31THE BLADDER AND

PROSTATE

DAVID SUTTON

DAVID SUTTON PICTURES

DR. Muhammad Bin Zulfiqar PGR-FCPS III SIMS/SHL

• Fig. 31.1 Full-length film from an IVU series on a patient with bladder extrophy treated with ureterosigmoidostomies. There is characteristic separation of the symphysis pubis. The ureters have been anastamosed to the sigmoid colon close to the midline. Reflux has predisposed to dilatation of the distal ureters (black arrows) and the left kidney shows changes of chronic pyelonephritis with cortical loss and calyceal clubbing. Contrast opacified urine has drained into the sigmoid colon and passed forwards into the rectum and retrogradely into the descending colon (white arrows).

• Fig. 31.2 Cystogram on an infant with prune-belly syndrome. There is a typical capacious flaccid bladder and absence of the prostate. A urachal diverticulum is demonstrated anteriorly (arrow).

• Fig. 31.3 Longitudinal (A) and transverse (B) ultrasound showing a urachal cyst as a thin-walled cylindrical echo-free area (arrow). The CT (C) demonstrates analagous features with a small area of calcification.

• Fig. 31.3 Longitudinal (A) and transverse (B) ultrasound showing a urachal cyst as a thin-walled cylindrical echo-free area (arrow). The CT (C) demonstrates analagous features with a small area of calcification.

• Fig. 31.4 MRI scan (transverse T2-weighted images) showing a small left paraureteric congenital bladder diverticulum (arrows).

• Fig. 31.5 Transverse image from a transrectal ultrasound examination showing a normal left seminal vesicle and a large right seminal vesicle cyst.

• Fig. 31.6 Transverse ultrasound image showing bladder wall thickening and echogenic clumps of inflammatory debris within the urine in a patient with severe cystitis.

• Fig. 31.7 Transverse ultrasound image (A) showing gross focal thickening of the right posterolateral bladder wall in a patient with acute Crohn's disease. Similar features are seen on CT (B), which also shows adherent swollen small bowel. An enterovesical fistula is present with gas seen in the bladder.

• Fig. 31.8 Longitudinal ultrasound of the bladder (A) showing localised wall thickening in tuberculous cystitis (arrowhead) and dilated distal ureter (arrows). Similar heaped-up appearance of the bladder mucosa is seen on CT (B) around the ureteric orifice. The IVU (C) also demonstrates the localised bladder wall thickening, narrowing of the ureteric orifice and dilatation of the distal ureter.

• Fig. 31.8 Longitudinal ultrasound of the bladder (A) showing localised wall thickening in tuberculous cystitis (arrowhead) and dilated distal ureter (arrows). Similar heaped-up appearance of the bladder mucosa is seen on CT (B) around the ureteric orifice. The IVU (C) also demonstrates the localised bladder wall thickening, narrowing of the ureteric orifice and dilatation of the distal ureter.

• Fig. 31.9 Plain film (A) showing linear calcification along the bladder wall and distal left ureteric walls. CT (B, different patient) is highly sensitive for the demonstration of bladder wall calcification and will also show the soft-tissue wall thickening which may be gross and (as here) associated with rectal wall thickening. (Courtesy of Dr Shadley Fataar of the Royal Hospital, Muscat, Oman.)

• Fig. 31.10 Longitudinal ultrasound of the bladder showing wall thickening and trabeculation (replacement of normal smooth inner aspect by regularly undulating appearance).

• Fig. 31.11 Bladder view from an IVU series in a patient with bladder outflow obstruction due to prostatic hyperplasia. The bladder is trabeculated and saccules (arrows) are beginning to develop. The distal ureters are showing some elevation in association with the prostatic enlargement and the bladder wall disease has provoked some fullness of the distal left ureter.

• Fig. 31.12 Longitudinal ultrasound of the bladder showing gross sacculation, best seen along the posterior wall, in a patient with severe longstanding outflow obstruction.

• Fig. 31.13 Transverse ultrasound image of the bladder showing two posterior-lying diverticula.

