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191

The Society of Uroradiology: Abstracts from 1989 Meeting

The Florida, abstracts

Society of Uroradiology met in Naples, September 23-24, 1989. The following were presented at the meeting.

Contents An

interactive computer-based tutorial for teaching uroradiology. Amis ES, Esser PD, Hovsepian DM, Starren JB, Alderson P0 Can the post void film be deleted from urography? Kenney PJ, Schwartzberg MS, Han SY, Stanley RJ, Tishler JMA, Koehler RE, Daniel WW Renal calculi: role of ultrasound Vrtiska TJ, Hattery RR, King BF, Smith LH, Williamson B, Hartman GW, Brakke DM Extracorporeal shockwave lithotripsy with electromagnetic acoustic device Lithostar results in over 250 patients. McClennan BL, Clayman RV, Denstedt ‘3 Acute and chronic renal vascular changes in a rabbit model of renal ESWL. Fajardo LL, Hillman BJ, Donovan JM, Weber C, Moran ME, Drach GW Percutaneous nephrostomy procedures in horseshoe kidneys. Papanicolaou N, Yoder IC, Pfister RC Renal ablation by retrograde intrarenal reflux of Ethanol. David RD, Layfield U, Fuchs GJ, Barbaric ZL Thermic ablation of prostate. Castaneda WR, Castaneda F Renal abscess drainage: experience in thirty patients. Cronan 33, Deyoe L, Dorfman GS, Lambiase R, Paolella LP, Haas RA Retrograde dilatation prostate. Castaneda WR,

Castaneda

F

Percutaneous biopsy of malignant renal masses: indications and follow-up. Ridlen M, Cronan JJ, Dorfman GS, Paolella LP, Esparza A Advances in retrograde ureteral stent placement. Mitty HA, Dan 53, Train JS Upper pole hydronephrosis in infants. Winters ND, Lebowitz RL Improving the specificity of hydronephrosis. Cronan JJ, Scola FH Normal size of the adult kidney by real time ultrasound. Cronan ‘33, Rosenfield AT Urine profiles following diatrizoate and lohexol Lv. in four different nephropathies. Thomsen US, Golman K, Larsen 5, Hemmingsen L, Skaarup P, Holm ‘3 Value of non-ionic contrast medium in previous reactors. Experience thus far. Fischer NW,

Siegel Selective Winfield

Herbert Preliminary

R Fallopian AC,

tube Moore

D,

canalization Segars J,

(SFTC). Holburn G,

C experience

with

fluoroscopic

trancer-

vical Fallopian tube recanalization. Amendola MA, Banner MP, Pollack HM, Sondheimer S Comparative value of hysterosalpingography (HSG) and MR imaging of the uterus prior to myomectomy. Yoder IC, Papanicolaou N Small renal neoplasms: clinical, pathologic and imaging features. Levine E, Huntrakoon N, Wetzel LH Renal cell carcinoma discovered incidentally during gallbladder ultrasonography Bush WH Observations on the growth of renal parenchymal neoplasms. Bosniak MA, Birnbaum BA, Megibow AJ, Lubat E, Gordon RB CT and sonographic characteristics of lymphangioma of the retroperitoneum. Davidson AJ, Hartman DS Extra-adrenal retroperitoneal paragangliomas: clinical, pathological and CT findings. Hayes WS, Davidson AJ, Grimley PM, Hartman DS Transrectal ultrasound guided biopsy of the prostate: experience with 211 cases. Krause R, Cuttino JT, Scholz FJ, Larsen CR Local staging of prostate carcinoma with endorectal surface MRI. Schnall MD, Imai Y, Pollack NM, Lenkinski RE, Kressel HI The hilum of the testis - a sonographic imposter of neoplastic disease. Bird KI, Blair D, Rosenfield AT The clinical utility of P-31 MRS in the evaluation of human testicular pathology. Hricak H, Chew NM, Carrol P

An Interactive Computer-Based Tutorial for Teaching Uroradiology: Amis ES, Esser PD, Hovsepian DM, Starren JB, Alderson P0 (ColumbiaPresbyterian Medical Center, New York, NY 10032) Computer-aided instruction has become an increasingly popular complement to the traditional methods of teaching. Since the format is nonlinear, the student is no longer confined to a defined path and may search through related materials as interest warrants. We have constructed such a tutorial for teaching uroradiology. The system uses a Macintosh II (Apple) with dual monitors and software based on the Hypercard program developed by Apple. Currently, learning modules include anatomy, embryology and congenital anomalies. A data base of approximately 40 digitized radiographs (1024 x 1024) supplements an equal number of line-illustrations and an appropriate amount of text. With expansion to include modules for urologic disease, the data base should increase to include several hundred illustrations and radiographs.

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URORADIOLOGY

Each module is constructed to maximize interaction between the student and the presented material. The textual information is layered so that it remains hidden until the student wishes to learn more. Help files and quick access to course maps allow for easy navigation through each module, precluding the need for any previous computer experience. A current goal is for this tutorial to be added to the growing list of diverse programs which may be shared within the medical education

community.

