Original Article Diagnostic Performance of Magnetic Resonance Hysterosalpyngography: Initial Results A.A. Kohana,b,*, M.C Kucharczykc, N.T. Posadasa,d, M.N. Napolia, S. Gile, N.A. Fuentesf, R.D. García Mónacoa and C.R. Chacóna a Servicio de Radiología, Hospital Italiano de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina b CERIM, Ciudad Autónoma de Buenos Aires, Argentina c Servicio de Radiología, Instituto Oncológico Alexander Fleming, Ciudad Autónoma de Buenos Aires, Argentina d Servicio de Radiología, Instituto Médico de Alta Complejidad, Salta, Argentina e Servicio de Ginecología, Hospital Italiano de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina f Servicio de Medicina interna, Hospital Italiano de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina Recibido el 15 de julio de 2016; aceptado el 24 de diciembre de 2016 *Correspondance author. E-mail: [email protected] (A.A. Kohan) Abstract Objective: Determine the diagnostic performance of magnetic resonance histerosalpyngography (MR-HSG) using lapa- roscopy as a method of reference. Materials and Methods: 22 patients were included. MR-HSG was performed in a 1.5 Tesla MR scanner. Afterwards, patients underwent laparoscopic chromotubation. MR images were examined by two trained radiologist and tubal pa- tency was determined in consensus. Descriptive and diagnostic performance analyses were performed. Results: MRHSG had a 91% success rate. Exam duration was 49±15min, injected volume 26±16 cm3 and pain scale 30±19 out of 100. Sensitivity and Specificity of MRHSG was 100% for global and left Cotte test and 25% and 93.3% for right Cotte test, respectively. Only 2 minor and no major complications were observed. Discussion: Our initial results have shown high sensitivity and specificity. Even though other studies have analyzed MR- HSGs potential for tubal patency assessment and have already yielded good results, the use of a flawed gold standard such as conventional HSG always left margin for a reasonable doubt, thus precluding a solid evidence based recom- mendation. Nevertheless, if we compare our results to those published, we can observe a high degree of agreement in that positive spillage is correctly diagnosed with specificities near or at 100%. Conclusion: MR-HSG is a feasible and safe alternative to conventional or virtual HSG, sonohisterography, and chromo- tubation. Key Words: Magnetic Resonance Imaging, Hysterosalpingography, Infertility, Laparoscopy, Tubal Obstruction Introduction While hysterosalpingography (HSG) continues to be the Between 10 and 15% of couples have problems conceiving. method of choice for assessing tubal patency and the uterine Out of that population, 40-50% of the causes are second- cavity, there is an increasing number of published literature ary to the female reproductive system: peritoneum 20-25%, addressing the capability of MR to perform such task by us- 1, 8-15 uterus 2-5% and the fallopian tubes 10% as individual cause ing diluted gadolinium (Gd) . The main weakness of the and 25-40% as concomitant causes1, 2. available literature is the lack of a proper homogeneous gold Even if magnetic resonance (MR) imaging is able to detect standard to make comparisons with MR findings and to un- most of these pathologies, no hard evidence has yet been derstand the real diagnostic capabilities of MR hysterosalpin- provided to determine the real tubal patency assessment ca- gography (MR-HSG), as most published literature has used pabilities of this method2-5. The most widely used method for for comparisons HSG alone or a mixture of HSG and an oc- 8, 10-15 this condition is hysterosalpingography, although it is far from casional laparoscopy . being reliable, with sensitivities ranging approximately from If MR-HSG proved to be reliable in the diagnosis of tubal 53 to 65% and specificities ranging approximately from 80 to patency, a relatively important number of potential benefits 87%6, 7. Chromotubation (the current gold standard method) would become available for the target population. For once, requires a surgical procedure and general anesthesia. we could provide patients being evaluated for fertility issues Rev. Argent. Radiol. 