• Fig. 31.14 Bladder image from an IVU examination showing a large right-sided diverticulum (A). On the postmicturition film the bladder has emptied but the narrow necked diverticulum remains contrast filled (B).

• Fig. 31.15 CT scan demonstrating a large right posterolateral diverticulum.

• Fig. 31.16 T1 -weighted MRI showing a large right-sided bladder carcinoma (arrowheads) and a small left-sided diverticulum (arrow) containing a further deposit of carcinoma.

• Fig. 31.17 Full-length film showing right-sided inguinal herniation of the distal right ureter and part of the bladder.

• Fig. 31.18 Cystogram in a patient with gross ureteric reflux and vesicovaginal fistula following previous radiotherapy and pelvic surgery for pelvic malignancy. Arrows indicate contrast within the vagina.

• Fig. 31.19 Coronal T,-weighted (A) and transverse STIR (B) images from an MRI scan of the pelvis of a patient with an extensive pelvic haemangioma in association with Klippel–Trenaunay syndrome. There is a large lobulated mass over the dome of the bladder which is continuous with further dilated vessels running posteriorly in the left hemipelvis and into the left buttock.

• Fig. 31.20 Longitudinal ultrasound of the bladder showing a polypoidal bladder carcinoma (A). Transverse ultrasound of the bladder on a different patient (B) showing two sessile deposits of carcinoma.

• Fig. 31.21 Transverse ultrasound of a large sessile bladder carcinoma with calcific encrustation appearing as intense superficial echogenicity with marked distal acoustic shadowing.

• Fig. 31.22 Plain film of the bladder area showing irregular calcification over a bladder carcinoma.

• Fig. 31.23 Bladder images from IVU studies. Bladder carcinoma is seen as one or more filling defects with a variety of patterns. (A) A small slightly lobulated left-sided filling defect. (B) Multiple irregular filling defects are seen related to the dome and lateral walls of the bladder with a large basal filling defect. Bilateral ureteric obstruction is developing, worse on the right where tumour can be seen invading along the distal ureter. (C) Extensive irregular wall thickening is present, particularly along the bladder base. Lytic bone metastases are seen affecting the medial aspect of the right iliac bone and the lateral aspect of the left iliac bone (arrows).

• Fig. 31.23 Bladder images from IVU studies. Bladder carcinoma is seen as one or more filling defects with a variety of patterns. (A) A small slightly lobulated left-sided filling defect. (B) Multiple irregular filling defects are seen related to the dome and lateral walls of the bladder with a large basal filling defect. Bilateral ureteric obstruction is developing, worse on the right where tumour can be seen invading along the distal ureter. (C) Extensive irregular wall thickening is present, particularly along the bladder base. Lytic bone metastases are seen affecting the medial aspect of the right iliac bone and the lateral aspect of the left iliac bone (arrows).

• Fig. 31.24 MRI scan on a young adult female with a bladder base rhabdomyosarcoma. Coronal postcontrast T 1 -weighted (A) and sagittal T2 - weighted images (B) show a large heterogeneous mass of tumour invading the anterior wall of the vagina.

• Fig. 31.25 Range of appearances of bladder calculi on plain films. (A) Classical jackstone calculus. (B) Laminated calculus. (C) Agglomerated calculi that have formed on catheter balloons in a patient with bladder damage due to previous trauma (note distortion of the bony pelvis). (D) Multiple small bladder calculi, probably forming on fragments of prostatic tissue following a previous transurethral resection of prostate. (E) Two years later the same patient shows significant further growth of the small k bladder calculi.

• Fig. 31.25 Range of appearances of bladder calculi on plain films. (A) Classical jackstone calculus. (B) Laminated calculus. (C) Agglomerated calculi that have formed on catheter balloons in a patient with bladder damage due to previous trauma (note distortion of the bony pelvis). (D) Multiple small bladder calculi, probably forming on fragments of prostatic tissue following a previous transurethral resection of prostate. (E) Two years later the same patient shows significant further growth of the small k bladder calculi.

