Eric S. Rovner

Endoluminal magnetic resonance imaging in the evaluation of urethral diverticula in women

OBJECTIVESnAccurate determination of the size and extent of urethral diverticula can be important in planning operative reconstruction and repair. Voiding cystourethrography (VCUG) is currently the most commonly used study in the preoperative evaluation of urethral diverticula. We reviewed our experience with the use of endoluminal (endorectal or endovaginal) magnetic resonance imaging (eMRI) in these patients as an adjunctive study to VCUG to evaluate whether the MRI provided anatomically important information that was not apparent on VCUG.nnnMETHODSnA retrospective analysis of all patients with a clinical diagnosis of urethral diverticula undergoing MRI at a single institution was performed. Patients were evaluated with history, physical examination, cystoscopy, VCUG, and eMRI. Endoluminal MRI was retrospectively compared to VCUG with respect to size, extent, and location found at operative exploration.nnnRESULTSnTwenty-seven consecutive patients underwent endorectal or endovaginal coil MRI in the evaluation of suspected urethral diverticula. Twenty patients subsequently had attempted transvaginal operative repair of the diverticulum. In 2 patients, eMRI demonstrated a urethral diverticulum, whereas VCUG did not. Operative exploration in these patients revealed a urethral diverticulum. In 14 of 27 patients, the VCUG underestimated the size and complexity of the urethral diverticulum as compared to eMRI and operative exploration. In 13 of 27 patients, the size, location, and extent of the urethral diverticulum on VCUG correlated well with the eMRI and/or operative findings.nnnCONCLUSIONSnWe have found endorectal and endovaginal coil MRI to be extremely accurate in determining the size and extent of urethral diverticula as compared to VCUG. This information can be critical when planning the approach, dissection, and reconstruction of these sometimes complex cases.

Angiomyolipoma of the renal sinus: diagnosis by percutaneous biopsy

We report a case of angiomyolipoma of the renal sinus discovered incidentally during an evaluation for microscopic hematuria. Diagnosis was confirmed by percutaneous aspiration biopsy performed with magnetic resonance imaging control allowing differentiation of this entity from other fatty tumors of the renal sinus including liposarcoma, lipoma, and sinus lipomatosis.

Magnetic resonance imaging of a “saddle bag” urethral diverticulum

A woman presented with pelvic pain and recurrent urinary tract infections 2 years after transvaginal repair of a urethral diverticulum, Martius flap, and pubovaginal fascial sling. Physical examination revealed a tender 2-cm anterior vaginal wall mass. Voiding cystourethrography (VCUG) demonstrated a urethral diverticulum with possible circumferential involvement of the urethra (“saddlebag”diverticulum)(Fig.1).Cystourethroscopy demonstrated a wide diverticular neck at the 4 o’clock position in the urethral lumen, approximately 1.5 cm from the bladder neck. Magnetic resonance imaging (MRI) with an endovaginal coil was performed to evaluate the postsurgical anatomy as well as the anterior extent of the diverticulum relative to the urethral lumen. There was no evidence of the previously placed fascial sling or Martius fat pad on the MRI scan. The fluid-filled diverticulum (Fig. 2, open arrows) was seen completely encircling the urethra, with the inner mucosal lining of the diverticulum adherent to the outer wall of the urethra. Figure 2 demonstrates the usual anatomic location of urethral diverticula, which often dissect between the two leaves of fascia comprising the urethropelvic ligament1 (Fig. 2, large solid arrows). The junction of the urethral lumen and the diverticular cavity (neck of the diverticulum [Fig. 2, small arrow]) is seen as a disruption in the circumferential continuity of the spongy tissue of the urethra in approximately the same location as seen on cystourethroscopy. In the sagittal plane (Fig. 3), the diverticulum appears to extend anterior and posterior to the urethra (large arrow) from near the bladder neck to beyond the midurethra in close proximity to both sphincteric areas. The potential compromise or damage to both proximal and distal continence mechanisms was an important consideration during the planned excision and reconstruction of this complex urethral diverticulum. The patient underwent transvaginal excision of the diverticulum with a partial urethrectomy, urethral reconstruction, Martius flap, and pubovaginal fascial sling. At exploration, the diverticulum was noted to completely encircle the urethra and was tightly adherent to the urethral wall, as noted on the MRI scan. Fortunately, the MRI scan predicted this occurrence, and a portion of the dorsal diverticular wall was preserved to facilitate construction of a segment of neourethra. Although the true incidence is unknown, urethral diverticula may occur in up to 1% to 6% of the population.1 Presentation is nonspecific but may include pain, dyspareunia, anterior vaginal wall mass, and recurrent urinary tract infection.2 The sensitivity and specificity of VCUG and MRI in the diagnosis of urethral diverticula have not been clearly delineated; however, MRI may be more sensitive in the diagnosis of complex urethral abnormalities.3 In cases where the diverticular neck is narrowed, inflamed, or edematous, or when the diverticulum is loculated, VCUG may underestimate the size and/or extent of the diverticulum because the contrast medium may not flow freely From the Division of Urology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania Reprint requests: Daniel S. Blander, M.D., Department of Urology, University of Texas-Southwestern Medical School, 5323 Harry Hines Boulevard, Dallas, TX 75235-9110 Submitted: February 2, 1998, accepted: September 18, 1998 FIGURE 1. Right posterior oblique voiding image demonstrating a urethral diverticulum with possible circumferential involvement of the urethra. IMAGES IN CLINICAL UROLOGY

