Detection of urethral diverticula in women: comparison of a high resolution fast spin echo technique with double balloon urethrography.

PURPOSE: We compared a rapid high resolution magnetic resonance imaging (MRI) technique to contrast urethrography for the detection of urethral diverticula in women. MATERIALS AND METHODS: During a 19-month interval 13 patients with clinically suspected urethral diverticula were evaluated with MRI and contrast urethrography. All patients were referred by a urologist, and had clinical signs and symptoms suggesting the presence of a urethral diverticulum. Double balloon urethrography was performed in 12 patients and voiding cystourethrography was done in 1. MRI was performed using a fast spin echo T2-weighted pulse sequence and a dedicated pelvic multicoil. Following a sagittal localizer sequence 3 mm. thick axial sections were obtained from the bladder base through the entire urethra. Total imaging time was 15 minutes. RESULTS: In 7 patients MRI and urethrography were negative for urethral diverticula, and in 3 cystourethroscopy was negative. In 1 patient MRI revealed a vaginal inclusion cyst confirmed by surgery. Three patients had no other studies or procedures performed. In 6 patients MRI was positive for urethral diverticula, including 4 in whom the diverticulum was confirmed at surgery, 1 who declined surgery and 1 who was lost to followup. Of the 4 patients (75%) with a surgically confirmed diverticulum double balloon urethrogram was negative in 3. CONCLUSIONS: MRI is a valuable noninvasive technique for determining the presence of urethral diverticula as well as detecting other abnormalities. In our study MRI had a higher sensitivity for detecting diverticula and a much higher negative predictive rate.

Endoscopic management of complete obstruction of a ureteroneocystostomy in an infant.

We present the case of an 18-month-old female who, after bilateral ureteroneocystostomies, developed complete obstruction at the left ureteroneocystostomy site. Using endourologic techniques, patency of the ureteroneocystostomy was re-established and has remained unobstructed during her 4-year follow-up.

Transvaginal uterine cervical dilation with fluoroscopic guidance: preliminary results in patients with infertility.

PURPOSE: To assess efficacy of uterine cervical dilation performed with fluoroscopic guidance to treat patients with infertility who have cervical stenosis, false channels within the endocervical canal, or both. MATERIALS AND METHODS: Fifteen patients in whom infertility was diagnosed were referred because the uterine lumen could not be accessed. Three of the patients had endometriosis. With fluoroscopic guidance, the cervix was cannulated and the endocervical canal was dilated with an angioplasty balloon or with dilators. Five patients underwent simultaneous fallopian tube recanalization. Five of 15 patients who underwent dilation subsequently underwent in vitro fertilization for embryo transfer (IVF-ET) or intrauterine insemination. RESULTS: Four patients became pregnant. Of those four, one underwent IVF-ET and one underwent intrauterine insemination. Two patients became pregnant spontaneously. In the five patients who underwent IVF-ET or intrauterine insemination and in the remaining eight patients, the cervix could be easily cannulated up to 7 months after dilation. CONCLUSION: Dilation of the uterine cervix may provide options for treatment in selected patients with infertility. The effect of dilation on patients with other sequelae of cervical obstruction such as endometriosis remains uncertain.

CT urography in the evaluation of urinary tract disease.

OBJECTIVE: The purpose of this study was to evaluate the efficacy of using limited CT through the kidneys following excretory urography in selected situations. MATERIALS AND METHODS: Within 2 h of excretory urography 568 patients had add-on CT without using additional contrast medium. In 487 patients with hematuria the results of the combined studies were compared with blinded prospective interpretations of each. In addition 81 patients had add-on CT for specific urographic questions. RESULTS: Of the 345 renal parenchymal masses seen on CT in both groups, only 185 were detected prospectively on excretory urography. For the 81 patients who had CT because of abnormalities seen on excretory urography, including 54 with pseudotumors, findings were clarified and the correct diagnosis made. In 27 of 30 patients with lesions in the collecting system the lesions were detected only on excretory urography. CONCLUSION: Excretory urography followed by limited CT increases the diagnostic accuracy for detecting, characterizing, or ruling out urinary tract disease by combining the high sensitivity of traditional excretory urography for detecting lesions in the collecting system and ureter with the high accuracy of CT for parenchymal and perinephric lesions without an additional patient visit or additional contrast medium. Because it leaves so few unanswered questions, the combination of standard excretory urography and limited CT is an excellent screening study in selected situations. It can be performed quickly, at controlled cost, is highly accurate, and is convenient for the patient, the referring physician, and the examining department.

