Diagnosis of urethral diverticula in women: value of MR imaging

Imaging of urethral disease: a pictorial review

Retrograde urethrography and voiding cystourethrography are the modalities of choice for imaging the urethra. Cross-sectional imaging modalities, including ultrasonography, magnetic resonance (MR) imaging, and computed tomography, are useful for evaluating periurethral structures. Retrograde urethrography is the primary imaging modality for evaluating traumatic injuries and inflammatory and stricture diseases of the male urethra. Sonourethrography plays an important role in the assessment of the thickness and length of bulbar urethral stricture. Although voiding cystourethrography is frequently used to evaluate urethral diverticula in women, MR imaging is highly sensitive in the demonstration of these entities. MR imaging is also accurate in the local staging of urethral tumors.

Paraurethral leiomyoma in a female causing urinary obstruction

We report a case of paraurethral leiomyoma in a female patient, in which the first symptoms were dysuria and sensation of incomplete voiding. The physical examination revealed a mass in the anterior vaginal wall. The diagnosis was made through ultrasonography and pelvic MRI and confirmed by transvaginal ultrasound-guided needle biopsy. The surgical excision was accomplished without opening the urinary tract. A review of the relevant published studies and a suggestion for the appropriate management of these cases are included.

Transvaginal sonography in the diagnosis, management and follow-up of complex paraurethral abnormalities

Most urethral diverticula are thought to result from infection and obstruction of the paraurethral ducts and glands. When rupture of a resulting retention cyst or abscess occurs into the urethra, a diverticulum is formed. We report two cases of paraurethral abnormalities: urethral diverticulum and paraurethral abscess. Transvaginal sonography, with its high-resolution visualization of the lower urinary tract, may aid in the diagnosis and treatment of such disorders. Using three-dimensional technology, the internal architecture of the paraurethral abnormalities and their spatial relationship to the urethra and bladder, important considerations at surgery, are clearly demonstrated on ultrasonography. Complete excision of complex paraurethral anomalies may be performed under transvaginal sonographic monitoring without inadvertent injury to the bladder or urethra.

Pelvic Pain: Overlooked and Underdiagnosed Gynecologic Conditions

Chronic pelvic pain is a common, disabling problem among women. Although chronic pelvic pain can be produced by many conditions, some gynecologic causes are frequently overlooked and underdiagnosed, resulting in inappropriate referral and inadequate treatment. The gynecologic conditions most often unrecognized are endometriosis, adenomyosis, pelvic congestion, and less common congenital and acquired abnormalities. Transvaginal ultrasonography (US) is helpful for assessing endometriotic cysts but has a limited role in the diagnosis of adhesions or peritoneal implants. The classic magnetic resonance (MR) imaging features diagnostic of endometrioma are a cystic mass with high signal intensity on T1-weighted images and loss of signal intensity on T2-weighted images. When transvaginal US findings are suggestive of adenomyosis, MR imaging is used as the definitive imaging modality for diagnosis. High-resolution transvaginal US and MR imaging can help establish the diagnosis of adenomyosis with a high degree of accuracy, since the imaging appearance closely correlates with the histopathologic characteristics. Pelvic varices can be identified by using transvaginal US with color Doppler and Doppler spectral analysis. Three-dimensional T1 gradient-echo sequences performed after the intravenous administration of gadolinium are the most effective MR imaging sequence for demonstrating pelvic varices. Blood flow in pelvic varices appears with high signal intensity. Recent advances in radiologic imaging and therapeutic procedures make it possible to diagnose accurately the conditions producing chronic pelvic pain in most women and to guide effective treatment.

Urethral diverticula: a diagnostic dilemma

OBJECTIVE

To review the urethral diverticula encountered in a tertiary-referral urogynaecology unit.

PATIENTS AND METHODS

The case-notes of all women who had a diverticulectomy between March 1996 and May 2001 were reviewed. Demographic details, symptoms at presentation, duration of symptoms before diagnosis, investigations, operative details, postoperative complications and symptoms at follow-up were considered.

