Retrograde Cystography Research Articles

Bladder Rupture in Immediate Postrenal Transplant Period of Uncertain Cause

Bladder rupture in patients undergoing renal transplant is rare. A 26-year-old man underwent a deceased-donor renal transplant. Postoperatively, he showed a good clinical course, but after removal of the urethral catheter, he complained of pain in the lower aspect of the abdomen and in the left flank. Findings of abdominal computed tomography and retrograde cystography revealed an extraperitoneal bladder rupture. We did not identify specific causes for this condition and believe that the bladder rupture was spontaneous. However, we could not rule out the possibility of traumatic rupture by the double-J ureteral stent. We decided to manage this case conservatively, with an indwelling urethral catheter and antibiotics, instead of by surgical repair. Results of repeated serial cystography during the treatment showed decreased contrast extravasation, and cystographic findings at 6 weeks showed no leakage of contrast medium. We confirmed complete healing of the ruptured bladder and removed the urethral catheter. Since then, the patient has maintained good renal function without any complications.

Cystographie isotopique indirecte couplée à la scintigraphie rénale corticale et détection des reflux vésicorénaux chez les nourrissons et les enfants atteints de pyélonéphrite

Vesico-uretero-renal reflux (VRR) and urinary tract infection are closely linked. Without any treatment, reflux nephropathy, hypertension and renal dysfunction are very often encountered. That is why a precocious and reliable diagnosis of RVR should be made. Our retrospective study included 33 infants and children suffering from acute pyelonephritis (APN). They were explored by both 99mTc-MAG3 indirect isotopic cystography (IIC), 99mTc-DMSA cortical renal scintigraphy performed on the same day, and radiological retrograde cystography (RRC). A VRR was expected on the same side than the pyelonephritic kidney. Results from IIC versus RRC and versus renal cortical acute pyelonephritis lesions, which were proved by the “gold standard” DMSA scan, were obtained. IIC detected a same-sided VRR in 52% and CRR in 33% of our patients. Some of them had bilateral lesions. IIC detected an homolateral VRR in 59% instead of 38% with RRC (P<0.05). IIC is a physiological noninvasive examination with a convenient sensitivity and dosimetry to search a VRR. Moreover, it gives in the same time interesting functional information on the kidneys and the urinary tract. Each of these characteristics can be favorably compared with RRC.

Dismembered pyeloplasty for ureteropelvic junction syndrome treatment in children

Open dismembered pyeloplasty remains the preferred surgical technique for ureteropelvic junction syndrome (UPJS) in most paediatric urology units. The authors present their experience of 230 patients and describe their form of presentation, treatment and early and long-term results. Retrospective analysis of clinical records of 230 patients submitted to dismembered pyeloplasty in an 8-year period, from 1999 until 2007. Pre-operative data, early and long-term complications were registered. Image studies included renopelvic ultrasonography, mercapto-acetyl triglycine (MAG3) renal scan with furosemide test and, in some cases, elimination urography and retrograde cystography. Pre-operative and post-operative results were compared. Median age of our patients at time of surgery was 14.9 months (range: 21 days until 16.6 years). The majority of patients were male (72%, n = 166) and 74% (n = 120) had pre-natal diagnosis. The majority of hydronephrosis were in the left side (61%, n = 141). There were only 3% of complications in early post-operative period: four had acute pyelonephritis, two had renocutaneous fistula and one died due to respiratory failure. Mean follow-up period was 5 years, ranging from 12 months to 9.7 years. There was only one case of recurrence with the need of reoperation. Comparing pre-operative and post-operative imaging results, we found that 89% had normal renal function, 7% diminished but better than before and 2% equal as before surgery. Open dismembered pyeloplasty is a safe and effective treatment in paediatric UPJS.

