0:00

On to the next case.

0:02

So this is a 49-year-old woman who presented with infertility.

0:08

Again, I start with my sagittal T2 non fat saturated images.

0:16

Anterior compartments looking okay.

0:19

In my middle compartment, my uterus is anteverted but retroflexed.

0:23

So my brain is already telling me that there's something going on.

0:27

There's this big mass back here that is involving both the middle compartment

0:33

and tethering back to the posterior compartment back here.

0:36

So we're going to need to dive into that.

0:40

If I look at my axials here,

0:43

so we have one ovary back here on the left.

0:50

We have our right ovary back here.

0:53

They're kind of displaced.

0:54

They're very posterior in location and they're kind of medialized.

0:57

So that's going to be something important for us to discuss as well.

1:03

Then I switch and pull up my T1 fat saturated images

1:10

next to the T2s, so that I can get a sense of both

1:13

the T1 and the T2 character of things at the same time.

1:17

So these

1:20

T2 hyperintense lesions that I'm seeing in both ovaries are more

1:24

T1 hyperintense than they are T2 hyperintense.

1:26

So these are some bilateral endometriomas.

1:30

This area of abnormality along the posterior uterine serosa

1:35

is predominantly T2 and T1 hypointense.

1:38

Although, I'm also seeing areas of T1 hyperintensity

1:42

within it and little cystic areas of T2 hyperintensity within it.

1:46

That's going to tell us what type

1:47

of morphology of deep infiltrating endometriosis we're dealing with.

1:53

I apologize if this is getting a little grainy as I scroll through too quickly.

1:58

And then we're also seeing this kind

2:00

of very T2 dark stellate scarring sort of appearance.

2:06

Okay, so let's put this all together.

2:11

And we'll do so with the sagittal images.

2:22

So here along the posterior uterine serosa,

2:26

at the location of what's called the torus uterinus, which is the junction

2:30

of the uterine body and this uterine cervix along the posterior serosa.

2:36

So right here. It's called the torus uterinus.

2:39

There is a big endometriotic implant,

2:42

and it is both active glandular and chronic stromal fibrotic in morphology.

2:47

So the active glandular part are these

2:50

T1 hyperintense glands that are hemorrhagic and the cystic spaces.

2:57

And the chronic stromal fibrotic component is the T2 dark stellate

3:02

component that is tethering the rectum to the uterus,

3:07

obliterating the rectouterine space here,

3:10

and then extending along both uterosacral ligaments.

3:14

So the uterosacral ligaments extend

3:16

from the torus uterinus on both sides, posteriorly and laterally

3:21

and insert along the sacrum

3:24

on both sides, and help to suspend the uterus and the pelvis.

3:31

If we look at the axial T2s, we can appreciate the morphology

3:37

of that chronic stromal fibrotic component much better.

3:43

And we can see from the torus uterinus, which is right here,

3:47

there's extension of T2 hypointensity, posterolaterally on both sides.

3:52

That's involvement of the very proximal uterosacral ligament.

4:01

Right.

4:01

So I think that was everything that I wanted to point out on this case.

4:05

So we can go to the next question, please.

4:09

So which of the features of this case

4:12

that we've talked about has the biggest impact on surgical planning?

4:15

Is it the presence of both active glandular and chronic stromal fibrotic morphologies?

4:19

The Rectouterine space obliteration?

4:22

Retroflexion of the uterus or the bilateral endometriomas?

4:27

Perfect. Everybody got it right.

4:29

It is rectouterine space obliteration.

4:31

And again, that's really important

4:33

to the surgeons because they do these surgeries laparoscopically and if

4:35

the space is scarred down, they literally cannot get their scope beyond it.

4:40

The active glandular and chronic stromal fibrotic morphologies,

4:43

the presence of endometriomas,

4:45

the retroflexion of the uterus,

4:46

all of those are just findings of that endometriosis,

4:49

but they don't have specific implications for the surgery itself.