Diffusion-weighted magnetic resonance imaging in the detection of testicular torsion: feasibility study.

PURPOSE: To investigate the feasibility and usefulness of diffusion-weighted magnetic resonance imaging in the detection of testicular torsion. MATERIALS AND METHODS: Institutional Review Board approval and informed consent from all participants were obtained. Consecutive 28 patients with acute scrotal symptoms were included in this study. Fat-suppressed T2-weighted, dynamic subtraction contrast-enhanced, and diffusion-weighted images were obtained in the coronal plane with a 1.5 T MR unit. An apparent diffusion coefficient (ADC) map was reconstructed from the diffusion-weighted images obtained with b-factor of 0 and 800 s/mm(2). Comparisons of ADC values between the affected and nonaffected testes were performed with Mann-Whitney's U-test. RESULTS: Diffusion-weighted and ADC images with diagnostic quality were obtained in 23 out of the 28 patients (82%). In testicular torsion (n = 9), the mean ADC value of the twisted testes was significantly lower than that of the nonaffected testes (0.750 ± 0.297 vs. 1.017 ± 0.165 × 10(-3) mm(2)/sec, P < 0.05). In other scrotal disorders (n = 14), there was no significant difference in the mean ADC value of the testes between the affected and nonaffected side (P = 0.655). The affected-to-nonaffected ratio of ADC value was significantly lower in testicular torsion than that in other scrotal disorders (P < 0.05). CONCLUSION: Diffusion-weighted imaging of the scrotum with testicular ADC measurement can allow for the detection of testicular torsion without any use of contrast media.

MR imaging of testicular torsion: features of testicular hemorrhagic necrosis and clinical outcomes.

PURPOSE: To determine whether emergency subtraction dynamic contrast-enhanced MR imaging (DCE-MRI) in combination with T2- and T2*-weighted imaging of the testis is useful in the evaluation of patients with testicular torsion. MATERIALS AND METHODS: Fourteen patients with surgically proven testicular torsion were examined using preoperative emergency MRI, including T2-weighted, T2*-weighted, and DCE-MRI. The affected testis was examined histologically in eight patients who underwent orchiectomy, and by postoperative follow-up MRI in six patients who underwent orchiopexy. The diagnostic criteria for testicular torsion and detection of hemorrhagic necrosis in the affected testis in emergency MRI were decreased or no perfusion in DCE-MRI and a spotty and/or streaky pattern of low or very low signal intensity in T2- and T2*-weighted images. The intraoperative findings and clinical outcomes were also compared. RESULTS: The histological findings and follow-up MR images revealed total or partial necrosis of the affected testis in 10 of the 14 patients. In the diagnosis of complete torsion, the sensitivities were 100% for DCE-MRI and 75% for T2- and T2*-weighted imaging. In the detection of testicular necrosis, T2- and T2*-weighted imaging showed the highest accuracy (100%), followed by 12-hour time from onset (93%), intraoperative findings (79%), and DCE-MRI (71%). CONCLUSION: Emergency MRI can help diagnose testicular torsion and detect testicular necrosis when DCE-MRI is used in combination with T2- and T2*-weighted images.

[Evolution of common clinical path for transurethral resection of prostate (TURP)].

OBJECTIVES: Improvement of perioperative management for transurethral resection of the prostate (TURP) by revising the common clinical path was investigated in multiple hospitals. METHODS: We discussed perioperative outcomes using the common path in 2002 and revised it for 2003. Changes in perioperative outcomes between 2002 and 2003 and differences among hospitals were compared. RESULTS: There were no statistically significant differences in age, proportion of patients with mildly impaired activity of daily living and/or impaired cognition, general anesthesia, operating duration, resected weight, incidence of intraoperative complications and blood transfusion between 2002 and 2003. Although there were no differences in preoperative hospital stay, re-hospitalization rate and charges for surgery and anesthesia, Foley catheter was removed significantly earlier from postoperative day 2.9 to 2.3 and total medical charge significantly decreased from 43,703 to 39,661 units (1 unit = 10 yen). The incidence of postoperative pyrexia increased from 2.4% to 11.2% in 2003, however, the incidences of epididymitis, postoperative bleeding and postoperative difficulty on micturition remained stable. The average and standard deviation of postoperative hospital stay and total medical charge at each hospital decreased, however, differences among hospitals found in 2002 remained in 2003. CONCLUSION: We found that standardization can be accomplished by discussing perioperative management using a common path in multiple hospitals and revising the path as needed. Common clinical path should be a valid method of advancing standardization in Japan.