Delayed Presentation of Intravesical Bone Penetration after Pelvic Ring Fracture

Retrograde cystography and computed tomography (CT) are considered the gold standard for investigating bladder and pelvic bone injury. However, these methods can miss extraperitoneal bladder rupture caused by a penetrating bone fragment from a pelvic bone fracture. We experienced a routine conventional cystography and CT scan that failed to identify penetration of the bladder by a bone fragment, which thus delayed optimal treatment. Therefore, different diagnostic methods such as CT cystography or cystoscopy should be considered to rule out penetrating injury by a bony fragment in patients with extraperitoneal bladder rupture.

CEUS Retrograde Cystography Is Helpful in Percutaneous Drainage of Complex Posttransplant Lymphocele

After monolateral dual kidney transplantation, a 69 years old male patient developed symptomatic lymphocele with mild hydroureteronephrosis, impaired renal function, and right inferior limb oedema. A percutaneous ultrasound-guided drainage of the fluid collection was planned, but the complex mutual relations between the collection and the renal hilus did not allow to identify a suitable route for a safe drainage insertion during conventional ultrasound examination. A retrograde cystography using echographic contrast agent was, therefore, performed, and it clarified the position of both ureters and the renal vessels, permitting an harmless ultrasound-guided percutaneous lymphocele drainage. In conclusion contrast-enhanced ultrasound retrograde cystography may be helpful in percutaneous drainage of complex posttransplant lymphocele.

Urinary ascites

A middle-aged male presented with abdominal pain and ascites following a fall in alcoholic intoxicated state. Evaluation revealed microscopic hematuria and severe renal failure. Ascitic fluid analysis showed high urea and creatinine values suggesting it to be a urinary ascites. Retrograde cystography confirmed intraperitoneal bladder rupture. Following continuous bladder drainage ascites subsided and serum creatinine has reduced to 3 mg/dL. This case report highlights the importance of ascitic fluid analysis as a pointer to diagnose urinary ascites secondary to intraperitoneal bladder rupture.

Early versus delayed repair of vesicouterine fistula

Vesicouterine fistulas (VUF) are a pathological and uncommon connection between the uterus and the bladder. Although rare, they are usually related to cesarean section. Nowadays, their incidence increases because of the increase in Cesarean sections. Patients with VUF may have various clinical presentations. The main symptoms are urinary incontinence, which may be associated with hematuria. Vesicouterine fistulas are usually associated with psychological distress and have a negative effect on quality of life. The accurate and early diagnosis of VUF can be difficult. There are multiple ways to investigate VUF and several examinations may be required to confirm the diagnosis; these examinations may include a cystoscopy, a retrograde cystography, methylene blue test and a computed tomography scan. We present 3 cases of vesicouterine fistula with successful surgical repair in which 2 patients had an early repair. One patient had an early surgical repair because of intractable pain and the other patient because of the large size of the fistula. The fistula repair surgeries were uneventful and the patients had an unremarkable recovery. We report that early surgical management is technically feasible without significantly increasing the difficulty of the surgery, with an excellent outcome in selected patients.

Surgical Treatment of Iatrogenic Rectourinary Fistula—York-Mason Technique—a Case Report

Introduction. Recto-urinary fistulas resulting from trauma or surgery are a serious and debilitating complication. They represent a challenge not only because of the difficulty on choosing the best technique to solve them but also because of the risk of recurrence. Spontaneous cure is rare. Materials and Methods. We describe the case of a 61-years-old man that on the 9th postoperative day of a laparoscopic radical prostatectomy (LRP) started with fecaluria and liquid faeces. Recto-urinary fistula was confirmed at the 10th postoperative day by CT scan and contrast enema. Discussion. We chose the York-Mason technique, because it is simple to perform, effective and has minimal morbidity. This is a posterior, transrectal, and transsphincteric approach, carried out on healthy tissues without previous scarring phenomena. Results. The postoperative period progressed without complications, and the patient discharged on the 4th day. The closure of the fistula was confirmed radiologically by retrograde cystography after 4 weeks allowing the removal of drainage catheter. The reconstruction of intestinal transit was carried out 2 months later. Conclusion. The York-Mason technique, a transrectal and transsphincteric approach with minimal morbidity, proved to be effective on the resolution of the recto-urinary fistula, a rare complication of the radical prostatectomy.