RESULTS

In all, 18 women had had a urethral diverticulectomy. The median (range) time from presentation to diagnosis was 9.5 (2-96) months. The symptoms before surgery were variable; after surgery there were significant improvements in the symptoms of frequency, terminal dribbling and recurrent urinary tract infections (P < 0.05). There was no improvement in urgency, urge incontinence, nocturia and stress incontinence. Eleven of the 18 diverticula were palpable on vaginal examination. Video cysto-urethrography was used in 15 women and the diverticulum was seen in 14. In addition, seven women had additional lower urinary tract pathology.

CONCLUSIONS

Urethral diverticula have no classical presentation; they often present with many symptoms and it is important that the diagnosis is not overlooked. Video cysto-urethrography is a good diagnostic test and allows the simultaneous evaluation of function of the whole of the lower urinary tract.

Female paraurethral cysts: experience of 25 cases

OBJECTIVE

To report and describe the diagnosis and treatment of female paraurethral cysts.

PATIENTS AND METHODS

Twenty-five cases of cysts of the external female genitalia were diagnosed over a 7-year period, using a physical examination, routine blood tests, urine analysis, abdominal ultrasonography and cysto-urethroscopy in all. The cysts were incised, drained and marsupialized; no attempt was made to excise or remove the internal wall of the cyst and it remained in situ.

RESULTS

All patients responded to simple marsupialization, with no recurrence of the cyst.

CONCLUSION

Cysto-urethroscopy and a limited laboratory and imaging evaluation were enough for the diagnosis.

[Female urethral diverticulum. Report of a case]

PURPOSE

We describe the successful repair of a large and complex urethral diverticulum in a female by transvaginal approach. Epidemiology, diagnostic methods, treatments and complications of female urethral diverticula are reviewed.

PATIENTS AND METHODS

A 35-year-old woman with a history of postvoid dribbling, dyspareunia and recurrent urinary tract infections for 4 months was referred. Magnetic resonance imaging demonstrated two fluido-filled collections in the pelvis of 3.5 and 1 cm in size respectively which may be a very large and complex diverticulum, however, Bartholin gland cyst could not be rule out. Cystourethroscopy revealed a urethral diverticulum at 10 mm from the bladder neck with two ostia. It was performed transvaginal diverticulectomy and an anterior vaginal wall flap was placed. The published literature on female urethral diverticula was identified using a Pubmed Medline search and analysed.

RESULTS

Convalescence was unremarkable. Suprapubic cystostomy tube was removed 2 weeks after surgery. The patient regained normal voiding. In the published literature there are no agreement neither in the diagnostic nor in the surgical techniques for female urethral diverticula.

CONCLUSIONS

Urethral diverticula are diagnosed with increasing frequency. However, this entity continues to be overlooked because the symptoms may mimic other disorders. Cystourethroscopy, retrograde urethrograme using a double balloon catheter and recently magnetic resonance imaging may diagnose this disease. The cure rate of urethral diverticula with appropriate surgical management has a range of 86-100%. Complete excision through the anterior vaginal wall is the most successful treatment modality with minimum postoperative complications.

Evaluation of lower urinary tract symptoms in females

PURPOSE OF REVIEW

Ongoing controversy exists as to the extent of the necessary evaluation of the female presenting with lower urinary tract symptoms. Most would agree that a detailed history, a physical examination and a urine analysis are essential components of the initial evaluation of lower urinary tract symptoms in the female. Beyond these assessments, however, there are no universally accepted guidelines or recommendations. In selected patients, a urodynamic, endoscopic and/or radiographic evaluation may be indicated. When further investigation of lower urinary tract symptoms is being considered, individual test characteristics, including sensitivity, specificity, reproducibility and accuracy, must be balanced against such factors as cost, morbidity, discomfort, availability and invasiveness. This review discusses some of the recent reports, controversies and developments in the evaluation of lower urinary tract symptoms in the female, and briefly reviews the most recent relevant International Continence Society subcommittee publications.