[Implementation of a common clinical path for transurethral resection of prostate (TURP) in multiple hospitals].

PURPOSE: To investigate the length of hospitalization and medical charges when a common clinical path for TURP (transurethral resection of prostate) was implemented in multiple hospitals. PATIENTS AND METHODS: This study included 310 patients in 2001 and 298 in 2002, who were diagnosed with benign prostatic hyperplasia and who underwent TURP in seven hospitals in Japan. While the patients were treated according to the managing methods of each hospital in 2001, the patients were managed using a common clinical path in 2002, on which we conferred and established in 2001. We investigated the change of various outcome indicators before and after implementation of the common clinical path. RESULTS: The background of patients and surgical outcome in 2002 were equal to those in 2001, except in incidence of preoperative urinary tract infection, general anesthesia and blood transfusion, and number of surgeons. Implementation of a common clinical path shortened the pre- and postoperative hospital stay, duration of bed rest, administration of antibiotics and Foley catheter indwelling, and reduced the standard deviation of these indicators. The total medical charge decreased from 515,439 to 491,935 yen. However, outcomes were considerably different among the seven hospitals. Multivariate analyses identified the hospitals, cognitive impairment, preoperative indwelling catheter and preoperative variance as the factors affecting preoperative hospital stay, and the hospitals, co-existing disease, blood transfusion, postoperative urinary tract infection and postoperative variance as factors affecting postoperative stay. Based on these analyses, we determined four exclusion criteria against using a common clinical path: 1) patients requiring examination or surgery other than TURP simultaneously, 2) patients whose ADL disturbance, cognitive impairment, past history and/or coexisting disease are expected to affect postoperative convalescence, 3) patients with a preoperative indwelling catheter just before operation, and 4) patients with preoperative urinary tract infection. By excluding 122 (39.4%) and 129 (43.3%) patients fulfilling the above criteria in 2001 and 2002, respectively, there were reduction in the length of pre- and postoperative hospital stay, and the total admission fee. Furthermore, there were decrease in their standard deviations. CONCLUSIONS: A common clinical path was valid for reducing variance of the critical indicators affecting the clinical course of TURP and shortening the pre- and postoperative stay in the multiple hospitals. It is mandatory to establish the standard perioperative management for TURP from the viewpoint of urologists, under the circumstances of the impending introduction of the Diagnosis Procedure Combination (DPC).

[A questionnaire survey for TURP hospitalization by clinical path].

PURPOSE: We conducted a questionnaire survey to elucidate the rating of the patients who underwent transurethral resection of the prostate (TURP) and were managed by a common clinical path during hospitalization. PATIENTS AND METHODS: At the day of discharge from seven hospitals in Japan, the questionnaires were handed to 298 patients who underwent TURP in 2002. In the path, it was determined that the patients should be admitted one day before surgery and discharged on the seventh postoperative day. RESULTS: The questionnaires were returned by 240 (80.5%) patients. Of the 212 patients answering a question regarding the desirable preoperative hospital stay, 58 (27.4%), 85 (40.1%) and 46 (21.7%) considered 1, 2 and 3 days as a desirable preoperative stay, respectively. Of the 206 answering a question about the desirable postoperative hospital stay, 54 (26.2%), 28 (13.6%) and 60 (29.1%) considered 7, 8 and 9-10 days as a desirable postoperative hospital stay, respectively. Of the 240 patients, 229 (95.4%) received the path for the patients, 234 (97.5%) understood the treatment methods well and 229 (95.4%) understood the schedule during hospitalization well. Two hundred thirty-six (98.3%) and 218 (90.8%) patients answered that as scheduled, they started to have meals and started to walk, respectively. Continuous drip infusion was terminated in 219 (91.3%) as scheduled, and indwelling catheters were removed in 215 (89.6%) as scheduled. CONCLUSIONS: This questionnaire survey elucidated that approximately 70% of the patients who underwent TURP wanted to stay 1 or 2 days before surgery and 7 to 10 days after surgery. We consider it very important that patients understand well the treatment methods, complications, schedules during hospitalization and criteria for discharge when they are managed using the clinical path, so they will accept better a length of hospital stay that is shorter than that which they had desired.

[A case of malignant lymphoma with bilateral adrenal involvement].

Since the adrenal gland is a common site of metastatic disease, it is sometimes difficult to find the primary lesion only by diagnostic imaging. We report a case of non-Hodgkin's lymphoma with bilateral adrenal involvement, in which percutaneous needle biopsy was useful to determine the histology.