Biomedical subjects
Publications and source records attributed to H M Pollack.
We describe the occurrence of a renoduodenal fistula related to a nephrostomy tube in a patient with xanthogranulomatous pyelonephritis and renal calculi. The patient was successfully treated by nephrectomy. Etiological, diagnostic and therapeutic aspects are discussed.
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Endorectal surface coil magnetic resonance (MR) imaging was used to stage the local extent of prostate cancer in 22 patients. The endorectal coil images were acquired with a 10-12-cm field of view and a 4-mm section thickness. All pathologic specimens were reviewed by one pathologist. Endorectal surface coil MR imaging was 82% accurate in the differentiation of stage B from stage C cancer. One case was overestimated, and three cases were underestimated. The three underestimated cases consisted of two cases of microscopic capsular invasion and one case of minimal seminal vesicle invasion. In a comparison of retrospective, blinded readings of endorectal coil and body coil images, there was an average improvement in accuracy of 16% in staging prostate cancer with endorectal coil images.
The advent of ultrasonography and the development of intrarectal techniques have made possible semiquantitative prostatic volumetrics for more accurate preoperative assessment of benign prostatic hyperplasia (BPH) as well as earlier diagnosis of prostatic carcinoma (PC). Computed tomography has increased the scope of prostatic imaging by including regional lymph nodes as well. Magnetic resonance imaging (MRI) has enabled viewing of the internal architecture of the prostate gland, thus allowing precise diagnosis of BPH and recognition of carcinoma. MRI is also the most exact method of staging PC.
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In conclusion, it would appear from present evidence that several statements can be made. First, MRI is the most accurate method of staging the periprostatic spread of carcinoma. Both the prostate and the regional nodes can be evaluated. The role of ultrasound is, at present, unclear. Second, the utility of CT has diminished with the emergence of high-quality MRI, but in situations in which MRI scans are inconclusive (e.g., in the assessment of paraaortic node disease, in which images are degraded by peristaltic movement), CT may be useful. Third, the choice of method for the assessment of nodal disease is a more difficult question. Although MRI and CT have replaced lymphography in most centers, the latter study, especially when combined with fine-needle aspiration biopsy, still is useful. Fourth, bone metastases are best assessed with scintigraphy, which can point to areas requiring supplemental plain radiography. An MRI study of the spine, although highly sensitive, is not practical. Fifth, MRI is superior to CT myelography in assessing spinal disease. Finally, the chest radiograph is the mainstay of assessing chest involvement.
The preoperative magnetic resonance imaging (MRI) studies of 31 patients with surgically proven renal cell carcinomas obtained with a 1.5 Tesla unit were retrospectively reviewed to assess the accuracy of MRI for staging of tumor. According to the Robson classification 12 patients were found at surgery to have Stage I renal carcinoma, three patients had Stage II, ten had Stage IIIA, one had Stage IIIB, two had Stage IIIC, one had Stage IVA, and two had Stage IVB disease. Twenty-five (81%) of 31 patients were staged correctly by MRI. Clearly MRI showed venous tumor extension without the need for intravenous contrast administration. Also, MRI had a negative predictive value of 95%, and a positive predictive value of 100% for the evaluation of inferior vena cava tumor thrombus. At 1.5 Tesla MRI is an excellent staging modality in the preoperative evaluation of renal carcinoma. It is especially recommended in patients with equivocal computed tomography findings and in all patients with contraindications to the intravenous use of iodinated contrast material.
Computed tomography (CT) was performed on four patients in whom excretory urograms revealed marked displacement of the kidneys and/or ureters. CT in each case was remarkable for the presence of excessive accumulation of normal retroperitoneal fat and failed to document the existence of a retroperitoneal neoplasm, lymphadenopathy, or other pathological mass.
MRI, because of its multiplaner capability and high soft tissue contrast, is ideally suited for examination of the prostate. The normal prostatic zonal architecture and periprostatic anatomy can be visualized. The use of an endorectal surface coil greatly enhances resolution. Clinical application to the study of BPH, prostate carcinoma, prostatic cysts, and inflammatory disease is discussed. MRI appears to be emerging as the modality of choice for imaging the prostate.
Intravascular papillary endothelial hyperplasia (Masson's tumor) is a rare benign reactive lesion usually found in thrombosed subcutaneous blood vessels. We report a case of Masson's tumor of the kidney, and discuss the relevant clinical, radiographical and pathological aspects.
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Without question, significant changes, and for the most part significant advances, have been made in the management of patients with urolithiasis during the past decade. The newer therapeutic measures have generally made it easier for patients to be treated, but the decision-making process for the urologist has become more complex. In the past, the issue whether to follow a patient with a stone or to intervene with surgery or transurethral cystoscopic basketing was decided based on well-established guidelines that had developed over many years. Today, the indications for intervention appear to be less stringent, and in the minimally symptomatic or asymptomatic patient who would not have been operated on previously, there appears to be an expanding desire for prophylactic management. For whatever reasons, once it has been established that a stone is present and the decision has been made to intervene, subsequent decisions regarding the technical approach may also not be as simple as in the past. Ten years ago, for example, a stone in the abdominal ureter was removed by a ureterolithotomy, and the principal decision involved placement of the incision. Today, the same calculus may be approached by ESWL with or without a stent, by antegrade percutaneous techniques, or by retrograde ureteroscopic techniques using rigid or flexible endoscopes with baskets, ultrasonic lithotrites, or lasers. Although the specific indication for specific techniques continue to evolve, it has become evident that information obtained by the radiographic evaluation of the urinary tract is critical in the decision-making process. The intravenous urogram, including the initial plain film, remains the primary diagnostic modality and, in the absence of extenuating clinical features, is often the sole test required to make a decision regarding the best therapeutic modality. A variety of clinical features from the history or physical examination, or concerns raised by the intravenous urogram, may necessitate alternative or additional techniques to better define the anatomy, the renal function, or other pathology. The urologist therefore needs to be familiar with the information that can be obtained from the uroradiologist's vast armamentarium in order to make the most appropriate recommendations to the patient for diagnosis and management.
