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.

Current role of MR imaging in the staging of adenocarcinoma of the prostate.

Surgical cure of adenocarcinoma of the prostate (ACP) is possible in over 80% of cases when the disease is confined to the gland capsule. The endorectal probe for magnetic resonance (MR) imaging has increased resolution of the prostate gland and capsule, which has improved the sensitivity and specificity for staging ACP (.65 sensitivity, .69 specificity for body coil; .87 sensitivity, .85 specificity for the endorectal coil). Normal glandular regions in the peripheral zone and central zone have significantly higher citrate levels than ACP and fibromuscular and fibrous benign prostatic hyperplasia at proton spectroscopy. ACP has a higher phosphomonoester-phosphocreatine ratio than normal glandular tissue at phosphorus spectroscopy. The combination of endorectal coil MR imaging for local spread, and body coil MR imaging for advanced disease, makes MR imaging the premier imaging modality for the preoperative staging of ACP.

Use of endorectal surface coil magnetic resonance imaging for local staging of prostate cancer.

A total of 111 patients with clinically localized prostate cancer (stage A or B) underwent endorectal surface coil magnetic resonance imaging (MRI) for preoperative staging of the disease. Of the patients 43 with advanced disease on endorectal surface coil MRI (33 with stage C and 10 with stage D disease) received alternative therapy, as did 21 with stage B disease on MRI. The overall staging accuracy for the remaining 47 patients was 68%, with a 74% accuracy rate in staging advanced disease and a 91% accuracy rate for depiction of seminal vesicle involvement. Failure to recognize microscopic extracapsular disease was responsible for the majority of staging inaccuracies in this highly select group of patients. Endorectal surface coil MRI provides extremely high resolution images of the prostate and periprostatic structures, and is an exciting new modality for local staging of prostatic carcinoma.

Tuberculous epididymitis and epididymo-orchitis: sonographic findings.

The findings at scrotal sonography in 10 patients with tuberculous epididymitis and in 2 with nontuberculous epididymitis are presented. In 6 patients with tuberculous epididymitis the testes were also involved (epididymo-orchitis). The most notable sonographic findings of tuberculous epididymitis were an enlarged epididymis, predominantly in the tail portion, and marked heterogeneity of the echo texture of the involved epididymis. Sonographic findings of associated testicular involvement consisted of a diffusely enlarged hypoechoic testis or ill defined focal intratesticular hypoechoic areas, or an irregular margin between the testis and epididymis. The sonographic findings encountered in patients with tuberculous epididymitis appear to be different from those encountered in nontuberculous epididymitis. Sonography might prove helpful in aiding the clinical distinction between these 2 forms of epididymitis and in demonstrating associated testicular involvement in tuberculous epididymitis.

Balloon dilation of ureteral strictures after renal transplantation.

Ten ureteral strictures that developed in nine patients after renal transplantation were managed with balloon catheter dilation and placement of a ureteral stent. Four strictures were successfully dilated (40%), with a follow-up of 15-42 months (mean, 29 months). Comparison of these cases with the six cases of unsuccessfully dilated strictures failed to show any substantial differences between the groups with respect to demographics, stricture characteristics, or radiologic management techniques. However, strictures that developed at the ureteroneocystostomy site responded favorably more often (three of four strictures) to balloon catheter dilation than did strictures in other locations. The authors' experience is not as favorable as that of others who have managed renal transplant-related ureteral strictures in a similar manner. Nonetheless, their experience reinforces the efficacy of balloon catheter dilation of ureteral strictures that develop after renal transplantation as an effective alternative to surgical revision in a substantial percentage of patients.

The seminal tract in patients with ejaculatory dysfunction: MR imaging with an endorectal surface coil.