Prise en charge et évolution des méga-uretères primitifs de découverte anténatale

To study the diagnostic and outcome aspects of antenatally diagnosed primary megaureters and analyse the results of the postnatal medicochirurgical management. The authors report a retrospective analysis of 12patients been born between 1998and 2009with primary megaureter antenatally diagnosed between 20and 32weeks of gestation. A postnatal radiological assessment comprising urinary tract ultrasound, DTPA or MAG3renal scintigraphy, retrograde cystography, DMSA renal scintigraphy and intravenous urography was performed. All the patients were put under urinary antiseptic treatment and followed since the birth. This study comprised nine boys and three girls, all been born at term with normal trophicity. Mean age of antenatal diagnosis of hydronephrosis was 26weeks of gestation. Mean age of definitive postnatal diagnosis was ten months. Left megaureter was seen in five children, right in two cases and five patients had bilateral megaureter comprising a total of 17 renal units of which eight units were non-obstructed/non-refluxing, three units were refluxing, five units were obstructed and one unit was obstructed and refluxing. Megaureter was associated to controlateral ureteropelvic junction obstruction syndrome in one patient and to ipsilateral ureteral duplicity with a superior polar kidney in another case. Renal function was less than 20% in four renal units. The mean follow-up was four years (range: 10months to 11years). Outcome was marked by urinary infections in seven cases of which four patients had non-obstructed/non-refluxing megaureter. Six patients required surgical correction, two for non-obstructed/non-refluxing megaureter complicated with urinary recurring infections, three for obstructed megaureter with severe renal functional deterioration and one patient for bilateral refluxing megaureter grade V. Two other patients required surgical treatment, one for controlateral ureteropelvic junction obstruction syndrome and the other for ipsilateral ureteral duplicity with destroyed superior polar kidney. Mean age at surgery was 22,6months (range: 6months to 7years). Half of our patients with antenatal diagnosis of primary megaureter required surgical correction. Urinary recurring infections, renal functional deterioration less than 20% and importance of ureteral dilatation with vesico-ureteric reflux grade V were predictive factors for surgery.

Bedside Ultrasound Diagnosis of a Traumatic Bladder Rupture

Background Urinary bladder rupture is a complication of both blunt and penetrating trauma. Significant morbidity and mortality can result from a missed rupture and its ensuing complications. Patients who are at risk for traumatic bladder rupture should undergo appropriate testing to expedite the diagnosis. Current diagnostic modalities include computed tomography (CT) cystography, and retrograde cystography. Although these modalities carry a sensitivity and specificity of 95–99% and 95–100%, their utility is limited by the resources and staff available. Furthermore, both techniques require that a potentially hemodynamically unstable trauma patient be transported out of the Emergency Department for the entire duration of the procedure. Objective The following case report reviews the incidence and management of traumatic bladder rupture and describes how emergency physicians (EP) can use ultrasound to make this diagnosis quickly and safely at the bedside. Case Report The case report describes a patient involved in a motor vehicle collision with a history concerning for urinary bladder injury. A bedside ultrasound study performed by the EP was used to establish the diagnosis of urinary bladder rupture. The ultrasound demonstrated a small contracted urinary bladder with copious free fluid anterior to the bladder wall. The diagnosis was confirmed by CT and the patient was taken expeditiously to the operating room. Conclusion This case provides an example of how bedside ultrasound can be used to make an accurate and timely diagnosis of urinary bladder rupture and help expedite patient care.

Giant bladder diverticulum

We present the case of a 73-year-old man affected by progressive and painful abdominal distension and paresthesia/hypoesthesia at the left leg. US and CT-scan revealed the presence in the left retroperitoneum of a large cystic mass without parietal thickening or enhancement after contrast injection. This mass disappeared after positioning a vesical Foley's catheter and a retrograde cystography confirmed the suspected diagnosis of a large bladder diverticulum due to a severe prostatic hypertrophy; the patient underwent an open diverticulectomy and endoscopic prostatic resection. Bladder diverticula can occasionally appear as complex pelvic masses not obviously connected to the bladder, eventually leading to diagnostic confusion; while small size diverticulum resolves with relief of bladder outlet obstruction, open or laparoscopic diverticulectomy is needed in large size diverticulum if symptomatic, even considering the possible tumor harboring.