RECENT FINDINGS

The proceedings of the International Consultation on Incontinence, as well as recent publications by a number of its subcommittees, have provided some guidance for the structured evaluation of lower urinary tract symptoms in the female, especially with regard to the investigation of urinary incontinence. The role of urodynamics and radiographic imaging continues to be refined. Magnetic resonance imaging is, at present, still primarily a research tool in the evaluation of lower urinary tract disorders in the female; however, a clinical role for this technology is evolving.

SUMMARY

The goal of a diagnostic evaluation is the accurate characterization of lower urinary tract symptoms for the purposes of treatment. Ideally, a brief, low-cost, non-invasive evaluation would provide a high degree of diagnostic accuracy. However, existing technology is limited in this regard. Until future refinements permit a completely non-invasive, cost-effective and accurate analysis of female lower urinary tract symptoms, existing technology must be appropriately utilized. Well-conducted, evidence-based, prospective studies are needed.

Diagnosis and reconstruction of the dorsal or circumferential urethral diverticulum

PURPOSE

Uncommonly a saddlebag urethral diverticulum (UD) may extend circumferentially around the urethra dorsally or anteriorly with compromise of the adjacent tissues. Excision of the entire mucosalized surface of this type of UD may leave an extensive gap in the urethra. Unfortunately the full extent of a saddlebag UD is often not appreciated on preoperative imaging and it is only discovered intraoperatively when potential reconstructive flaps have already been compromised. The advent of endoluminal magnetic resonance imaging (eMRI) has provided outstanding preoperative staging that has greatly aided in the successful reconstruction of the cases. We present our experience with the diagnosis and reconstruction of these complex UDs.

MATERIALS AND METHODS

A review of 41 patients with UD at a single institution revealed 9 with circumferential involvement of the urethra confirmed on eMRI. All patients had voiding cystourethrography as the initial diagnostic modality. Four of the 9 patients had had at least 1 prior attempt at surgical repair elsewhere. Presenting symptoms included severe pain in 7 of the 9 patients, recurrent cystitis in 7, a vaginal mass in 2 and mixed urinary incontinence in 6. Eight of the 9 patients had undergone attempted surgical repair. Surgical reconstruction consisted of complete division of the urethra to access the dorsal wall of the UD with partial urethrectomy. Urethral continuity was restored by end-to-end urethroplasty in 5 patients and by tubularizing the dorsal (anterior) wall of the UD to construct a neourethral segment in 3. A Martius flap and pubovaginal sling were used selectively. Postoperatively voiding cystourethrography was performed in all patients to document absence of the UD. Self-administered patient questionnaires were completed preoperatively and postoperatively.

RESULTS

All patients report subjective relief of pain. Six of 8 patients did not use pads for incontinence. One patient used 2 to 3 pads daily for stress urinary incontinence symptoms and 1 had persistent urgency with rare incontinence, for which she used 1 pad daily. Complications included a distal urethrovaginal fistula in 1 patient and urethral stricture in 1.

CONCLUSIONS

Circumferential UD is an unusual problem. However, with the use of eMRI as a diagnostic and staging modality the incidence may be higher than previously realized. Preoperative knowledge of the extent of the UD is helpful in ensuring complete excision of the UD and optimizing urethral reconstruction. We conclude that excision and reconstruction of the circumferential UD is possible with excellent symptomatic and anatomical results.

Transvaginal ultrasound for the diagnosis of urethral diverticulum

PURPOSE

We reviewed our experience with urethral diverticula and transvaginal ultrasound to evaluate female patients with this condition.

MATERIALS AND METHODS

All female patients who underwent transvaginal ultrasound during evaluation for urethral diverticulum at our institution between May 1995 and April 2002 were identified by searching a data base. We reviewed the diagnostic evaluation and compared diagnostic techniques with transvaginal ultrasound for diagnosing urethral diverticulum.

RESULTS

Of the 25 patients with suspected urethral diverticulum who underwent transvaginal ultrasound as a diagnostic procedure 10 (40%) were diagnosed with urethral diverticulum, including 10 in whom it was confirmed by surgery or other diagnostic procedures. Transvaginal ultrasound was less expensive than the other diagnostic modalities and in no case did it miss a urethral diverticulum that was identified by another diagnostic technique. Urethral diverticulum was detected on 1 of 3 voiding cystourethrograms (33%) and this study missed the diagnosis in 1 case that was diagnosed by transvaginal ultrasound. Three cases of urethral diverticulum were noted on transvaginal ultrasound after they were missed by cystoscopy. Videourodynamics were unable to diagnose urethral diverticulum.

