Perivesical Space Research Articles

CT cystography in the evaluation of major bladder trauma.

Computed tomographic (CT) cystography has been advocated in lieu of conventional cystography in the initial work-up of patients with suspected urinary bladder trauma. CT cystography was applied to a classification scheme for bladder injury based on the degree of wall injury and anatomic location and demonstrated characteristic imaging features for each type of injury. In bladder contusion (type 1), findings are normal. In intraperitoneal rupture (type 2), CT cystography demonstrates intraperitoneal contrast material around bowel loops, between mesenteric folds, and in the paracolic gutters. Manifestations of interstitial injury (type 3) include intramural hemorrhage and submucosal extravasation of contrast material without transmural extension. In extraperitoneal rupture (type 4), the path of extravasated contrast material is variable: Extravasation is confined to the perivesical space in simple extraperitoneal ruptures, whereas in complex extraperitoneal ruptures, contrast material extends beyond the perivesical space and may dissect into a variety of fascial planes and spaces. Combined intra- and extraperitoneal rupture (type 5) usually demonstrates extravasation patterns that are typical for both types of injury. Familiarity with these CT cystographic features allows accurate classification of bladder injury and allows prompt, effective treatment with less radiation exposure than and without the added cost of conventional cystography.

Magnetic resonance imaging of postpartum pelvic hematomas: early experience in diagnosis and treatment planning

The purpose of this study was to determine the utility of magnetic resonance imaging (MRI) in detecting and localizing clinically non-apparent postpartum pelvic hematomas, and to describe the therapeutic implications of MRI in these patients. MRI examinations were performed on seven women with pelvic pain and/or fullness following difficult vaginal deliveries. None had clinically evident hematomas, and none were scheduled for surgery. Hematomas in the pelvis were identified with conventional T 1-weighted, and conventional and fast spin echo T 2-weighted sequences. Intravenous contrast was not used. Pelvic hematomas were identified in contiguity with the vagina, cervix, and bladder, within the broad ligament, and in the presacral space. In two patients, hematomas were confined to the perivaginal and pericervical regions. In three patients, perivaginal hematomas extended between the double layers of the broad ligaments. In one patient, a perivaginal hematoma extended into the perivesical space. In one patient, a hematoma was identified only within the presacral space. Based on MRI as the only contributory imaging study, five patients were treated successfully with invasive means and two patients were managed successfully with conservative means. MRI successfully detects and localizes postpartum hematomas, information that often is unavailable from the clinical examination. This information facilitates decisions regarding the need for intervention and the appropriate type of procedure when intervention is necessary for this potentially life-threatening problem. We advocate the use of MRI to evaluate patients at risk for postpartum hemorrhage following difficult vaginal deliveries.

Communications of the pelvic extraperitoneal spaces and their relation to the abdominal extraperitoneal spaces: helical CT cadaver study with pelvic extraperitoneal injections.

To evaluate flow patterns and anatomic appearances in the pelvic extraperitoneal spaces and to determine their relation to the abdominal extraperitoneal spaces. Helical computed tomographic (CT) guidance was used for injection of up to 1,000 mL of iodinated contrast material into one pelvic extraperitoneal space in each of five cadavers. Staged-volume injections into two prevesical spaces, one paravesical space, and one perivesical space were followed by helical CT. The injected pelvic extraperitoneal spaces freely communicated with each other and with the perirenal and anterior and posterior pararenal spaces of the abdomen. This abdominal communication was via the large infrarenal space posteriorly and the circumferential extraperitoneal spaces about the peritoneal cavity bounded deeply and superficially by the parietal peritoneum and transversalis fascia, respectively. The contrast material reached the diaphragm superiorly and the femoral vascular sheath space and inguinal canals inferiorly. After crossing the midline both anterior and posterior to the peritoneal cavity, the contrast material reached the mesenteric root in four cadavers and the propericardial space of the thorax in two cadavers. Intercommunication of the various extraperitoneal compartments occurs predominantly via the fascial-defined spaces, which contain mainly adipose tissue, but potential conduits exist through the communicating neurovascular structures where the fascia is anatomically perforated.