Can the Kenney Tishler Alabama,

Post Void Film be Deleted From Urography?: PJ, Schwartzberg MS, Han SI, Stanley RJ, JMA, Koehler RE, Daniel NW (Univ. of Birmingham, AL 35233)

The post-void film (PVF) has been considered an important component of an intravenous urogram to evaluate for urinary retention. Recent literature has questioned its need especially in light of cost-effectiveness. We examined the hypothesis that a scout film obtained immediately after voiding can determine whether a PVF should be performed. Six experienced radiologists prospectively read 115 consecutive routine intravenous urograms. Patients were neither selected nor excluded based on presence or absence of voiding symptoms. Bladder volumes were calculated on both scout and conventional PVF’s from two measurments on the AP film (volume 0.3 (width)(height) ). Subjective impressions (normal, small or large residual) were also collected and independently correlated with calculated volumes. The volumes calculated from scout and PVF were within 25 ml in 62% of cases. The bladder appeared large (>7Sml) on the scout film in 31 cases; and in 10, the bladder was normal. In 21, the PVF confirmed inability to empty, but added no information. Of the 73 other cases, PV films did not significantly alter the radiographic impression. Therefore, for patients with a post-void bladder volume estimated from the scout film as insignificant, a PVF is unnecessary. If the scout shows large volume, PVF should be done, since some of these patients will be able to void normally.

Renal Hattery Hartman

Calculi: RR, King GW, Brakke

Role of Ultrasound: BF, Smith LH, DM (Mayo Clinic,

Vrtiska Williamson Rochester,

TJ, B, MN

55905) This work consists of evaluation of a population of patients being followed for renal stone disease. Patients with stone disease routinely have baseline laboratory and imaging studies and periodic follow-up examinations which include a KUB with plain tomograms. KUB with tomograms in our setting is the standard imaging examination to determine: 1) presence or absence of stones; 2) size, number, density and location of stones; 3) change in stone disease over time. These patients had standard KUB with tomograms, as well as renal ultrasound. Renal ultrasound was performed and interpreted prospectively without the knowledge of the findings on the KUB with tomograms. Both studies (KUB with tomograms and ultrasound) were compared and analyzed retrospectively. The initial group consists of 32 selected patients with stone disease and ten normal patients. Stone analysis was available in 20 patients and consisted of 12 patients with calcium oxalate, three with magnesium ammonium phosphate, two with cystine and three with uric acid stones. Significant findings were seen in several patients

ABSTRACTS

AJR:154,

January 1990

on ultrasound in addition to the findings related to the presence of stones. These occult abnormalities consisted of obstructive hydronephrosis due to a distal ureteral stone, segmental caliectasis due to infundibular obstruction, pyonephrosis, post-ESWL perinephric hematoma and cholelithiasis. Ultrasound was also helpful in detecting faintly opaque stones and in evaluating an especially thin patient with scoliosis in a patient with pelvic kidney and in several elderly patients who had difficulty with breath holding. The following ultrasound “pitfalls” were encountered: detection of stones in the presence of collecting system gas and stents, echogenic pyramids without nephrocalcinosis, shadowing from renal sinus fibrosis and non-shadowing interfaces due to vessels, fornices, pericalyceal fat and possibly Randall’s plaques. Several major issues regarding ultrasound will be the focus of continuation of this study. These consist of evaluating “non-shadowing” interfaces, determining and false-negative/false-positive and specificity/sensitivity and assessing the reproducibility of findings with follow up exams.

Extracorporeal Shockwave magnetic Acoustic Device Over 250 Patients: Denstedt J (Mallinckrodt St. Louis, MO 63110)

Lithotripsy Lithostar* McClennan Institute -

with

ElectroResults in BL, Clayman RV, of Radiology,

The Lithostar (Siemens) was the first lithotripter to use an electromagnetic acoustic source (EMAS) for production of shockwaves integrated into a multipurpose uroradiologic table eliminating the requirement for a waterbath. The experience with 266 pts treated between 12/86 -11/87 with 298 treatments will be presented. The majority of pts (95%) were treated on an out-pt basis using only i.v. sedation and/or transcutaneous electrical nerve stimulation. Three-month follow up abdominal radiographs were available for review on 122 pts The average treatment time was 104 mm. with an average of 3,600 shockwaves delivered. Initial fragmentation occurred in 89% of pts. The stone-free rate at 3 no. was 70%, the incidence of retreatment was 7% and the need for post-shockwave lithotripsy auxiliary procedures was 16% and depended on stone size and location. Hematuria occurred in 71% of pts and 1 case of perirenal hematoma was noted. No pt required open surgery or blood transfusion. Follow-up radiography included plain abdominal radiographs, oblique views and tomograms when necessary. An “effectiveness quotient” is introduced: % stone free / primary treatment + retreatment rate + aux. procedure rate. This formula is used to compare the performance of a variety of lithotripters for a given set of conditions, i.e. stone size, location and composition. From our data, we conclude that the effectiveness of Lithostar EMAS lithotripter is equivalent or better than other second generation lithotripters for all types of renal calculi and as effective as the HM-3 waterbath machine for stones in 1 cm or less range. The Lithostar approach to ESWL is effective lithotripsy with minimal analgesia requirements and a cost effective out-pt therapy.