• Fig. 31.25 Range of appearances of bladder calculi on plain films. (A) Classical jackstone calculus. (B) Laminated calculus. (C) Agglomerated calculi that have formed on catheter balloons in a patient with bladder damage due to previous trauma (note distortion of the bony pelvis). (D) Multiple small bladder calculi, probably forming on fragments of prostatic tissue following a previous transurethral resection of prostate. (E) Two years later the same patient shows significant further growth of the small k bladder calculi.

• Fig. 31.26 Transverse ultrasound of the bladder showing an echogenic spiculated calculus with distal acoustic shadowing.

• Fig. 31.27 Cystogram performed via a suprapubic catheter in a patient with major pelvic trauma and anterior pelvic fractures. There is florid extravasation from the bladder neck tear. Contrast remains extraperitoneal. There is associated trauma to the urogenital diaphragm and contrast extends inferiorly into the perineum (arrow). The line of the urethra is shown by the course of the urethral catheter.

• Fig. 31.28 (A) Intraperitoneal rupture, in this case visible on IVU. III defined contrast extravasation is seen around bowel loops immediately superior to the bladder (arrows). (B) Cystogram showing intraperitoneal rupture with contrast outlining the ceca! pole and the outer aspect of the right side of the bladder dome.

• Fig. 31.29 CT cystogram. There is an extensive bladder neck rupture. (A) The bladder cannot be distended, due to the size of the rupture, and remains collapsed (arrow). Contrast has flooded into the perivesical space anteriorly and shows florid extension superiorly (B) in the extraperitoneal space behind the anterior abdominal wall.

• Fig. 31.30 Bladder image from an IVU study showing a heavily trabeculated neuropathic bladder.

• Fig. 31.31 (A) Urinary diversion techniques: left, ileal conduit; right, ureterosigmoidostomy. (B) Reconstruction with an intestinal 'neobladder' after cystectomy. (C) Cystoplasty techniques: left, augmentation cystoplasty; right, substitution cystoplasty. (D) Boari bladder flap technique.

• Fig. 31.31 (A) Urinary diversion techniques: left, ileal conduit; right, ureterosigmoidostomy. (B) Reconstruction with an intestinal 'neobladder' after cystectomy. (C) Cystoplasty techniques: left, augmentation cystoplasty; right, substitution cystoplasty. (D) Boari bladder flap technique.

• Fig. 31.31 (A) Urinary diversion techniques: left, ileal conduit; right, ureterosigmoidostomy. (B) Reconstruction with an intestinal 'neobladder' after cystectomy. (C) Cystoplasty techniques: left, augmentation cystoplasty; right, substitution cystoplasty. (D) Boari bladder flap technique.

• Fig. 31.31 (A) Urinary diversion techniques: left, ileal conduit; right, ureterosigmoidostomy. (B) Reconstruction with an intestinal 'neobladder' after cystectomy. (C) Cystoplasty techniques: left, augmentation cystoplasty; right, substitution cystoplasty. (D) Boari bladder flap technique.

• Fig. 31.32 Stentogram 10 days after fashioning an ileal conduit. Two stents have been positioned at the time of surgery, running through the conduit and then into the two ureters. Contrast has been injected via the stents to outline the ureters and then, as the contrast flows antegradely, the conduit. In this case very little contrast passes into the conduit, as most is seen to extravasate at the level of the uretroileal junction inferiorly into the pelvis.

• Fig. 31.33 Normal conduitogram (loopogram) showing typical small bowel mucosa in the conduit and free reflux into modestly dilated ureters.

• Fig. 31.34 Barium enema (prone angled view) showing the characteristic wide separation of the symphysis pubis seen in bladder extrophy. The patient was treated in childhood with bilateral ureterosigmoidostomies and has developed large colonic adenomas at the site of insertion of the ureters (arrows).

• Fig. 31.35 (A) Early cystogram following fashioning of an orthotopic neobladder. Normal postoperative appearances. The two ureters are seen entering the afferent loop, which drains into the main body of the neobladder. No extravasation is seen, the anastamoses are intact. Both urethral and suprapubic balloon catheters are still present. (B) Early cystogram on a similar reconstruction. In this case the right ureter enters the afferent loop somewhat lower than the left. There is a stent still present in the left ureter running into the afferent loop because of concerns about the integrity of the left-sided anastamosis. This is justified because there is substantial extravasation from this anastamosis, running superiorly into the left retroperitoneum (arrowheads).

