Biological and Clinical Sciences Research Journal
ISSN: 2708-2261
DOI: https://doi.org/10.47264/bcsrj0201014
Biol. Clin.
Sci. Res. J., Volume, 2021: e014
Systematic Review Article
EFFECTIVENESS OF RADIOLOGICAL IMAGING TECHNIQUES
(X-RAYS, MDCT, AND MRI) FOR DIAGNOSIS OF PELVIC FISTULA: A SYSTEMATIC REVIEW
SHAHZAD
M1, ANJUM N2,
SIRAJ S1, OMER MA*3, SHABBIR R1, MASOOD A4
1Sahiwal Medical College Demonstrator Pathology
Department Section Microbiology, Pakistan
2Radiology Department, The University of Lahore, Lahore, Pakistan
3Department of Radiology
DHQ Hospital Sheikhupura, Pakistan
4WAPDA Hospital
Faisalabad, Pakistan
Corresponding author email: dr.arslan14@gmail.com
Abstract: This study aimed to evaluate the diagnostic performance of
different imaging techniques for preoperative detection of pelvic fistula.
Imaging and classification of female genital abnormalities considerably pelvic
floor fistulas are significant. We conducted a systematic review of the available
literature to highlight the effectiveness of different radiological imaging
techniques (X-RAY, U/S, CT, MRI) for the diagnosis of different types of pelvic
fistulas to see the limitations of conventional scanning and testing over
modern imaging techniques and to show the effectiveness of choosing one imaging
modality over other depending upon multiple dynamics e.g., site and types of
fistula. The controlled and regular research cases (n= 9) available in English
from 2011 to 2020 were included in the criteria of research. The evidence
databases were used for the assessment of certain studies analytically by way
of the PEDro scale and explicated under decision guidelines. In all relevant
articles were identified and included in this systematic review. The
radiological techniques showed improved diagnostic performance that established
the effectiveness of imaging advancement for the administration and treatment
of pelvic fistula. Conventional methods have less sensitivity and specificity
as compared to modern techniques. X-RAY fistulography and ultrasonography have
less sensitivity and specificity as compared to CT scan but still found
beneficial in the diagnosis of colovaginal, uterovesical fistula and considered
as the most basic clue about the existence of a malignant fistula
respectively.it is verified that MDCT is the safer accurate and offered more
detailed defects in the diagnosis of urogenital, urethrorectal, lower
urogenital tract fistulas, upper and middle vaginal fistulas colovesical
fistulas(along with X-RAY), and prostate symphyseal fistula(along with MRI). It
has been concluded that MRI can access colovesical fistulas inherited vaginal
fistulas and prostate symphyseal fistulas(along with CT) more efficiently. It
has been concluded that diagnostic imaging for all pelvic fistula is useful, to
help physicians, particularly radiologists, in the diagnosis of pelvic
fistulas. The choice of imaging technique is dependent upon multiple factors.
Advanced medical imaging techniques XRAY, MDCT MRI) are considered more recommended choices as
compared to conventional imaging.
Keywords:
MDCT, X-Rays, CT-Scan,
MRI, Gynecology, Pelvic Fistula, Diagnostics, Radiology
Introduction
Fistula is one of the
most life threatening and non-fatal complications of gynecologists which the
world ever seems to panic most, yet ureteric injury
comes close second (Alperin et al., 2013). The term “fistula” runs from the Latin language that
means “tube” or “pipe” and is referred as an abnormal linkage between mesothelial or epithelial surfaces
(Warembourg et
al., 2017). Though an infrequent surgical problem, specialized surgeons
prerequisite to be familiar with the risk factors, epidemiology, treatment, and
evaluation of females with fistulae, as fistula cause acute incontinence signs
in females who develop with such challenging disease. Pelvic fistulae have been
recognized all over the ages, with fistulae well-known in wrinkled Egyptian
ladies (Tunitsky, Abbott, & Barber,
2012). Fistulae can develop among a diversity of pelvic structures
and can occur due to diverse causes (van Ramshorst et al., 2020). In the developed world,
the occurrence of pelvic fistula development after hysterectomy has been
reported at 0.1 per cent with vesicovaginal fistulae
arising in 1 out of 500-2,000 hysterectomies. Based upon a population study of
62,379 hysterectomies, the occurrence of pelvic fistula was 1 in 6000 after
vaginal hysterectomy, 1 in 1,000 after abdominal hysterectomies, and1 in 500
with laparoscopic hysterectomy (Selvaggi and Pellino, 2015). Labour dystocia is a general cause of pelvic fistula development
in underdeveloped countries with rates of occurrence within the range of 0.5 to
6.5 per 1,000 deliveries and incidence rates from 5.5 to 80.5 per 1,000
deliveries in Southern Asia and Africa (Kondo et al., 2011). Due to better-quality prenatal care together with
access to cesarean and supervised labor and delivery, fistulae triggered by
obstructed labor are rare currently in the United States. However, pelvic
fistulae still occurs after acute cesarean deliveries, perineal
lacerations, peripartum hysterectomy, uterine
rupture, and dilation and curettage to retained conception products (Abbott et al., 2014).