Acute and Chronic Renal Vascular Changes in a Rabbit Model of Renal ESWL: Fajardo LL, Hillman BJ, Donovan 3M, Weber C, Moran ME, Drach GW (Univ. Medical Center, Tucson, AZ 85724’) Concerns about the risk of vascular damage tension. We performed

safety and ESWL

of ESWL include the the genesis of hyperon the right kidneys

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AJR:154,

URORADIOLOGY

January 1990

of 14 rabbits using a Dornier XL-l experimental lithotriptor. The left kidney of each animal served as a control. Six rabbits immediately underwent in vivo renal microangiography with a barium-gelatin mixture. Five hundred micro sections of experimental and control kidneys were contact-radiographed on high resolution plates (30 kV, 2.5 mA, 30 minutes), which were examined by light microscopy. The other eight rabbits underwent the same procedure three months following lithotripsy. Among the acute phase animals, all six experimental kidneys showed microangiographic changes. These included extensive subcapsular and cortical barium extravasation. Disruption of an arcuate vein was evident in one kidney. Visualized foci of hypoperfusion are believed related to compression by unopacified hemorrhage or infarction. All experimental kidneys from the animals undergoing delayed microangiography showed focal scarring. Scarring was predominantly peripheral, resulting in crowded glomeruli surrounded by avascular regions and aberrant microvasculature In this model, ESWL damaged the cortical circulation and resulted in persistent deformities of the microvasculature that could be responsible for the abnormal secretion of renin.

Percutaneous Kidneys: (Massachusetts

Nephrostomy Papanicolaou General

Procedures in Horseshoe N, Yoder IC, Pfister RC Hospital, Boston, MA 02214)

Over a period of three years we performed 11 percutaneous nephrostomy procedures in eight male adult patients with horseshoe kidneys. One patient with bilateral ureteral obstruction from bladder neoplasm required bilateral antegrade internal ureteral stent placement for drainage. Seven patients with stone disease underwent nine procedures, including five percutaneous tract dilatations for percutaneous ultrasonic lithotripsy and four simple nephrostomy tube insertions for irrigation following shock wave lithotripsy. Ureteral access was sought in seven and achieved in six procedures via mid or upper pole calyceal approach. The lower pole calyces, although a frequent and safe target for percutaneous nephrostomy tube insertions in nonfused kidneys, were avoided both because of their anteromedlal location in horseshoe kidneys and the difficulty in instrumenting the anteriorly located ureter via a lower pole approach. No bleeding nor other complication related to the percutaneous nephrostomy procedures was encountered, despite the alleged presence of multiple renal arteries in many horseshoe kidneys. Percutaneous uroradiologic procedures in horseshoe kidneys appear to be safe and effective. The interventionist should be aware of the technical modifications applied to these kidneys.

Renal Ablation by Ethanol: David Barbaric ZL (Univ. 90024-1721)

Retrograde Intrarenal RD, Layfield U, of California, Los

Reflux Fuchs Angeles,

of GJ, CA

The purpose of this study was to evaluate the feasibility of accomplishing renal ablation by retrograde instillation of ethanol into the collecting system under pressure. Traditionally ablation has been accomplished via transarterial embolization. In some instances, such as severe renal artery stenosis or upper moiety obstruction in an infant, this may not be technically possible. Six minipigs (12 kidneys) were used in the experiment. The ureter was catheterized under

ABSTRACTS

193

cystoscopic control, general anesthesia and fluoroscopy. Over a guide wire, an 8F occlusive balloon catheter was inserted into the ureter creating acute ureteral obstruction for 30 minutes. Thereafter, the urine in the upper system was replaced with 98% ethanol using an open manometer at 50 cm of ethanol pressure for 30 mm. The catheter was then removed. The pigs tolerated the procedure without difficulty. The procedure was repeated on the opposite kidney prior to sacrifice. Excretory urograms were obtained after the procedure The kidneys were subjected to pathohistological examinations ranging from one hour to six months after treatment. The results ranged from total ablation to focal areas of scarring in the long-term kidneys, and areas of hemorrhagic necrosis in acute kidneys. It is possible to accomplish total ablation with the regimen described above, although further work is necessary to further refine the protocol.

Thermic Castaneda Minneapolis,

Ablation of F (Univ. MN 55455)

Prostate: of Minnesota

Castaneda Medical

WR, School,

Thermal ablation of the central prostate was performed in ten dogs. A retrograde transurethral approach was utilized using a 20 mm balloon catheter. The balloon was inflated above the external sphincter, dilating the entire prostatic urethra and bladder neck. Fluid within the balloon was then heated using either a bipolar radiofrequency probe or circulating heated fluid. The temperature and duration of thermal ablation were variable. Multiple temperature probes were placed within the prostate and in the urethra to monitor the thermal effect. Baseline and followup retrograde urethrograms were obtained. The animals were sacrificed immediately, and the bladder, prostate gland and external sphincter were removed. The gross pathological changes included periurethral necrosis and peripheral hemorrhage and edema. These changes depended on the temperature and length of the thermal injury and decreased toward the periphery. Histologic changes included complete destruction of the urethral epithelium and moderate degree of necrosis of prostatic tissue. The subacute and chronic changes of this treatment are being investigated and will be presented. If experimental thermal ablation of the central prostate proves to be successful, it may be an alternative means of non-surgical treatment of patients with prostatic hypertrophy, particularly those with median bar prominence.

