Pelvic incidentalomas.

Recent advances in multi-detector computed tomography, magnetic resonance imaging, and ultrasound have led to the detection of incidental ovarian, uterine, vascular and pelvic nodal abnormalities in both the oncology and non-oncology patient population that in the past remained undiscovered. These incidental pelvic lesions have created a management dilemma for both clinicians and radiologists. Depending on the clinical setting, these lesions may require no further evaluation, additional immediate or serial follow-up imaging, or surgical intervention. In this review, guidelines concerning the diagnosis and management of some of the more common pelvic incidentalomas are presented.

Staging of colorectal cancer.

CT, MR, and TRUS play complementary roles in staging CRC. Further improvements in these techniques will improve the accuracy of preoperative staging and thereby help optimize patient treatment and outcome.

Radiation-induced changes in the central nervous system and head and neck.

Radiation therapy of the brain, neck, and spine can be associated with radiation-induced changes that are increasingly evident radiologically. These changes affect the central nervous system (focal necrosis, diffuse white matter injury, atrophy, mineralizing microangiopathy, telangiectasia, optic neuropathy, large vessel vasculopathy), bone (fatty replacement of marrow, osteoradionecrosis, sinus inflammation), and superficial and deep soft tissues and include neoplasia. Focal necrosis, which most commonly occurs at the treatment site, is seen at computed tomography (CT) and magnetic resonance (MR) imaging as a ring-enhancing mass with edema and mass effect, findings similar to those of tumor recurrence. Diffuse white matter injury appears as hypoattenuating (at CT) or hyperintense (at MR imaging) small foci near the frontal or occipital horns or as a confluent band extending from the ventricles to the corticomedullary junction. Fatty replacement of marrow is the most common osseous complication seen on MR images. Osteoradionecrosis, which occurs most often in the mandible, appears as a focal lytic area at CT and with abnormal marrow signal and cortical destruction at MR imaging. The most common changes in the superficial soft tissues of the head and neck, edema and fibrosis, are seen radiologically as skin thickening and increased soft-tissue attenuation with stranding of subcutaneous fat. Meningioma, the most common radiation-induced CNS tumor, can be distinguished from spontaneous meningiomas on the basis of clinical characteristics (eg, presence of focal alopecia and scalp atrophy).

Malpractice and radiologists in Cook County, IL: trends in 20 years of litigation.

OBJECTIVE: The purpose of this article is to report the prevalence and nature of malpractice litigation involving radiology over a 20-year period and to identify trends among types of lawsuits filed. By recognizing where medicolegal risks lie in radiology, risk-management processes can be developed to minimize malpractice exposure and to improve patient care. MATERIALS AND METHODS: We conducted a retrospective study of all malpractice lawsuits (18,860) filed against physicians in the greater Chicago area between January 1, 1975, and December 31, 1994. About twelve percent (2219) involved radiologic procedures or radiologists. These lawsuits were divided into six groups: slip-and-fall, radiation oncology, failure to order a radiologic examination, complications, missed diagnoses, and miscellaneous. The yearly percentage of each category relative to the total number of radiology-related suits was determined, and then each group was further divided by specific diagnosis or incident. RESULTS: Along with all medical malpractice lawsuits, radiology-related suits rose dramatically until 1985, when there was a marked but temporary decline caused by tort reform measures enacted in Illinois. Since then, lawsuits have resumed their annual upward climb, although the overall percentage related to radiology has remained relatively constant (10-15%). The relative number of radiology-related lawsuits in specific categories has changed over the past two decades: the percentages of slip-and-fall, radiation oncology, and miscellaneous cases have decreased, but percentages for the remaining three groups have increased. Lawsuits related to missed diagnoses, which account for the largest category of radiology-related cases, have increased from 34% to 47% of the total. The greatest increase in this category is for breast cancer. Lawsuits claiming injury from complications, the largest subgroup of which is angiography, have grown slightly, but cases alleging failure to order a radiologic examination have shown the greatest percentage increase in the 20-year period, growing from 20% in 1975-1979 to 30% in 1990-1994. This rise is attributed to the greater number of claims involving mammography, CT, MR imaging, and angiography. The growth in failure-to-order lawsuits will have important ramifications as managed care and health reform proposals attempt to limit use of radiologic services. CONCLUSIONS: Notwithstanding the fact that tort reform measures in Illinois decreased the frequency of malpractice litigation temporarily in 1985 and will likely do so again in 1995, medical malpractice is likely to continue to plague radiologists unabatedly for many years to come.

Vesicourethral healing following radical prostatectomy: is it related to surgical approach?