• Fig. 31.36 IVU 1 year after fashioning an orthotopic neobladder. There is no upper tract dilatation and the ureters drain satisfactorily into the afferent loop; this drains into the neobladder, which is nicely seen on the full length film (A) and has a remarkably normal appearance. The postmicturition film (B) shows satisfactory emptying of the neobladder and reveals the characteristic mucosal pattern of the constituent small bowel.

• Fig. 31.37 Full-length film from an IVU study on a patient 1 year after fashioning a Mitrofanoff reservoir. The appearances are satisfactory. The left pelvicalyceal system shows minimal fullness, which will require monitoring; the right-sided collecting system shows no dilatation at all. Incidental note is made of the complete duplex system on the right, which will have increased the complexity of the surgical procedure.

• Fig. 31.38 Bladder images from IVU studies on two patients with Boari flap procedures: (A) shows only prominence of the right superolateral angle of the bladder in keeping with a small flap. (B) shows a patient who required resection of a substantial length of ureter and has a much longer flap reconstruction.

• Fig. 31.39 Cystogram 1 0 days after radical prostatectomy. There is a substantial right posterolateral leak at the level of the anastamosis of the bladder on to the urethra, seen on the posteroanterior (A) and steep right anterior oblique (B) views. This requires conservative treatment with catheter drainage for 1-2 weeks and then repeat cystographic assessment

• Fig. 31.40 Longitudinal (A) and transverse (B) ultrasound images of the bladder showing moderate lobulated benign prostatic enlargement with areas of calcification.

• Fig. 31.41 Transrectal ultrasound (transverse images) on patients with benign prostatic hyperplasia. (A) shows marked prostatic enlargement. The central gland shows a multinodular appearance with a benign cyst (arrow) and gross enlargement. This has displaced and compressed the more echogenic peripheral zone. (B) shows more modest disease with less central gland enlargement. A benign cyst (arrowhead) and an adenomatous nodule (arrows) can be identified.

• Fig. 31.42 Bladder image from an IVU series showing marked prostatic enlargement as a smooth bladder-base mass. Some trabeculation of the bladder wall is also visible.

• Fig. 31.43 Transrectal ultrasound (transverse images) on patients with clinical prostatitis. (A) shows periurethral calcification but an otherwise essentially normal young adult gland. (B) Older patient with some benign prostatic enlargement. There is calcification at the junction of the peripheral and central gland and a slightly motheaten appearance to the central gland.

• Fig. 31.44 Transrectal ultrasound (transverse images) on patients with prostatic cancer. (A) shows a tiny peripherally placed carcinoma as a hypoechoic nodule (arrows) easily seen against the remainder of the normal hyperechoic peripheral gland. (B) shows a larger area of reduced echogenicity (arrowheads) replacing much of the left peripheral gland and showing an ill-defined infiltrative margin towards the adjacent central gland. It currently, however, still appears confined by the prostatic capsule. (C) shows an extensive prostatic cancer seen as a sheet of echopoor material that has replaced the normal peripheral gland and is infiltrating anteriorly into the central gland.

• Fig. 31.44 Transrectal ultrasound (transverse images) on patients with prostatic cancer. (A) shows a tiny peripherally placed carcinoma as a hypoechoic nodule (arrows) easily seen against the remainder of the normal hyperechoic peripheral gland. (B) shows a larger area of reduced echogenicity (arrowheads) replacing much of the left peripheral gland and showing an ill-defined infiltrative margin towards the adjacent central gland. It currently, however, still appears confined by the prostatic capsule. (C) shows an extensive prostatic cancer seen as a sheet of echopoor material that has replaced the normal peripheral gland and is infiltrating anteriorly into the central gland.

• Fig. 31.45 Transrectal ultrasound (transverse image) showing multifocal echo-poor prostatic cancer (two nodules identified by arrowheads).