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From June 1985 to November 1986, 17 patients with calculi in horseshoe kidneys presented to our hospital for evaluation and possible treatment with extracorporeal shock wave lithotripsy. Of these patients 14 were treated with extracorporeal shock wave lithotripsy; the calculi in 2 could not be localized and focused at the F2 focal point, and 1 was asymptomatic and has been followed conservatively. Four patients required repeat extracorporeal shock wave lithotripsy. Adjunctive procedures included preoperative retrograde catheter placement (5 patients), postoperative percutaneous nephrostolithotomy (1), ureteroscopy for ureteral fragments (2) and placement of a double pigtail stent (1). Of 14 patients 11 (79 per cent) have been rendered free of fragments with extracorporeal shock wave lithotripsy and adjunctive measures as needed. We conclude that most patients with calculi in a horseshoe kidney can be managed primarily with extracorporeal shock wave lithotripsy.
Fluoroscopically guided, transconduit retrograde catheterization of ureters that have been diverted to a bowel conduit is often feasible in patients with patient ureteroenteral anastomoses who might otherwise require a percutaneous nephrostomy (PCN) for reasons other than high-grade anastomotic obstruction. This procedure was attempted on 14 occasions and successfully accomplished on 12. In 11 of these cases, retrograde catheterization obviated PCN to provide renal drainage for a partially obstructing ureteral stricture or obstructing renal calculi, to remove ureteral calculi, or to insert a new ureteral stent after an unsuccessful attempt to exchange an existing occluded retrograde ureteral stent. The procedure also obviated Whitaker testing. On one occasion the retrograde procedure greatly facilitated subsequent PCN in an obese patient with faintly opaque calyceal calculi. These procedures were accomplished with standard angiographic equipment and, in many instances, Teflon sheaths in the bowel conduit to stabilize catheters and guide wires. No complications were encountered. The two patients whose ureters could not be catheterized in retrograde fashion subsequently required PCN.
High-resolution magnetic resonance (MR) imaging of 24 fresh radical prostatectomy specimens was performed on an experimental 1.9-T system. Direct correlation between the findings in 7-micron-thick macrosections and their corresponding MR images was possible. Fourteen patients had macroscopic evidence of cancer. In all 14 cases, the carcinoma nodules appeared as areas of low signal intensity on images obtained with a repetition time of 2,500 msec and an echo time of 80 msec. Ten of 14 nodules had well-defined margins and consisted of densely packed glandular elements, which displaced the surrounding normal glandular material of higher signal intensity. Ten specimens displayed benign prostatic hyperplasia (BPH). The MR characteristics of this entity were quite variable but relatively predictable, depending on the distribution and size of the glandular elements, as well as the composition of the surrounding stroma. In BPH, the changes began in the central portion of the gland. The areas of highest signal intensity corresponded to dilated glandular elements (cystic ectasia), while the areas of lowest signal intensity corresponded to collagen (scar) and fibromuscular stroma. Nodules of mixed glandular BPH and fibromuscular BPH were found to have signal intensities similar to those of well-differentiated nodules of prostatic adenocarcinoma.
Because of complex variables and unsettled treatment issues, a standardized prescription for imaging the acutely traumatized kidney cannot be written. Imaging considerations are based on treatment considerations and will vary from place to place, from patient to patient, from physician to physician, and even from time to time in the same institution. The condition of the patient, the availability of resources and personnel, and (especially) whether existing treatment policy is conservative or aggressive will govern the selection of studies. Above all, since the kidney may be only one of several organs requiring immediate investigation, it is always the totality of the situation that sets the tone for the imaging process. A synthesis of prevailing thought is depicted diagrammatically in Figure 2 and is summarized as follows: CT is the most informative radiologic study in renal trauma and is the examination of choice in patients suspected of having serious renal injuries or associated injuries amenable to CT evaluation. CT is wasteful, however, in the stable, asymptomatic patient who is perceived to have only a minor, exclusively renal injury. Here, excretory urography is an acceptable alternative. Most of these patients will have normal findings at urography, all but ruling out significant renal damage. The vast majority of patients will fall into this category but for those whose urograms do not provide adequate information for management, CT is performed next. Sonography and radionuclide imaging, while advocated in some quarters, do not enjoy wide acceptance in the United States as first-line triage studies. They are usually reserved for selected situations, mainly for follow-up. Arteriography still has a place, primarily in preoperative road mapping, and for therapeutic interventions such as embolization of bleeding vessels and arteriovenous fistulas. The role of MR imaging has yet to be defined. The choice of imaging in renal trauma requires discretion, judgement, and common sense. Standard protocols are useful, but there is a place for flexibility and the customizing of individual approaches.