Renal Patients: Lambiase Hospital,

Abscess

Drainage: Experience Cronan JJ, Deyoe L, R, Paolella LP, Haas RA Providence, RI 02902)

in Dorfman (Rhode

Thirty GS, Island

Thirty patients, 16 women and 14 men ranging in age from 5-83 years, with renal and perirenal abscesses underwent percutaneous drainage. Fever > 101#{176}F, flank or abdominal pain, and leukocytosis were the most common presenting symptoms with 93% having at least one and 83% having at least two of these symptoms. Recent surgery and/or immunosuppression was identified in 21 of 30 patients. Ten of the 14 post-operative patients had surgical procedures involving the urinary tract. The radiographic diagnosis was made by US, CT, or both in 87% of the patients. Abscess size ranged from 4cc-650cc and all were drained via CT or fluoro-

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1 94

URORADIOLOGY

scopic guidance. The type of the tube used varied according to the size of the abscess. Percutaneous drainage alone was curative in 20 (66%) patients determined by resolution of symptoms or follow-up CT. Seven (23%) had improvement of symptoms but required surgery to remove tumor (2 patients), poorly or nonfunctioning kidney (4 patients), or a loculated abscess (1 case), all with eventual cure. Three patients (10%) with multiple medical problems expired before resolution could be documented, although death was not felt to be directly related to failure of therapy. All patients were treated initially in the hospital but 12 (40%) had their tube managed as an out-patient without complications (2-50 days). Percutaneous drainage alone most often produces cure but occasionally adjunctive surgery is required for resolution of the abscess. A significant number of patients can have their tube managed safely on an out-patient basis.

Retrograde Castaneda Minneapolis,

F

Dilatation (Univ. MN 55455)

of

Prostate: Minnesota

Castaneda WR, Medical School,

We have currently undertaken a clinical trial of prostatic urethroplasty with balloon catheters in a series of 150 patients with prostatism. All were candidates for TURP. A thorough preand post-procedure evaluation has been completed to assess the results and effectiveness of the procedure. The procedure is done on an outpatient basis, under topical anesthesia aided by mild intravenous sedation The morbidity is minimal. The procedure is simple to perform, but a few guidelines have to be followed. This procedure has much greater patient acceptance and could be performed on almost any patient regardless of medical condition. The preliminary results are very encouraging, especially in patients with predominant lateral lobe hypertrophy. In this group, the success rate is 75%. All of these patients have been followed for longer than six months, with the longest follow-up being more than three years. The success rate drops to approximately 25% in the patients with predominant middle lobe enlargement This is probably due to the ball-valve effect that this hypertrophied median lobe exerts over the bladder neck. No adverse effects, such as retrograde ejaculation, incontinence or impotence, have occurred.

Percutaneous Indications Dorfman Hospital,

Biopsy of Malignant and Follow-up: Ridlen GS, Paolella LP, Esparza A Providence, RI 02902)

Renal Masses: M, Cronan JJ, (Rhode Island

Percutaneous biopsy of mass lesions in many body areas has become a safe, accurate method for establishing a pathologic diagnosis. However, reports have suggested that this is a less safe procedure for renal masses because of possible tract seeding at the biopsy site. We reviewed the medical records of 36 patients who had percutaneous biopsy of solid renal masses since 1982. Indications for percutaneous biopsy included work-up prior to a renal embolization procedure, equivocal CT findings and inoperability due to disseminated metastatic disease. A tissue diagnosis of renal malignancy was established in each case. Thirty-three of 36 patients were proven to have renal cell carcinoma and the other three, all of whom were pediatric patients, had Wilm’s tumors. Clinical follow-up on these patients now ranges from 18 months to five years.

ABSTRACTS

AJR:154,

January

1990

Utilizing the skinny needle technique, there has not been a single case of local recurrence along the biopsy tract. In addition, there were no serious complications resulting from the biopsy procedure itself, even though many of these patients were poor candidates for an open surgical procedure. Percutaneous biopsy resulted in a 79% reduction in charges when compared to the cost of an open procedure ($685 vs $4,805). Skinny needle biopsy of solid renal masses is a safe, accurate and cost effective procedure in the proper

setting.

Advances Mitty Medicine,

in HA,

Dan New

Retrograde Ureteral SJ, Train JS (Mt. York, NY 10029)

Stent Sinai

Placement: School

of

Retrograde ureteral stent placement has traditionally been a solo cystoscopic procedure. The failure rate in patients with ureteral obstruction due to tumor has been in the range of 30-40%. Increasingly, the radiologist has a role to play either as a participant during the cystoscopic approach or as the principal operator, obviating the need for cystoscopy during retrograde fluoroscopic stent replacement. Interventional radiologic technology can transform a difficult or failing cystoscopic stent placement into a short, less traumatic procedures. In particular, introducing newer guide wires such as the “super stiff” and “glidewire” in conjunction with open ended catheters into the cystoscopic suite can make traversing even the most tortuous ureters quite routine. Antegrade stent sets such as the 8F and lOF Percuflex (Medi-Tech, Watertown, MA) may also be used in a retrograde manner. We have used this device in 23 patients in a retrograde manner via the cystoscope or to replace a pre-existing stent per urethra using fluoroscopy. The distal end of a ureteral stent can be grasped under fluoroscopic guidance and brought out through a urethral catheter. A standard guide wire exchange technique is used to insert the new stent.

