Low diagnostic sensitivity of cystoscopy and cystography of surgically confirmed vesicoenteric fistulae.

PURPOSE: The objective of this study was to assess the accuracy of cystoscopy and cystography, as compared to other diagnostic studies, in identifying vesicoenteric fistulae (VEF) in a contemporary series of patients with surgically confirmed VEF. METHODS: With institutional review board approval, we performed a single-center retrospective review of surgically confirmed VEF between 2002 and 2018. Demographic data, comorbidities, symptoms, and diagnostic evaluation were reviewed. The sensitivity, specificity, and accuracy of cystoscopy in diagnosis of VEF were compared to cross-sectional imaging. RESULTS: The study cohort consisted of 51 patients with surgically confirmed VEF secondary to diverticular disease. Diagnostic evaluation included cross-sectional imaging with CT (94%), colonoscopy (82%), cystoscopy (75%), cystography (53%), and barium enema (26%). Cystoscopic evaluation definitively demonstrated evidence of VEF in 34% of patients, while 55% of patients had nonspecific urothelial changes on cystoscopy without definitively demonstrating VEF. Comparatively, the sensitivity of VEF was 25% for cystography and 84% for CT. CONCLUSIONS: In clinical practice, the diagnostic work-up of VEF is variable. In the modern era of managed care, inclusion of cystoscopy and cystography in the evaluation of VEF does not contribute a substantial additive benefit over standard cross-sectional imaging. Cystoscopy and cystography could potentially be eliminated from the diagnostic evaluation of VEF, in the absence of a concern for malignancy, in an effort to minimize unnecessary invasive testing as well as health care expenditures.

T4 urothelial carcinoma in undiagnosed closed bladder exstrophy in a post-menopausal female.

It is rare to see an adult presenting with exstrophy of the bladder. Malignant conversion in exstrophy occurs in 4%, with adenocarcinoma as the most common histopathology. We report the first case of metastatic high grade urothelial carcinoma with squamous and sarcomatoid differentiation arising from undiagnosed, closed bladder exstrophy in a female at advanced age with associated bilateral deep vein thrombosis and clot retention. The patient developed clinical progression of disease despite neoadjuvant gemcitabine-cisplatin and salvage (or palliative) radiotherapy. To the best of our knowledge, this is the first reported case of a primary urothelial malignancy in occult bladder exstrophy.

Isolated Spongy Urethral Rupture from Abrupt Coital Distractive Force.

The classic presentation of penile fracture is a cracking or snap sound, with sharp pain, immediate detumescence, swelling, deformation and ecchymosis. A penile fracture involves rupture of the tunica albuginea of one or both corpora cavernosa. Concomitant urethral rupture is reported to occur in 10% to 20% of penile fracture cases. Isolated urethral injury without penile fracture is extremely rare. We report the first case of isolated pendulous urethral rupture from an abrupt coital distractive force. We include a literature review and discussion of isolated urethral trauma secondary to sexual intercourse. Retrograde urethrography rendered a stunning clinical image which was integral to the diagnosis and management of this patient's injury.

Metastatic Adenocarcinoma of the Prostate Presenting as Supraclavicular and Bulky Generalized Lymphadenopathy with a Benign Digital Rectal Exam.

A 63-year-old male presented with complaints of an enlarging left supraclavicular mass and weight loss. Computed tomography demonstrated a large retroperitoneal mass causing displacement of the adjacent organs, and moderate left hydroureteronephrosis. Multiple pulmonary nodules, lytic spinal lesions, and generalized lymphadenopathy including the left supraclavicular region were seen. Serum prostate-specific antigen level was 2064.0 ng/mL. Digital rectal exam revealed an enlarged prostate without nodularity. Biopsy of the supraclavicular node demonstrated prostatic adenocarcinoma. The diagnosis of lymphoma may be initially suggested, however, prostatic origin should be considered even when the prostate exam is not grossly abnormal.