Ultrasound–Guided Interventional Techniques in the Pelvis - SD

Introduction

Hi everybody.

I am Malari radiologist from Georgia.

Today I'll have talk about ultrasound in pelvis interventions.

Concept of Interventional Radiology

A couple words about the concept of interventional radiology.

The key is that radiologists often can see pathology better than surgeon after invasion into the body, so the target is seen.

Can we image the instruments the same time?

The answer is yes.

So we can perform and monitor biopsies and treatment procedures without any surgical incision.

Actually, this is the concept of interventional radiology.

Interventional radiology means imaging guidance, advantages of minimally invasive or low invasive treatment.

They have practically no contraindications.

Usually they do not need general anesthesia, no surgical trauma and might be performed repeatedly.

And finally, they are cost saving and having no or less hospital stay to overview.

Overview of Diagnostic and Treatment Procedures in the Pelvis

If we overview the diagnostic and treatment procedures in pelvis, and possible imaging guidance techniques.

First of all, we should mention biopsies, which might be performed on the ultrasound CT and MR guidance Aspiration Procedure also might be performed on the ultrasound, CT or MR Guidance, drainage ultrasound, combination of ultrasound and fluoroscopy.

CT and MR might be used as a guidance technique embolization to uterine fibroids bleeding in cases of, neoplasm trauma are performed under the angiography, control using digital subtraction and subtractive angiography.

Different ablation techniques like radio frequency ablation, high intensity feco ultrasound, laser induced terminal treatment or clear ablation also might be performed under ultrasound and CT guidance in some cases under MR Guidance.

Focus on Ultrasound and Ultrasound-Fluoroscopy Guided Procedures

Also, today we focus on ultrasound and ultrasound fluoroscopy guided procedures, non obstetrical applications, diagnostic procedures.

This is performed under ultrasound guidance, treatment procedures, aspiration and rinsing under ultrasound guidance and drainage Under ultrasound are combination of ultrasound and fluoroscopy guidance.

Approaches Used

What kind of approaches we can use?

First of all, of course, it's percutaneous approach when we use ultrasound or combined ultrasound fluoroscopy guidance and end cavity vaginal and rectal approaches when we use, again, ultrasound or combination of ultrasound and fluoroscopy.

Biopsied Organs in the Small Pelvis

The the most frequent, uh, biopsied organ in small pelvis is prostate.

Of course, any small pel with solid muscle also may undergo the biopsy and the ultrasound guidance treatment.

The, today we'll have a talk about small pelvis cystic masses.

These are tubal ovarian abscesses, post-surgery, cystic infected masses like after GYN surgery or rectal or some other type surgery, ovarian, ovarian, cys, prosta abscess, and para proctitis.

Low Invasive Treatments for Small Pelvis Cystic Masses

What kind of low invasive treatment we use?

This is aspiration rinsing, which we do to tub bo Arian abs, ovarian cyst, prosthetic abscess and para proctitis and drainages.

We perform to tub bo Arian abs and post-surgery masses.

Equipment for Procedures

This is the equipment which we use for those procedures.

You see here, very simple C-arm unit.

This is operating table, which is of course x-ray.

Loosened then can be moved, can move patient from the area of oscopy to area of ultrasound and of course, ultrasound machine.

You see here the transducers.

This one is convex array with needle, uh, guidance capability, which we use for percutaneous approach.

And endo cavity probe, which we use, uh, with also with needle guidance capability, which we use for, uh, endo rectal or endo vaginal interventions.

Biopsy Devices

Biopsy devices. This is, uh, France and needle.

You see here, this needle with internal canula.

And this is, uh, needle without the internal steel it, I'm sorry.

Uh, you see here the cutting edges of this needle.

So when you deploy it into the, um, target, you move it back and forth and around its axis, same time, uh, using the syringe constant, uh, negative pressure is applied, sucking the material into the needle.

So it's cutting aspiration device.

This is the biopsy gun you see here.

It's, uh, inner needle and out canula, which cuts the tissue sample, which is seen after you open it.

You see, uh, here the sample for, uh, tissue morphology.

This, uh, biopsy gun might be different lengths.

Needle of this.

Those guns might be of different lengths and diameter, um, depending on the aim of the biopsy devices for aspiration and rinsing.

You see here a set of the puncture needles of different diameters starting from 22 gauge, which is so-called shiba needle, which is, which does not require even, uh, anesthesia, even local anesthesia.

So thin it is.

And, uh, this is the connecting tube and syringe, which fac, which enables us to aspirate the content of punctured mass devices for drainage.

Drainage Devices

This is one step, um, device.

Uh, as you see, we use pigtail catheters, uh, with tip fixation thread, which are very comfortable because they do not re require the fixation to the skin, especially, it's impossible.

It's important when we, uh, perform end d cavity intervention device for, um, uh, drainage, again, using G wire technique.

Uh, we see here the puncture needle.

We use usually 18 gauge needle, which ac which accepts, um, guidewire of, uh, 0.0 38 inch diameter.

And again, finally, uh, pigtail catheter with tip fixation thread is located in the target.

Biopsy Procedure Example

This is the procedure of the biopsy. This is the prostate.