CONCLUSIONS

Transvaginal ultrasound is effective for evaluating patients with suspected urethral diverticulum. It is less expensive and may identify diverticula missed by other diagnostic modalities.

Dynamic MR imaging of female organ prolapse

MR imaging is a viable technique for evaluating pelvic organ prolapse. Dynamic imaging with adequate increase in abdominal pressure is necessary for a successful study. Rectal contrast for patient defecation is easy to administer and also allows for the diagnosis of rectal abnormalities. Additional work is needed on the soft tissue changes of prolapse and grading criteria for MR.

[The female urethral diverticula: apropos of 21 cases]

PURPOSE

Our goal is to study the clinical, radiological and therapeutic particularity of the female urethral diverticula via a retrospective study of 21 cases.

PATIENT AND METHODS

Twenty one females, with a mean age of 37 years (range 15 to 62 years) presenting an urethral diverticula, were treated between 1988 and 2000. Clinical examination made diagnosis in all cases. Cystorethrography shown a direct image of diverticula in 100% of cases and intravenous Pyelography in only 24% of cases. The urethral diverticula was excised via a transvaginal approach in all cases.

RESULTS

Eighteen patients had favourable immediate outcome. Three patients presented an urethrovaginal fistula treated surgically in one case and by bladder drainage in one case. The last patient refused treatment and she was lost to follow-up. After a median follow-up of 54 months (range 18 to 120) only three patients have some urinary urgency that was treated by anticholinergics.

CONCLUSION

Female urethral diverticula is a rare disease, the diagnosis is easy and only surgical excision gives good results.

Endoluminal sonography of the genitourinary and gastrointestinal tracts

OBJECTIVE

Endoluminal sonography with high-frequency catheter-based transducers is a technique well suited to imaging structures beyond the lumen of the hollow viscus. The purpose of this article was to review some aspects of endoluminal sonography, including instrumentation, clinical applications in the gastrointestinal and genitourinary tracts, and its three-dimensional reconstruction.

METHODS

The development of 6F to 10F catheter-based ultrasonic probes has made this technique available for use within a variety of lumina. Endoluminal sonography with frequencies of 9 to 20 MHz has been used for evaluation of a wide range of abnormalities in both the genitourinary and gastrointestinal tracts.

RESULTS

Uses in the gastrointestinal tract include quantification of esophageal varices, distinguishing between various submucosal lesions, and measuring the degree of fibrosis in scleroderma. In the genitourinary system, endoluminal sonography has been used to guide collagen injection, to diagnose urethral diverticula and upper tract neoplasms, to locate crossing vessels and septa for guiding endopyelotomy, and to identify submucosal calculi.

CONCLUSIONS

High-resolution endoluminal sonography is a new sonographic approach for evaluation of the genitourinary and gastrointestinal tracts. This should lead to the expansion of the diagnostic capabilities of sonography, providing important information for decision making relative to patient care and minimally invasive interventional procedures. Reconstructed three-dimensional endoluminal sonography has the potential to become a valuable tool in both the research and clinical areas.

Magnetic resonance imaging for urinary incontinence

Magnetic resonance imaging provides the most accurate, versatile and safe imaging of the pelvic floor. Images can be produced to show sections in any plane and even in three dimensions. The resolution is such that detail as good as that seen in histological sections is possible. Once standardization of data acquisition and patient positioning is agreed we look forward to a new era of increasingly accurate diagnoses of incontinence, allowing tailored management, both surgical and nonsurgical.

