Orthotopic neobladder reconstruction: findings on excretory urography and CT.

OBJECTIVE: The excretory urographic and CT appearance of orthotopic ileal neobladder reconstruction after cystectomy and its complications are described. MATERIALS AND METHODS: We retrospectively reviewed the excretory urograms and CT scans of 32 patients (29 men and three women, 35-76 years old) with transitional cell carcinoma of the bladder who underwent orthotopic neobladder reconstruction with anastomosis to the native urethra after cystectomy. The radiologic review consisted of 25 excretory urograms in 20 patients and 37 CT scans in 21 patients. RESULTS: On excretory urography, the afferent segment of the neobladder was identified as a contrast-filled structure in all 20 patients, and was located in the right lower quadrant in 18 (90%). On CT, the afferent segment and the neobladder were identified in all 21 patients. Delayed imaging performed after initial scanning in 12 (57%) of 21 patients was helpful for revealing detailed anatomy such as the ureteral-afferent limb anastomoses. Complications occurred in two patients and were caused by a lymphocele in one and a urine leak from the neobladder in the other. In six other patients we found evidence of recurrent or metastatic tumor or both: two had local pelvic recurrence and pelvic nodal metastases, two other patients had metastatic nodal disease, one patient had a malignant distal ureteral stricture, and the sixth patient had distant osseous metastases. CONCLUSION: Orthotopic neobladder reconstruction after cystectomy has a characteristic appearance on both excretory urography and CT. Knowledge of this appearance and the altered anatomy is useful to recognize complications and tumor recurrence. Delayed images during excretory urography and CT are useful to define the ureteral-afferent limb anastomosis with the neobladder and also to differentiate between postoperative collections.

The periurethral glands do not significantly influence the serum prostate specific antigen concentration.

PURPOSE: The periurethral glands are known to produce prostate specific antigen (PSA). With ultra-sensitive assays now routinely available, it is necessary to determine if the periurethral glands significantly influence serum PSA concentration after radical prostatectomy. MATERIALS AND METHODS: Serum PSA levels of 46 men, 51 to 89 years old (median age 67) who underwent radical cystoprostatectomy and total urethrectomy, were compared with those of 92 men 46 to 91 years old (median age 67) who underwent radical cystoprostatectomy only. All men had transitional cell carcinoma of the bladder without gross or microscopic evidence of prostate cancer and all underwent ileal conduit diversion. Serum was obtained at least 1 year postoperatively. Each specimen was analyzed using the Tosoh, Immulite, and Yu and Diamandis ultra-sensitive PSA assays with analytical detection limits of 0.02 ng./ml., 0.004 ng./ ml. and 0.002 ng./ml., respectively. RESULTS: Median PSA for the radical cystoprostatectomy with urethrectomy group was 0.00 ng./ml. (range 0.00 to 0.14) for each of the 3 assays. For the radical cystoprostatectomy only group the median Tosoh and Immulite PSA assay levels were 0.01 ng./ml. (range 0.00 to 0.22), and median Yu and Diamandis PSA assay level was 0.00 ng./ml. (range 0.00 to 0.31). CONCLUSIONS: The greatest difference in median PSA levels that could be found between men with and without periurethral glands when using 3 different ultra-sensitive assays was 0.01 ng./ml., indicating that the periurethral glands do not have a clinically significant effect on serum PSA concentration after radical prostatectomy. Thus, a serum PSA level above the residual cancer detection limit following radical prostatectomy, even if obtained with a ultra-sensitive assay, reflects either malignant or benign residual prostatic tissue, rather than the presence of periurethral glands.