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Cystourethrography as a Teaching Aid in Prostatic Surgery
Vol. 95, June Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright © 1966 by The Williams & Wilkins Co.
CYSTOURETHROGRAPHY AS A TEACHING AID IN PROSTATIC SURGERY A. M. BELKER, R.H. FLOCKS, D. A. CULP
AND
M.A. IMMERGUT
From the Department of Urology, State University of Iowa Hospitals, Iowa City, Iowa
Pre- and postoperative cystourethrograms are valuable teaching aids in prostatic surgery. The technique used at the University of Iowa was initially described by Flocks in 1933.1 While only a limited number of persons can visualize the prostatic anatomy endoscopically, cystourethrography allows a virtually unlimited number of examiners to assess the prostatic configuration. METHOD
A preoperative cystourethrogram is performed in the outpatient clinic when the patient is admitted to the hospital. Since it is desirable to detect the presence of vesicoureteral reflux the cystourethrogram is performed immediatel; prior to the excretory urogram. This order of procedure is reversed if the patient has only equivocal symptoms of bladder neck obstruction, in which instance an estimation of residual urine is made from the post-voiding excretory cystogram, thus avoiding instrumentation. If necessary, instrumentation then may be performed. A plain film of the abdomen (KUB) is obtained; (fig.1, A) a No. 18 or 20F catheter is inserted and residual urine is measured. A standard opaque cystogram in the anteroposterior position is then made using either 4 per cent sodium iodide or 20 per cent methiodal sodium (skiodan) as the contrast material. The bladder capacity, elevation and outline, in addition to the presence of reflux, are noted (fig. 1, B). The patient is placed in the right posterior oblique position (transverse axis of pelvis at an angle of 45 degrees to the table top), with the right thigh flexed and the left thigh straight. The opaque contrast material is completely washed from the bladder, the bladder is filled to capacity with air and another film is made. This film demonstrates any soft tissue shadow (due to intravesical prostatic enlargement) in the air-filled bladder (figs. 1, C and 2, A and C). Because an inflated catheter bulb could be mistaken for inAccepted for publication July 23, 1965. 1 Flocks, R. H.: The roentgen visualization of the posterior urethra. J. Urol., 30: 711-736, 1933.
travesical prostatic tissue by the novice, care is taken to deflate the bulb prior to the air cystogram. Following the air cystogram, the patient remains in the same position and the catheter is removed, taking care to compress the urethra from the time of catheter removal until the final film has been completed. This urethral compression prevents the patient from voiding the air between films. A final film is obtained as the last portion of 30 to 50 cc of a highly viscous contrast material is rapidly injected into the urethra. Contrast media of relatively low viscosity are not capable of adequately demonstrating the prostatic urethra. In contrast, the highly viscous contrast medium used for the final film in this procedure is capable of filling the prostatic urethra and maintaining its distended configuration for the time of the film exposure. In our institution, a medium locally termed tragacanth gel is used to make this film (fig. 3). It is prepared by mixing commercially available tragacanth powder, U.S.P. first with glycerin, the latter serving as a wetting agent. To this is added distilled water, benzalkoniurn. chloride (zephiran chloride) and propyliodione aqueous (dionosil), the latter being the contrast medium. The ingredients are mixed and autoclaved and packaged in 16-ounce containers. The completed mixture has an iodine content of approximately 5 per cent and is highly viscous. Since tragacanth gel occasionally can be irritating to the urothelium, we thoroughly wash it from the bladder after the final film has been obtained. A No. 18 or 20F catheter is used for this irrigation, since irrigation of the highly viscous material through smaller catheters becomes a somewhat laborious produre. The irritative property of tragacanth gel also causes us to omit its use in patients having significant hematuria or pyuria, as well as in those having acute inflammatory conditions within the urinary tract. If a urethral stricture is suspected from the history, or is found when the catheter is inserted, injecting and voiding urethrograms are performed using one of the standard low viscosity contrast media rather than tragacanth gel.
