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Ultrasound at the intersection of art, science and technology: complete septate uterus with longitudinal vaginal septum

2021; Wiley; Volume: 57; Issue: 3 Linguagem: Inglês

10.1002/uog.23609

1469-0705

Artur Ludwin,

Uterine Myomas and Treatments

Is expert ultrasound science, technology or art? Ultrasound measurements, pattern recognition and the operator's expertise are important for an accurate diagnosis. However, modern ultrasound technology also provides images with color, illumination and realistic or surrealistic features, which, not infrequently, look like works of art. Some ultrasound images even seem to belong to different art movements, such as realism, pop art and impressionism. However, traditional art galleries do not exhibit ultrasound images. To fill this gap, this article presents a ‘vernissage’ dedicated to one of the most common complex Müllerian anomalies, namely, complete septate uterus with longitudinal vaginal septum. The images were obtained in a 22-year-old woman who was examined due to suspicion of a complex congenital uterocervicovaginal anomaly. The patient was unable to engage in intercourse owing to severe pain. Gynecological examination revealed an intact hymen, vestibulovaginal stenosis and suspected longitudinal vaginal septum, which prohibited speculoscopy and transvaginal ultrasound assessment. To diagnose and differentiate the uterine, cervical and vaginal morphology of the patient, ultrasound examination was performed using a machine (Voluson E10, GE Healthcare, Zipf, Austria) with an endocavitary volume probe (RIC5-9-D) inserted transrectally. Real-time transrectal sonography (TRS) of the uterus and vagina comprised three parts: (1) imaging of the uterine body including the cervix; (2) separate imaging of the cervix; and (3) imaging of the cervix and vagina using saline contrast sonovaginohysterography with acquisition of three-dimensional (3D) datasets, for offline analysis of the coronal view of the uterus and cervix (Figures 1 and 2) and use of HDlive render mode (virtual speculoscopy) (Figure 3) immediately after the exam1, 2. This comprehensive ultrasound technique allowed elucidation of the morphology of this complex vaginal anomaly and classification as complete septate uterus (based on 3D-TRS) with septate cervix (based on 3D-TRS with virtual speculoscopy) and longitudinal vaginal septum (based on virtual speculoscopy). The presented images were created using HDlive silhouette render mode with fun color, manipulation of transparency and virtual light function. The differentiation between complete septate, bicornuate and didelphic uterus is based on assessment of the external uterine fundal contour and the presence or absence of external fundal division and its degree, respectively1, 3. When external fundal uterine indentation is absent in a uterus with internal complete division of the uterine cavity, as in the present case, then the diagnosis of a complete septate uterus is made1, 3, 4. If an external cleft is present, its depth should be measured and a diagnosis made according to the used classification system1, 4. The differentiation between a septate and a double cervix is based on subjective impression, because so far there is no specific classification with measurable criteria and cut-offs for the description of cervical deformities1, 2. According to gynecological and ultrasound findings, a more detailed classification of longitudinal vaginal septum can be made, based on four main features: (1) completeness of vaginal division (partial and complete types); (2) symmetricity (symmetric and asymmetric position); (3) association with the cervix (merged and isolated forms); and (4) concomitant vaginal openings (normal and narrow (vaginal stenosis or hymen persistent) openings)5. Considering the ultrasound findings in the present case, the inability to have intercourse due to pain was recognized to be associated with the presence of a longitudinal vaginal septum classified as complete type with symmetric form, merged with the cervix and with persistent hymen. The patient underwent vaginoscopic vaginal septum resection and hysteroscopic uterocervical metroplasty to restore sexual function and potentially improve reproductive function, respectively5. One month after the operation, the patient was able to have intercourse without experiencing pain. The presented approach to the management of complex Müllerian anomalies allowed a complete and accurate diagnosis to be established in a single visit using modern 3D ultrasound technology, creation of high-quality imaging documentation and assessment of eligibility for treatment, when treatment is considered to be potentially beneficial6. The presented images from this case have been given specific titles, as the author believes that some modern ultrasound images cross the border from diagnostic tools to art and deserve to be entitled as such. Data sharing not applicable - no new data generated