{"paper_id":"81b1ec9e-5b65-4817-bed6-156facf30bf6","body_text":"Imaging Med. (2018) 10(2) 29\nISSN 1755-5191\nHigh-intensity focused ultrasound of \nuterine fibroids and adenomyosis: \nmaneuver technique for bowel loops \nlocated inside the treatment window\nIntroduction\nUterine fibroids and adenomyosis are two \ncommonly gynecological benign tumors \nnegatively affected women’s health [1,2]. \nHigh-intensity focused ultrasound (HIFU) \nis a promisingly alternative treatment to \nconventional surgery and is increasingly \nworldwide used because of its completely \nnon-invasive method [3-6].  During the \nablation procedure, appearance of bowel loops \ninside the treatment window was generally \nproblematic because hard elements and air \nbubbles inside bowel loops absorb and reflect \nultrasound energy caused unpredictable \nthermal injury even bowel perforation [7,8].  \nThus, in this concise communication, we aimed \nto introduce the filling bladder, filling rectum, \nand emptying bladder (BRB) technique for \nmanipulating bowel loops out of the treatment \nAppearance of bowel loops in the sonication beam path during high-intensity focused ultrasound (HIFU) ablation therapy is a \nproblematic condition. Filling bladder, filling rectum and, emptying bladder (BRB) maneuver technique might be helpful in producing \na non-bowel treatment window for HIFU ablation of uterine fibroids and adenomyosis and ensuring the safety profile for patients.\nKEYWORDS:  high-intensity focused ultrasound   uterine fibroids  adenomyosis  BRB maneuver technique\nNguyen Minh Duc* & \nHuynh Quang Huy\nDepartment of Radiology, Pham Ngoc \nThach University of Medicine, Ho Chi \nMinh city, Vietnam\n*Author for correspondence:\nbsnguyenminhduc@pnt.edu.vn\nFigure 1. (A) Sagittal T2W images show adenomyosis on the posterior wall of \nthe anteverted uterus (white asterisk) with bowel loops above the tumor (blue \narrow), which tend to move into the space between the tumor and abdominal \nwall (red arrow). (B) Filling bladder with 400 ml normal saline (black asterisk) \ngenerates bowel loops out of the treatment window (orange arrow).\nwindow in order to establish the safety profile \nfor patients. \n „ BRB technique\nFilling the bladder with normal saline via a \nFoley catheter will not only elevate the uterus \nupward but also shove the bowel loops out of \nthe treatment window when they tend to move \ninto the space between the abdominal wall and \nthe uterus as seen in Figure 1 [9,10].\nFilling the rectum with ultrasound gel \nthrough a rectal catheter is also beneficial \nfor pressing the uterus forward and reducing \nthe distance between the uterus and anterior \nabdominal wall as seen in Figure 2. In addition, \nthis manipulation also reduces bowel loop \nmovements into the space between the uterus \nand the rectum [9,10].\nFinally, emptying bladder concurrent with \nSHORT COMMUNICATION\n\na rectum full of ultrasound gel is predicted to \nproduce a non-bowel treatment window as \nseen in Figure 3 [9,10]. In some circumstances, \nafter emptying bladder, the bowel loops tend \nto relocate into the treatment window; thus, \nrefilling the bladder with normal saline and \nkeeping the bladder dilated during the treatment \nprocess should be considered. Kim et al. [10] \nstated that the most significant factor affected to \nthe unsuccessful rate of BRB technique was the \nsmall size of uterus.\nConclusion\nThe BRB maneuver technique plays an \nimportant role in generating a non-bowel \ntreatment window for HIFU ablation of uterine \nfibroids and adenomyosis.\nDisclosure statement\nConflict of interest: The authors of this \nmanuscript report no conflict of interest.\nFigure 2. (A) Sagittal T2W images show the uterine fibroid on the anterior \nwall of the retroverted uterus (white asterisk) with bowel loops above the \ntumor (blue arrow) which tend to move into the space between the tumor and \nabdominal wall (red arrow). (B) Filling rectum with 150 ml ultrasound gel (blue \nasterisk) generates upward and forward uterine movements, shrinks the space \nbetween the tumor and abdominal wall (green arrow), and bowel loops out of the \ntreatment window (orange arrow).\nFigure 3. (A) Sagittal T2W images show the focal adenomyosis on the posterior \nwall of the anteverted uterus (white asterisk) with bowel loops above the \ntumor (red arrow). (B) Filling bladder with 300 ml normal saline (black asterisk) \nand filling rectum with 150 ml ultrasound gel (blue asterisk) generate uterus move \nupward and forward. (C) Emptying bladder meanwhile with the pressure of filled \nrectum makes the uterus move forward and downward and bowel loops out of the \ntreatment window (blue arrow).\nImaging Med. (2018) 10(2)30\nSHORT COMMUNICATION Duc, Huy\n\nSHORT COMMUNICATION\nREFERENCES\n1. Stewart EA. Uterine fibroids. N. Engl. J. Med . \n372, 1646-1655 (2015).\n2. Bergholt T , Eriksen L, Berendt N et al. Prevalence \nand risk factors of adenomyosis at hysterectomy. \nHum. Reprod. 16, 2418-2421 (2001).\n3. Ferrari F , Arrigoni F , Miccoli A et al . \nEffectiveness of magnetic resonance-guided \nfocused ultrasound surgery. Radiol. Med . 121, \n153-161 (2016).\n4. Behera MA, Leong M, Johnson L et al. Eligibility \nand accessibility of magnetic resonance-\nguided focused ultrasound (MRgFUS) for the \ntreatment of uterine leiomyomas. Fertil. Steril. \n94, 1864-1868 (2010).\n5. Arleo EK, Khilnani NM, Ng A et al. Features \ninfluencing patient selection for fibroid \ntreatment with magnetic resonance-guided \nfocused ultrasound. J. Vasc. Interv. Radiol . 18, \n681-685 (2007).\n6. Zhang X, Li K, Xie B et al . Effective ablation \ntherapy of adenomyosis with ultrasound-\nguided high-intensity focused ultrasound. Int. J. \nGynaecol. Obstet. 124, 207-211 (2014).\n7. Ko JKY, Seto MTY, Cheung, VYT . Thermal \nbowel injury after ultrasound-guided high-\nintensity focused ultrasound for uterine \nadenomyosis. Ultrasound. Obstet. Gynecol . 27, \n1-6 (2017).\n8. Hwang DW , Song HS, Kim HS et al. Delayed \nintestinal perforation and vertebral osteomyelitis \nafter high-intensity focused ultrasound \ntreatment for uterine leiomyoma. Obstet. \nGynecol. Sci. 60, 490-493 (2017).\n9. Kim YS, Bae DS, Park MJ et al. T echniques to \nexpand patient selection for MRI-guided high-\nintensity focused ultrasound ablation of uterine \nfibroids. AJR. Am. J. Roentgenol . 202, 443-451 \n(2014).\n10. Kim YS, Lim HK, Rhim H. Magnetic resonance \nimaging-guided high-intensity focused \nultrasound ablation of uterine fibroids: Effect of \nbowel interposition on procedure feasibility and \na unique bowel displacement technique. PLoS. \nONE. 11, 7-12 (2016).\nImaging Med. (2018) 10(2) 31\nHigh-intensity focused ultrasound of uterine fibroids and adenomyosis: maneuver \ntechnique for bowel loops located inside the treatment window","source_license":"CC0","license_restricted":false}