MRI and its role in the evaluation and surgical decision making in patients with challenging IPP presentations: descriptions of MRI findings and algorithm for patient management.

UNLABELLED: Study Type - Diagnostic (case series) Level of Evidence 4 What's known on the subject? and What does the study add? It is known that magnetic resonance imaging (MRI) is safe and effective for imaging patients with inflatable penile prostheses (IPPs). Previous series have reported results of MRI for imaging series of patients with IPPs. The impact on management in particular with regard to salvage procedures is not well defined. This study represents the largest known experience with MRI evaluation of IPPs. This also provides an algorithm that assists with decisions regarding utilization of MRI and treatment planning based on results. OBJECTIVE: • In some patients who undergo placement of an inflatable penile prosthesis (IPP) the device may function inadequately. We describe the use of magnetic resonance imaging (MRI) for anatomical localization and detection of prosthesis malrotation, angulation, displacement and erosion in IPPs with equivocal clinical examination. PATIENTS AND METHODS: • We prospectively performed MRI by a defined protocol including T1-weighted imaging, and transaxial, sagittal and coronal fat-saturated fast spin-echo T2-weighted imaging in both deflated and inflated states to evaluate patients seen at our referral centre for IPP-related complaints. • We retrospectively reviewed 32 such MRI studies performed as a supplement to clinical examination between 2000 and 2008. RESULTS: • Of 32 cases, 75% (24/32) underwent surgical intervention. Of these, 45% (11/24) underwent device salvage procedures including cylinder revision in 33% (8/24), cylinder replacement in 8% (2/24) and pump replacement in 4% (1/24). • MRI was most useful for determination of surgical approach in those with abnormal physical examination, and for justification of either surgical or expectant management in those with indeterminate physical examination. CONCLUSIONS: • MRI is safe and effective for imaging genitourinary prostheses. • We found MRI to be a valuable adjunct for evaluation of IPP-related complaints when clinical examination is equivocal as it detected a variety of prosthetic and corporal abnormalities and impacted management decisions regarding observation, replacement or device salvage procedures. • We provide technique, results and an algorithm that can be beneficial in this complex subset of patients.

Lower urinary tract leiomyoma: is excision necessary?

INTRODUCTION/OBJECTIVES: Our objective was to review our experience with lower urinary tract leiomyomata to determine if presentation, exam and imaging allows for stratification of the treatment of this rare lesion. MATERIALS AND METHODS: A retrospective review of current practice was performed from the Mayo Clinic Rochester database identifying 13 female patients and 10 males from 1995-2008, focusing on the clinical presentation, cystoscopic findings, imaging and operative approaches. RESULTS: Symptomatic patients had larger lesions, were more likely to be females, or had midline periurethral or bladder neck lesions. Cystoscopic findings were uniformly described as submucosal polypoid lesions without surrounding erythema or mucosal involvement, a hallmark in the differential. There were no cases of rapid growth of these lesions. There were no recurrences after complete excision with follow up ranging in some cases for up to 4 years. CONCLUSIONS: Lower urinary tract urethral leiomyomata are benign lesions that can be clearly differentiated on the basis of modern imaging from malignant or other benign lesions. While these lesions can cause obstructive voiding symptoms, resection or excision is required only for relief of symptoms, and not for tissue confirmation. In comparison to the presentation of leiomyosarcoma, this benign mass presents with slowly progressive symptoms, is firm but with rounded contours on exam, mucosal ulceration is absent. Imaging confirms benign appearing, albeit, ectopic muscle tissue. Rare forms of metastatic uterine smooth muscle tumors are also easily differentiated from this lesion. Adoption of a conservative approach for the asymptomatic and benign appearing lesion appears prudent.

Retroperitoneal mucinous cystadenocarcinoma in a man: case report and review of the literature.

In the English medical literature, 27 cases of primary retroperitoneal mucinous cystadenocarcinoma have been published. We report the second case of a primary retroperitoneal mucinous cystadenocarcinoma in a man. The patient was an 83-year-old man, with a large 26 x 20 x 16-cm retroperitoneal cystic mass causing abdominal discomfort and cachexia, who underwent excision of the mass. Prior reports suggest that this type of tumor has an aggressive clinical course, and surgical excision is the treatment of choice. These rare tumors need to be included in the differential of retroperitoneal cystic tumors.