MR imaging of the male and female urethra

Conventional radiographic contrast material-enhanced studies (eg, retrograde urethrography [RUG], voiding cystourethrography [VCUG], double-balloon catheter urethrography) and ultrasonography are useful in evaluating the anatomy of the urethra but are limited in demonstrating anatomic derangement of adjacent structures. Since the anatomic details of both the urethra and periurethral tissues can be evaluated noninvasively with magnetic resonance (MR) imaging, this modality can be used as an adjunctive tool for evaluation of urethral abnormalities. In patients with congenital anomalies, MR imaging is reserved for cases of intersex anomalies or complex genitourinary anomalies, in which evaluation of internal organs is essential. MR imaging may demonstrate diverticula that are not seen on radiographic contrast-enhanced studies, including VCUG, RUG, or double-balloon catheter study. In cases of inflammation, MR imaging can demonstrate not only inflammatory infiltration around the urethra but also the presence of a periurethral abscess or sinus tract. In cases of trauma, MR imaging is helpful in assessing the presence and extent of anterior or posterior urethral injury and predicting the occurrence of complications. At MR imaging, a fistula can be seen as a direct communicating channel with an adjacent organ. In patients with urethral tumors, the major role of MR imaging is in local staging.

Prevalence of cystic paraurethral structures in asymptomatic women at endovaginal and perineal sonography

AIM

To prospectively assess the prevalence of paraurethral cystic structures in asymptomatic adult women.

PATIENTS AND METHODS

One hundred and forty consecutive women undergoing endovaginal sonography with no history of lower urinary tract symptoms.

RESULTS

Paraurethral cystic structures were identified in 4/140 subjects (2.9%). Ultrasound assessment allowed rapid definition of the site, size and vascularity of these lesions and was well tolerated by the patient.

CONCLUSION

This is the first prospective ultrasound study to determine the prevalence of paraurethral cystic structures in a large consecutive cohort of asymptomatic women. Our findings are in accordance with previously published post-mortem data and surgical series which have estimated the prevalence of paraurethral cystic structures to be between 1 and 6%.

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

OBJECTIVES

Accurate 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.

METHODS

A 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.

RESULTS

Twenty-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.

CONCLUSIONS

We 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.

Experience with endoluminal ultrasonography in the urinary tract

Ultrasonography has been an invaluable tool in the field of urology for its noninvasiveness, safety, and relatively low cost. However, examination of the ureter with ultrasound is difficult because of the distance of the transducer from the ureter and because of intervening structures such as nonconductive bowel gas. As smaller probes have become available, attempts have been made to apply them to endoluminal use. Endoluminal ultrasonography has been employed in urology to examine the proper placement of injected collagen, diagnose urethral diverticula, diagnose and stage upper tract transitional-cell carcinoma, locate crossing vessels to guide endopyelotomy, diagnose submucosal calculi, and examine the severity and length of ureteral strictures.

Symptomatic paraurethral corpus spongiosum cyst in a male patient

The case of a 25-year-old man presenting with lower urinary tract symptoms who was found to have a noninflammatory posterior corpus spongiosum cyst is presented. The case was successfully managed by surgical excision and presents an uncommon cause of lower urinary tract dysfunction through irritation of the posterior urethra.

MRI of the female pelvis

MRI is a proven modality to evaluate the female pelvis. Excellent soft tissue contrast, sensitivity for the detection of fluid, and the multiplanar imaging capabilities of MR allow noninvasive demonstration of normal anatomy and pathological processes. Most female pelvic MRI studies are performed to answer specific questions and must, therefore, follow carefully developed protocols, which are discussed in this article. The principal MRI techniques and strategies outlined in this work include: (1) the evaluation of reproductive dysfunction, anatomic variants; (2) specific obstetrical applications; (3) oncologic evaluation and tumor staging; (4) problem solving (i.e., the characterization of abnormalities detected by ultrasound); and (5) the evaluation of urethral disease.

