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Original Research |
1 Department of Radiology, Albert Einstein College of Medicine and Montefiore
Medical Center, 111 E 210th St., Bronx, NY 10467.
2 Department of Obstetrics and Gynecology, Albert Einstein College of Medicine
and Montefiore Medical Center, Bronx, NY 10467.
3 Department of Epidemiology and Population Health, Biostatistics Unit, Albert
Einstein College of Medicine and Montefiore Medical Center, Bronx, NY
10467.
Received March 15, 2005;
accepted after revision September 21, 2005.
Address correspondence to M. W. Stein
(mstein17{at}aol.com).
Abstract
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MATERIALS AND METHODS. One hundred twenty-one women who had undergone hysterectomy (mean age, 51 years; range, 31-80 years) were studied using transabdominal or transvaginal sonography. Seventy-six patients were acquired retrospectively and 45 prospectively. Hysterectomy types included abdominal, 52% (63/121); supracervical, 17% (20/121); vaginal, 17% (20/121); and unknown, 15% (18/121). Two reviewers, who were blinded to clinical information, evaluated each cuff or remnant in consensus. Transabdominal anteroposterior, transvaginal anteroposterior, and transvaginal length measurements before and after transducer compression, and amount of color Doppler flow as shown by percentage of color pixels (n = 36 patients) were correlated with hysterectomy type and patient age.
RESULTS. Supracervical cuffs were larger (p < 0.01) than abdominal and vaginal hysterectomy cuffs (transabdominal sonography anteroposterior, 2.8 vs 1.5 and 1.6 cm; transvaginal sonography anteroposterior, 3.3 vs 1.8 and 1.7 cm; and transvaginal length, 3.0 vs 2.1 and 1.9 cm). Anteroposterior measurements, but not length, decreased significantly with advancing age. Transvaginal length decreased with compression (mean, 0.84 cm; p < 0.0001). Color Doppler flow scores (minimum, 56% [20/36]; mild, 28% [10/36]; moderate, 14% [5/36]; and absent, 3% [1/36]) did not vary with age, time since surgery, or type of surgery.
CONCLUSION. The remnant is larger in every dimension after supracervical hysterectomy compared with both abdominal and vaginal hysterectomy and commonly shows some color Doppler flow.
Keywords: cervical remnant • color Doppler sonography • gray-scale sonography • gynecological imaging • hysterectomy • pelvic imaging • vaginal cuff
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The literature describing the postoperative appearance of the vaginal cuff is limited. The current postoperative anteroposterior vaginal cuff size quoted in the literature is up to 2.1 cm, a figure based on one prospective transvaginal sonographic study of 16 volunteers by Schoenfeld et al. [2]. One earlier prospective transabdominal sonographic study of vaginal cuff size by Parulekar [3] showed an average anteroposterior thickness of 1.4 cm (range, 0.7-3.0 cm).
Our purpose was to establish normal diameters for the vaginal cuff and cervical remnant for each surgical group, including mean values with SDs.
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Hysterectomies were performed for a variety of reasons, including uterine leiomyomas in most patients (58%) (n = 70), prolapsed uterus (n = 7), endometritis (n = 3), endometriosis (n = 3), cervical carcinoma (n = 2), ovarian carcinoma (n = 2), abnormal Papanicolaou test (n = 2), abnormal vaginal bleeding (n = 2), endometrial carcinoma (n = 1), endometrial hyperplasia (n = 1), cervical carcinoma in situ (n = 1), pelvic mass (n = 1), intrauterine fetal demise (n = 1), placenta accreta (n = 1), and placenta previa (n = 1). In the remaining 23 patients, the indication for hysterectomy was unknown. Sonography was performed for a variety of reasons, including pelvic pain (n = 64), suspected pelvic mass (n = 23), fever (n = 11), ovarian cyst (n = 9), vaginal bleeding (n = 3), abnormal Papanicolaou test (n = 2), hematuria (n = 2), and weight loss (n = 2). One patient each had the reason for sonography stated as a history of uterine, cervical, or breast cancer; dysuria; or fibroids. Of the 121 women, 12 were imaged within 21 days after hysterectomy (9 for fever and 3 for pelvic pain).
The surgical approaches used included abdominal hysterectomy in 52% (63/121), supracervical hysterectomy in 17% (20/121), and vaginal hysterectomy in 17% (20/121). Surgical history was not available in 15% (18/121) of patients.