Upper Pole Lebowitz 02115)

Hydronephrosis in RL (The Children’s

Infants: Hospital,

Winters Boston,

WD, MA

To discover the impact of new imaging modalities on the diagnosis and treatment of infants with hydronephrosis of the upper pole of a duplex collecting system, we reviewed the records and imaging studies of 40 such patients seen between 6/82 4/89. Nineteen (48%) had an ectopic ureterocele. Thirty-three (83%) were girls. Thirty-three (83%) had an abnormal prenatal sonogram, but that the hydronephrosis was of an upper pole was recognized in only one third, and only 1 ureterocele was seen. Postnatal sonography was performed in 30 (75%). It modified the diagnosis in 21 (70%), and 10 additional ureteroceles were discovered. Thirteen infants with an abnormal prenatal sonogram were placed on prophylactic antibiotics and none developed urinary infection. Ten infants presented with urinary infection. Five had prenatal sonography, and none had received prophylactic antibiotics. Voiding cystourethrography was performed in all 40, 46% had reflux, and 7 additional ureteroceles were seen. All 40 had excretory urography. There was no opacification of the upper pole in 63%. Nonfunction was confirmed by scintigraphy in all but one. Thirty six (91%) underwent upper pole nephrectomy or upper-to-lower ureteroureterostomy. Of the 8 who also had decompression of the

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AJR:154,

January

URORADIOLOGY

1990

ureterocele from above, only 3 had later surgery on the bladder. We conclude that: 1) prenatal sonography was usually nonspecific for upper pole hydronephrosis, 2) postnatal sonography modified prenatal diagnosis in most cases, 3) voiding cystourethrography was the most sensitive modality for detecting both a ureterocele and reflux, 4) excretory urography was very accurate, 5) after prenatal detection of hydronephrosis, prophylactic antibiotics should be instituted soon after delivery and, 6) most surgery was on the upper rather than the lower urinary tract.

Improving Cronan Providence,

the

JJ,

Specificity Scola FH (Rhode RI 02902)

of

of the Adult Cronan JJ, Providence,

195

cation, and position of the kidney on supine prone films could contribute to this discrepancy. The minimal decrease in size of the kidney with age probably results from fibrolipomatosis maintaining size in spite of an overall decrease of renal parenchyma and weight. This theory is consistent with prior pathologic series which have demonstrated a decreased weight of the kidneys with aging yet noting a smaller decrease in length. Very little difference existed between the size of the right and left kidneys. Using the data collected we have constructed a plot of normal adult renal size based upon two standard deviations from the mean.

Hydronephrosis: Island Hospital,

Ultrasound has consistently demonstrated a high degree of sensitivity in evaluating kidneys for the presence of renal obstruction. The bench mark used for obstruction has been hydronephrosis. Hydronephrosis, however, can be present without dilatation. This has resulted in false positive rates up to 25%. Over the course of the last two years, we have utilized numerous techniques to improve the specificity of the finding of grade 1 hydronephrosis. True grade 1 hydronephrosis has proven consistently to be an important finding in some patients but has often led often to employment of numerous more invasive techniques to determine if obstruction is present. Employment of Baysian analysis and Doppler ultrasound has proven most useful. Hydronephrosis, when evaluated with pulsed Doppler or color flow ultrasound, often proves to be a non-entity. Instead “pseudohydronephrosis” is present and the Doppler signal demonstrates that either an artery or vein is mimicking hydronephrosis. In our clinical practice, we have significantly improved the specificity of ultrasound for evaluating renal obstruction by utilizing Doppler. Additionally, the significance of grade 1 hydronephrosis should be determined by factoring the conditional probability of the finding with the prior probability of obstruction as determined by the clinician. Using decision analysis in a Bayesian fashion, grade 1 hydronephrosis is easily handled in clinical practice.

Normal Size Ultrasound: Island Hospital,

ABSTRACTS

Kidney Rosenfield RI 02902)

by

Real Time AT (Rhode

Renal size by urography is well defined. Similar data has not been collected to define the range of the adult kidney in supine position utilizing real time scanning. We assessed 268 adult patients referred to us for non-urologic ultrasound evaluation. Patients were excluded from this series if they had any abnormality of creatinine or BUN, a history of diabetes, or any prior history of renal disease or surgery. Three separate longitudinal measurements of each kidney were taken during the examination. Our data yielded the following results: Right side, a mean length of 10.82 cm. Minimum length was 7.3 cm. with a maximum of 14.2. One standard deviation equals 1.44 cm. Left side equals 10.93 cm. in length. Minimum size was 6.5 cm., and maximum size was 14.7 cm. One standard deviation equals 1.16 cm. Only a minimal decrease in renal size (R = -.20, p < .001) with age was otse rved. As expected renal length is smaller than that previously reported with urography. Multiple factors such as osmotic diuresis (.5-1cm) magnifi-

Urine Profiles Following Diatrizoate and lohexol I.V. in Four Different Nephropathies: Thomsen HS, Golman K, Larsen 5, Hemmingsen L, Skaarup P, Holm ‘3 (Herlev Hospital, flerlev, Denmark) The effect of diatrizoate, iohexol and saline on urine profiles (albumin, glucose, sodium, and the enzymes NAG, GGT, and LDH), serum profiles, and kidney histology was studied in male rats with normal kidneys, Fanconi’s syndrome (proximal tubular dysfunction) induced by sodium maleate i.v., vasomotor nephropathy induced by glycerol i.m. (rhabdomyolysis), cyclosporin A nephrotoxicity (preglomerular vasoconstriction), and Adriamycin nephrosis (glomerular damage). The effect of diatrizoate and iohexol varies from one animal model of nephropathy to another. The findings in normal kidneys are not reproduced in diseased kidneys. Glomerular dysfunction (albuminuria) following contrast media may be one factor of limited importance for the development of contrast medium induced nephropathy; tubular cell effect may be a dominating factor in this entity. Generally iohexol does not seem to be less nephrotoxic in rats than diatrizoate. In one nephropathy (e.g. Fanconi’s syndrome) it may be an advantage to use iohexol, in another (e.g. glycerol nephropathy) diatrizoate should be used, in a third (e.g. cyclosporin A nephropathy and Adriamycin nephrosis) it does not matter which type is used.