OBJECTIVES: To explore how the occurrence of vesicourethral anastomotic strictures (bladder neck contractures [BNC]) following radical prostatectomy was dependent on these variables: postoperative urine extravasation, type of anastomosis, size of prostate, and surgical approach. METHODS: We retrospectively reviewed 143 cases over 36 months for the occurrence of early BNC (6 to 12 months follow-up). Voiding cystourethrograms (VCUC) were performed in all patients at 3 weeks. Radical retropubic prostatectomy (RRP) with direct anastomosis was performed in 93 cases, RRP and Vest anastomosis in 35 cases, and radical perineal prostatectomy (RPP) in 15 cases. RESULTS: The overall incidence of extravasation was 14.1%. Procedure-specific rates of incidence of extravasation were RPP 33.3%, RRP 18.1%, and radical retropubic with Vest anastomosis (Vest) 6.1%. Mean prostate weight was not significantly different between patients with or without extravasation. The anastomotic site was classified as being irregular (plicated) or smooth in appearance on the VCUG images. An irregular appearance was noted among 81% of the RRP, 42.4% of the Vest, and 40% of the RPP. Bladder neck contractures occurred in 29% of patients with Vest anastomosis, 14.1% with RRP, and none of the patients undergoing RPP. Only 1 patient in both the Vest and RRP group who experienced BNC was noted to have extravasation on VCUG at 3 weeks. CONCLUSIONS: We have noted that the type of anastomosis (Vest traction sutures) significantly increases the likelihood of early bladder neck contracture following radical prostatectomy. The presence of contrast extravasation on the postoperative VCUG study (implying urinary extravasation) did not influence the formation of an anastomotic stricture as long as patients were maintained with catheter drainage until resolution of extravasation. The appearance of the newly constructed bladder neck on the postoperative VCUG image was not predictive of a subsequent contracture.

Vesicourethral anastomotic strictures after radical prostatectomy: efficacy of transurethral balloon dilation.

PURPOSE: To assess the efficacy of transurethral balloon dilation of vesicourethral anastomotic strictures after radical retropubic prostatectomy. MATERIALS AND METHODS: Forty-five consecutive patients in whom vesicourethral anastomotic strictures developed after radical prostatectomy underwent fluoroscopically guided transurethral balloon dilation (n = 27), cystoscopically guided transurethral incision of the bladder neck (n = 10), or dilation performed by urologists who used various techniques (n = 8). RESULTS: Transurethral balloon dilation was successful in 16 (59%) of 27 patients. Ten of the 11 patients who did not respond favorably underwent transurethral incision of the bladder neck. Seven (70%) of these patients required either repeat attempts or subsequent balloon dilation. New urinary incontinence developed in one patient treated primarily with transurethral incision of the bladder neck but in no patients treated with transurethral balloon dilation. CONCLUSION: Anastomotic strictures after radical prostatectomy can be effectively treated with transurethral balloon dilation with no serious complication. Refractoriness to balloon dilation may be related to the presence of dense scar tissue.

Voiding cystourethrography after radical prostatectomy: normal findings and correlation between contrast extravasation and anastomotic strictures.

OBJECTIVE: Vesicourethral anastomotic strictures are an important complication of radical prostatectomy for prostatic cancer. Their formation has been attributed to extravasation of urine at the anastomosis and to the surgical technique used to construct the anastomosis. Our study examines whether the formation of a vesicourethral anastomotic stricture correlates with (a) contrast extravasation seen on postoperative voiding cystourethrograms and (b) the surgical technique used to construct the vesicourethral anastomosis. We also describe the postoperative appearances of the anastomosis. MATERIALS AND METHODS: One hundred and forty-two patients who underwent radical retropubic prostatectomy at our institution between June 1, 1987, and December 31, 1991, were included in the study. Of these, 101 had a direct end-to-end vesicourethral anastomosis, and 41 had their anastomosis constructed with traction sutures (Vest procedure). Voiding cystourethrograms were obtained 3 weeks after the prostatectomy. The appearance of the anastomosis, the presence of extravasation of contrast material at the anastomotic site, and the relationship of the subsequent formation of an anastomotic stricture to extravasation were evaluated. The influence of the surgical technique used to construct the vesicourethral anastomosis on the development of anastomotic strictures was analyzed. RESULTS: Contrast extravasation at the anastomotic site was seen in 14 (14%) of 101 patients who had a direct procedure and in three (7%) of 41 patients who had a Vest procedure. No relationship was found between contrast extravasation and subsequent formation of a stricture. Anastomotic strictures occurred in 16 (16%) of 101 patients who had a direct anastomosis and in 12 (29%) of 41 patients who had a Vest procedure. The surgical technique used to construct the vesicourethral anastomosis influenced the appearance of the vesicourethral anastomosis on cystourethrograms. CONCLUSION: Contrast extravasation at the anastomotic site is not infrequently seen on voiding cystourethrograms obtained after radical retropubic prostatectomy and resolves with continued drainage via a Foley catheter. As long as catheters are left in place until anastomotic healing is complete, extravasation of contrast material (implying urine extravasation at the anastomotic site) does not influence the subsequent formation of anastomotic strictures. Anastomoses that heal more slowly are no more likely to develop strictures than normally healing ones. Construction of the vesicourethral anastomosis by using the Vest procedure is a significant risk factor for stricture formation.