Книги по МРТ КТ на английском языке / Advanced Imaging of the Abdomen - Jovitas Skucas

Most malignancies are detected late and are associated with a poor prognosis.

Ultrasonography reveals a diverticular neoplasm as an intraluminal, hyperechoic, nonshadowing tumor that does not change with a change in patient position.A cystogram may not detect the diverticulum, and a diverticular tumor is thus missed. Computed tomography and MRI outline an intraluminal soft tissue tumor. An MRI in oblique planes can identify the diverticular neck and establish that a tumor is indeed within the diverticulum. Localized tumor infiltration is seen as focal diverticular wall thickening. Occasionally associated calcifications are detected.

Herniation

Clinical

A cystocele is a bladder hernia, although many authors use this term in a narrower sense to describe bladder prolapse into the vagina. In women, a common type of cystocele consists of an abnormal bulge by the bladder into the anterior vaginal wall due to weakness in the pubocervical fascia. The appearance of such a cystocele, with bladder outline below the symphysis pubis, is familiar to most radiologists. These cystoceles become more prominent with the patient upright. Many are associated with generalized pelvic floor laxity and stress incontinence (incontinence is discussed in the next section).

In men, a common site for bladder hernias is into the inguinal canal; in women, femoral canal hernias are more common. In men most inguinal hernias are direct and more often on the right.

Unless large or obstructed, most bladder hernias are asymptomatic. Some men have twophase micturition that improves when pressure is exerted on the scrotum. Clinically, some men with a bladder hernia are suspected of prostatism but no bladder outlet obstruction is found. Complications include bladder incarceration or even infarction in a strangulated hernia. A massive inguinoscrotal bladder hernia can lead to acute renal insufficiency.

Complete bladder inversion through the urethra is very rare (39); a cystogram through

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an orifice posterior to the extruded mass yielded a bladder volume of 20mL.

Imaging

A bladder groin hernia, regardless of type, is identified by IV urography or cystography; in some patients a hernia becomes evident only when they are upright or prone, or if a delayed radiograph is obtained. With suspicion of a bladder groin hernia, video urodynamic imaging with the patient standing is helpful. The presence of lateral displacement of the distal ureter, a small visualized bladder volume, and incomplete bladder base visualization suggest a bladder hernia. Most appear as widemouthed bladder protrusions into the inguinal region. Bilateral inguinal bladder hernias are not uncommon.

Technetium-99m–methylene diphosphonate (MDP) bone scintigraphy detects a bladder groin hernia through increased inguinal region activity that changes with a change in patient position. Bone scintigraphy will also detect bladder herniation into the scrotum.

Incontinence

Urinary incontinence is considerably more common in women, and most incontinence classifications pertain to women.

Women

Clinical

Urinary incontinence is related to pelvic organ prolapse and other pelvic floor abnormalities and is discussed in more detail in Chapter 12. In young girls presenting with incontinence, an ectopic ureter inserting below the urethral sphincter or even into the vagina should be suspected.

Urinary incontinence is traditionally divided into three subtypes: stress, urge, and mixed. Stress incontinence occurs in a setting of increased intraabdominal pressure and insufficient urethral resistance. Urge incontinence consists of an inability to inhibit bladder contractions. At times urge incontinence is precipitated by coughing or straining and the two

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types of incontinence overlap. Mixed incontinence is common and probably consists of several variants. Most classifications are based on stress incontinence, although some women with urge incontinence or a mixed type are also undoubtedly included. One classification sof stress urinary incontinence is based on endorectal US findings of urethral hypermobility, bladder neck incompetence, intrinsic urethral sphincter incompetence, and whether a cystocele is present or not. At times the urethral sphincter does not function normally because of prior surgery and fibrosis or a spinal cord lesion.

Urethral hypermobility results in an excessive change in urethral axis with straining and leads to urinary incontinence. Senior radiologists probably remember performing chain cystograms to help detect stress incontinence, a study that has been supplanted by newer imaging modalities.

Imaging

Voiding cystourethrography (VCUG) has been used to evaluate stress incontinence, yet this examination appears to be of limited value. It detects less than two-thirds of stress incontinence; false positives include women with detrusor instability and urge incontinence. Previously taught measurements of posterior vesicourethral angle change, urethral descent, urethral inclination and presence of a urethrocele on straining, detected on a VCUG, have been questioned in their ability to predict stress incontinence, yet some of these findings are now being resurrected with MRI studies.