Value of Reactors. Siegel R Rochester,

Non-Ionic Experience (Univ. of NY 14642)

Contrast Thus Rochester

Medium in Previous Far: Fischer HW, Medical Center,

At high risk for a reaction to intravascular contrast medium injection are those patients who have had a significant reaction to a prior contrast injection. Experience thus far shows that prior reactors receiving low osmolar, r.on-ionic medium have had a very low incidence of reaction, about 4%, much lower than the literature leads one to expect with ionic high osmolar media (HOCM). None of the reactions have been fatal and most have been minimal.

Selective Winfield AC, C (Vanderbilt 37232-2675)

and lity. the tion Via

Fallopian Tube Moore D, Segars Univ. Medical

Canalization (SFTC): J, Holburn G, Herbert Center, Nashville, TN

Obstruction of the fallopian tube is a common frequently correctable etiology of infertiOcclusion of the proximal (cornual) end of fallopian tube may be amenable to recanalizausing interventional radiologic techniques. a transcervical approach, a coaxial system of

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196

URORADIOLOGY

9 French, 5 1/2 French, and 3 French catheters and appropriate guide wires may be employed to enter the proximal portion of the occluded fallopian tube and restore patency. As of 8/1/89, we have performed SFTC on twenty patients, attempting restoration of patency in twenty-eight fallopian tubes obstructed at the proximal segment. The study group consists of women presenting with infertility for one year or greater, who demonstrated associated unilateral or bilateral tubal occlusion. To date, three pregnancies have been achieved, two intrauterine pregnancies, and a single intratubal salpingitis isthmica nodosa in the proximal portion of the tube. We believe that SFTC offers a viable alternative to surgery for infertile patients with occlusive proximal fallopian tube disease.

Preliminary Experience With Fluoroscopic Transcervical Fallopian Tube Recanalization: Amendola MA, Banner MP, Pollack HM, Sondheimer S (Hospital of the Univ of Pennsylvania, Philadelphia, PA 19104) During the last nine (9) months we have performed fluoroscopic transcervical fallopian tube recanalization for treatment of female infertility caused by tubal obstruction in 12 patients. The technique we used was a variation of the one described by Thurmond and Rosch involving the use of a vacuum cup hysterograph with a coaxial catheter set for selective transcervical catheterization of the fallopian tubes. We have observed that the use of a guidewire (Meditech) will often allow cannulation of occluded tubes after failure of standard guidewires. There were 12 female patients between 26 and 41 years of age (average: 32). Recanalization was successful in 17 of 19 tubal obstructions for an overall technical success rate of 89%. The only complications encountered were two instances of tubal perforation with a small guidewire. No apparent clinical sequelae have been encountered in the follow up of these patients. At the time of this writing, two (2) women have conceived and have an ongoing intrauterine pregnancy.

#{231}arative Value of Hysterosalpingography and MR Imaging of the Uterus Prior to Yoder IC, Papanicolaou N (Massachusetts Hospital, Boston, MA 02114)

(HSG) Myomectomy: General

A series of patients is presented, who have been evaluated with HSG and pelvic MRI prior to myomectomy. The relative contribution of each diagnostic study to the operative approach and result is compared. Large mural or serosal fibromas were removed by a lower abdominal incision. Hysteroscopic myomectomy permitted the transvaginal removal of small submucous fibroids. Submucous myomas were invariably detected on HSG, because they produced an indentation on or a filling defect within the uterine cavity. MRI accurately delineated the number, size and location of fibroids in relation to the uterine cavity. However, if the latter is severely distorted, the endometrium may be obscured and the relationship of the myoma to the cavity is more difficult to determine. Pelvic MRI may substitute for HSG preoperatively if a nonionizing technique is preferable, especially when serial studies are anticipated. Smaller myomas are more likely to be accurately localized by MRI than larger ones.

ABSTRACTS

AJR:154,

January 1990

Small Renal Neoplasms: Clinical, Pathologic Imaging Features: Levine E, Huntrakoon M, LH (Univ. of Kansas Medical Center, Kansas KS 66103) Read by title only.

and Wetzel City,

Small renal neoplasms are being discovered with increased frequency because of the widespread use of abdominal CT and sonography. Little is known about their natural history. We therefore retrospectively reviewed clinical, pathologic and imaging findings in 22 patients with surgically confirmed solitary renal neoplasms 3 cm or less in diameter. Eighteen lesions were first found by CT, three by sonography and one by IV urography. Three lesions were discovered because the patients had hematuria. Nineteen were incidental radiologic diagnoses in patients without renal symptoms. Of 22 neoplasms, 15 (68%) were renal cell carcinomas, six (27%) were oncocytomas, and one (5%) was a lymphoma. Fourteen carcinomas (93%) were confined to the kidney, and one showed microscopic capsular invasion. Metastases did not develop in any patient with carcinoma, indicating that small carcinomas usually have good prognoses. Patients with carcinomas had a mean follow-up of 42 months. All neoplasms were visible on CT However, characterization of these lesions sometimes required a combination of CT and sonography and occasionally angiography. The carcinomas, oncocytomas and solitary renal lymphoma could not be distinguished radiologically. Small renal neoplasms are most often found incidentally by CT performed in patients without renal complaints. Most are low stage carcinomas and some are oncocytomas.