Acute flank pain: comparison of non-contrast-enhanced CT and intravenous urography.

PURPOSE: To compare non-contrast-enhanced computed tomography (CT) and intravenous urography (IVU) in the evaluation of patients who present with acute flank pain and in whom ureteric obstruction is suspected. MATERIALS AND METHODS: The findings at non-contrast-enhanced CT and IVU in 20 patients with acute flank pain were compared for the presence or absence of ureteric obstruction and delineation of ureteric stones. RESULTS: Twelve of the 20 patients had non-contrast-enhanced CT and IVU findings consistent with ureteric obstruction. Of these 12 patients, five had a ureteric stone that was demonstrated on both non-contrast-enhanced CT scans and IVU radiographs, six had a stone that was depicted on non-contrast-enhanced CT scans only, and in one patient a stone could not be delineated definitively on either non-contrast-enhanced CT scans or IVU radiographs. Eight patients had findings at non-contrast-enhanced CT and IVU consistent with the absence of obstruction. CONCLUSION: Non-contrast-enhanced CT is more effective than IVU in precisely identifying ureteric stones and is equally effective as IVU in the determination of the presence or absence of ureteric obstruction.

Technical aids in investigation and management of urethral diverticula in the female.

Three aids in the diagnosis and management of urethral diverticula are described. First, the technique of double-balloon urethrography has been modified. Diluted contrast medium is used to inflate the intravesical and external balloons so that improved delineation of the anatomy of the diverticular pouches is obtained with undiluted contrast medium. Second, for identification and irrigation with antibiotic solution of the nondraining pouches of compound diverticula, an angiographic catheter is placed in the most distal pouch using fluoroscopically guided manipulation, and then this catheter is replaced with a pigtail-shaped nephrostomy drainage catheter. Third, a 7 F Foley catheter balloon is placed in thin-walled and friable diverticular pouches to facilitate dissection.

Percutaneous isolated liver perfusion for treatment of hepatic malignancy: preliminary report.

Chemotherapy for primary or metastatic hepatic malignancy is limited by poor tumor response and dose-related systemic toxicity. As an alternative to chemotherapy infusion by vein or by the hepatic artery, the authors have developed a percutaneous technique of isolated liver perfusion that allows the regional delivery of high-dose chemotherapy to the liver with little systemic toxicity. After placement of a hepatic artery infusion catheter, an 18-F double-balloon catheter is placed into the inferior vena cava through the opposite femoral vein. Balloons are inflated above and below the hepatic veins, thus isolating hepatic venous outflow. The effluent passes through fenestrations in the catheter and is pumped through charcoal hemoperfusion filters where the drug is removed. The filtered blood is returned to the patient through the internal jugular vein. Fifteen treatments have been conducted in eight patients in a phase I dose-escalation study with use of 5-fluorouracil (5-FU). While it is premature to assess tumor response to isolated liver perfusion, the data demonstrate that the procedure is safe and is tolerated by patients. Pharmacokinetic studies show a 5-FU extraction of up to 85%, with minimal drug leakage into the systemic circulation. This technique shows potential for improving liver tumor response while decreasing systemic toxicity.

Diagnosis of uterine anomalies: relative accuracy of MR imaging, endovaginal sonography, and hysterosalpingography.