Perineal US can be performed after injecting a hyperechoic contrast agent transurethrally. With the patient upright, contrast outlines the inferior part of the bladder. Stress incontinence is associated with the presence of a cystocele, a funnel-like opening of the proximal urethra, an increase in the retrovesical angle, and bladder neck descent. By evaluating bladder neck mobility relative to the symphysis pubis, perineal US achieved a sensitivity of only 78% and a specificity of 77% in detecting stress incontinence (40), and the authors concluded that perineal US is not sensitive enough to be used for predicting stress incontinence. Nevertheless, perineal US appears superior to the lateral view chain urethrogram if bladder

neck mobility is studied during a Valsalva maneuver.

Depth and width of proximal urethral dilation during coughing and Valsalva maneuver are readily assessed by perineal US. Bladder neck descent occurs both in continent and incontinent women. The urethra dilates during coughing and Valsalva maneuver both in incontinent and some continent women and dilation per se does not imply incontinence.

An alternative technique is endorectal US in a standing position, the bladder filled with saline, and the test performed at rest and during a Valsalva maneuver; those with stress incontinence have a larger pubovesical angle during both resting and straining than controls; however, considerable overlap exists. Endorectal US shows the midurethral cross-sectional area to be significantly smaller in women with stress incontinence than in those without, a difference due to a significantly smaller peripheral striated muscle component in those with stress incontinence (41); this peripheral striated muscle surrounded the urethra completely in 36% of women without stress incontinence, but only in 5% of those with severe incontinence. The urethropelvic ligament thickness was significantly thinner in those with stress incontinence. The clinical application of these findings in formulating therapy remains to be established.

Endovaginal US measures the distance from the bladder neck to the symphysis pubis. Various displacement criteria with and without stress have been suggested to detect urinary stress incontinence, none achieving popularity.

Magnetic resonance imaging is acquiring a primary role in evaluating stress incontinence, although technical limitations exist with horizontal bore MR units; ideally, the study should be performed with the patient in the upright position. Sagittal T2-weighted MRI identifies a cystocele as a posteriorly bulging bladder into the vagina. High resolution endovaginal MR provides detailed dynamic pelvic floor visualization during straining when using T2weighted single-shot fast spin echo (FSE) sequences without contrast. Levator ani thinning is associated with stress urine incontinence (42). Varying degrees of protrusion, including prolapse, are identified. Stress incontinence is associated with a greater vesicourethral angle and larger retropubic space than found in continent women. Both bladder floor descent and

cervical descent is greater in incontinent than in nulliparous women, but symptoms do not always correlate with the amplitude of bladder floor descent (43).

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tinence. These consist of self-detachable crosslinked silicone balloons and a biocompatible filler material. This technique is most effective in treating intrinsic sphincter deficiency.

Therapy

A vesicourethropexy (Marshall-Marchetti operation) has a high early postoperative success rate, which decreases with time. Postoperative imaging identifies an elevated bladder base. A similar bladder elevation is also occasionally seen due to large degenerative bony spurs at the symphysis pubis.

A number of bulking agents, including autologous fat, polytetrafluoroethylene, and bovine collagen have been injected to treat stress incontinence but most are associated with either side effects or limited long-term results. Periurethral collagen (glutaraldehyde crosslinked bovine collagen) injection has become popular therapy for symptomatic urinary stress incontinence since gaining United States Food and Drug Administration approval. The agent is injected under local anesthesia. It appears to be biocompatible with little evidence of a foreignbody or immunologic reaction. Collagen is partially reabsorbed within several years. A follow-up of 24 months after periurethral collagen injection in women with severe urinary incontinence resulted in a continent rate of 33%, with 39% improved and 28% considered to be failures (44). Complications include urinary urgency and incontinence, at times irreversible, hematuria, and urinary retention. Urinary tract infection after collagen injection is uncommon.

Comparing posttherapy transvesical and endovaginal US, the endovaginal approach reveals collagen in more patients; collagen is identified as circumscribed masses at the bladder base having varying echogenicity. Magnetic resonance imaging identifies collagen as hyperintense foci within the urethral wall; neither visualized collagen volume nor its position are related to clinical outcome.

Periurethral silicone implants in women with intrinsic sphincter deficiency resulted in a subjective success rate of 80% at 6 weeks and 60% at 1 year (45).