Renal During (Virginia

Cell Carcinoma Gallbladder Mason Clinic,

Discovered Ultrasonography: Seattle, WA

Incidentally Bush 98111)

WI!

If the ultrasonic examination of a patient with “gallbladder symptoms” also includes the kidneys, a substantial percentage of renal carcinomas will be discovered and these will be at an earlier stage. Of 65 patients with renal cell CA discovered between January, 1984 and January, 1988, tumors in nine patients (14%) were discovered incidentally by ultrasonography requested for gallbladder evaluation. These nine tumors averaged only 4.7cm in diameter. Four were left sided, four right and one patient’s were bilateral. All were either stage I or II. By comparison, renal carcinoma discovered by ultrasonography done for urinary tract or other abdominal symptoms averaged 6.2 cm; renal cancers found by excretory urography done for urinary symptoms averaged 7.7 cm. Considering the improved curability of the smaller, early detected renal cell carcinoma, it is recommended that the right kidney be evaluated always during even a limited gallbladder ultrasonographic exam and that, as often as feasible, the examination be expanded to include the left kidney.

Observations Neoplasms: Lubat E, New York,

on the Growth of Renal Parenchymal Bosniak MA, Birnbaum BA, Megibow AJ, Gordon RB (New York Univ. Medical Center, NY 10016)

The growth rate of small well marginated renal parenchymal neoplasms is virtually unknown because they are usually removed when they are discovered unless the lesion is missed or misdiagnosed

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URORADIOLOGY

initially (and previous studies are available) or surgery is not performed because of severe medical disease. In this context we have been able to collect 13 well marginated renal parenchymal tumors in 11 patients that have had follow up evaluation for over two years. The follow ups range from two years to eight years with a mean of 3.5 years. The tumors ranged in size initially from 1.5 to 4.0 cm in size (mean 2.2) and they all grew slightly during the follow up periodranding from 0.2cm to 5.5cm with a mean of 1.8cm. No tumors metastasized during the follow up period. Seven of the cases have pathological proof (renal adenocarcinoma) with the remaining patients still alive with their tumors. While this is a small number of total cases to make any definite conclusions, the presentation of this material is felt warranted since there is very little material on this subject available in the literature and the relatively slow growth rate of these small well marginated tumors might justify a conservative (non-operative) approach in somr elderly patients who are poor operative risks or who would otherwise have to undergo dialysis if surgery was PC r formed.

CT and Sonographic Characteristics of Lymphangioma of the Retroperitoneum: Davidson AJ, Hartman (Armed Forces Institute of Pathology, Washington, DC 2036-6000) Read by title only.

DS

Eighteen retroperitoneal lymphangiomas in 11 males and seven females were evaluated retrospectively for discriminating CT and sonographic features. Age was evenly distributed from birth to the sixth decade. CT (n-14) localized the lymphangioma as predominantly perirenal in six, predominantly pararenal in seven and predominantly pelvic in one. In five, the lymphangioma occupied more than one space. In three, the lymphangioma involved and may have arisen from adrenal, bladder or kidney. Seven masses were unicameral and seven multiloculated. Septa and walls were thick in all except two. One had a calcified wall. Fluid content of locules varied from water to 35 HU in six patients or visibly contained blood or debris in eight. Chylous values were absent. Sonography (n=l7) characterized the lymphangioma as unicameral in six, multilocular in ten and indeterminate in one. Septa were thick in nine of ten multiloculated lesions. Fluid was uncomplicated in 11 and echoic in six. In six, the lymphangioma was markedly elongated and extended from pelvis to superior retroperitoneum. We conclude that lymphangioma has distinctive CT and sonographic features that may be the basis for differentiation from other retroperitoneal masses.

Extra-Adrenal Retroperitoneal Paragangliomas: Clinical, Pathological and CT Findings: Hayes WS, Davidson AJ, Grimley PM, Hartman DS (National Naval Medical Center, Bethesda, MD 20814-5011) The clinical, pathological and computed tomography (CT) findings of 33 extra-adrenal retroperitoneal paragangliomas in 28 patients were reviewed retrospectively. There were sixteen males, twelve females. The average age of the group was 37 years with a range from 11 to 70 years. Twenty-four patients (86%) had hypertension. Biochemical studies were performed in 18 of the 24 patients with hypertension and the results were elevated in all. Four patients (14%) had malignant paragangliomas. The cytologic features and growth patterns of all tumors in this

ABSTRACTS

197

study extra-

were the same as those described for both and intra-adrenal paragangliomas. Tumors were classified by locations as suprarenal (26%), renal hilus (32%) or infrarenal (42%). Functional tumors were on the average smaller (7.0cm) than nonfunctional tumors (12.0cm), but the two groups overlapped. Smaller tumors were more likely to be of homogeneous density with well defined margins, while larger tumors were more inhomogeneous with irregular margins. Our findings indicate that extra-adrenal retroperitoneal paragangliomas are functionally active more frequently than previously reported and that they are readily detected by CT as soft tissue masses closely associated with the entire length of the abdominal aorta. However, no pathognomonic CT features were found that distinguished and were uniquely those of paragangl iomas.