818
CYSTOURETHROGRAPHY FOR TEACHING PROSTATIC SURGERY
819
Fm. 1. All four films from same patient; prostate, 2 to 3 plus and benign. A, plain film shows small jackstone calculus. B, opaque cystogram shows relatively smooth bladder which is elevated, no reflux noted. C, air cystogram, marked intravesical protrusion of prostate. D, injecting urethrogram superimposed on air cystogram. Marked elongation from sphincteric impression to internal urethral orifice. Considerable spreading and lack of anterior angulation indicate enlargement confined to lateral lobes. Despite considerable intravesical growth, majority of this gland is located intraurethrally. (Postoperative results in same patient shown in figure 7, B.)
Recently we have used a commercially available highly viscous urethrographic contrast medium, thickened sodium acetrizoate (thixokon)*, to ascertain its value in the preoperative cystourethrogram. Its non-irritating property has been confirmed by others 2- 6 and the films pro-
* Supplied through the courtesy of Mallinckrodt Pharmaceuticals, St. Louis, Missouri. 2 Kaufman, J. J. and Russell, JVI.: Cystourethrography: Clinical experiences with the newer con-
duced are of good diagnostic quality. Therefore, we believe the medium is a satisfactory substitute for the occasionally irritating tragacanth gel. trast media. Amer. J. Roentgenol., 75: 884-892, 1956. 3 Kaufman, J. J.: Experiences with thixokon: An aqueous, thixotropic urethrographic medium. J. Urol., 78: 188-191, 1957. 4 Thompson, L M.: A safe contrast medium for urethrography. Amer. J. Roentgenol., 80: 627630, 1958. 5 Goddard, D. W.: Experiences with thixokon:
820
BELKER AND ASSOCIATES
Fm. 2. A and B, prostate 2 plus and benign: A, marked intravesical protrusion. B, spreading seen for only short distance above sphincter indicates small intraurethral lateral lobes. Marked anterior tilting of contrast material upon entry into bladder indicates large intravesical portion to be median lobe tissue. (Compare findings to those in figure 1.) C and D, prostate 3 plus and benign: C, marked intravesical protrusion. D, spreading and elongation of prostatic urethra are considerable. Absence of significant anterior angulation shows that entire intravesical portion, as well as small extravesical portion, is due to enlargement only of lateral lobes. (Postoperative results in same patient are shown in figure 8, A.)
After the positions of the external sphincter, verumontanum and vesical neck have been noted, the size and configuration of the prostate are estimated. Elongation of the prostatic urethra indicates enlargement due to benign hyperplasia The new urethrographic medium. J. Urol., 81: 225-,-226, 1959. 6 Glenn, J. F.: Thixokon cystourethrography. Amer. J. Roentgenol., 80: 631-634, 1958.
or carcinoma. Anterior angulation or tilting of the column of contrast material indicates median lobe or posterior commissural prostatic hyperplasia (fig. 2, B). Widening or spreading of the diameter of the prostatic urethra as compared to the normal indicates enlargement of the lateral lobes (figs. 1, D; 2, Band D; 4, A and 5, C) while narrowing and straightening occur both in carcinoma of the prostate and in prostatitis (fig. 6, A). A tooth-
CYSTOURETHROGRAPHY FOR TEACHING PROSTATIC SURGERY
821
Fm. 3. Normal tragacanth gel cystourethrograms; note width of pros ta tic urethra and distance from impressions of verumontanum and external sphincter to bladder neck. A, 13-year-old boy. B, 42-year-old diabetic with no clinical evidence of prostatic disease and normal prostate on examination. (From: The Urinary Tract. Edited by H. D. Kerr and C. L. Gillies. Chicago, Illinois: Year Book Medical Publishers, Inc., 1944. Used by permission of Year Book Medical Publishers.)