The uterine ruptures in
obstetrics are also rare; however 22 per cent of such cases have been related
to simultaneous bladder injury that may lead infrequently towards pelvic
fistulae. It accounts for about 1 to 4 percent of all genitourinary fistula, with over 90 percent of them caused by
non-cancerous gynecological surgery (Abdulaziz et al., 2015). Majority of the cases
reported after cesarean deliveries but other causes comprise radiation,
malignancy, chronic infections for example tuberculosis or intrauterine device
derived ischemic necrosis. Other kinds of pelvic fistula including urethrovaginal and vesicocervical
are also occasional but have been reported after placement of cerclage (Nassar, 2011). Urethrovaginal fistula commonly occurs with the incident
range of 0.9-5 per cent after surgical treatment of urethral diverticulum (Tijdink et al., 2011).
Moreover, the occurrence
of iatrogenic ureteral injury in the course of major
gynecological surgeries is reported about 0.5-2.5 per cent with few of them
subsequent in fistula development (Iwamuro et al., 2018). The widely held (88 per
cent) of rectovaginal fistula occur due to childbirth
pain.A diversity of radiographic and examinations
studies have tried to recognize precisely and effectively pelvic fistulae.
Intravenous urography, barium enema, cystography, colporrhaphy, and vaginography might demonstrate the existence of appropriate
organs in medium, contrast, and outside the region but the fistulous tract
commonly fails to identify, partially because several fistulas are small,
oblique, and tortuously oriented (VanBuren et al., 2018). The multidetector
computed tomography (MDCT) and computed tomography (CT) reported to be the
beneficial techniques in representing a pelvic fistula; but, their drawbacks
include intravenous administration contrast and extra processes such as hysterography (Abou‐El‐Ghar et al.,
2012).
Figure 2 Pelvic and Rectovaginal Fistula on CT, MRI, and MDCT
Magnetic resonance
imaging (MRI) for pelvic fistulae is a noninvasive technique which allows the
prevention of iodine-based or allergic nephrotoxic
contrasts and used recently in the pelvic fistula diagnostics (de Miguel et al., 2012). Cystoscopy
provides information regarding the urinary tract, as about 12 per cent of vesicovaginal fistulae contains an ureterovaginal
fistula or concomitant ureteral injuries (Golabek et al.,
2013). Cystoscopic fistula imagining can evaluate the
spots whether it becomes mature. The mature fistulae present smooth margins
within bladder boundary while the immature fistulae frequently have an
appearance of bullous edema (Alperin
et al., 2013). In this systematic
review, it has been planned to explain the prevailing facts required to clarify
the evidence regarding the effectiveness of imaging techniques for diagnostics
of pelvic fistula.
Material and Methods
Inclusion Criteria
Only peer reviewed
research articles were included which evaluated different kinds of pelvic
fistula Participants in the trials were patients of any disease duration, of
all ages, and on any form of above mentioned radiological imaging techniques.
The patients were not selected during treatment trials and reports in any other
language except English.
Literature Sources and
Libraries
For the exploitation of
literature based insight studies for current research, Elsevier, Library
Genesis, Wiley Online Library, Cochrane libraries, Embase,
Medline, Google Scholar through PubMed in conjunction
with National Library NIH of Medicine have been explored with identical
keywords linked to radiological imaging techniques for diagnostics of diverse
kinds of pelvic fistulas. papers have been
systematically concluded to distinguish perspective approaches.
Study Design and
Interventions
Multiple randomized,
systematic and controlled procedures available in English from 2011 to 2020
were included in criteria of research. This constraint was implemented to
minimize the risks of unfairness with respect to consequence assessments. The
strategy to search the studies was followed by the Cochrane Movement Disorders
Group that cross‐referenced fundamentally
as text titles and keywords including radiological imaging techniques for diagnostics
of diverse kinds of pelvic fistulas.
