Uterine peaking – sonographic sign of vesico-uterine adhesion

Objective: In this paper we present our observation of a specific sign on transvaginal ultrasound that may help basic minimal invasive surgeons diagnose vesico-uterine adhesions preoperatively. Methods: The ultrasound images of the latest eleven patients who were preoperatively diagnosed with vesico-uterine adhesions using transvaginal ultrasound were compared with their intraoperative findings. Results: Ultrasonography showed a spectrum of changes from obliterated anterior cul-de-sac to dense fibrosis between the lower uterine segment and cervix with the bladder. Horn- or beak-shaped streaks of tissue with the same density of uterine myometrium is a sign of fundal attachment of vesico-uterine adhesions or of complete anterior cul-de-sac obliteration with adhesions going between the uterus and the anterior abdominal wall. Fine papillary peaking is seen in cases of dense lower uterine segment and cervical fibrosis without fundal involvement. These signs combined with limited mobility of the cervix and bladder base correlated with the presence of dense vesico-uterine adhesions. Conclusion: The described sonographic signs, two static and the other dynamic, may help basic minimal invasive gynecological surgeons who do not have advanced laparoscopic skills and do not feel comfortable dealing with an obliterated anterior cul-de-sac or dense vesico-uterine space fibrosis predict the presence of dense vesico-uterine adhesions allowing them to choose another route that they may be more comfortable with such as vaginal or abdominal hysterectomy or request assistance from a more experienced colleague.