• Fig. 31.46 Transrectal ultrasound (longitudinal image) showing echopoor tumour in the peripheral gland extending anteriorly into the adjacent central gland and superiorly into the seminal vesicle.

• Fig. 31.47 Transrectal ultrasound (transverse image) showing echo-poor tumour infiltrating throughout the prostate, predominantly the right lobe, and extending laterally through the capsule on the right into the periprostatic fat.

• Fig. 31.48 (A) Transverse T2 -weighted spin-echo (SE 2000/80) image demonstrating a chemical shift artefact in the frequency direction (horizontal) with a low-signal-intensity line at one edge of the bladder wall (straight solid arrow) and a high-signal band in the opposite wall (open arrow). (B) Bladder tumour (histological stage T2) with an intact low-signal bladder wall peripherally on a coronal intermediate-weighted spin-echo (SE 1200/26) image. t = tumour; u = urine.

• Fig. 31.49 Extensive T3b bladder tumour shown on (A) a transverse T 2 -weighted spin-echo (SE 3000/100) image; (B) transverse (at the same anatomical level as (A)) and (C) parasagittal T 2 -weighted spin-echo (SE 3000/100) images with fat suppression. The tumour (curved arrow) is infiltrating through the bladder wall (straight arrows), which is better appreciated on the fat suppression scans. p = prostate.

• Fig. 31.49 Extensive T3b bladder tumour shown on (A) a transverse T 2 -weighted spin-echo (SE 3000/100) image; (B) transverse (at the same anatomical level as (A)) and (C) parasagittal T 2 -weighted spin-echo (SE 3000/100) images with fat suppression. The tumour (curved arrow) is infiltrating through the bladder wall (straight arrows), which is better appreciated on the fat suppression scans. p = prostate.

• Fig. 31.50 Enhancing bladder carcinoma (t) in the posterolateral part of the bladder on a transverse T,-weighted spin-echo (SE 740/40) postgadolinium- DTPA image. Note the three layers—unopacified urine (u), signal void posteriorly in the bladder due to the superparamagnetic effect of high concentrations of gadolinium-DTPA, with a high-signal layer in between due to the paramagnetic effect of normal concentrations of gadolinium-DTPA. Also note the heterogeneity of signal within the middle layer due to urine flow. r = rectum; arrows = fluid levels.

• Fig. 31.51 Multiple confined bladder tumours (t) on transverse T 1 -weighted spin-echo (SE 740/40) (A) pre- and (B) early postgadolinium-DTPA images. Note the enhancing tumour anterolateral to the left is well visualised but the posterior-based lesions are obscured due to the high-signal effect of normal concentrations of gadolinium-DTPA. r = rectum; s = seminal vesicles; u = urine.

• Fig. 31.52 Histological stage T3b bladder carcinoma (curved open arrow) on transverse (A) T,-weighted spin-echo (SE 700/40) and (B) moderately T-2 -weighted spin-echo (SE 180/80) images. The intraluminal component of the tumour is wel shown in (A) buthe destruction of the low-signal blader wall (straight arrow) is better demonstrated in (B) Left-sided pelvic lymphadenopathy (n) shown in (A) is obscured in (B). b = bladder; r = rectum.

• Fig. 31.53 Extensive stage T3b bladder tumour (straight arrows) with bilateral obstructive uropathy on (A) transverse and (B) parasagittal T 2 -weighted spin echo (SE 3500/100) images with fat suppression. The dilated ureters (u) are clearly shown to contain high signal urine with no spread of the transitional cell carcinoma into the ureters. This was suggested on CT (not shown). There is also ascites (curved arrows) present.

• Fig. 31.54 Metastatic transitional cell bladder carcinoma on a transverse T-1 -weighted spin-echo (SE 520/15) image showing a soft-tissue mass in the perineum (arrow) involving the left corpus cavernosum and left inferior pubic ramus.

• Fig. 31.55 Pelvic lymphadenopathy (n) demonstrated on T 1 -weighted spin-echo (SE 740/40) images in (A) coronal and (B,C) transverse planes in different patients. The soft-tissue signal from the lymphadenopathy contrasts well with the signal void from flowing blood within adjacent vessels and high signal from surrounding fat. b = bladder; p = psoas muscles; t = bladder tumour; arrow = dilated left ureter filled with low-signal urine.

