It is used to image lesions in the urethra, bladder, ureter, and renal pelvis 1. The high quality of ultrasound images allows clear visualization of distinct anatomic layers and provides accurate representation of tubular and hollow structures with volumetric and geometric validation 4, A major advantage of this technique is its ability to image structures beyond the lumen of the tubular structure or hollow viscus In a study conducted by Goldberg et al.
Evaluation of the pathology and morphology of such tubular structures with multiplanar and surface-rendered images allow physicians to obtain valuable clinical information promptly ELUS is currently employed in the evaluation, diagnosis, and staging of a wide range of urological abnormalities, such as urinary incontinence. ELUS can be used to directly visualize the sphincter mechanism and identify this condition This technique is also used to guide collagen injection, which is used to treat urinary incontinence.
ELUS accurately identifies the submucosal location of collagen injection, avoids dispersion of the material, and augments the therapeutic efficacy in the treatment of urinary incontinence A novel dimension in ELUS creates new clinical advantages of this technique. For example, ELUS is used to diagnose stones in the ureter and renal pelvis, locate crossing blood vessels that produce compression of the ureter, diagnose tumors in the urinary bladder and ureter, diagnose lumen encroaching pathology, assist in tumor staging biopsy guidance, distinguish between embedded stones and aberrant vessels, guide intraluminal instruments, and distinguish superficial tumors from those with muscle invasion 2,6,15,22 Table Diagnosis and localization of urethral diverticula in females may pose a problem, as the urethral diverticulum can be easily misdiagnosed to be a redundant vaginal mucous Female urethral diverticulum or its contents such as stones, endometriosis or tumors may present with diverse symptoms such as voiding dysfunction, pelvic pain, dyspareunia, incontinence, dribbling, and urethral discharge.
Diverticula in females may be delayed or misdiagnosed, "mean interval between onset of symptoms to diagnosis was 5. From the diagnosis point, urethral diverticula can be classified into 2 main groups.
Female urethral diverticula whose ostia are open "open or communicating diverticula" where in the opening of the urethral diverticulum is wide and communicates with the main urethral lumen. Female urethral diverticulum whose ostia are closed, "closed or non-communicating diverticula" whose opening of the urethral diverticula is narrow or closed and is non-communicating with the main urethral lumen may present as cystic palpable mass on urethral examination.
Pressure dependent urethral contrast studies may fail to diagnose and locate the closed urethral diverticulum, in these difficult cases ELUS may become diagnostic technique of choice and play a key role in the future 2. Currently MRI, transvaginal ultrasound have been reported to help diagnose, locate and study the contents of the suspected "non-communicating or closed" urethral diverticulum Although miniaturized transducers guided ultrasound catheters are available, limitations of ELUS include restricted catheters flexibility, which may lead to noncoaxial or eccentric positioning of the intraluminal ultrasound probe, which may result in image artifacts, or loss of echo signals known as "echo drop outs".
In small or tortuous tubular lumens, malpositions of the ultrasound probes may preclude quantifications of lumen dimensions. Other limitations include invasiveness of the procedures with attendant risks of infection, luminal trauma, perforation, migration or ischemia due to lumen obstruction. Presence of gas in the diagnostic fields of bladder and ureter pose a hindrance to accurately visualize the lesions In addition, the lack of penetration of sonographic beams in ELUS places major limitations on the evaluation of the depth of the invasion in large greater than 2 CMS bladder tumors with a broad base Validation studies consistently suggest that future advances in endoluminal ultrasound technology are bound to improve and better this technique.
In an attempt to stretch high index of clinical suspicion of urologic diseases in the realm of pathology and clinical urology, ELUS provides an opportunity to exploit and enhance complimentary radiologic disparate disciplines for diagnosis of difficult upper and lower urinary tract lesions. ELUS may be useful to screen for early tumors of tubular and hollow anatomical structures of the urinary tract to diagnose screening of the upper and lower urinary tract in patients with refractory positive urine cytology with negative results obtained by currently available urologic instrumentation, contrast dependent studies or by other radiologic imaging such as MRI or computed axial tomography CAT scan.
Thickening of the luminal wall or hollow viscus may provide an early answer to the refractory positive cytology. Future advances in ELUS may compliment emerging robotic techniques that are currently used in laparoscopic urology Endoluminal diagnostic ultrasound should be designed to provide urologists with an opportunity to integrate other diagnostic disciplines. Ideal diagnostic instrumentation should include fast, efficient, non-complicated instruments with short learning curve: 1 The diagnosis should be easily duplicated; 2 Outcome should carry an increased sensitivity and specificity when compared to the present technologic advances; 3 Early detection diagnosis of malignant lesions of the tubular and hollow structures of the urinary tract and clarity of imaging should be easily achieved; 4 Miniature catheter based ultrasound technique and effective instrumentation with excellent diagnostic yield should be readily available at a small cost; 5 The technique should carry minimal morbidity and mortality; 6 The technology can be safely used in patients with contrast allergies and in pregnant patients.
The tubular lumen of the ureter can be utilized to study and explore vessel morphology combined with duplex Doppler technology. Endoluminal ultrasound is still in its infancy, advances in transducer-loaded flexible miniaturized catheters and computer software holds great promise. Long-term multi-institutional studies to examine lesions of the upper and lower urinary tract may provide a reliable answer to difficult diagnostic lesions in the ureters, bladder and urethra.
Lower urinary tract symptoms
Surg Gynecol Obstet. Scand J Urol Nephrol.. Odegaard S: High-resolution endoluminal sonography in gastroenterology. Eur J Ultrasound.
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Part II. Eur J Radiol. Annu Rev Biomed Eng. Radiol Clin North Amer. Grotas A, Grasso M: Endoluminal sonographic imaging of upper urinary tract: three-dimensional reconstruction. J Endourol. Trinkler FB: Ultrasound examination of the urogenital tract: indications and limits. Schweiz Rundsch Med Prax. Can J Urol.
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J Ultrasound Med. Eur Radiol. Ultrasound Med Biol. J Urol. Hickey N, Murphy J, Herschorn S: Carcinoma in a urethral diverticulum: magnetic resonance imaging and sonographic appearance. Mouritsen L, Bernstein I: Vaginal ultrasonography: a diagnostic tool for urethral diverticulum. Acta Obstet Gynecol Scand. Comput Aided Surg. We diagnose and treat benign inflammatory and infectious disorders, kidney stones, all types of voiding dysfunction and obstruction including incontinence and reconstruction of the upper and lower urinary tract , male infertility, and impotence.
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