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A very rare late complication of Boari bladder flap repair with development of pseudodiverticulum and recurrent genitourinary tract infection secondary to vesicoureteral reflux is presented. Radiologic evaluation of the patient comprised intravenous pyelography (IVP), micturating cystourethrogram, cystoscopy, and multislice computed tomography (MSCT).
We report MR imaging characteristics of a prostatic urethral polyp in a 35-year-old man. Traditionally, the methods of diagnosis include computed tomography, transrectal sonography, voiding cysto-urethrography, intravenous pyelography, urethroscopy, and cystoscopy. To our knowledge, MR findings have not been previously described. In this case, MR imaging clearly demonstrated a polypoid tumor located in the prostatic urethra with a stalk connected to the bladder neck. A pathological study revealed the polyp consisted of a fibrovascular core covered with a double layered, prostatic-type epithelium.
The purpose of the study was to assess the diagnostic performance of MR cystography with virtual cystoscopic and multiplanar reconstructions for detection of malignant bladder tumors. Thirty-two patients with 43 bladder tumors previously confirmed by cystoscopy (mean size 2.5 cm; 0.4-9.1 cm;) were examined at 1.5 T with a three-dimensional T2-weighted turbo spin echo sequence (TR=2911 ms, TE=500 ms, echo train length 256). Virtual cystoscopic reconstructions (VC) and multiplanar reconstructions (MPR) were obtained and analyzed separately by three radiologists without knowledge of the tumor location. Intraoperative or cystoscopic findings served as standard of reference. Sensitivities and specificities were calculated using a receiver-operating characteristic analysis with five levels of confidence. Area-under-curve values were similar for MPRs (0.952), VC (0.932) and the combination of both methods (0.954). Optimal sensitivity was 92.3% for MPR and 90.7% for VC, respectively, with a specificity of 91.1% for MPR and 90.4% for VC. The combination of MPR and VC resulted in a sensitivity of 90.7% and specificity of 94.0%. MR cystography is a promising, completely non-invasive technique for the detection of bladder lesions with a high diagnostic performance.
Laser resection (LR) of posterior urethral valves during infancy as early as possible after diagnosis appears to represent a safe and reliable method. In contrast to other procedures, LR allows valve ablation with thin cystoscopes and carries little risk, even in premature and newborn infants. Its application in seven children in the course of 2 years principally confirmed its suitability for use: it could be applied in all cases without any problems and led to extensive resection of the valve tissue and removal of the obstruction in all patients. The encouraging clinical findings were confirmed by control cystoscopies and micturating cystourethrograms. Complications arising from the method were not observed.
We describe an unconventional method of localizing a colovesical fistula by using a guide-wire, successfully carried out in a 45-year-old man with recurrent dysuria, pneumaturia, and suprapubic tenderness. First, we performed a cystoscopy to establish the fistulous tract in the bladder and passed the guide-wire through it. Next, we performed a colonoscopy, and the guide-wire was identified and brought out through the anus. This created a wire loop through the fistula. The transparietal catheter enabled us to detect the exact fistulous tract at laparotomy, making it possible to resect the inflamed colon and identify and resect the fistulous opening on the vesical wall. This technique allowed for a safer resection and a shorter operation time.
Within 10 days after cystoscopy causing urosepsis this patient developed persistant neckpain as initial symptom of vertebral osteomyelitis. E. coli was isolated from urine, blood cultures and later from bone biopsy. Antibiotic treatment did not stop the progress of the disease. A transverse spinal cord syndrome occurred due to a pathological fracture of C5 and C6 and operative decompression was necessary. The rapid onset of osteomyelitis was impressive. For effective treatment of bacterial osteomyelitis a bone biopsy is sometimes unavoidable and indicated.