Data Extraction
Entire research papers
were analyzed by three independent reviewers and data extracted as stated by
defined criteria resolved any inconsistencies by multiple discussions. Research
papers were evaluated for methodological quality by estimating definite
eligibility criteria, methods of blinding, and randomization disguise of
allocation, correspondence of baseline patients in treatment groups,
discrepancy in co-interventions obtained by patients all the way through the
trial duration, either a purpose to treat study was conducted, or the total
patients missing follow-up.
Quality Assessment
The Physiotherapy
Evidence Database (www.pedro.org.au) was used for assessment of certain RCTs
analytically by way of PEDro scale scores and
explained under decision guidelines. Generally, the PEDro
scale evaluates the practical quality of a research on the basis of imperative
principles. These features make the PEDro scale a
valuable instrument to evaluate the operational quality of physical therapy and
therapeutic trials. The trials were individually rated and evaluated the bias
risks by three authors. Studies were disqualified in the following analysis if
the 5 points cut-off was not touched by PEDro scale.
Results
The overall 600 papers
were recognized from electronic and additional searches however 250 were
duplicates. Subsequently with screening titles, abstracts, and interventions
180 studies were again skipped. The full-length texts were obtained for 30
papers of which 13 papers were removed as they did not run into inclusion
criteria and thus, 17 papers included in the final qualitative research as
represented by PRISMA flow diagram (Figure. 1).
Figure.1. Prisma
flowchart for selected studies
Table.1. Detailed information of selected studies
Authors |
Intervention |
Type of Pelvic Fistula |
Analysis Unit |
(Tang et al., 2012) |
MRI |
Colovesical fistula |
Patients |
(Botsikas
et a., 2012) |
MDCT |
Urogenital fistulas |
Patients |
(Sa et al., 2013) |
CT |
Urethral-rectal
fistula |
Patients |
(Farouk, 2014) |
X-Ray |
Ureterovaginal fistula |
Patients |
(Plateau etal., 2015) |
CT and MRI |
Prostate symphyseal fistula |
Patients |
(Kamanda,
2016) |
MDCT |
Lower urogenital tract fistulas |
Patients |
(Botsikas
et al., 2017) |
CT |
Upper and middle
vaginal fistulas |
Patients |
(Xu
et al., 2019) |
MRI |
Vaginal fistulas |
Patients |
(Mandava et al., 2020) |
CT and X-Ray |
colovesical fistula |
Patients |
Study Outcomes and
Qualitative Analysis
Tang et al. (2012) reported that they selected
different cases during the time period of 4 years with an ultimate clinical
diagnosis of colovesical fistula with the help of
MRI. The scans were revised in a consensus manner by two specialist
radiologists and quantified features of MRI. The morphology of the fistula
constantly came into three shapes. The most common shapes confirmed about 71
percent an intervening abscess amongst the bladder and bowel walls. The second
one 15 per cent was visible track and third about 13 per cent reported whole loss
of fat plane between the affected bladder and bowel. It verified the MRI as a
useful imaging intervention in the pelvic fistulae diagnostics. Botsikas et al.
(2012) performed the diagnostics of vesicovaginal and
ureterovaginal fistulas with the help of 64-MDCT
scanner (Sensation 64, Siemens Healthcare). Overall 3 patients were inspected
and clinical symptoms involved bladder catheterization and ureteral
pigtail along with urine dribbling. Consequently, it has been established that
MDCT is helpful in finding the exact localization of the fistula path along
with vaginal origins.
Sa et al. (2013) diagnosed the posterior urethral parameters related
to urethrorectal fistula using computed tomography
(CT) and conventional urethrography (CUG). Total 38
patients with posterior urethrorectal fistula were
examined and found the accuracy in stricture location determining higher with
93.12 per cent with CT as compared to conventional CUG of 70.59 per cent. It
verified that CT is safer, accurate, and offered more detailed defects as
compared to orthodox urethrography. Plateau et al., (2015) presented a very rare osteomyelitis pubis case in an old patient because of a
prostate symphyseal fistula that developed after a
few weeks of transurethral prostate resection. The patient also reported a
history of prostatic carcinoma cured by radio treatment that sometimes played a
part in the fistula development. CT along with excretory phase MRI were applied
and made sure of the final diagnostics. It proved MRI and CT as the best
imaging modalities for establishing a confident diagnosis of prostate symphyseal fistula which can also cause osteomyelitis
pubis.
Kamanda,
(2016) examined two cases of 29 and 51 years old females with cervix cancer and
vesicovaginal fistula respectively. MDCT cystography was applied to detect the existence or
nonexistence of urogenital fistulas..