Organ-sparing surgery for bilateral leydig cell tumor of the testis.

Leydig cell tumors of the testis are uncommon, and bilateral lesions are extremely rare. We report a case of bilateral Leydig cell tumor of the testis treated with radical orchiectomy and contralateral subtotal orchiectomy with the intent of preservation of hormonal function and fertility.

Pathophysiology and Classification of Voiding Dysfunction

The lower urinary tract functions as a group of inter-related structures whose purpose is to bring about efficient and low-pressure bladder filling, low-pressure urine storage with perfect continence (in the adult), and periodic voluntary urine expulsion (in the adult), again at low pressure. A simple way of looking at the pathophysiology of all types of voiding dysfunction will be presented, followed by a discussion of various systems of classification. Consistent with the author’s philosophy and prior attempts to make the understanding, evaluation, and management of voiding dysfunction as logical as possible (1), a functional and practical approach will be favored.

Extraperitoneal laparoscopic urethropexy with Marlex mesh

OBJECTIVESnExtraperitoneal laparoscopic urethropexy (ELU) has recently been developed as a minimally invasive procedure for the treatment of female stress urinary incontinence (SUI). Use of the laparoscopic stapling device and Marlex mesh in the extraperitoneal space may allow for a technically easier procedure and shorter operative times compared with other laparoscopic techniques without compromising long-term efficacy. We present our initial results and 2.5-year interim analysis with this alternative method of laparoscopic urethropexy.nnnMETHODSnTwenty-four consecutive patients with urodynamically demonstrated genuine SUI underwent attempted ELU at a single institution from December 1994 to December 1995. Operative data were collected from the patient chart, and follow-up data were obtained by telephone interview. Treatment was considered successful if, at last follow-up, a patient was using one or fewer pads daily and would recommend the procedure to a friend.nnnRESULTSnELU was completed in 22 of 24 patients. In 1 patient with a prior history of pelvic surgery, the preperitoneal space was not accessible. Of the 22 patients, 20 were available for follow-up. The mean operative time was 69 minutes. There were no intraoperative complications. At initial follow-up (mean 10.5 months), 18 (90%) of 20 patients reported subjective cure of SUI (one or fewer pads daily). At a mean follow-up of 29 months (range 23 to 34), 16 (80%) of 20 patients had subjective cure of SUI. Six patients would not recommend the procedure to a friend, all of whom had de novo urgency and/or urge incontinence. Thus, using our strict criteria, ELU was successful in 14 (70%) of 20 patients at a mean follow-up of 2.5 years. No patient has had permanent urinary retention.nnnCONCLUSIONSnELU can be performed rapidly and safely in patients without previous pelvic surgery. De novo urgency incontinence may be problematic. Future analysis of this subset of patients will determine whether this procedure is durable in the long term.

Clinical Application of Urologic Catheters, Devices and Products

Purpose The authors aim to equip the reader with a simple to reference text packed with clinical information on all types of urologic devices in a concise yet comprehensive fashion, which is unique compared to other urologic texts. This book gives the provider a basic understanding of the wide array of catheters, devices, and products, as well as indications for advanced applications of these items. The authors met their objectives while filling a necessary void in the urologic literature.