INTRODUCTION: The nephrogenic adenoma (NA) is a benign metaplastic lesion of the urothelium and is attributed to chronic irritation of the mucosa, by injury, infection, stone disease or intravesical instrumentations. We present our experience on this morbid entity, its clinical appearance in the urinary bladder, its frequency and relapses. Furthermore we reviewed the related recent literature and focused on its potential to neoplastic degeneration and the value of the new diagnostic modalities. PATIENTS AND METHODS: Four patients with NA of the urinary bladder are presented. The papilloid or polypoid formations observed by the cystoscopy were identified after the TUR, as NA of the urinary bladder. Their mean follow-up was 3.5 years. RESULTS: Remission of the symptoms was observed after TUR in all patients. Three out of four patients presented 1-7 relapses, while in one case, after seven NA relapses, a urothelial carcinoma of the bladder was diagnosed. CONCLUSIONS: Unlike histological features, the clinical - endoscopic characteristics of NA are non-specific. Even if it is not definitely considered like a premalignant condition, NA has to be followed up frequently and long lasting, because of its high recurrence rate. The combination of Cytology, Flow cytometry, DNA image analysis and Fluorescence in situ hybridization of bladder washings or voided urine, are of high value in monitoring NA of the urothelium.
Eighteen patients were studied prior to and again within 6 hours after transurethral resection or cystoscopy. In addition to hemodynamic measurements, detection of endotoxin by limulus assay and bacteriologic sampling; prekallikrein, C3, C3 proactivator and lysosomal enzyme levels were measured. In five patients limulus assays were positive, and in one, gram-positive bacteremia developed but limulus assay remained negative. All six had significant decreases in prekallikrein, C3 or C3 proactivator. Systemic vascular resistance fell in all six. Four additional patients who had a decrease in systemic vascular resistance were not endotoxemic or bacteremic; one of these had a decrease in prekallikrein only. In the remaining eight patients with neither bacteremia nor endotoxemia, systemic vascular resistance did not change or increase after instrumentation. One had a decrease in C3 proactivator, another in prekallikrein. There was no significant difference in age, disease, antibiotic therapy or bactermia in the two groups of patients. Four of the five resectional procedures were performed in the group that showed decreases in systemic vascular resistance. The data suggest that acute endotoxemia or gram-positive bacteremia in man is associated with depletion of prekallikrein, decreased peripheral resistance and, in some instances, activation of the complement system.
Controversy exists as to how many of the newer diagnostic procedures should be used to evaluate stress incontinence. Urethral closure pressure, uroflowmetry, barium paste, and chain cystograms may be unphysiologic and studies that are not required preoperatively for every patient. Two hundred fifty-three cases in this study were evaluated by history, stress test, and urinalysis alone, if no urgency component was present. The patients with urgency and stress incontinence were studied by routine cystoscopy. These patients all had stress incontinence that was socially unacceptable. The stress test was very simple and done without foreign bodies in the urethra, without sudden bladder distention, and without irritation of bladder mucosa. The patient simply came into the office with a full bladder and a desire to void, and the stress test was done with the patient in the standing position, with one doctor and one nurse in attendance. The results of treatment with this workup are presented with follow-up.
Thirty-four patients with colovesical fistulas seen over a recent 10 year period were reviewed. Diverticulitis was the most common cause of colovesical fistula, accounting for 71 percent of patients in our series. The majority of patients present electively, and most have urinary tract complaints. In those patients in our study who presented with systemic infection, urinary obstruction was present in 70 percent. Although proctosigmoidoscopy and barium enema examination are essential in the preoperative assessment, cystoscopy is the most useful test in suggesting or confirming the diagnosis of colovesical fistula. Intravenous urography is not necessary in the evaluation of these patients. The surgical treatment depends on the cause of the fistula. For patients with an inflammatory cause of the fistula, one-stage operative treatment is associated with low morbidity and decreased length of stay compared with operative treatment in more than one stage. In the presence of severe inflammation or inadequate bowel preparation, two-stage operative treatment is safe and effective. Operations in three stages for colovesical fistula are not indicated. The primary objectives in the management of colovesical fistulas due to unresectable malignancy are relief of intestinal and urinary obstruction and fecal diversion. Resection of the malignancy should be performed whenever possible.