2-D and 3-D endoluminal ultrasound: vascular and nonvascular applications

Endoluminal ultrasound using catheter-based transducers has been used for the evaluation of a wide range of abnormalities. To date, one of the most promising areas of clinical application is its use intravascularly for quantitating the degree of arterial stenosis and for monitoring the therapeutic effects of angioplasty in peripheral and coronary arteries. Uses in the gastrointestinal tract include quantification of the size and wall thickness of esophageal varices, distinguishing between various submucosal lesions and measuring the degree of fibrosis in scleroderma. In the genitourinary system, endoluminal ultrasound provides a unique intraoperative tool allowing the addition of a third dimension (depth) to endourological procedures. The indications for, and the use of, endoluminal ultrasound within the upper urinary tract can be expected to increase with more experience, and the procedure has become an important technique that yields information not available through other modalities. In the bronchotracheal tree, endoluminal ultrasound allows imaging and subsequent biopsy of lymph nodes and tumors that cannot be visualized at routine bronchoscopy. Three-dimensional (3-D) reconstruction of two-dimensional (2-D) ultrasound imaging is a new method in the evolution of intraluminal imaging. It provides information about spatial relationships of anatomic structures that cannot be evaluated using conventional 2-D imaging. Although still in its infancy, 3-D endoluminal ultrasound has the potential to become a dynamic tool in both the research and clinical areas.

Detection of urethral diverticula in women: comparison of a high resolution fast spin echo technique with double balloon urethrography

PURPOSE

We compared a rapid high resolution magnetic resonance imaging (MRI) technique to contrast urethrography for the detection of urethral diverticula in women.

MATERIALS AND METHODS

During a 19-month interval 13 patients with clinically suspected urethral diverticula were evaluated with MRI and contrast urethrography. All patients were referred by a urologist, and had clinical signs and symptoms suggesting the presence of a urethral diverticulum. Double balloon urethrography was performed in 12 patients and voiding cystourethrography was done in 1. MRI was performed using a fast spin echo T2-weighted pulse sequence and a dedicated pelvic multicoil. Following a sagittal localizer sequence 3 mm. thick axial sections were obtained from the bladder base through the entire urethra. Total imaging time was 15 minutes.

RESULTS

In 7 patients MRI and urethrography were negative for urethral diverticula, and in 3 cystourethroscopy was negative. In 1 patient MRI revealed a vaginal inclusion cyst confirmed by surgery. Three patients had no other studies or procedures performed. In 6 patients MRI was positive for urethral diverticula, including 4 in whom the diverticulum was confirmed at surgery, 1 who declined surgery and 1 who was lost to followup. Of the 4 patients (75%) with a surgically confirmed diverticulum double balloon urethrogram was negative in 3.

CONCLUSIONS

MRI is a valuable noninvasive technique for determining the presence of urethral diverticula as well as detecting other abnormalities. In our study MRI had a higher sensitivity for detecting diverticula and a much higher negative predictive rate.

Transrectal ultrasonography in the diagnosis of urethral diverticula in women

The diagnosis of urethral diverticula in women can be difficult. Several imaging modalities have been described for evaluating this entity: urethrography; transabdominal, transrectal, transvaginal, and transperineal ultrasonography; computed tomography (CT); and magnetic resonance (MR) can be helpful in evaluating a diverticulum and its relationship to the urethra. We report on four women aged 36 to 42 years with urethral diverticula. Transrectal ultrasonography (TRU) was the most useful diagnostic test in our series. TRU showed 7 urethral diverticula and provided information about its shape, volume, and content as well as its spatial relationship about its shape, volume, and content as well as its spatial relationship to the urethra. In two cases, multiple diverticula were detected when only a single lesion was clinically suspected. Transabdominal sonography failed to demonstrate small diverticula. CT examination did not provide additional information except for the passage of the contrast from the urethra to the diverticulum in one of the cases. Voiding cystourethrogram was positive in only one patient.