Intravesical Methylmethacrylate After Revision Hip Arthroplasty

Intrapelvic extrusion of cement during total hip replacement is common but complications are infrequently reported. Tissues affected by intrapelvic cement include bowel, vessels, nerves, ureters and bladder.' We report a case of 2 pieces of cement eroding sequentially into the bladder 5 years after right total hip replacement revision. CASE REPORT A 66-year-old woman with a history of congenital hip dysplasia, bilateral total hip replacements and revision of the right hip replacement in 1989 presented with recurrent afebrile urinary tract infections and intermittent episodes of gross hematuria 4 months in duration. Urine cultures yielded Escherichia coli and the patient responded to oral antibiotics. Anteroposterior radiography of the right hip confirmed stable protrusio from the revision site but no opacity was identified in the bladder region. Excretory urography showed medial deviation of the right ureter but no opacity in the bladder. Cystoscopy revealed a calcified mass in the right portion of the bladder. Open cystolithotomy was performed. A 5 cm. piece of orthopedic cement was seen eroding through the right lateral bladder wall (see figure). Attempts to mobilize the bladder from the right pelvic side wall were unsuccessful due to adhesions secondary to multiple orthopedic surgery. Via an intravesical approach the cement was removed using circumscribing excision. The perivesical space and defect in the Accepted for publication May 24, 1996. bladder wall were inspected, and no remaining cement was detected. Convalescence was uneventful. Eight months after surgery the patient complained of right lateral leg pain and urinary tract infections that did not resolve with antibiotics. An arthrogram showed a flow of contrast material from the right total hip replacement site into the perivesical space. Aspirated sinovial fluid and urine culture yielded group D Enterococcus. Repair of this fistula revealed a new piece of cement in the bladder wall. Partial cystectomy was performed to repair the bladder with omentum brought down to barricade the bladder from the medial wall of the implant. After 18 months the patient is mobile with the right hip and has no urinary complaints. DISCUSSION

Fungal Infections of the Perivesical Space

We describe 3 patients with fungal infection in the perivesical space who manifested lower abdominal pain and urinary tract symptomatology. Imaging studies demonstrated perivesical abnormalities. Urine culture was positive for fungus in only 1 patients. Management required surgical exploration, drainage, débridement of necrotic tissue and in 1 patient partial bladder resection. Systemic antifungal therapy was administered postoperatively. All patients had a successful outcome.

Management of Preexisting Inflatable Penile Prosthesis During Radical Retropubic Prostatectomy

A potentially difficult technical situation exists when a man with a functioning inflatable penile prosthesis elects radical prostatectomy as treatment for localized prostate cancer. Between February 1988 and June 1991 we encountered 8 men with a preexisting inflatable penile prosthesis who subsequently underwent radical retropubic prostatectomy. In 2 patients the reservoir portion of the prosthesis was in the perivesical space such that radical prostatectomy could be performed without difficulty. However, in 6 patients removal of the reservoir was necessary to complete the prostatectomy. In 3 of these 6 patients the reservoir was replaced at 3 to 6 months after radical prostatectomy and all 3 systems function well. The remaining 3 patients have not yet elected replacement of the reservoir. Only 1 patient had an infection and a complication attributable to the prosthesis. We believe that a preexisting inflatable penile prosthesis should not preclude successful radical retropubic prostatectomy, although temporary removal of the reservoir may be required.

Preperitoneal Approach for Hernia Repair: Clinical Application in Pediatric Urology

The preperitoneal approach for inguinal hernia repair rarely is indicated in children. However, we report on its clinical usefulness for children in whom the perivesical space must be exposed, such as during surgical repair of bladder exstrophy, ureterocele and ureteral reimplantation. This approach allows for a true high ligation of the hernia sac, and the repair is safe, fast and effective.

Mechanisms of Injury, Patterns of Extravasation and Management of Extraperitoneal Bladder Rupture Due to Blunt Trauma

During the last 7 years we have managed more than 100 cases of bladder rupture, the majority owing to blunt trauma. Of these ruptures 62 were extraperitoneal, including 59 (95 per cent) with associated pelvic fractures. Twelve patients had an associated urethral injury and 5 had a concomitant intraperitoneal bladder rupture. Complex injuries with extravasation outside the confines of the perivesical space were noted in 42 per cent of the patients. Extravasation extended into the scrotum, thigh, anterior abdominal wall and penis, and through the obturator foramen. The 41 patients who were treated with catheter drainage alone did well.