Intraperitoneally Placed Foley Catheter via Verumontanum Initially Presenting as a Bladder Rupture

Since urethral Foley catheterization is usually easy and safe, serious complications related to this procedure have been rarely reported. Herein, we describe a case of intraperitoneally placed urethral catheter via verumontanum presenting as intraperitoneal bladder perforation in a chronically debilitated elderly patient. A 82-yr-old male patient was admitted with symptoms of hematuria, lower abdominal pain after traumatic Foley catheterization. The retrograde cystography showed findings of intraperitoneal bladder perforation, but emergency laparotomy with intraoperative urethrocystoscopy revealed a tunnel-like false passage extending from the verumontanum into the rectovesical pouch between the posterior wall of the bladder and the anterior wall of the rectum with no bladder injury. The patient was treated with simple closure of the perforated rectovesical pouch and a placement of suprapubic cystostomy tube.

Failure of conventional retrograde cystography to detect bladder ruptures in pelvic trauma

Conventional retrograde cystography is often used to investigate patients with suspected bladder ruptures in pelvic trauma. Clinical indicators suggestive of a rupture include haematuria and suprapubic tenderness and should increase the suspicion of bladder and urinary tract injury and prompt the clinician to undertake further investigations. Two patients with high-energy pelvic fractures had bladder ruptures detected intraoperatively despite normal preoperative retrograde cystogram. Both patients had significant clinical indicators suggestive of underlying bladder and urinary tract injury. In both cases, a routine conventional retrograde cystogram was performed but failed to identify the full extent of the bladder injury. A possible reason for misdiagnosis in these cases is the delay between injury and investigation due to tertiary referral of care.

A Novel Surgical Technique for Management of Vesicoureteral Reflux Following Kidney Transplantation: Prospective Study of 12 Cases

The incidence of vesicoureteral reflux (VUR) varies between 10% and 80% of transplanted kidneys. In cases of failure of endoscopic treatment or recurrent urinary tract infections, surgical correction is proposed by ureteral reimplantation or pyeloureteral anastomosis using the native ureter. The aim of this study was to assess the results of a technique that increases the submucosal length of the ureter without a ureterovesical reimplantation. We treated 12 patients with VUR in the transplanted kidney by open surgery. Retrograde cystography showed resolution of reflux in all the patients. Our technique has the advantage of avoiding ureteral dissection thereby avoiding its devascularization and no invasion of the bladder mucosa.

Detection of urinary leakage after radical retropubic prostatectomy by contrast enhanced ultrasound – do we still need conventional retrograde cystography?

To prospectively evaluate the accuracy of transvesical contrast-enhanced ultrasound (CEUS) as an alternative method for the detection of anastomotic leakage after radical retropubic prostatectomy (RRP) in comparison with the current standard method of conventional retrograde cystography (CG). Forty-three patients underwent RRP for histologically proven localized prostate cancer. The vesico-urethral anastomosis was evaluated 8 days after RRP by CG and CEUS. Any peri-anastomotic leakage was assessed and determined in CG and CEUS as follows: no extravasation (EV), small leakage (≤0.5 cm), moderate leakage (>0.5 cm to ≤2 cm), large leakage (>2 cm diameter of EV seen). In total, 21 (49%) patients showed a watertight anastomosis. Ten (23%), two (4.7%) and ten (23%) patients showed a small, intermediate and large EV, respectively. In 31 cases (72%) there was 100% agreement of CG and CEUS for detection of no, moderate and large EV, respectively. In nine cases a small and in two cases a moderate EV was categorized as watertight anastomosis by CEUS. Only in one case did CG detect a small EV where a large EV was detected in CEUS. The agreement between both methods was 95% for detecting absence or large leakages. CEUS is a promising imaging modality that seems to be equivalent to CG for detecting the presence of a large anastomotic leakage that is clinically relevant for postoperative persistence of the indwelling catheter. CEUS could be a cheap and time-saving alternative to the CG without exposure of the patient to radiation.