The purpose of this study was to compare the relative accuracy of magnetic resonance (MR) imaging (n = 26), endovaginal sonography (EVS) (n = 14), and hysterosalpingography (HSG) (n = 20) in the classification of müllerian duct anomalies in 26 patients. There were 24 cases of surgically proved anomaly, and two patients had normal uteri (one with a vaginal septum). MR imaging allowed diagnosis of 24 of 24 cases (accuracy, 100%), and EVS was correct in 11 of 12 cases (accuracy, 92%). HSG was correct in only four cases. In the diagnosis of septate uterus, MR imaging demonstrated a sensitivity and specificity of 100% and EVS demonstrated a sensitivity of 100% and a specificity of 80%. Both MR imaging and EVS demonstrated a sensitivity and specificity of 100% in distinguishing those anomalies that did not require surgery. The high accuracy of MR imaging and EVS permit noninvasive differentiation of uterine anomalies and can spare women diagnostic laparoscopy, promoting cost-effective diagnosis.

Influence of combined intravenous and oral glucose administration on splanchnic glucose uptake in man.

The influence of intravenous plus oral glucose administration on splanchnic glucose handling was examined in healthy young individuals by combining the hepatic vein catheterization technique with the double glucose tracer method. After 1 h of steady state hyperglycaemia (11.7 mM) induced by intravenous glucose alone (hyperglycaemic clamp technique), subjects ingested 89 +/- 1 g of glucose, and the hyperglycaemic plateau was maintained for the subsequent 4 h by adjusting the exogenous glucose infusion rate. Over the 4-h absorptive period, only 51 +/- 4 g of oral glucose (i.e. 58 +/- 4% of the ingested load) appeared in the systemic circulation, while 193 +/- 15 g (1.072 +/- 0.83 mol) of glucose had to be infused exogenously to sustain the hyperglycaemia. Endogenous glucose production was suppressed by over 60%. Net splanchnic glucose balance switched from a positive value (i.e. net uptake) of 5.06 +/- 2.56 mumol min-1 kg-1 with intravenous glucose alone (0-60 min) to a negative one (i.e. net output) of 12.50 +/- 2.44 mumol min-1 kg-1 during 4 h (60-300 min) of intravenous + oral glucose. The mean rate of splanchnic glucose uptake was estimated to be 6.39 +/- 4.67 mumol min-1 kg-1 with intravenous glucose alone, and 8.83 +/- 4.28 mumol min-1 kg-1 with intravenous + oral glucose. In either case, the large majority (80-90%) of the glucose appearing in the systemic circulation was disposed of by extrasplanchnic tissues. These results indicate that pre-existing hyperglycaemia and/or hyperinsulinaemia inhibit gastrointestinal glucose absorption, and that oral glucose administration does not result in a major redistribution of intravenous glucose between splanchnic and extrasplanchnic tissues.

Ureteral injuries at laparoscopy: insights into diagnosis, management, and prevention.

The increasing use of laparoscopy as a therapeutic method mandates a reappraisal of the risks involved. Complications frequently described include injuries to the large and small bowels, bladder, and blood vessels. The world literature reports only eight cases of ureteral injury at laparoscopy. In this report, we present five additional cases of ureteral injury occurring at laparoscopy, in addition to a summary of those previously reported. Patients tend to present in the early postoperative period (48-72 hours) with low back pain, abdominal pain, leukocytosis, and peritonitis. The diagnosis should be made by intravenous pyelography; if possible, the injury should be stented by either the retrograde or percutaneous route. The injuries, except for one apparent trocar injury, involved the use of electrocoagulation, both unipolar and bipolar. The injuries occurred most commonly near the uterosacral ligaments. In 38% (five of 13) of the cases, the laparoscopy was performed for treatment of endometriosis. Three of the 13 patients eventually lost renal function of the affected side; two of these underwent a nephrectomy. Because visualization of the ureter near the cervix at the time of laparoscopy is difficult, especially in the presence of disease, laparoscopic procedures in this area must be carried out with caution.