paste effect of the column of contrast material within the bladder is seen with bladder neck contractures (fig. 6, B). The postoperative cystourethrogram is simple to perform. The bladder is filled to capacity with 20 per cent methiodal sodium, the catheter is removed and 1 or 2 films are made as the patient voids in the right posterior oblique position. A post-voiding film completes the study. These films will demonstrate whether a well-funneled prostatic urethra has been obtained, the position of any residual tissue and the ability of the patient to empty his bladder (figs. 4, 5 and 7). The method of injecting cystourethrography with tragacanth gel may be used to obtain this same information postoperatively (fig. 8), but the voiding method is accomplished more simply and thei·efore has been adopted as a routine postoperative study. DISCUSSION
A simple method of evaluating prostatic size and configuration pre- and postoperatively has been demonstrated. The preoperative cystourethrogram differs from those obtained at other institutions in several respects. The oblique air cystogram is used to estimate the degree of intravesical prostatic protrusion. Others have used
highly viscous contrast media to demonstrate the prostatic urethra radiographically,2- 6 but have not taken advantage of visualizing the colunm of contrast material against the background of the air-filled bladder. Films taken without such a background often are of poor quality for visualizing the intraurethral and intravesical prostatic relationships. Pulmonary embolism due to the use of oily contrast media has been reported, 6 , 7 but we have had no occurence of this with the currently used tragacanth gel mixture. The aforementioned precautions and contraindications for this method of cystourethrography nevertheless must be followed. The teaching values of the preoperative cystourethrogram are apparent. Since any number of persons can visualize the prostatic anatomy, dis'cussion is stimulated among the residents and senior staff concerning the proper surgical approach for each particular case. The postoperative voiding cystourethrogram eliminates a second endoccopic procedure. The surgeon can determine if an adequate prostatectomy has been performed. If the prostatectomy is incomplete, 7 Crabtree, E. G.: Venous invasion due to urethrograms made with lipiodoL J. Ural., 57; 380-389, 1947.
822
BELKER AND ASSOCIATES
Fm. 4. A, preoperative cystourethrogram shows elongation and apparent straightening. Could be confused with carcinoma except that slight spreading instead of narrowing is present. Prostate 1 plus and benign. B, same patient following transurethral resection of 25 gm.; well-funneled prostatic urethra, voided freely. Histological examination showed benign hyperplasia. C, transurethral resection of 42 gm., indentation due to residual tissue at apex anteriorly and also at base posteriorly. D, transurethral resection of 21 gm., imperfect anatomical result, residual tissue on floor at base and perhaps anteriorly just below bladder neck. Functional result good and patient had no further surgery.
CYSTOURETHROGRAPHY FOR TEACHING PROSTATIC SURGERY
823
Fm. 5. A, following suprapubic prostatectomy and Y-V bladder neck plasty. Large, well-funneled prostatic urethra, patient voided freely. B, 3 months following simple retropubic prostatectomy (carcinoma found in specimen) and 1 month following instillation of radioactive gold into residual prostatic tissue. Patient had stress incontinence at this time, but later gained continence.No re3idual tissue seen. Note reflux into seminal vesicle. C and D, pre- and postoperative films of same patient, prostate 2 to 3 plus and benign: C, marked elongation and spreading indicate marked enlargement confined mainly to lateral lobes (confirmed at surgery). D, following combined snprapubic-retropubic prostatectomy of 205 gm.; note where posterior bladder neck was sutured to floor of prostatic urethra. Patient had stress incontinence when film was obtained 2 weeks postoperatively.
824
BELKER AND ASSOCIATES
Fm. 6. A, typical narrowing, elongation and straightening seen with carcinoma of prostate. B, toothpaste effect of contrast material within bladder. Prostate small and benign. Bladder neck contracture confirmed endoscopically and resected transurethrally with good results.