Aszites und Makrohämaturie nach Bagatelltrauma unter Alkoholeinfluss

Isolated ruptures of the urinary bladder following minor traumas are a rare abdominal lesion. Diagnosis and treatment are a challenge to emergency physicians and surgeons. This case shows a 46-year-old patient admitted for a minor brain injury after falling during an episode of alcoholic intoxication. Ultrasound and CT scan of the abdomen showed intraabdominal fluid without a parenchymatous lesion. Also a hematuria was significant. The retrograde cystography showed intraabdominal contrast agent. The rupture of the urinary bladder was confirmed by laparoscopy and was intracorporal sutured in double layer technique. Without any postoperative complications the patient was discharged after 4 days. The retrograde cystography after 10 days showed no leckage and the urinary catheter could be removed.

A Case of Appendicovesical Fistula with a 30-Year History

A 36–year–old man was referred to our hospital after developing dull lower abdominal pain, pneumaturia, and fecaluria. He had a history of acute appendicitis treated without surgery at the age of 6, and had since experienced recurrent episodes of cystitis, pneumaturia, and fecaluria. Escherichia coli was cultured from the urine. Abdominal CT and MRI suggested an enterovesical fistula. Cystoscopy revealed a stone in the bladder, for which lithotripsy was performed. An unusual dilation of the appendix orifice was found on colonoscopy. Retrograde cystography did not show an enterovesical fistula ; however, a small bowel series using an ileus tube revealed an appendicovesical fistula. The patient therefore underwent surgery and the fistula was found between the right side of the bladder dome and the middle of the appendix. Appendectomy with partial cystectomy including the fistula was performed. We concluded that the appendicovesical fistula might have developed after appendicitis at the age of 6 and that the diagnosis could have been delayed for as long as 30 years because the fistula was well established. Appendicovesical fistula is a rare condition, generally forming after appendicitis. Direct imaging of the fistulous tract is not easy, and the fistula often takes a long time to diagnose. However, the diagnosis can be made if specific findings are present, and the disease is completely curable by operation.

Riparazione Trans-Vaginale di Fistola Neovescico-Vaginale

Introduction Neobladder vaginal fistula is a known complication after cystectomy and orthotopic neobladder in women. The exact incidence is still unknown, even if in some of the largest series is reported in about 5% of female patients. We present our personal experience with a case of neobladder vaginal fistula. Methods A fifty-year old woman affected by T2G3 bladder cancer underwent radical cystectomy and orthotopic neobladder in December 2007. Definitive pathological examination revealed pT3aN0G3 urothelial cancer with squamous aspects. Two cycles of neoadjuvant chemotherapy were administered before cystectomy. Three weeks after cystectomy, a retrograde cystography revealed a fistula between vagina and neobladder. At first, the patient was treated conservatively, keeping the urethral catheter for two months. Cystographies, repeated every month, recorded a reduction in size of the fistula but not the complete closure. A surgical correction was planned. Preoperative cystoscopy showed the neobladder opening of the fistula on the posterior wall. Then a transvaginal approach with fistula excision and a two layer cross suture were performed. Results At the cystography performed 1 month after surgical repair no fistula was detected, and the patient was completely dry. At 3 months follow-up the patient was completely dry. Conclusion The development of a neobladder-vaginal fistula is a significant, even if infrequent, complication after cystectomy. In our case, we performed a transvaginal approach without tissue interposition, with good results. Such procedure is easy and effective and, in our opinion, can be tempted as first line surgical treatment.