Implantable microballoons have also been used as therapy for female urinary incon-

Men

Continence after prostatectomy is maintained by an intact sphincter. Urinary stress incontinence after prostatectomy is generally due to sphincter dysfunction, such as scarring or decreased contractions, findings evaluated with endourethral US.

Transurethral collagen injection is used to treat urinary incontinence after radical prostatectomy. Collagen injection in men with incontinence result in a low continence rate: 20% to 24% in several studies; the success of the cure by collagen injection is influenced by the severity of the pretreatment incontinence, detrusor overactivity, and other factors. Endorectal US in men after collagen injection reveals hypoechoic masses adjacent to the bladder.

Children

Urinary incontinence is a common pediatric urologic problem. In infants the reflexcontrolled bladder matures to normal bladder function during the first several years of life as the bladder sphincter grows and central nervous control of micturition matures. Sufficient anatomic maturation is necessary before neurologic control is established.

Collagen injection for incontinence has achieved mixed results in children. One study reported that 5% of children became continent and 25% improved, and the authors questioned the high collagen injection cure rates previously reported for urinary incontinence in children (46).

Immunosuppression

Acute hemorrhagic cystitis is occasionally reported after a kidney transplant, probably due to an adenovirus infection.

Immunosuppressed renal transplant patients are more prone to developing a bladder lymphoma than the general population.

are mostly a complication of combined irradiation and orthotopic bladder replacement.

Postoperative upper tract surveillance is with IV urography, CT, and renal US. Postcontrast MRI should reveal normal renal enhancement and visualize the neobladder. Also, MRI provides renal function data similar to that obtained with scintigraphy. Dynamic digital urography using serial image acquisition after bolus contrast injection is a novel way of studying orthotopic ileal neobladders (48), but this technique is not widely practiced.

Postoperative surgical anatomy after orthotopic bladder reconstruction can be evaluated with 3D CT (virtual endoscopy); while such imaging is useful if reoperation is required, its need on a routine basis is not established.

Postoperative Complications

Urinary tract damage occurring during various gynecologic laparoscopic procedures includes bladder perforation, ureteral injury, and bladder fistula. The prevalence of these complications after major laparoscopic gynecologic surgery is probably similar to that seen after standard surgery.

Leak

Anastomotic leakage is a recognized complication of urinary tract reconstructive surgery

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(Fig. 11.11). The most common site is at the urethroenteric anastomosis. A majority of leaks are extraperitoneal in location; it is the intraperitoneal pouch leaks that are more difficult to detect with imaging. A number of leaks are delayed.

Catheter drainage or stenting as appropriate is therapeutic for most leaks.

Stones/Stricture

Patients with an enterocystoplasty or continent diversion are at risk for stone formation and ureterointestinal stricture. Patients with a continent diversion are more prone to developing stones than those with an augmentation or a substitution cystoplasty.

Surgical treatment of ureterointestinal strictures consists of open ureteral reimplantation. Percutaneous antegrade dilation is a viable alternative in some patients, but is plagued by a low success rate and recurrent restenosis.

Dilated ureters are common in patients with a neobladder, and it is difficult to differentiate between partial obstruction and dilation due to reflux and other causes. An IV urogram with furosemide is occasionally helpful in such a situation. Furosemide normally results in good contrast flow distally once renal pelves are opacified; on the other hand, increased renal pelvis and caliceal dilation and the lack of contrast washout during such diuresis imply an obstruction.

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Malignancy

A low but increased risk of cancer exists after various uroenteric anastomoses, generally beginning a decade or more after surgery. These range from adenocarcinoma to transitional cell carcinoma and squamous cell carcinoma. A reasonable approach is to recommend routine annual surveillance beginning about 10 years after the initial surgery.

Other Complications

An ileoileal intussusception is an uncommon complication of bladder augmentation. Computed tomography and MR should detect this complication.

An autostapler is often used when bowel is interposed in the urinary tract, with the metallic staples buried beneath the intestinal mucosa. A staple expressed into the bladder lumen acts as a nidus for subsequent stone formation.

An occasional patient with portal hypertension develops massive bleeding from ileal conduit peristomal varices; such bleeding can be controlled with transjugular intrahepatic portosystemic shunt (TIPS).

Examination Complications

Cystography

Rupture/Extravasation

Extravasation of contrast or even frank perforation is one of the complications of cystography. Typically a tear occurs during filling of an unused or partially used bladder. Patients with chronic renal failure appear to be at increased risk. Although rare, an indwelling catheter is associated with a bladder perforation; occasionally a Foley catheter occludes the bladder outlet and results in greater pressures than normal. Nevertheless, extravasation also occurs in patients with no known underlying risk factors. The most common site is lateral to the trigone, close to the ureteral insertion.