You see the needle tip, uh, tip of the biopsy, gun biopsy, gun fires, and you get the tissue sample.

In this case, percutaneous.

Aspiration Procedure Example

We used, uh, percutaneous approach for variance cyst aspiration.

It was 87 cc volume, uh, symptomatic cyst, which remained during several menstrual menstrual cycles.

You see here, 22 gauge gauge needle, which is inserted into the cyst.

And you can monitor, uh, in real time how it's this cyst is aspirated.

And finally it's gone.

And after this, we can remove the needle.

Drainage Procedure Examples

We use percutaneous approach for drainage.

Also, in this case, patient developed the post-surgery infected mass.

The, uh, she underwent the hysterectomy.

And, uh, here you see the puncture needle in the mass.

On this image you see, uh, opacified, uh, opacified cavity.

Uh, on this stage we already use fluoroscopy control and guidewire in this cavity, and the process of, uh, deployment of the drainage catheter in the mass.

Finally, pigtail catheter is placed, um, in infected mass.

Uh, and, uh, we inject the x-ray contrast agent performing histography and then re aspirated, making sure that, um, drainage is adequate In this case, you see here the CT image of the patient who developed this, uh, cystic mass air bubble containing cystic mass and the projection of the rectum.

It's not rectum.

Patient underwent the rectal surgery because of, uh, uh, rectal carcinoma.

So it's, uh, infected cystic mass.

As you see, it's possible to drain it using CT guidance, but because of, because of presence of lot of nerves here, it's not safe.

So we, we decided to perform to find a more safe approach.

And when transducer is placed on the perineum in a**l area, we immediately sew this mass.

So we use this approach.

You see here, the needle in the mass, uh, then you see here the G wire.

This is already under the fluoroscopy control.

You see the needle and G wire in the mass.

Finally, the pigtail catheter is placed, uh, in infected mass.

And the histography performed pacifying the drained cavity, which is, uh, pacified unevenly because of presence of, uh, debris in this mass regional approach.

Tub bo r and abscess.

You see how, um, 18 gauge needle is inserted into the mass, uh, internal canula.

Internal steel is removed and aspiration started, uh, which, uh, enables to wash out this, um, rinse this mess and aspirate it completely.

Vaginal Approach for Tubo-Ovarian Abscess Drainage

This is the case when we used vaginal approach for tube ary and abscess drainage.

This diagnostic, uh, MRI shows in the mid sagittal diagnostic MRI shows you, uh, the uterine fibroid a bit of empty bladder.

This is vagina, this is rectum.

And here you see two masses, which are, were responsible for pal peritonitis, which, uh, patient presented.

This is the exhale cut of this on this level.

Uh, so this is the procedure of per vaginal drainage.

You see here, the 18 gauge needle.

Uh, you see how, uh, contrast agent is injected in this viscous fluid and creating very nicely democratic border.

Uh, then guidewire is conducted, uh, via the needle canula, and we switch to x-ray control seeing this guidewire.

In opacified cavity, you see the process of catheter deployment according the, uh, guidewire.

Finally, the pigtail catheter is placed there, uh, and this big mass was completely aspirated and rinsed, but the second, the smaller one remained, uh, un collapsed in a weak.

You can see that this is again, fibroid, a bit of endometrium, empty bladder.

This is the, uh, catheter placed in the grained mass.

And as you see, there is no, uh, this is smaller masses also collapsed.

Uh, after the rinsing procedures, uh, saline was injected, uh, using the catheter.

And you see that this mast cannot contain even 3, 4, 5, uh, ccs of, uh, saline.

So it means that positive result was achieved and catheter was, uh, was withdrawn.

This is pre and post procedure. Mr.

Rectal Approach for Prostatic Abscess

Rectal approach is used for prostatic abscess.

In this case, you see one cc, uh, cystic mass in prostate, which was prosthetic abscess responsible for, uh, very high temperature was resistant to antibiotic or therapy.

This is the needle, uh, inserted into the mass.

Uh, and after the aspiration and rinsing procedure, uh, the patient has immediate relief and does not require further interventions.

Advantages of Ultrasound Guidance

I'd like to mention, um, to emphasize some, uh, advantages of ultrasound when we compare it with the CT guidance.

Generally, it's real time technique, but to be honest, we should mention that today, uh, real time CT fluoroscopy is also available, non-invasive.

It's no ionizing radiation.

Patient is, uh, exposed and is not exposed to ionizing radiation.

We have needle aiming and guiding capability, performing ultrasound, uh, guidance.

We have doppler capability, possibility of combination with other modalities and cost saving technique.

And one more advantage where, which I forgot to mention, is that we have possibility to get the imaging, imaging and, uh, the guidance of the procedure in any oblique inlined planes, which is impossible when you perform CT guidance, ultrasound or ct.

When we are talking about the small pelvis area, the most important probably is possibility of endo cavity approach.

Conclusion

In conclusion, ultrasound guidance using peritoneal and endo cavity approaches is the most effective in small pelvis diagnostic and treatment interventions.

Low invasive ultrasound guided management of small pelvis cystic masses is effective, safe, and cost-saving ultrasound guidance should be used as a gold standard for small pelvis interventions.

Thank you for your attention.