CYSTOURETHROGRAPHY FOR TEACHING PROSTATIC SURGERY
825
Fm. 7. A, postoperative voiding cystourethrogram after planned 2-stage transurethral resection of 97 gm. (55 and 42 gm.) of tissue demonstrates desired result. Large, smooth, concave and well-funneled prostatic urethra. Arrows show position of bladder neck. Patient voided freely with no residual urine. B, postoperative film of patient in figure 1, transurethral resection of 60 gm. followed by transurethral resection of another 10 gm. at time of delayed postoperative bleeding. Large, well-resected prostatic urethra, except for nubbin of residual tissue at apex anteriorly. Arrows show bladder neck. Patient voided freely and had no further operative procedures. C and D, voiding cystourethrograms on single patient: C, following transurethral resection of 55 gm. no filling of apical portion was noted, indicative of large amount of residual tissue in this area. D, following transurethral resection of another 33 gm., large, well-funneled prostatic urethra with no residual tissue was noted. Position of bladder neck easily seen. Patient voided freely after second procedure.
826
BELKER AND ASSOCIATES
Fm. 8. A, injecting tragacanth gel urethrogram in same patient shown in figure 2, C and D after transurethral resection of 85 gm. Good result.No residual tissue. B, injecting tragacanth gel urethrogram in another patient following transurethral resection of 36 gm. shows concave, well-funneled prostatic urethra and no residual tissue. the surgeon knows at once the areas that contain residual tissue. The postoperative voiding cystourethrogram also is of value to the staff in recogruzmg deficiencies in prostatic surgery as performed by residents and in advising about the correction of these deficiencies. A small amount of residual tissue in a patient who voids freely and has insignificant amounts of residual urine is not considered an indication for reoperation.
SUMMARY
Preoperative cystourethrography, utilizing an opaque cystogram, oblique air cystogram and a highly viscous urethrographic contrast medium against the background of an air cystogram, is a valuable adjunct to teaching the anatomy and configuration of prostatic diseases. Postoperative voiding cystourethrography offers an extremely simple means of accurately and rapidly assessing the results of prostatectomy. These methods have been extremely useful as teaching aids.
THE JOURNAL OF UROLOGY
Copyright © 1966 by The Williams & Wilkins Co.
CYSTOURETHROGRAPHY AS A TEACHING AID IN PROSTATIC SURGERY A. M. BELKER, R.H. FLOCKS, D. A. CULP
AND
M.A. IMMERGUT
From the Department of Urology, State University of Iowa Hospitals, Iowa City, Iowa
Pre- and postoperative cystourethrograms are valuable teaching aids in prostatic surgery. The technique used at the University of Iowa was initially described by Flocks in 1933.1 While only a limited number of persons can visualize the prostatic anatomy endoscopically, cystourethrography allows a virtually unlimited number of examiners to assess the prostatic configuration. METHOD
A preoperative cystourethrogram is performed in the outpatient clinic when the patient is admitted to the hospital. Since it is desirable to detect the presence of vesicoureteral reflux the cystourethrogram is performed immediatel; prior to the excretory urogram. This order of procedure is reversed if the patient has only equivocal symptoms of bladder neck obstruction, in which instance an estimation of residual urine is made from the post-voiding excretory cystogram, thus avoiding instrumentation. If necessary, instrumentation then may be performed. A plain film of the abdomen (KUB) is obtained; (fig.1, A) a No. 18 or 20F catheter is inserted and residual urine is measured. A standard opaque cystogram in the anteroposterior position is then made using either 4 per cent sodium iodide or 20 per cent methiodal sodium (skiodan) as the contrast material. The bladder capacity, elevation and outline, in addition to the presence of reflux, are noted (fig. 1, B). The patient is placed in the right posterior oblique position (transverse axis of pelvis at an angle of 45 degrees to the table top), with the right thigh flexed and the left thigh straight. The opaque contrast material is completely washed from the bladder, the bladder is filled to capacity with air and another film is made. This film demonstrates any soft tissue shadow (due to intravesical prostatic enlargement) in the air-filled bladder (figs. 1, C and 2, A and C). Because an inflated catheter bulb could be mistaken for inAccepted for publication July 23, 1965. 1 Flocks, R. H.: The roentgen visualization of the posterior urethra. J. Urol., 30: 711-736, 1933.