Extraperitoneal paravesical spaces: CT delineation with US correlation.

The extraperitoneal space around the urinary bladder is lamellate, just like the retroperitoneal space around the kidneys. The bladder, urachus, and obliterated umbilical arteries lie within the perivesical space, surrounded by umbilicovesical fascia, analogous to the perinephric space within the renal fascia. A much larger prevesical space, analogous to the anterior pararenal space, lies anterior and lateral to the umbilicovesical fascia. Posterior to the urinary bladder, the lower uterine segment or seminal vesicles lie within the perivesical space, rather than in a separate compartment, corresponding to the posterior pararenal space. The cul-de-sac, and the inferolateral extension of its peritoneal layers as the rectovaginal or rectovesical septum, separate the posterior perivesical space from the rectum. The sectional anatomy of these spaces, and particularly their computed tomographic and ultrasound appearances, were noted in normal anatomic sections, patients with extraperitoneal fluid collections, and a cadaver into which fluid was injected.

Bladder injury in blunt pelvic trauma.

Clinical and radiologic findings in 97 patients with bladder injury secondary to blunt pelvic trauma were reviewed. Fifty-five patients had extraperitoneal bladder rupture; 35, intraperitoneal rupture; two, interstitial bladder injury; and five, combined intraperitoneal and extraperitoneal bladder rupture. Of the 61 of 97 patients with film studies available for review, two patients with surgically proved intraperitoneal rupture had false-negative cystograms. In two other cases of intraperitoneal rupture, the diagnosis was established with cystography but was not demonstrated with urography. All cases of extraperitoneal rupture were demonstrated cystographically; in 15 cases in this group, the injury was complex, with extravasation of contrast material beyond the confines of the perivesical space. In two additional patients, incomplete bladder injury termed "interstitial bladder rupture" was identified. A classification of bladder injury based on cystographic patterns of extravasation is proposed.

Die Verletzung der hinteren Harnröhre

Injuries of the posterior urethra are a result of a blunt trauma of the pelvic ring, lacerations of the perineum and iatrogenic perforations due to transurethral manipulations. Traumatic lesions of the posterior urethra in about 10% of these patients suffer also a bladder laceration. The diagnosis of a urethral injury is ascertained by i. v. urogram and urothrography. If a urethral trauma is suspected the insertion of a catheter should be avoided in any case. The treatment is divided in emergency treatment, which means evacuation and drainage of the haematoma and extravasation and suprapubic urinary derivation made by the surgeon and the primary realignment or delayed urethral reconstruction, both interventions being reserved for well trained urologists. Minimal lesions characterized by a preserved continuity in small extravasations in the urothrography are sufficiently treated by a suprapubic urinary diversion. Severe injuries are treated by realignment of the urethra over a splint, drainage of the perivesical space and urinary diversion. 63% of the patients treated by this modality had perfect results and there was no need for further therapy. The proper replacement of the fractured pelvic bones are an integrated part of our plan of treatment. About 12% of patients with pelvic fracture and injury of the posterior urethra experience loose their potency. These can be explained by neurovascular injury. Impotence does not seem to be caused by surgical treatment, since the rate of impotence is similar in patients treated by primary realignment and suprapubic urinary diversion only.