Society of Uroradiology Award paper. The pars infravaginalis gubernaculi: importance in the identification of the undescended testis.

The gubernaculum, a cordlike structure that extends from the testis to the scrotum and guides the testis in its descent, has a bulbous termination, the pars infravaginalis gubernaculi. We reviewed seven surgically proved cases in which the pars infravaginalis gubernaculi was mistaken for an undescended testis on imaging studies. The studies included sonography (five cases), CT (two cases), and MR imaging (two cases). Identification of the mediastinum testis on sonograms or MR images confirms that a structure is testis and not the pars infravaginalis gubernaculi. In two of these patients, testicular venography was used to further identify the undescended testis. In these two patients, the pampiniform plexus, which is used to identify the presence and position of testis, was located adjacent to the pars infravaginalis gubernaculi. Our experience indicates that the pars infravaginalis gubernaculi can be similar in appearance to the undescended testis on any imaging study. The finding of an apparent cord leading to a testislike structure on caudad sectional imaging does not obviate searching for the testis as far as the renal hila.

Detection of renal masses: sensitivities and specificities of excretory urography/linear tomography, US, and CT.

A prospective blinded study of 201 patients was performed to determine the relative sensitivities and specificities of excretory urography/linear tomography (EU/LT) and ultrasound (US) for the diagnosis of renal parenchymal masses. Computed tomography (CT) was used as a standard. EU/LT permitted detection of 10% of CT-confirmed masses (cystic or solid) less than 1 cm, 21% of lesions greater than or equal to 1 cm but less than 2 cm, 52% of lesions greater than or equal to 2 cm but less than 3 cm, and 85% of lesions 3 cm or more in diameter. US permitted detection of 26% of CT-confirmed lesions less than 1 cm, 60% of lesions greater than or equal to 1 cm but less than 2 cm, 82% of lesions greater than or equal to 2 cm but less than 3 cm, and 85% of lesions 3 cm or more in size. The results confirm the relative insensitivity of EU/LT for masses less than 3 cm in diameter and of US for masses less than 2 cm. Further, they suggest that CT may have a role not only in evaluation of cases in which the urographic or sonographic results are questionable or positive, but also in confirmation of apparently negative urographic findings when clinical suspicion of a lesion is high.

Measurement of L-[1-14C]leucine kinetics in splanchnic and leg tissues in humans. Effect of amino acid infusion.

Although whole-body leucine flux is widely measured to study body protein turnover in humans, the contribution of specific tissues to the total-body measurement remains unknown. By combining the organ-balance technique with the systemic infusion of L-[1-14C]leucine, we quantitated leucine production and disposal by splanchnic and leg tissues and by the whole body, simultaneously, in six normal men before and during amino acid infusion. At steady state, disposal of arterial leucine by splanchnic and leg tissues was calculated from the percent extraction (E) of L-[1-14C]leucine counts: uptake = E x [Leu]a x flow. Tissue release of cold leucine (from protein turnover) into vein was calculated as the difference between leucine uptake and the net tissue leucine balance. In the postabsorptive state, despite substantial (P less than .01) extraction of L-[1-14C]leucine by splanchnic (23 +/- 1%) and leg (18 +/- 2%) tissues, net leucine balance across both tissue beds was small, indicating active simultaneous disposal and production of leucine at nearly equivalent rates. Splanchnic tissues accounted for approximately 50% of the measured total-body leucine flux. During amino acid infusion, the net leucine balance across splanchnic and leg tissues became positive, reflecting not only an increase in leucine uptake but also a marked suppression (by approximately 50%, P less than .02) of cold leucine release. This reduction in splanchnic and leg leucine release was indicated by a sharp decline in whole-body endogenous leucine flux.(ABSTRACT TRUNCATED AT 250 WORDS)

Traumatic aortic rupture: false-positive aortographic diagnosis due to atypical ductus diverticulum.