Computer assisted determination of the dose-area product in retrograde urethrography

Retrograde urethrography (RUG) is a dynamic radiological procedure in which the cumulative dose-area product (DAP) comprises radiation doses derived from both fluoroscopy and radiography. In the present prospective study, digital retrograde urethrographs (Prestilix 1600X/DRS, General Electric) were obtained in 40 consecutive male patients (mean age 60.6 years; range 23-88 years) presenting for evaluation of urinary pathology. The radiation dose was recorded as the dose-area product. From these data, a computer program (Diasoft 2.0, PTW, Freiburg, Germany) then determined the respective proportions of the total radiation dose deriving from fluoroscopy and radiography, as well as the number of radiographic exposures. The average total radiation dose was 316 cGy cm2. In five of the 40 patients examined (12.5%), the number of radiographic exposures registered by the program and, hence, the calculated DAPs were erroneous. In the remaining 35 patients, the average proportion of the cumulative DAP resulting from fluoroscopy was 81%, while that deriving from radiography was 19%. The computer program utilized in this study makes possible an intelligent evaluation of the DAP in dynamic procedures such as RUG. Since fluoroscopy is responsible for 81% of the cumulative DAP at RUG, a significant decrease in applied radiation dose may be achieved by reducing fluoroscopy time or by using pulsed fluoroscopy.

Giant Gartner duct cyst: magnetic resonance imaging findings

Gartner duct cysts derive from remnants of the vaginal portion of the mesonephric (Wolffian) ducts. In cases of incomplete regression of these ducts, cysts can develop due to secretory activity [1]. Clinically, those cysts are usually asymptomatic, their size not exceeding 2 cm in diameter. In rare cases with larger cysts, the presence of dyspareunia and problems in obstetric delivery are described [2, 3]. We present a case of a histologically proven symptomatic Gartner duct cyst with a size of 16 x 15 x 8 cm. To my knowledge, this is the largest Gartner duct cyst ever reported in the imaging literature.

Nephrogenic adenoma arising from a urethral diverticulum: magnetic resonance features

Nephrogenic adenoma is a rare benign tumor of the urinary tract. Although its most commonly arises within the urinary bladder, this tumor may also occur within a urethral diverticulum. We report the magnetic resonance imaging (MRI) findings of a nephrogenic adenoma arising within a urethral diverticulum in a 43-year-old woman. MRI appears to be helpful in showing the anatomic extent of the lesion as well as differentiating it from other anterior vaginal wall masses.

Intraoperative endo-luminal ultrasound evaluation of urethral diverticula

The imaging accuracy of a catheter-based endo-luminal ultrasound system was compared to traditional imaging techniques for surgical treatment of urethral diverticula in 7 women and 1 man. At surgical repair the urethra was catheterized directly with a 6.2F or 9F (12.5 or 20 MHz.) catheter-based ultrasound transducer, generating a 360-degree transaxial real-time image. The endo-luminal ultrasound images were compared with preoperative voiding cystourethrography (7 patients), transvaginal ultrasound examinations (3) and double balloon urethrograms (2). Surgical diverticulectomy was then done with endo-luminal ultrasound monitoring. Intraoperatively, all diverticula were well visualized by endo-luminal ultrasound, which demonstrated improved identification of the size and orientation of urethral diverticula, sludge within the diverticula, the extent of periurethral inflammation, diverticular wall thickness, and the distance between the diverticular wall and urethral lumen. In 3 patients the urethral connections of the diverticula were exceptionally well visualized. Comparison with traditional imaging revealed 2 false-negative and 1 false-positive voiding cystourethrograms, 1 false-negative transvaginal ultrasound study and 1 false-negative double balloon urethrogram. Intraoperative monitoring of the urethra enabled precise anatomical dissection, eliminated all diverticular components, and prevented inadvertent urethral and bladder neck injury. Urethral endo-luminal ultrasound is a valuable new adjunct in the evaluation of a variety of urethral abnormalities. This new ultrasound application permits visualization of the precise size, location, orientation and characteristics of urethral diverticula and surrounding tissues. Through enhanced imaging, surgical repair is facilitated. Further application of this technique should increase the diagnostic accuracy of urethral imaging beyond radiographic techniques currently available.

The role of magnetic resonance imaging in problematic gynecologic diagnoses

MRI is a modality that provides excellent anatomic detail, especially of soft tissue and bone. Comparison of T1-weighted and T2-weighted images offers significant diagnostic information of pelvic pathology. In five problematic gynecologic cases, magnetic resonance imaging (MRI) provided key information for optimal treatment planning or a definitive diagnosis for the gynecologist.