 0 38 diameter G wire and catheter for drainage. Usually we use metallic stiffening canula, which facilitates the placement of the catheter.

Case Examples

Percutaneous Approach for Ovarian Cyst Aspiration

Here you see the example of percutaneous approach for a warrior cyst aspiration. This is 90 cc volume orient cyst, which was which remained during the several menstrual cycles and was symptomatic causing down pain. Here you see 22 gauge needle. This is the needle guide guidance trace. And you see how the needle 22 gauge needle is inserted in no ian cyst. And on these pictures, you see how gradually the cyst is aspirated completely. By the way, the patient had no recurrence after this procedure.

Percutaneous Drainage Procedure

Percu approach might be used for drainage procedure procedures. This is the cystic infected cystic mass in patient who under underwent the surgery of because of GYN malignancy. It was infected seroma. Here the needle is inserted into the mass. You see here how guidewire, how guidewire is conducted, and you see opacified cavity under which you this is the second stage of the control under we control it using fluoroscopy unit. And finally, the pigtail catheter is placed in this mass. You see how contrast agencies agent is injected, and you see how this drained cavity is filled by contrast agent, and you see this after the aspiration of the content.

Post-Rectal Surgery Infected Mass

This is the case of which is was also performed percutaneous post recal surgery infected mass. You see the CT image, here is posteriorly from the bladder. You see the gas containing mass, which was post-surgery infected seroma. A patient underwent the surgery because of rectal cancer and the rectum was removed. So here is just the fluid which contains gas bubbles, definitely abscess as you see, it's possible to drain this abscess using CT guidance from this or this approach. But when we put patient on the left, the cubitus position and place transducer in the a**l area, we see immediately this mass. And that was the most safe approach for this case, which was performed under ultrasound guidance. You see here the needle in the cystic mass. After this we you see the we switch to the second stage of guidance. It's fluoroscopy guidance. You see the needle tip and the G wire in the mass. The pigtail catheter is placed in the mass and the contrast agent shows the opacified cavity of the abscess.

Vaginal Approach for Tubo-Ovarian Abscess

Vaginal approach. This procedure was performed to tub bo abscess. You see the needle guide here and 18 gauge needle, which is inserted in tube bo abscess. This is a needle steel it, which is removed and aspiration and rinsing procedure. You see here the aspiration and rinsing procedure which was performed several times using saline. And finally the mass was aspirated completely.

Endo-Rectal Approach for Prostatic Abscess

Another example of end rectal approach. This is rectal aspiration of prosthetic abscess. You see here, the prostate and the small up to one cc cystic mass, which turned out to be the prosthetic abscess and caused very severe clinical findings. Despite the active medical treatment, antibiotic or therapy, it was resistant. Here you see how the needle is inserted while they are using the react approach into the cystic mass, which was very viscous, which has very ous content. And you see the gradual aspiration of this abscess and rinsing of the residual cavity by saline.

Results and Conclusion

Ultrasound and combined ultrasound fluoroscopy guidance in low invasive management of small pelvis cystic masses was successful in 95.5% of cases.

And in conclusion, I'd like to mention that ultrasound guidance using peritoneal and endo cavity approaches is the most effective in small pelvis cystic masses, low invasive treatment, low invasive imaging guided management of small pelvis cystic masses is effective save and cost saving. It should be used as a gold standard in small pelvis cystic masses treatment.

Thank you for your attention.