The interpretations of 314 thoracic aortograms obtained over a 4 1/2-year period for possible traumatic rupture were reviewed to determine the frequency and causes of false-positive examinations. The radiographs and clinical records of all patients whose aortograms were abnormal or equivocal were examined. Two hundred consecutive thoracic aortograms that had been interpreted as normal were reviewed to determine the frequency and character of normal morphologic variations at the aortic isthmus, with particular attention to ductus diverticula, in an attempt to identify means of reducing the number of examinations that were equivocal or false-positive for aortic rupture. Aortic rupture was diagnosed with confidence in 12 patients (4%), and all were surgically proved. Another nine aortograms (3%) were equivocal when standard aortographic criteria for rupture were used. For four of the nine, further imaging studies indicated normal aortas, but five patients underwent thoracotomy. Two of these had aortic rupture, two had ductus diverticula, and one had an ulcerated plaque at the site of aortographic abnormality. Thus, false-positive aortograms led to unnecessary surgery in three cases--1% of all 314 aortograms and 14% of the 21 aortograms that were not clearly normal. In summary, two (14%) of 14 aortic ruptures in our series could not be distinguished at aortography from anatomic variants or disease not requiring surgery. To avoid false-negative diagnosis, we must accept occasional false-positive diagnoses, necessitating exploratory thoracotomy with its attendant risks.

Obstetric and nonmalignant gynecologic bleeding: treatment with angiographic embolization.

Eight patients (seven post partum, one post abortion) with massive pelvic hemorrhage related to pregnancy and one patient with uncontrollable bleeding following a cervical biopsy underwent angiography to facilitate the identification and treatment of bleeding sites. In all nine patients pelvic hemorrhage was successfully controlled with embolization under angiographic guidance. Angiographic embolization allowed preservation of the uterus in six patients referred prior to hysterectomy, and one patient subsequently became pregnant. When conservative measures and minor surgical repairs have failed, embolization should be the next step in the treatment of postpartum hemorrhage to avoid major surgery in an unstable patient and to maintain reproductive function.

Hemorrhagic focal bacterial nephritis: findings on gray-scale sonography and CT.

Five patients with acute focal bacterial nephritis and hematuria had sonographic and CT findings atypical for renal infection. Sonographically, each presented with an echogenic focus in the renal parenchyma. Noncontrast CT images showed an area of increased density in the corresponding segment of the kidney in three patients, mixed high and low density in one patient, and low density alone in the remaining patient. It is proposed that these appearances result from the presence of hemorrhage at different stages, associated with focal infection. Venous compromise is suggested as the etiology.

Removal of infused amino acids by splanchnic and leg tissues in humans.

To compare the contributions of splanchnic and skeletal muscle tissues to the disposal of intravenously administered amino acids, regional amino acid exchange was measured across the splanchnic bed and leg in 11 normal volunteers. Postabsorptively, net release of amino acids by leg (largely alanine and glutamine) was complemented by the net splanchnic uptake of amino acids. Amino acid infusion via peripheral vein (0.2 g X kg-1 X h-1) caused a doubling of plasma insulin and glucagon levels and a threefold rise in blood amino acid concentrations. Both splanchnic and leg tissues showed significant uptake of infused amino acids. Splanchnic tissues accounted for approximately 70% of the total body amino acid nitrogen disposal; splanchnic uptake was greatest for the glucogenic amino acids but also included significant quantities of branched-chain amino acids. In contrast, leg amino acid uptake was dominated by the branched-chain amino acids. Based on the measured leg balance, body skeletal muscle was estimated to remove approximately 25-30% of the total infused amino acid load and approximately 65-70% of the infused branched-chain amino acids. Amino acid infusion significantly stimulated both the leg efflux and the splanchnic uptake of glutamine (not contained in the infusate). We conclude that when amino acids are infused peripherally in normal humans, splanchnic viscera (liver and gut) are the major sites of amino acid disposal.