Some patients develop intramural intravasation, while others have frank bladder wall rupture. Many of these patients remain asymptomatic. Cystoscopic findings range from isolated mucosal tears and diffuse mucosal hemorrhage to frank rupture.

Many extravasations resolve without therapy, aside from maintaining a low luminal pressure.

Autonomic Dysreflexia

In patients with previous spinal cord injury, imaging studies leading to bladder or colonic distention should be approached cautiously. Autonomic dysreflexia is caused by spinal cord lesions above the T6 level. It is not an uncommon complication in patients with a cord lesion who are undergoing manipulative urologic procedures such as cystography or voiding cystourethrography. It is also occasionally encountered with a barium enema or similar procedures. It is induced by overstimulation of a-adrenergic fibers in the bladder neck. With a rise in intravesical pressure the bladder neck is stretched and a-adrenergic receptors excrete norepinephrine. Elevated circulating norepinephrine level leads to peripheral arterial constriction and hypertension. Normally this peripheral arterial constriction is countered by splanchnic vessel dilation, but with a spinal cord lesion above T6 no reflex portal vessel dilation occurs. The resultant hypertension stimulates the carotid sinus, and aortic arch baroreceptors which result in bradycardia and vasodilation above the cord injury level. Impulses originating from stretched bladder or colon afferent sensory nerve endings ascend to the point of spinal cord injury and initiate the release of sympathetic motor impulses in efferent tracts, leading to sympathetic hyperreflexia and spasm and vasoconstriction below the level of injury. Clinically, both systolic and diastolic hypertension, bradycardia, nausea, abdominal pain and redness, and profuse sweating of the head and neck develop. It can be life-threatening.

In patients with a spinal cord lesion, constant blood pressure monitoring should be considered during manipulative radiologic procedures so that the onset of this syndrome is detected in its early phase; generally terminating the procedure and bladder drainage resolves the hypertension. Therapy of autonomic dysreflexia differs from treatment of typical contrast reactions; namely, treatment is to remove the inciting cause and treat the hypertension, if still present. Occasionally hypertension persists even when the inciting stimulus is removed, and fast-acting antihypertensive therapy may be necessary. If needed, patients at risk for auto-

nomic dysreflexia can be premedicated with a- blocking agents prior to the procedure.

Catheter Related

The balloon of a chronic indwelling catheter may not deflate. An attempt at bursting the balloon should minimize the possibility of leaving any catheter fragments in the bladder. An in vitro study comparing the results of a needle technique, overinflation, instillation of ether, and using a stylet through the inflation channel found that a needle technique achieved the best results with the fewest fragments (49).

A knot can form during catheterization of a continent stoma and lead to acute urinary retention. Similar catheter knotting within the bladder is a complication of cystourethrography; some of these knots can be untied using a stiff guidewire.

References

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Technique

Hysterosalpingography

Conventional

The gold standard in evaluating tubal patency is laparoscopy, although in many institutions hysterosalpingography is commonly used. In developed countries hysterosalpingography is performed with fluoroscopic visualization; in others, where fluoroscopic equipment often does not exist, a delayed anteroposterior image after contrast instillation is an alternative.

The primary application of hysterosalpingography is in evaluating infertility. This examination is readily performed by most radiologists, does not require anesthesia, and side effects and complications are uncommon, with the major complication being pelvic infection. The indications for this examination have decreased considerably, and the current major indication is to determine whether fallopian tubes are patent or not. It has been supplanted by magnetic resonance (MR) in evaluating most müllerian duct anomalies. This examination does not evaluate well the fimbriated fallopian tube ends and external structures. A lack of intraperitoneal contrast spill does not establish tubal obstruction; spasm, mucous plugs, and technical factors in performing the study also result in nonspillage. Thus in one study only 84% of the nonpatent tubes at hysterosalpingography were obstructed at perioperative salpingoscopy

(1).

A number of studies have commented on an increased pregnancy rate after hysterosalpingography. The choice of a water-soluble versus an oil-soluble contrast agent in performing hysterosalpingography does not affect the subsequent rate of term pregnancy (2).