Technique
Sonography was performed with an Acuson XP or Sequoia system (Siemens
Medical Solutions) using narrow-band variable-frequency transducers (a 2-4-MHz
vector transducer for transabdominal examinations and a 5-8-MHz simple
end-fire transducer for transvaginal examinations) or with an ATL HDI 5000
system (Philips Medical Systems) using wideband transducers (2-5-MHz curved
linear transabdominally and 4-8 MHz transvaginally). The highest frequency
transducer possible was used for each patient. Color Doppler sonography was
performed using scale and filter settings to optimize the detection of slow
flow. Fifteen women underwent transabdominal pelvic sonography, 26 underwent
transvaginal sonography, and 80 underwent both transabdominal and transvaginal
examinations. If a patient underwent both scanning techniques, both
measurements were used in the data analysis. In those women who had undergone
abdominal or vaginal hysterectomy, the size of the vaginal cuff was measured.
In those women who had undergone supracervical hysterectomy, the size of the
cervical remnant was measured. All measurements were in centimeters.
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The cuff was also compressed using the transvaginal probe, and length and anteroposterior measurements before and after compression were recorded (Figs. 2A and 2B). With compression, the probe was pushed into the tissue until the cuff or cervical remnant was maximally compressed or the patient could not tolerate further compression. These measurements were made manually with calipers on film in the retrospective portion of the study and with electronic calipers at the time of the examination in the prospective portion of the study. Note was made if abnormal findings such as fluid collections were associated with the cuff.
Image Analysis
For the prospective cases (45/121), Doppler flow assessment was made on the
transvaginal examination in 36 patients. Color Doppler flow within the cuff
was visually estimated using a scale of 0-4, in which a score of 0 indicated
no flow; 1, trace flow (< 10% of the color box occupied by color pixels);
2, mild flow (10-30% of the color box occupied by color pixels); 3, moderate
flow (30-50%); and 4, high flow (> 50% of the color box occupied by color
pixels) (Fig. 3).
To correct for the influence of the bladder volume on the anteroposterior measurement of the vaginal cuff or cervical remnant in transabdominal cases, bladder distention was graded on a scale of 1-4, with 1 indicating the least degree of urinary bladder distention and 4, the greatest bladder distention. Bladder volume was calculated according to the formula for a prolate ellipse (length x width x height x 0.52). Grades 1, 2, 3, and 4 corresponded to bladder volumes of less than 100 mL, 101-200 mL, 201-300 mL, and greater than 300 mL, respectively. The bladder was emptied for the transvaginal measurement. Bladder volume and grade of distention were considered in the analysis as possible covariates. The bladder volume was analyzed as a continuous variable.
Each examination was evaluated by two of five radiologists in consensus, who were blinded to the patient age, type of surgery, and history. One fellowship-trained, experienced sonologist participated in every image review along with a pool of four other radiologists who reviewed cases depending on their availability. Cuff size, compressibility, and Doppler flow were correlated with type of hysterectomy, patient age, time since surgery, degree of bladder distention, and surgical indications. In addition, time since hysterectomy was further stratified into the immediate postoperative period (defined as < 3 weeks) and more than 3 weeks after surgery.
Statistical Analysis
Descriptive statistics for continuous variables are presented as means and
SDs or as medians and ranges, as appropriate. Relative frequencies are
presented as percentages. An intraclass correlation coefficient was computed
to assess the degree of agreement between the transvaginal anteroposterior and
transabdominal anteroposterior measurements. Analysis of variance was used to
assess differences among surgeries with regard to cuff size measurements using
the Duncan multiple range tests to assess pairwise differences.
Distributions of transvaginal length measurements with compression were examined for normality and found to be not normal; a Kruskal-Wallis test was performed to determine the significance of differences among surgery types with regard to this measurement. Spearman's correlation coefficients were computed to assess associations between time since hysterectomy and cuff sizes because on review of scatterplots relationships deviated slightly from linearity [4]. Multiple linear regression analyses were used to derive models that related cuff size measurements to bladder size and type of surgery. A Mantel-Haenszel chi-square test was performed for statistical analysis to assess the association between type of surgery and Doppler vascularity measured on an ordinal scale. Findings were considered significant at p < 0.05.
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For those women who had their surgery 3 weeks or more before sonography, the mean transabdominal anteroposterior dimension was 1.8 ± 0.8 cm, the mean transvaginal anteroposterior dimension was 2.0 ± 0.8 cm, and the mean transvaginal length diameter was 2.2 ± 0.9 cm. For those women whose surgery was performed less than 3 weeks before the sonography, the mean transabdominal anteroposterior dimension was 1.7 ± 0.9 cm, the mean transvaginal anteroposterior dimension was 3.0 ± 1.4 cm, and the mean transvaginal length was 2.4 ± 0.7 cm. A significant difference was seen with regard to the transvaginal anteroposterior measurement only between those who had surgery less than 3 weeks and those who had surgery 3 weeks or more before imaging (p < 0.05). Five patients had fluid collections adjacent to the vaginal cuff. A good degree of agreement was seen between the transvaginal anteroposterior and transabdominal anteroposterior measurements, with an intraclass correlation coefficient of 0.52.