travesical prostatic tissue by the novice, care is taken to deflate the bulb prior to the air cystogram. Following the air cystogram, the patient remains in the same position and the catheter is removed, taking care to compress the urethra from the time of catheter removal until the final film has been completed. This urethral compression prevents the patient from voiding the air between films. A final film is obtained as the last portion of 30 to 50 cc of a highly viscous contrast material is rapidly injected into the urethra. Contrast media of relatively low viscosity are not capable of adequately demonstrating the prostatic urethra. In contrast, the highly viscous contrast medium used for the final film in this procedure is capable of filling the prostatic urethra and maintaining its distended configuration for the time of the film exposure. In our institution, a medium locally termed tragacanth gel is used to make this film (fig. 3). It is prepared by mixing commercially available tragacanth powder, U.S.P. first with glycerin, the latter serving as a wetting agent. To this is added distilled water, benzalkoniurn. chloride (zephiran chloride) and propyliodione aqueous (dionosil), the latter being the contrast medium. The ingredients are mixed and autoclaved and packaged in 16-ounce containers. The completed mixture has an iodine content of approximately 5 per cent and is highly viscous. Since tragacanth gel occasionally can be irritating to the urothelium, we thoroughly wash it from the bladder after the final film has been obtained. A No. 18 or 20F catheter is used for this irrigation, since irrigation of the highly viscous material through smaller catheters becomes a somewhat laborious produre. The irritative property of tragacanth gel also causes us to omit its use in patients having significant hematuria or pyuria, as well as in those having acute inflammatory conditions within the urinary tract. If a urethral stricture is suspected from the history, or is found when the catheter is inserted, injecting and voiding urethrograms are performed using one of the standard low viscosity contrast media rather than tragacanth gel.
818
CYSTOURETHROGRAPHY FOR TEACHING PROSTATIC SURGERY
819
Fm. 1. All four films from same patient; prostate, 2 to 3 plus and benign. A, plain film shows small jackstone calculus. B, opaque cystogram shows relatively smooth bladder which is elevated, no reflux noted. C, air cystogram, marked intravesical protrusion of prostate. D, injecting urethrogram superimposed on air cystogram. Marked elongation from sphincteric impression to internal urethral orifice. Considerable spreading and lack of anterior angulation indicate enlargement confined to lateral lobes. Despite considerable intravesical growth, majority of this gland is located intraurethrally. (Postoperative results in same patient shown in figure 7, B.)
Recently we have used a commercially available highly viscous urethrographic contrast medium, thickened sodium acetrizoate (thixokon)*, to ascertain its value in the preoperative cystourethrogram. Its non-irritating property has been confirmed by others 2- 6 and the films pro-
* Supplied through the courtesy of Mallinckrodt Pharmaceuticals, St. Louis, Missouri. 2 Kaufman, J. J. and Russell, JVI.: Cystourethrography: Clinical experiences with the newer con-
duced are of good diagnostic quality. Therefore, we believe the medium is a satisfactory substitute for the occasionally irritating tragacanth gel. trast media. Amer. J. Roentgenol., 75: 884-892, 1956. 3 Kaufman, J. J.: Experiences with thixokon: An aqueous, thixotropic urethrographic medium. J. Urol., 78: 188-191, 1957. 4 Thompson, L M.: A safe contrast medium for urethrography. Amer. J. Roentgenol., 80: 627630, 1958. 5 Goddard, D. W.: Experiences with thixokon:
820
BELKER AND ASSOCIATES
Fm. 2. A and B, prostate 2 plus and benign: A, marked intravesical protrusion. B, spreading seen for only short distance above sphincter indicates small intraurethral lateral lobes. Marked anterior tilting of contrast material upon entry into bladder indicates large intravesical portion to be median lobe tissue. (Compare findings to those in figure 1.) C and D, prostate 3 plus and benign: C, marked intravesical protrusion. D, spreading and elongation of prostatic urethra are considerable. Absence of significant anterior angulation shows that entire intravesical portion, as well as small extravesical portion, is due to enlargement only of lateral lobes. (Postoperative results in same patient are shown in figure 8, A.)