Other Imaging Techniques

Selective catheterization of the fallopian tubes (selective salpingography) is useful if hysterosalpingography reveals a blocked tube and further intervention is contemplated. If needed, a guide wire is inserted through the tube and a catheter is advanced into the tube.At times a fallopian tube believed to be obstructed will be shown to be patent with this technique.

Endovaginal ultrasonography (US) during air and saline instillation into the uterus also evaluates tubal patency (variously called sonosalpingography, hysterosalpingosonography, and similar names). The use of B-mode US and Doppler US to assess tubal flow of a contrast agent and thus establish tubal patency have been proposed, but with limited success.

A liquid containing air bubbles, such as agitated saline or one containing human serum albumen, can be used as a contrast agent during sonographic hysterosalpingography. Fluid and air bubbles are seen in the cul-de-sac if the fallopian tubes are patent. These procedures are similar to hysterosalpingography except that endovaginal US is used.

In a woman with a contraindication to iodine-based contrast, tubal patency can be established by magnetic resonance imaging (MRI) after infusing gadolinium–diethylenetri- amine pentaacetic acid (Gd-DTPA); the presence of contrast material in the peritoneal cavity implies tubal patency.

Anecdotal hysterosalpingoscintigraphy using technetium-99m (Tc-99m)–macroaggregated albumin (MAA) has been reported.

Computed Tomography

Pelvic CT is commonly used to evaluate gynecologic disease. Computed tomography is especially useful in staging malignancies. An occasional false-positive diagnosis of malignancy does occur, and among other entities it includes pelvic actinomycosis, chronic appendicitis, and even an ectopic pregnancy.

Ultrasonography

A number of terms describe US of the female pelvic structures: sonography, sonohysterography, hysterosonography, vaginosonography, transvaginal echography, and other similar terms are used. Saline may or may not be instilled into the uterine cavity prior to scanning. The examination is performed either using a transabdominal approach or the probe is positioned in the vagina, uterus, or rectum. Ultrasonography during surgery uses a sterile intraabdominal probe.

For consistency, the terms transabdominal, endovaginal, and endorectal US are used here. Whenever intrauterine saline is instilled it is specifically mentioned. Unless Doppler is mentioned, the examination involves conventional US.

Intraoperative US is useful in guiding difficult dilation and curettage (D&C). Endovaginal sonohysterography aids some operative intrauterine biopsies and resections, although its effectiveness compared to hysteroscopy is not known.

Transabdominal US provides a general overview of the pelvis. It is limited in obese patients. Endovaginal US allows the use of higher frequency transducers and thus has better resolution than a transabdominal approach, but it has a limited field of view, especially of large tumors.

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The two studies are therefore complementary and at times both need to be performed.

Endovaginal US is generally considered more specific in detecting adnexal and ovarian disorders than transabdominal US. In women with postmenopausal bleeding, endovaginal US improves clinical diagnostic accuracy and the certainty of diagnosis. Both conventional and Doppler US are feasible. No definite contraindication to endovaginal US exists. A threedimensional (3D) endovaginal US technique is employed in some centers; whether it provides any advantage over the current 2D techniques remains to be established.

The terms sonohysterography and hysterosonography are generally used to indicate that the uterine cavity has been distended with fluid, usually sterile saline. It then should be qualified whether the examination is performed transabdominally or endovaginally. Sterile saline injected into the uterine cavity acts as a sonographic window for endovaginal US. Such scanning achieves higher resolution than is obtainable with conventional endovaginal US. A number of publications have reported sensitivities and specificities of over 95% for this technique in detecting intracavitary lesions, and this technique has gained wide acceptance. Yet a word of caution is in order about this procedure: A risk of intraperitoneal malignant cell dissemination exists in a setting of endometrial cancer. In an elegant study of infusion sonohysterography using 10 to 20mL of saline performed when the abdomen was open but prior to the start of a surgical procedure, fluid spilled from the fallopian tubes was shown to contain malignant cells (3). Whether the use of sterile water rather than saline to lyse free tumor cells is helpful remains to be established.

Intrauterine US has a higher sensitivity and specificity than an endovaginal approach in detecting uterine abnormalities. Some authors have suggested that intrauterine US might replace hysterosalpingography for uterine study. This may be so, although part of the reason may be the poor study quality of much of hysterosalpingography, especially with digital filming—gross contrast-filled uterine images provide no intrauterine details.

The indications for intrauterine US are not yet settled, but it appears to have a role between that of hysterosalpingography and hysteroscopy.