Statistically smaller transabdominal and transvaginal anteroposterior measurements were seen with advancing patient age (p < 0.0001 and p < 0.0004, respectively) and with time since hysterectomy (p < 0.04). The decrease in transvaginal length with increasing age and time since hysterectomy was not statistically significant (p < 0.08). The decrease in transvaginal length with compression was significant (p < 0.0001), but the decrease in the transvaginal anteroposterior measurement with compression was not statistically significant (p < 0.7). The mean decrease in transvaginal length with compression was 0.84 cm. The transvaginal length measurements with compression were not significantly different among the different surgical groups (Table 1).
In the 36 patients who underwent color Doppler examination, the mean Doppler flow score was 1.5 (± 0.76 [SD]) (median score, 1). Twenty patients (55.6%) had minimal flow, 10 (27.8%) had mild, 5 (13.9%) had moderate, 1 (2.8%) had no flow, and none (0%) had high flow. No association was noted between patient age, time since surgery, or type of surgery and the Doppler flow score.
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There is a paucity of literature on this topic. In 1982, Parulekar [3] studied 80 women with transabdominal sonography, of whom 58 had had an abdominal hysterectomy; 10, a vaginal hysterectomy; 4, a supracervical hysterectomy; and 8, unknown procedures. That study found an average anteroposterior cuff measurement of 1.4 cm, with no significant difference in size between the vaginal and abdominal hysterectomy groups [3], which is similar to our results. In 1990, Schoenfeld et al. [2] studied 16 posthysterectomy patients with transvaginal sonography and found the anteroposterior measurement to vary between 0.9 and 2.1 cm.
Because of the paucity of literature on this topic, we undertook this study with a larger number of patients, using transabdominal and transvaginal techniques, using color Doppler sonography, and stratifying posthysterectomy patients by type of surgical procedure and age.
We found that the size of the cervical remnant in women after supracervical hysterectomy is larger in every dimension than the vaginal cuff in women who have undergone transabdominal or transvaginal hysterectomies. However, it is only in the precompression data that a statistically significant difference exists between the cervical remnants and vaginal cuffs. This difference is obliterated with maximal compression, as seen in Table 1. The mean transvaginal anteroposterior and length measurements for the supracervical group are 3.3 and 3 cm, respectively (Table 1). This trend is statistically significant even after controlling for patient age and bladder distention. No significant difference was seen in the size of the vaginal cuff in those women who underwent abdominal hysterectomy compared with those who had a vaginal hysterectomy.
The finding of a large remnant in the supracervical hysterectomy patients is intuitively obvious, but it has important clinical implications. For example, if the radiologist describes an enlarged cuff on sonography, an extensive workup and possible biopsy may be required. It is often apparent from the images that residual cervix is present because of the appearance of the tissue and the finding of nabothian cysts, as shown in Figure 4. However, in those cases in which the presence of a cervical remnant is not obvious, the radiologist must know the type of hysterectomy that was performed before describing an abnormally enlarged cuff. Our study establishes reference standards for each surgical group, including mean values with SDs, thus providing a quantitative rather than qualitative assessment of vaginal cuff or cervical remnant size.
Limitations of our study include the retrospective nature of many of our cases, the variable length of time since surgery, and the subjective qualitative assessment of color Doppler findings. Also, a limitation in the retrospective portion of our study, which may be a source of error, was the use of calipers on film to measure the vaginal cuff or cervical remnant dimensions as opposed to electronic calipers used in the prospective part of the study at the time of sonography. In addition, intra- and interobserver variability in measuring the vaginal cuff or cervical remnant was not assessed. Furthermore, the degree of resistance perceived when inserting the endovaginal probe and the patient's level of tolerance might somewhat affect the reproducibility of the transvaginal length measurements.
The vaginal cuff size decreases in every dimension with advancing patient age, but this decrease is not statistically significant for transvaginal length. After menopause, whether surgically induced or spontaneous, estrogen levels decline, and the vagina and cervix atrophy, both in overall size and in epithelial thickness. A goal of a future study should be to establish normative values for vaginal cuff size in relation to decade of life.
The decrease in size of the vaginal cuff or cervical remnant with transvaginal transducer compression is a phenomenon that has not been described previously. This likely occurs as a result of the normal compliance and elasticity of the vaginal tissues. Our patient population did not include any women with known primary or secondary neoplastic involvement of the cuff. Future study will reveal whether compressibility of the vaginal cuff will be a differentiating feature between the normal and the abnormal cuff.
We have also shown that it is common to see blood flow within the cuff on color Doppler sonography. Almost all subjects showed at least minimal cuff flow. One must keep this in mind when evaluating patients for suspected cuff cellulitis because it is important to differentiate true hyperemia from normal vascularity.
In conclusion, our study establishes mean sizes and ranges for the vaginal cuff and cervical remnant in the posthysterectomy patient. These measurements vary by patient age and type of surgical procedure.
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