After the positions of the external sphincter, verumontanum and vesical neck have been noted, the size and configuration of the prostate are estimated. Elongation of the prostatic urethra indicates enlargement due to benign hyperplasia The new urethrographic medium. J. Urol., 81: 225-,-226, 1959. 6 Glenn, J. F.: Thixokon cystourethrography. Amer. J. Roentgenol., 80: 631-634, 1958.
or carcinoma. Anterior angulation or tilting of the column of contrast material indicates median lobe or posterior commissural prostatic hyperplasia (fig. 2, B). Widening or spreading of the diameter of the prostatic urethra as compared to the normal indicates enlargement of the lateral lobes (figs. 1, D; 2, Band D; 4, A and 5, C) while narrowing and straightening occur both in carcinoma of the prostate and in prostatitis (fig. 6, A). A tooth-
CYSTOURETHROGRAPHY FOR TEACHING PROSTATIC SURGERY
821
Fm. 3. Normal tragacanth gel cystourethrograms; note width of pros ta tic urethra and distance from impressions of verumontanum and external sphincter to bladder neck. A, 13-year-old boy. B, 42-year-old diabetic with no clinical evidence of prostatic disease and normal prostate on examination. (From: The Urinary Tract. Edited by H. D. Kerr and C. L. Gillies. Chicago, Illinois: Year Book Medical Publishers, Inc., 1944. Used by permission of Year Book Medical Publishers.)
paste effect of the column of contrast material within the bladder is seen with bladder neck contractures (fig. 6, B). The postoperative cystourethrogram is simple to perform. The bladder is filled to capacity with 20 per cent methiodal sodium, the catheter is removed and 1 or 2 films are made as the patient voids in the right posterior oblique position. A post-voiding film completes the study. These films will demonstrate whether a well-funneled prostatic urethra has been obtained, the position of any residual tissue and the ability of the patient to empty his bladder (figs. 4, 5 and 7). The method of injecting cystourethrography with tragacanth gel may be used to obtain this same information postoperatively (fig. 8), but the voiding method is accomplished more simply and thei·efore has been adopted as a routine postoperative study. DISCUSSION
A simple method of evaluating prostatic size and configuration pre- and postoperatively has been demonstrated. The preoperative cystourethrogram differs from those obtained at other institutions in several respects. The oblique air cystogram is used to estimate the degree of intravesical prostatic protrusion. Others have used
highly viscous contrast media to demonstrate the prostatic urethra radiographically,2- 6 but have not taken advantage of visualizing the colunm of contrast material against the background of the air-filled bladder. Films taken without such a background often are of poor quality for visualizing the intraurethral and intravesical prostatic relationships. Pulmonary embolism due to the use of oily contrast media has been reported, 6 , 7 but we have had no occurence of this with the currently used tragacanth gel mixture. The aforementioned precautions and contraindications for this method of cystourethrography nevertheless must be followed. The teaching values of the preoperative cystourethrogram are apparent. Since any number of persons can visualize the prostatic anatomy, dis'cussion is stimulated among the residents and senior staff concerning the proper surgical approach for each particular case. The postoperative voiding cystourethrogram eliminates a second endoccopic procedure. The surgeon can determine if an adequate prostatectomy has been performed. If the prostatectomy is incomplete, 7 Crabtree, E. G.: Venous invasion due to urethrograms made with lipiodoL J. Ural., 57; 380-389, 1947.