• Fig. 31.55 Pelvic lymphadenopathy (n) demonstrated on T 1 -weighted spin-echo (SE 740/40) images in (A) coronal and (B,C) transverse planes in different patients. The soft-tissue signal from the lymphadenopathy contrasts well with the signal void from flowing blood within adjacent vessels and high signal from surrounding fat. b = bladder; p = psoas muscles; t = bladder tumour; arrow = dilated left ureter filled with low-signal urine.

• Fig. 31.56 Resected stage T1/T2 bladder tumour with a focal area of wall thickening (straight arrows) and ulcer crater (curved arrow) with no residual tumour on a coronal T2 -weighted spin-echo (ESE 3000/100) image with fat suppression. (1.5 T IGE Horizon using a phased-array pelvic coil.)

• Fig. 31.57 Cyst of Cowper's gland (c) on spin-echo (A) sagittal intermediate- weighted (SE 1100/26) and (B) transverse T 2 -weighted (SE 2000/80) images. Note that the urethra is well visualised between the anterior and posterior parts of the cyst in (A). b = bladder; p = prostate; r = rectum; s = symphysis pubis; v = seminal vesicles; straight arrow = urethra; curved arrow = bulb of penis.

• Fig. 31.58 Stage T3a prostate carcinoma (arrow) posterolateral to the right in the peripheral zone infiltrating through the capsule into the adjacent neurovascular bundle. p = peripheral zone; c = central gland.

• Fig. 31.59 1,111 ,,,use T2 -weighted spin-echo (SE -uuu 80) image through the prostate of an 80-year-old patient. Note that there is no differentiation between the central and peripheral zones due to benign prostatic hypertrophy. p = prostate; r = rectum; s = symphysis pubis; arrows, periprostatic venous plexus.

• Fig. 31.60 Benign prostatic hypertrophy (p) on a fat-suppressed corona! T2 -weighted spin-echo (FSE 3500/100) image. Arrows = periprostatic venous plexus. (1.5 T IGE Horizon using a phased-array pelvic coil.)

• Fig. 31.61 Multifocal prostatic carcinoma (curved arrows) in the left peripheral zone with associated benign prostatic hypertrophy on a transverse T2-weighted spin-echo (FSE 4000/104) image. Note the area of high signal (straight arrow) in the more posteriorly placed tumour due to haemorrhage from recent biopsy.

• Fig. 31.62 Prostatic carcinoma (stage T2) in the right peripheral zone (arrow) abutting onto the capsule on a fat-suppressed transverse T-2 weighted spin-echo (TSE 350/10) scan. Note the coincidental benign prostatic hypertrophy. (1.5 T Philips Gyroscan using the body coil.)

• Fig. 31.63 Stage T4a prostatic carcinoma (arrow) infiltrating the bladder base on a fat-suppressed coronal T 2 -weighted spin-echo (TSE 3500/100) image. This tumour was not detected on transrectal ultrasound examination (not shown). (1.5 T Philips Gyroscan using the body coil.)

• Fig. 31.64 (A,B) Mucin-secreting adenocarcinoma of the prostate (straight arrows) extending through the capsule with a large right pelvic nodal metastasis (n) on transverse T2 -weighted spin-echo (SE 2000/100) images. Note the similar high signal from the primary prostatic tumour and nodal disease.

• Fig. 31.65 Stage T3a prostatic carcinoma extending through the capsule (arrow) posterolaterally to the left with involvement of the adjacent neurovascular bundle on a fat-suppressed transverse T 2 -weighted spin-echo (TSE 5000/11 7) image. (1.5 T IGE Horizon using a phased-array pelvic coil.)

• Fig. 31.66 Recurrent rectal carcinoma (t) infiltrating an enlarged prostate (p) from benign prostatic hypertrophy. b = bladder, curved open arrow = perforation into the perirectal fat space; straight arrows = thickened left perirectal fascia.