The outcomes verified that MDCT cystography by means
of vaginal tampons is an inexpensive, safe, and simple technique for diagnosing
the urinary fistulas. Botsikas et al., (2017) explored the potential character of a CT imaging for
realizing vaginal obstruction and opacification to
demonstrate fistula patency. The examinations were performed on 3 patients and
were technically effective as the patients revealed the presence of fistula
pathways from the vaginal fornix between the necrotic cavity and vagina of a
recurrent cervical cancer. It concluded CT-vaginography
as an officially feasible protocol which offers functional and structural
evidence about medically suspected pelvic fistula. Xu
et al., (2019) investigated the
manifestations of MRI for inherited vaginal fistula. The clinical data and MRI
findings of 12 patients were established by laparoscopy and hysteroscopic
surgery and retrospectively examined. MRI mostly manifested as hemorrhage and
dilatation in the cervical canal, vaginal upper part, and uterine cavity. It
has been concluded that MRI can assess the kind of vaginal fistula accurately
along with linked complications as well as make diagnosis efficient. Hence, it
can be recommended as the effective evaluation intervention. Mandava et al.,
(2020) tried to compare the accurateness of computed tomography (CT) and sonography for recognizing malignant fistulas. Total 35
patients were examined for complex pelvic fistula The
specificity and sensitivity of ultrasound for detection were 72 percent and 66
percent correspondingly. The outcomes recommend that though ultrasound is not
the best as compared to CT as a major imaging technique to detect fistulas, it
can offer the most basic clue about the existence of a malevolent fistula.
Discussion
Imaging and
classification of female genital abnormalities considerably pelvic floor
fistulas are significant, however have the following fundamentals: (a)
understanding of the anatomy and morphology of the female genitourinary tracts
and relations with different kinds of pelvic fistulas; (b) understanding of
irregularities involved in the development in addition to the resorption of pelvic fistulas (Shi et al., 2018). It has reported in a previous study that diagnostic
imaging for all such kinds of malformations has been presented with prominence
on the more complicated abnormalities, which are better addressed on current
trending technology basis (Watanabe et al.,
2014).
In the management of
pelvic floor fistula, the recurrence is a major problem particularly in complex
and persistent fistulas, which is typically because of undetected or missed
infection in the course of surgical treatment (Nadır
et al., 2011). With the passage of
time, preoperative imaging of fistulas in pelvic regions has become a regular
practice to support the radiologist surgeons understand the anatomy of fistula
and planning the applicable management consequently so that the probabilities
of recurrence may be decreased. CT and MRI are commonly used in pelvic fistula
imaging currently and so is the case with radiological fistulography
(Liang et al., 2013). The accuracy of
X-ray fistulography in recognizing the extensions and
internal opening has been found to be minimum 16 per cent with false-positive
rate of 10% and hence is not considered trustworthy in appropriately
diagnostics of fistula in the pelvic regions (Thabet et al., 2012). However, in certain
patients such as in extrasphincteric fistulas or in
fistulas subsequent because of inflammatory bowel disease, fistulography
has been valuable in representing the intestinal communication of fistula
(Kumar et al., 2012). Modified MDCT fistulography, in contrast, has been reported to be more
valuable as compared to the conservative ones (Gage et al., 2013).
Pelvic endosonography is a rapid, non- or minimally invasive
approach that offers high-resolution pictures of the in pelvic regions and the
adjacent structures and therefore may deliver the comprehensive fistula anatomy
with regard to the levator plates, sphincter complex,
and related potential areas (Donghai et al., 2013). Another study reported 3D
technology with improved diagnostics and endosonography
accuracy more than 2D imaging as the precisions for primary pathways, secondary
pathways, and internal overtures have enhanced from 89.4 per cent, 83.3 percent
and 87.9 percent for 2D imaging to 98.5 percent 98.5 percent and 96.4 percent
correspondingly, for 3D method (Brinjikji et al., 2016).
Conclusion
The recurrent and
complex fistula in the pelvic region must undertake a preoperative imaging for
a better sympathetic of the nature and progression of the infection to decrease
the probabilities of recurrence. The choice of imaging technique is dependent
upon multiple dynamics such as the characteristics of the diseases and the
patients, the benefit of exclusive technology over others, surgeon’s
partiality, budget and accessibility of the technique, and the expertise of the
radiologist. The use of conventional scanning and testing is no longer favored
unless in certain situations. At the same time, MRI, MDCT and X-Ray are the
recommended choices for imaging fistula in pelvic regions, computed tomography
is the emerging modality that has also presented with equivalent outcomes and
might be preferred because of its easier and rapid availability than usual
methods.
Conflict of interest
The authors declared absence of
conflict of interest.
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