822
BELKER AND ASSOCIATES
Fm. 4. A, preoperative cystourethrogram shows elongation and apparent straightening. Could be confused with carcinoma except that slight spreading instead of narrowing is present. Prostate 1 plus and benign. B, same patient following transurethral resection of 25 gm.; well-funneled prostatic urethra, voided freely. Histological examination showed benign hyperplasia. C, transurethral resection of 42 gm., indentation due to residual tissue at apex anteriorly and also at base posteriorly. D, transurethral resection of 21 gm., imperfect anatomical result, residual tissue on floor at base and perhaps anteriorly just below bladder neck. Functional result good and patient had no further surgery.
CYSTOURETHROGRAPHY FOR TEACHING PROSTATIC SURGERY
823
Fm. 5. A, following suprapubic prostatectomy and Y-V bladder neck plasty. Large, well-funneled prostatic urethra, patient voided freely. B, 3 months following simple retropubic prostatectomy (carcinoma found in specimen) and 1 month following instillation of radioactive gold into residual prostatic tissue. Patient had stress incontinence at this time, but later gained continence.No re3idual tissue seen. Note reflux into seminal vesicle. C and D, pre- and postoperative films of same patient, prostate 2 to 3 plus and benign: C, marked elongation and spreading indicate marked enlargement confined mainly to lateral lobes (confirmed at surgery). D, following combined snprapubic-retropubic prostatectomy of 205 gm.; note where posterior bladder neck was sutured to floor of prostatic urethra. Patient had stress incontinence when film was obtained 2 weeks postoperatively.
824
BELKER AND ASSOCIATES
Fm. 6. A, typical narrowing, elongation and straightening seen with carcinoma of prostate. B, toothpaste effect of contrast material within bladder. Prostate small and benign. Bladder neck contracture confirmed endoscopically and resected transurethrally with good results.
CYSTOURETHROGRAPHY FOR TEACHING PROSTATIC SURGERY
825
Fm. 7. A, postoperative voiding cystourethrogram after planned 2-stage transurethral resection of 97 gm. (55 and 42 gm.) of tissue demonstrates desired result. Large, smooth, concave and well-funneled prostatic urethra. Arrows show position of bladder neck. Patient voided freely with no residual urine. B, postoperative film of patient in figure 1, transurethral resection of 60 gm. followed by transurethral resection of another 10 gm. at time of delayed postoperative bleeding. Large, well-resected prostatic urethra, except for nubbin of residual tissue at apex anteriorly. Arrows show bladder neck. Patient voided freely and had no further operative procedures. C and D, voiding cystourethrograms on single patient: C, following transurethral resection of 55 gm. no filling of apical portion was noted, indicative of large amount of residual tissue in this area. D, following transurethral resection of another 33 gm., large, well-funneled prostatic urethra with no residual tissue was noted. Position of bladder neck easily seen. Patient voided freely after second procedure.
826
BELKER AND ASSOCIATES
Fm. 8. A, injecting tragacanth gel urethrogram in same patient shown in figure 2, C and D after transurethral resection of 85 gm. Good result.No residual tissue. B, injecting tragacanth gel urethrogram in another patient following transurethral resection of 36 gm. shows concave, well-funneled prostatic urethra and no residual tissue. the surgeon knows at once the areas that contain residual tissue. The postoperative voiding cystourethrogram also is of value to the staff in recogruzmg deficiencies in prostatic surgery as performed by residents and in advising about the correction of these deficiencies. A small amount of residual tissue in a patient who voids freely and has insignificant amounts of residual urine is not considered an indication for reoperation.
SUMMARY
Preoperative cystourethrography, utilizing an opaque cystogram, oblique air cystogram and a highly viscous urethrographic contrast medium against the background of an air cystogram, is a valuable adjunct to teaching the anatomy and configuration of prostatic diseases. Postoperative voiding cystourethrography offers an extremely simple means of accurately and rapidly assessing the results of prostatectomy. These methods have been extremely useful as teaching aids.