Résection transuréthrale de prostate ou incision cervicoprostatique dans les suites immédiates d’une transplantation rénale

The objective of the study was to analyse the results of a transurethral resection of the prostate (TURP) or a transurethral incision of the prostate (TUIP) performed immediately after kidney transplantation. For the patients who had undergone a transurethral surgical procedure immediately following a renal transplantation, their files were systematically reviewed. Depending on prostate volume, TURP or TUIP was performed. The preoperative assessment included past medical history, clinical examination, retrograde cystography and PSA. Among the 256 patients having had a renal transplantation between 2001 and 2006, 12 TURP and eight TUIP were done. The procedure was performed 15.2 days (10-30) after the transplantation. The average day of urethral catheter removal was 3.1 days (2-15) after the transurethral procedure. Mean postoperative maximum flow rate was 22.1 ml/s (18-33) and postvoiding residual urine volume was not significant. One patient suffered from two acute urinary retentions that were treated by temporary intermittent self-catherization. Four patients were diagnosed with acute prostatitis. The procedure for benign prostatic hyperplasia did not alter renal function. With a follow-up of 34.2 months (12-73), 18 patients had no urologic symptoms with a mean IPSS score of 4 (3-6). TURP or TUIP gives good results immediately following a renal transplantation.

A Rare Case of Female Bladder Spontaneous Rupture

Bladder spontaneous rupture in the woman represents an extremely rare urologic emergency; its cause can be iatrogenic, neoplastic or diabetic. Materials and Methods A 56-year-old woman was referred to our unit because of the presence of acute abdominal pain, oligoanuria and vomiting for two days. At physical examination, the patient presented with confusional state, acute urinary retention and gross hematuria after urethral catheterization. Laboratory data demonstrated important metabolic abnormalities: hyperglycemia (946 mg/dL), acute renal failure (serum creatinine: 3.25 mg/dL), hyponatremia (120 mEq/L) and metabolic acidosis. At the CT of her abdomen and pelvis, a suspected bladder rupture (right lateral wall) was revealed, and confirmed after performing a retrograde cystography. Personal history was negative for trauma; glycemia was never controlled despite an important familiarity for type I diabetes. An episode of painless gross hematuria had occurred one month before, treated by the physician with antibiotics. Firstly the metabolic and electrolyte imbalance was corrected and then an emergency explorative laparotomy was performed. An important urinary leakage in the pelvis and a mild peritoneal effusion were documented. Furthermore, an important leak of papillary-like neoplastic material from the vesical breach was detected. The neoplasm seemed to involve the whole bladder. The surgical treatment consisted in bladder raphia, accurate washing of perivesical space, difficult salvage cystectomy (tenacious adhesions due to the urinary leakage) and bilateral ureterocutaneostomy. During the postoperative stay, the patient showed a difficult glycemia control with insulin therapy and wound dehiscence healed by second intention. The hospital discharge was on day 30, with the patient in good health and acceptable glycemia control. Results The pathological diagnosis was a G2 non-invasive urothelial carcinoma, also involving a vesical diverticulum; the neoplasm was associated with an erosive chronic cystitis with aspects of transparietal micro-abscessual flogosis (pT1 G2 N0 Mx). The patient will perform a CT scan 3 months after surgery before possibly starting chemotherapy. Conclusions Bladder spontaneous rupture in the woman is an extremely rare pathology; in the reviews we analyzed, it is dealt with as a clinical condition that more often occurs in patients submitted to pelvic surgery followed by adjuvant radiotherapy. Invasive bladder neoplasms, predominantly the sarcomatoid ones, are the second more frequent cause mentioned in the literature. Diabetic uropathy of the bladder associated with purulent bacterial cystitis in the elderly is the third cause, which is mentioned in two articles only. At last, only one study indicates the superficial urothelial bladder cancer (pT1- G2) as the responsible for this dramatic event. In our case, the suspected bladder diabetic uropathy, characterized by reduced perception of micturition stimulus, the increase in vesical capacity and detrusorial hypocontractility, were probably an important concomitant cause of this dramatic clinic condition, in association with the large superficial urothelial neoplasm. Moreover, diabetic neuropathy could explain the delay of patient presentation to the physician. Urinary leak, probably occurred 2 days before diagnosis, created an important metabolic imbalance and remarkable surgical difficulties. The timely treatment allowed for the resolution of a clinical condition associated with an elevated mortality due to septic shock.