Transrectal Prostate: Cuttino Medical

Ultrasound Guided Biopsy of the Experience with 211 Cases: Krause R, JT, Scholz FJ, Larsen CR (Lahey Clinic Center, Burlington, MA 01805)

Transrectal guided biopsy of the prostate has become an integral part of the workup of prostate cancer. We have performed biopsies in 211 patients. Indications for biopsy include palpable nodule, palpable induration, suspicious lesion noted on transrectal ultrasound and patients with a high index of suspicion for prostate malignancy (positive bone scan, elevated acid phosphatase and elevated prostatic specific antigen). Biopsy in 211 patients yielded 94 cancers (45% positive); ultrasound was positive (hypoechoic lesion in 89 (95%). There were 117 patients (55%) with benign pathology (hypertrophy, atypia, prostatitis). Of these ultrasound was suspicious for malignancy (false positive) in 79 (67%). Complications were minimal (hematuria, hematochizia, prostatitis, and sepsis). Five patients required admission for intravenous antibiotics. Transrectal guided biopsy of the prostate is a relatively safe, easy procedure, well-tolerated by patients and with a high positive yield. Radiologists are ideally suited to monitor and perform this procedure.

Local Staging of Prostate Carcinoma with Endorectal Surface MRI: Schnall MD, Imai Y, Pollack NM, Lenkinski RE, Kressel HY (Hospital of the Univ. of Pennsylvania, Philadelphia, PA 19104) [Award-winning paper] Although the use of an endorectal surface coil has been shown to improve the resolution of MR images of the prostate gland, the clinical utility of this technique has yet to be established. We used endorectal surface coil MR to examine the patterns of growth and MR characteristics of biopsy-proved prostatic carcinoma in 35 patients. In a subgroup of this cohort consisting of 12 patients who underwent radical prostato-seminal vesiculectomy, surgical and pathological confirmation of MR staging was available, including whole mount specimen correlation in some cases. Surface coil images revealed, in more detail than body coil images, the extent of the malignancies, and especially, their relationship to anatomical landmarks such as the prostatic capsule, the neurovascular bundle, the penprostatic vascular plexus and periprostatic fat important to local staging of the neoplasm. Prospective staging with endorectal surface coil MRI agreed with surgical-pathological staging

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in 11 of 12 cases (92%). The discordant case was the first case imaged in this study, and, retrospectively, it was felt that study was interpretated incorrectly. There was excellent correlation between endorectal surface coil MRI and the whole mount specimens with regard to the intra and extraprostatic extent of tumor. These results suggest that endorectal surface coil MRI is a promising tool for the local staging of prostatic malignancy.

The Hilum of the Testis A Sonographic Imposter of Neoplastic Disease: Bird KI, Blair D, Rosenfield AT (Yale Univ. School of Medicine) The hilum of the testis is a normal variant that may mimic a tumor or other abnormality. Sonographically, it presents as a unilateral hypoechoic mass or as two such masses. Based on sonographic/ pathologic correlation using cadaver studies and surgical specimens as well as Doppler flow studies in clinical patients, we have found that this hypoechoic region consists of small veins along with some fibrous tissue. The criteria for characterizing such a lesion as representing this normal variant are: 1) the mass or masses are contiguous with the epididymis; 2) on sonographic sections perpendicular to the mediastinum testis, the lesion is symmetric about the linear echogenic mediastinum; 3) duplex Doppler may show venous flow within the lesion (although the flow may not be appreciated if the veins are small); 4) in some patients definite evidence for the vascular etiology of the lesion can be seen on color Doppler or MRI scanning.

ABSTRACTS

The Clinical Utility of P-31 MRS of Human Testicular Pathology: Carrol P (Univ. of California, 94143-0628)

AJR:154,

January 1990

in the Evaluation Hnicak H, Chew WM, San Francisco, CA

lH MR imaging is a useful adjunct to ultrasound in the diagnosis of various testicular diseases. While 111 MRI demonstrates excellent sensitivity, often the findings are inconclusive lacking tissue specificity. In this prospective study, we attempt to determine the clinical utility of combined lH MRI/P-3l MRS in the evaluation of human testicular disease, specifically for the diagnosis of testicular torsion, orchitis, fibrosis and tumor. Thirteen patients (torsion N=2, orchitis N=l, testicular atrophy N=4, tumor N=6) were studied using a l.5-T GE Signa system. Imaging was performed with Tl(600/20) and T2(2500/20/80) weighted sequences, and spectra were collected from each testis with a 3.5 cm coil, a TR of two seconds and 100 averages. Results of the combined MRI/MRS studies were confirmed with surgical or biopsy results. Imaging alone depicted the pathology in each patient but could not differentiate between orchitis, fibrosis or tumor. In torsion, Tl-weighted images demonstrated an increase in signal intensity but T2-weighted images demonstrated no abnormalities while P-3l MRS demonstrated a marked increase (above phosphomonesters) (PM) in levels of inorganic phosphate (Pi) and reduced levels of ATP. P-31 spectra of testicular tumors varied with tumor type but in general, all showed increases in Pi levels (although never above PM) and increases in PM/B-ATP peak area ratios. Testicular atrophy exhibited spectra with decreased concentrations of phosphorous containing compounds and decreases in PM/B-ATP peak area ratios as well. Combined MRI and MRS findings increased our diagnostic accuracy and should be used in problem cases.