Pelvic lipomatosis. Case of inferior vena caval obstruction

PELVIC lipomatosis is a term used by Fogg and Smyth1in 1968 to describe the overgrowth of normal fatty tissue, limited to the perirectal and perivesical spaces in the pelvis. This entity initially was reported by Engles in the five cases with radiolucent changes surrounding the pelvic viscera.2Since that time, approximately 60 cases have been reported. Its clinical and roentgenographic findings are well established, as are the major complications of infection and urinary tract obstruction. The association of pelvic lipomatosis and inferior vena caval obstruction has been made by Schechter in a single case report.3Further review of the literature yielded the report of congenital venous anomalies associated with pelvic lipomatosis.4To our knowledge, ours is the second report of pelvic lipomatosis as a primary disease entity with a resultant vena caval obstruction. Report of a Case A previously healthy 30-year-old man was admitted to The

Pelvic Lipomatosis

PELVIC lipomatosis is a term used by Fogg and Smyth¹in 1968 to describe the "overgrowth of normal fatty tissue, limited to the perirectal and perivesical spaces in the pelvis." This entity initially was reported by Engles in the five cases with radiolucent changes surrounding the pelvic viscera.²Since that time, approximately 60 cases have been reported. Its clinical and roentgenographic findings are well established, as are the major complications of infection and urinary tract obstruction. The association of pelvic lipomatosis and inferior vena caval obstruction has been made by Schechter in a single case report.³Further review of the literature yielded the report of congenital venous anomalies associated with pelvic lipomatosis.⁴To our knowledge, ours is the second report of pelvic lipomatosis as a primary disease entity with a resultant vena caval obstruction. <h3>Report of a Case</h3> A previously healthy 30-year-old man was admitted to The

Influence of exploratory celiotomy on the management of carcinoma of the cervix. A preliminary report.

The policy of treating patients with Stages IB and IIA carcinoma of the cervix by radical hysterectomy and pelvic lymphadenectomy led to the initiation of laparotomy staging of carcinoma of the cervix in 1970. Two-hundred twenty patients were subjected to surgical staging at which time bilateral aortic lymphadenectomies and biopsies of perirectal and perivesical spaces were done. If these were negative, radical hysterectomy and pelvic lymphadenectomy were performed in patients with surgical Stage IB and IIA. Para-aortic node involvement was seen in 7%, 14%, 18%, and 19% in patients with Stages IB, IIA, IIB, and IIIB, respectively, in the context of the surgical material being heavily weighed in favor of early stage disease. The methods of management in these patients were designed according to the findings at exploratory celiotomy. Twenty-one patients were found to have positive para-aortic nodes and received en bloc pelvis and para-aortic irradiation. Four patients are alive and well at 63,23,20, and 19 months, respectively. One patient is alive with disease at 18 months. Two died from other causes at 34 and three months. There was no difference in the survival of the two groups of patients among 75 with negative para-aortic nodes, who received either pelvic irradiation alone or pelvic and para-aortic irradiation on the basis of possible presence of subclinical disease not dissected at the time of surgery.

X-ray diagnosis of the staging of bladder tumors--especially in pelvic angiography

To determinate the adequate method of treatment for bladder tumors and to establish the prognosis, “Staging” plays a most important role.With the presacral method, 600ml of oxygen was injected into the perivesical space and 100ml of air was instilled into the empty bladder.Then according to the percutaneous method of Seldinger, a catheter was introduced into one of the femoral arteries, and was flushed with 40ml of 76% Urografin at the level of aortic bifurcation.Serial angiography was then taken and ten films have been exposed at the intervals of 1/2 second. Pathological findings that have been obtained are:1) Increase of vascularity on the side of the tumor 2) network formation in the tumor region 3) corkscrew vessels in the tumor region 4) tortulous vessels in the tumor region 5) decrease or vanishing of the vascularity in the center of the tumor in some cases 6) dense, sustained blush of the tumor region (tumor stain) 7) several changes from proximal to distal portion of the vesical artery 8) vessel-widening on the side of the tumor 9) vessel-displacement on the side of the tumor 10) the growth of a new blood vessel which stems from the healthy side and supplies the tumor 11) rapid visualization of the venous phase on the side of the tumor 12) disarrangement of the vascularity on the bladder wall, especially in the capillary phase 13) parieto-visceral anastomosis in the internal iliac artery.The follow up histopathological examinations have been done on 18 cases to evaluate the accuracy of the X-ray diagnosis, and 15 cases were proved to be accurate. Out of the 13 pathological findings mentioned above, 1)-6) seem to be due to the tumor mass, and 7)-13) due to tumor infiltration, especially 11)-13) to deep infiltration. The method and the pathological findings are discussed, and some interesting cases are presented.