Twenty-six patients with signs and symptoms of ejaculatory dysfunction (hemospermia, hypospermia, oligospermia, or painful ejaculation) were examined with high-resolution MR imaging with an endorectal surface coil. Findings were abnormal in 15 patients. Abnormalities detected included four cases of müllerian cysts, three cases of wolffian cysts, one case of anaplastic prostatic carcinoma, and various noncystic abnormalities of the seminal vesicles and ejaculatory ducts, including ejaculatory duct obstruction and seminal vesiculitis. In all cases, depiction of both the normal and abnormal anatomy of the entire seminal tract, including the vas deferens, seminal vesicles, and ejaculatory ducts, was excellent. This depiction of the detailed anatomy of the prostatic cysts made it possible to suggest specific diagnoses. Our results show the value of MR imaging with an endorectal surface coil in the examination of patients with ejaculatory dysfunction.

Computed tomography and magnetic resonance imaging of the female lower urinary tract.

Computed tomography (CT) and magnetic resonance (MR) imaging have become invaluable imaging modalities in the diagnosis of diseases involving the lower urinary tract. Both CT and MR imaging are able to accurately stage bladder carcinoma, with MR imaging able to distinguish between superficial and deep muscle invasion of tumor. CT and MR are also the studies of choice for evaluating retroperitoneal fibrosis, which often affects the urinary tract; MR imaging is often able to detect the presence of active inflammation and occasionally rule out a malignant cause. MR imaging holds promise for the evaluation of stress urinary incontinence and urethral disease. Although diseases of the distal ureter continue to be most accurately diagnosed by intravenous urography and retrograde studies, CT and MR imaging may serve a helpful secondary role.

MR imaging in adenocarcinoma of the prostate: interobserver variation and efficacy for determining stage C disease.

Patients with adenocarcinoma of the prostate confined to the gland (stage B) are candidates for a potentially curative surgical procedure (radical retropubic prostatectomy). However, patients with adenocarcinoma that penetrates the capsule or invades the seminal vesicles (stage C) are no longer considered good candidates for surgical cure of their disease. The purpose of this study was to compare the ability of four radiologists to detect stage C disease on MR images and to evaluate interobserver variability. One hundred consecutive MR studies of the prostate were reviewed independently by four radiologists to determine whether the cancer was stage C (capsule penetration or seminal vesicle invasion by tumor). A radical prostatectomy was performed in each case, and careful histologic assessment was made of the prostatic capsule and seminal vesicles for any evidence of stage C disease. The sensitivity, specificity, and accuracy (true-positive + true-negative/100 patients) in detecting stage C disease were calculated for each of the four readers. Four receiver-operating-characteristic curves were generated and compared by means of the univariate z score. Percentage agreement was calculated for five specific areas of the prostate on MR images, and observations made by the best reader were compared with the other three to help determine interreader variability. The results showed that the sensitivity and specificity of MR imaging in detecting stage C disease ranged from .24 to .61 (mean, .48) and .49 to .79 (mean, .66), respectively. The accuracy of MR imaging ranged from .47 to .61 (mean, .55). The univariate z score test showed that one of the readers significantly differed from the other three. The average percentage agreement between that reader and the other three was 70% for the five separate anatomic regions. This study shows that considerable interobserver variation exists in the interpretation of MR images for staging cancer of the prostate. The average accuracy among four radiologists in determining the presence of stage C adenocarcinoma of the prostate from MR images was only slightly above a chance guess at .55.

Magnetic resonance imaging in carcinoma of the prostate.

Over the past few years, magnetic resonance imaging (MRI) has been shown to be of great value in imaging the pelvis. Its advantages derive from its multiplanar capability and high soft-tissue contrast, which are particularly significant in imaging the prostate and seminal vesicles. MRI, particularly with endorectal surface coils, provides excellent visualization of the prostate and periprostatic anatomy in multiple planes. It is also useful in evaluating the remainder of the pelvis, including lymph nodes and the bony pelvis. This makes MRI the most reliable noninvasive staging modality for prostate cancer.

Interventional procedures in the upper urinary tract.

The introduction and acceptance of percutaneous nephrostomy as a safe and effective alternative to surgical nephrostomy served as the impetus for the development and expansion of an ever-increasing number of techniques that are encompassed by the term "interventional uroradiology." This article reviews many of the nonvascular interventional techniques that have proliferated during the past decade and that are currently used in the kidney, ureter, and perinephric space. The authors emphasize those procedures that are most frequently employed, as well as their own preferences and perspectives on these procedures.