2017;81(1): 3-11 3 Diagnostic Performance of Magnetic Resonance Hysterosalpyngography: Initial Results with a single examination to assess all diseases: endometrio- [volumetric interpolated breath-hold examination] and T1- sis, uterine/vaginal malformations, leiomyomas, adenomyosis weighted three-dimensional [3D] angiographic sequence), and polycystic ovaries, among others. Considering the study during (TRU-FISP [true fast imaging with steady state preces- population, additional benefits would be the lack of ionizing sion] and T1-weighted 3D angiographic sequence) and after radiation, the use of a more innocuous contrast (gadolinium intrauterine injection (VIBE and T1-weighted 3D angiograph- vs. Iodine) and no requirement of general anesthesia. ic sequence). In the present study we intend to determine the diagnostic The diluted mixture was injected at a rate of 0.3ml per second performance of MR-HSG using laparoscopic chromotubation with an automatic stop if the pressure raised above 30 mmHg as the reference method. inside the uterine cavity. Initial injection volume was 20ml for all patients which was reduced if the patient triggered an alarm due to pain or extended if the physician performing Materials and Methods the procedure considered it insufficient for a diagnostic study. For this prospective research study, approval was obtained All the patients were dismissed with written instructions and from our institutional Ethics Committee for Research Studies. contact numbers in case of complications after they were All subjects included provided informed consent. asked to mark in a visual analog pain scale the degree of pain/discomfort felt during the study. No antibiotics were pre- Population scribed either before or after the procedure. Patients from the fertility section of the Gynecology depart- Three days after the examination, patients were telephoni- ment at our institution were prospectively enrolled in this cally contacted to inquiry about potential complications and ongoing protocol from July 2010 to May 2014. the acceptability of the examination. The main inclusion criterion for this protocol was that patient should be of childbearing age, referred for diagnostic MRI of the Image Analysis pelvis with subsequent laparoscopic surgery as standard of care. Assessment of tubal patency was done independently by Exclusion criteria were: active infection of the pelvis, any two experienced radiologists with 8 and 6 years of experi- type of gynecological cancer, impossibility of undergoing ence in gynecologic radiology by using RAIM Alma® (Alma IT MR examination, pregnancy, known allergy to Gd and any Systems, Barcelona, Spain). They were blinded to all relevant gynecologic procedure performed between both diagnostic clinical information about the fallopian tubes (hysterosalpin- methods. gography, surgical resection, etc.). Other imaging findings (endometriosis, uterine morphology, ovarian pathology, etc.) Magnetic Resonance were also recorded in a tabular way. MR imaging was performed in a 1.5 Tesla scanner (Siemens Uterine enlargement was determined by a subjective assess- Avanto®, (Erlangen, Germany) . Patients were requested to ment. When there was discrepancy between their findings, attend the radiology department at least an hour before the agreement was reached by a joint reading of the images. study. Upon arrival they were taken to a private medical of- fice were they changed and removed all metallic objects. Af- Laparoscopic Chromotubation terwards, while lying in a gurney, using sterile technique, a Patients were operated on no longer than three months af- 5Fr or 7Fr hysterosalpingography catheter (Angiotech™, PBN ter the MR examination. Chromotubation was performed Medicals, Denmark) was placed inside the uterus of the pa- according to the surgical technique before the main surgi- tients with the help of a speculum. After uterine canalization, cal procedure. The gynecologist was blind to the MR-HSG the patients were kept in the gurney until the MR scanner results. became available. Patient transfer from the gurney to the After placing the patient under general anesthesia and fol- exam table was done with the help of bed-sheets while the lowing insertion of the trocars and laparoscopic camera, the patients remained still to avoid dislodgement of the catheter. disposable uterine manipulator, VCare (ConMed, Utica, NY) Once the patient was placed in the MR scanner, the cath- was placed and 10-20ml of methylene blue was injected eter was connected to an automated infusion pump (Optistar through the device into the uterine cavity to confirm spillage Elite Injector™, Mallinckrodt, Dublin, Ireland) that contained of the dye in the pelvic cavity and, therefore, check for tubal 60 ml of Gd diluted in saline solution (1:100). A body sur- patency (Fig. 1). Data was recorded in a tabular way. face coil was placed over the pelvis of the patients and they were positioned for pelvic MR. The routine examination pro- Data analysis tocol is detailed in Table 1. The dynamic images detailed in Continuous variables were reported as mean and standard the intrauterine contrast phase were performed before (VIBE deviation or median and interquartile range, according to the 4 Rev. Argent. Radiol. 2017;81(1): 3-11 A. Kohan et al. distribution observed. Categorical variables were described Results as proportions. Sensitivity,