Congenital rectourethral or anourethral fistulae without imperforate anus in males are rare, representing less than 1% of anorectal malformations. We report our experience with two males with "N type" urethral fistulae. One, a 5-year-old boy, presented with recurrent urinary tract infections (UTIs) and passage of urine per anus. Investigations included a voiding cystourethrogram (VCUG), which demonstrated a fistula from the urethra to the anus. On physical examination, a small perianal opening was noted just outside the anus, which drained a small amount of urine after voiding. The fistula was excised via a perineal approach. The second patient is a 5-year-old boy with a long history of recurrent UTI requiring multiple hospitalizations since the newborn period. Chronic renal failure developed as a complication of repeated urinary tract infections. Investigations showed a single hydronephrotic pelvic kidney and a small bladder. He underwent numerous diagnostic and reconstructive procedures including cystoscopy and augmentation cystoplasty. Recurrent infections continued and an N type anourethral fistula was eventually diagnosed. The fistula was located between the anal canal and the membranous urethra. An anterior perineal approach was also used. Both fistulae were easily located, and reconstructive surgery of the urethra was not required. Postoperative VCUGs in both patients were normal. They have been free of infection with normal urinary continence since resection of the fistula. Congenital N type anourethral fistulae are rare, but should be considered in cases of recurrent urinary tract infections. The diagnosis may be missed by endoscopic procedures, but VCUG should demonstrate the fistulous tract.
Nine children were treated with crossed fused renal ectopia, and in 8 there were serious other urinary tract malformations which were surgically correctable. The finding of crossed fused renal ectopia warrants complete urologic investigation including cystogram and cystoscopy to rule out surgically correctable pathology in the urinary tract.
Metastatic melanoma, although rarely recognized clinically, may involve the urinary tract in a high percentage of cases. Routine excretory urography and cystoscopy may establish the diagnosis of recurrent metastatic melanoma and prevent further surgical exploration.
In a retrospective review, 52 patients with interstitial cystitis have been studied. Patients with persistent lower tract irritative symptoms, repeatedly sterile urine, and negative urine cytology must be suspected of having interstitial cystitis, and a diagnosis of urethral syndrome in such patients is highly questionable until cystoscopy under anesthesia has been performed. We believe that the finding of multiple petechia-like hemorrhages (glomerulations) on the second distention of the bladder is the hallmark of interstitial cystitis, and that a reduced bladder capacity and a Hunner's ulcer represent a different (classic) stage of this disease. In all stages, the characteristic histologic finidng is submucosal edema and vasodilation. The presence of eosinophils and mast cells is variable, and even in the classic disease the muscularis often appears to be normal. Immuno fluorescent studies and laboratory tests, including the fluorescent antinuclear antibody test (FANA), have not helped us to diagnose (or investigate) interstitial cystitis. Bladder instillations with a 0.4 per cent solution of oxychlorosene sodium (Clorpactin WCS-90) have provided remarkable relief for many patients with this disease, particulary those with the classic form.
Four hundred ninety-eight episodes of 150 women with female urethral syndrome (lower urinary tract symptoms without definite objective findings) were evaluated. Internal urethrotomy appeared less effective than cystoscopy and dilation. Office dilation with larger sounds appeared less effective than a 16 F sound. Antibacterials and anticholinergics showed no clear evidence of effectiveness.
A basic problem in evaluating hematuria is the large number of diagnostic possibilities. The causation may be suspected after the initial history and physical examination, and can be confirmed with appropriate studies. The addition of standard tests such as urine culture, intravenous pyelography, and cystoscopy will reveal the source of hematuria in many other cases and will bring the percentage of patients with a clear diagnosis up to 60 or 70 per cent. The physician must be careful in selecting further studies in the remaining patients, since the procedures necessary for diagnosis may be expensive, unpleasant, and potentially harmful, and the probability of finding a treatable condition is low. The diagnostic protocol described in this article is designed to reduce the studies performed to a minimum, while still identifying those individuals who can benefit from therapy.
Colovesical fistulas were identified in 42 patients. Diverticulitis was the underlying cause in 40 per cent of the patients. Carcinoma of the colon or cervix caused 33 per cent of the fistulas. Cystoscopy was the most effective procedure in diagnosing the fistulas. Surgical therapy had to be individualized to the patient's condition. Fistulas secondary to radiation were associated with a high complication rate.
Transabdominal ultrasonography of the bladder was performed in 25 examinations on 20 patients being treated for bladder carcinoma. The presence or absence of tumor was accurately gauged in all 20 patients. As compared to cystoscopy, tumor staging was less accurate. Eleven of 15 patients with tumor present were accurately staged. Edema, intravesicular clot, and tumor calcification caused overstaging of tumors. Poor bladder distensibility limited examinations. Three patients were followed up with serial examinations, and sonography accurately determined the response to therapy.