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Ureteral stone diagnosed with 3-dimensional transvaginal ultrasonography

Published:April 25, 2017DOI:https://doi.org/10.1016/j.ajog.2017.04.026

      Case notes

      A 45-year-old woman presented with low abdominal and low back pain, which had slowly increased over 3 months. Two-dimensional transvaginal sonography revealed an anechoic cylindrical shadow with a round isoechoic mass accompanied by posterior acoustic shadowing (Figure 1, A). The B-mode histogram revealed the same brightness in the contents of both the urinary bladder and the cylindrical structure, suggesting that the cylindrical structure was a dilated ureter containing urine (Figure 1, B). Three-dimensional images obtained with the be Crystal Vue (Samsung Medison Ltd, Seoul, Republic of Korea) mode and the Realistic Vue (Samsung Medison Ltd) function clearly visualized the internal and external contours of the urinary bladder and dilated distal ureter obstructed with a ureteral stone at the ureterovesical junction (Figure 1, C). Additional imaging studies were performed to confirm the tentative diagnosis of ureteral stone at the ureterovesical junction (Figure 2, A to C). Under general anesthesia, cystoscopy and exploration of the right ureterovesical junction revealed the presence of a ureteral stone (Figure 2, D). Extirpation of the ureteral stone was performed, and the patient was discharged on the second day after the operation with an uneventful recovery.
      Figure thumbnail gr1
      Figure 1Transvaginal ultrasonography suggesting a stone in a dilated distal ureter
      A, Round isoechoic mass of U S and posterior acoustic shadowing (*) in hypoechogenic tubular structure suggesting dilated U and bladder (Bl). B, B-mode brightness histogram reveals same brightness (dotted circle) of contents of both urinary Bl and U. C, Three-dimensional images clearly visualize urinary Bl and dilated distal U obstructed with distal U S and posterior acoustic shadowing (*).
      Lee. Ureteral stone with 3D transvaginal ultrasonography. Am J Obstet Gynecol 2017.
      Figure thumbnail gr2
      Figure 2Imaging studies performed to confirm diagnosis of distal ureteral stone based on finding of transvaginal sonography
      A, Kidney, ureter, and bladder radiography demonstrating dilated right distal ureter (arrow). B, Abdomen-pelvic computed tomography (CT) with enhancement revealing ureter stone (arrow) in dilated right distal ureter. C, Three-dimensional reconstructed CT revealed round mass (arrow) in right ureteric course. D, Cystoscopic finding of whitish ureteral stone exposed on exploration of right ureteric orifice.
      Lee. Ureteral stone with 3D transvaginal ultrasonography. Am J Obstet Gynecol 2017.

      Comments

      Transvaginal pelvic ultrasonography provides clear images of the pelvic organs, including the uterus, ovaries, fallopian tubes, and pelvic cavity, without the hazard of radiation. Therefore, it is widely used for the evaluation of women with gynecological symptoms. The lower urinary system, including the urinary bladder, urethra, and the distal ureter can also be examined by using transvaginal ultrasonography in most cases.
      • Pateman K.
      • Mavrelos D.
      • Hoo W.L.
      • Holland T.
      • Naftalin J.
      • Jurkovic D.
      Visualization of ureters on standard gynecological transvaginal scan: a feasibility study.
      Considering the reports that about 92.7% of transvaginal pelvic ultrasonographic examinations performed by experts or intermediate level operators visualized the distal ureter
      • Pateman K.
      • Mavrelos D.
      • Hoo W.L.
      • Holland T.
      • Naftalin J.
      • Jurkovic D.
      Visualization of ureters on standard gynecological transvaginal scan: a feasibility study.
      and that 85% of ureteric stones are located in the distal ureters,
      • Khullar V.
      • Cardozo L.D.
      • Salvatore S.
      • Hill S.
      Ultrasound: a non-invasive screening test for detrusor instability.
      we agree with the authors’ conclusion that gynecologists should consider the evaluation of the urinary system in routine pelvic sonography. In conclusion, the use of 3-dimensional reconstructed images by adding the recently developed postrendering techniques can provide additional information in the evaluation of the lower urinary system to the conventional pelvic sonography in the 2-dimensional mode.

      References

        • Pateman K.
        • Mavrelos D.
        • Hoo W.L.
        • Holland T.
        • Naftalin J.
        • Jurkovic D.
        Visualization of ureters on standard gynecological transvaginal scan: a feasibility study.
        Ultrasound Obstet Gynecol. 2013; 41: 696-701
        • Khullar V.
        • Cardozo L.D.
        • Salvatore S.
        • Hill S.
        Ultrasound: a non-invasive screening test for detrusor instability.
        Br J Obstet Gynaecol. 1996; 103: 904-908

      Linked Article

      • 3D transvaginal sonography in obstetrics and gynecology
        American Journal of Obstetrics & GynecologyVol. 218Issue 1
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          We certainly agree with the authors, Lee and Yoon,1 in that 3-dimensional transvaginal ultrasonography (3D TVS) clearly offers additional clinical value as a diagnostic imaging tool, well beyond 2D TVS. The identification of a ureteral calculus within the ureter provides a good example of this value; such use should be encouraged and broadened. One can even say that, with the confirmatory diagnosis from the use of 3D TVS, the other imaging modalities (eg, computed tomography) may not have even been necessary to use in this case.
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        American Journal of Obstetrics & GynecologyVol. 218Issue 1
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          We appreciate the insightful comments expressed by Drs Levine and Fernandez regarding our recent report on the ureter stone diagnosed with 3-dimensional (3D) transvaginal ultrasonography. We absolutely agree with the authors’ opinion that the 3D sonography provided additional useful information to the 2-dimensional sonography. As Drs Levine and Fernandez commented, the imaging studies that were performed to confirm the diagnosis of distal ureteral stone in our case might not be needed in other cases, considering the additional cost and radiation exposure.
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