Radiologic Detection of Prostatic Carcinoma by Double Contrast Retrograde Urethrocystography

Vol. 114, November

THE JOURNAL OF UROLOGY

Printed in U.S.A.

Copyright© 1975 by The Williams & Wilkins Co.

RADIOLOGIC DETECTION OF PROSTATIC CARCINOMA BY DOUBLE CONTRAST RETROGRADE URETHROCYSTOGRAPHY WINSTAN WONG, T. SAITO

AND

H. OGAWA

From the Department of Surgical Urology, Toranomon Hospital, Tokyo, Japan

ABSTRACT

A method of radiologic visualization of the male urethra especially for detecting prostatic carcinoma is reported. This method is called double contrast retrograde urethrocystography and is similar to that of Flocks in combining air cystography and retrograde urethrography but it differs in the manner of making the exposure. In our method the exposure is made with the patient in an exaggerated Trendelenburg's position to allow the contrast medium injected into the bladder to accumulate at the dome. Thus, in the urethrocystogram obtained by this method, the bladder neck and the prostatic urethra immediately adjacent to it are always clearly visualized unlike that obtained by conventional retrograde urethrography, evacuation cystourethrography and sometimes even the method of Flocks, in which these regions are prone to be covered and masked by the contrast medium injected and accumulated in the bladder. Therefore, with our method the radiological detection and differentiation of the malignant lesion involving these regions are more accurate and definite. From our clinical experiences the mode of compression and displacement caused by benign prostatic hypertrophy is continuous and regular, while that caused by prostatic carcinoma is interrupted, irregular and with moth-eaten and granular defects. Four cases are reported. There are several radiological methods to evaluate lesions in the male urethra. Currently, retrograde urethrography and evacuation cystourethrography are used most commonly. The former method is designed to detect lesions at the anterior urethra, while the latter is designed to detect lesions at the posterior urethra. 1 Since there are difficulties in performing evacuation cystourethrography, retrograde urethrography is the most widely used technique, especially in the urological outpatient clinics. However, in both of these urethrograms the bladder neck and the prostatic urethra immediately adjacent to it often are not depicted clearly since they are either overlapped or covered by the contrast medium injected within the bladder. The method of Flocks in combining air cystography and retrograde urethrography has merit in this respect 2 but even with this method the bladder outlet is sometimes blurred by the injected contrast medium spraying over it. This blurred effect can be avoided by making the exposure with the patient in an exaggerated Trendelenburg's position. The urethrocystogram thus obtained would clearly depict the bladder outlet as well as its adjacent prostatic urethra and would make the detection and differentiation of the malignant lesion involving this region possible. Accepted for publication May 23, 1975. 746

Herein the technique of double contrast retrograde urethrocystography is described and 4 cases are reported. TECHNIQUE

With the patient on the x-ray table in the supine position catheterization is performed to evacuate any residual urine from the bladder and to introduce 200 to 300 ml. air. The x-ray table is then adjusted to the 20-degree head-down position. A syringe equipped with a plastic adaptor is filled with 30 ml. viscous, water soluble contrast medium (70 per cent endografin) and injected retrogradely from the external urethral meatus. When half of the injection is given slight pressure is applied on the piston of the syringe to quicken the speed of injection and an anteroposterior exposure is made. In case a comparison is needed the content of the bladder is evacuated again and an oblique retrograde urethrogram is made. Figure 1, A is a normal double contrast retrograde urethrocystogram and B is its schematic drawing. In a normal double contrast retrograde urethrocystogram the injecting stream, bladder neck, verumontanum and the prostatic, membranous, bulbous and pendulous urethra are depicted. Therefore, any lesion which would cause a deformity in the bladder neck and its adjacent prostatic urethra can be easily detected.

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CASE REPORTS

and 30 gm. of the hypertrophic prostatic tissue were removed. The histopathologic report was benign. Case 2. A 57-year-old man had stage IV prostatic carcinoma. When he was first examined the serum acid phosphatase was 22.3 King-Armstrong units and the alkaline phosphatase was 40 KingArmstrong units. A retrograde urethrogram and double contrast retrograde urethrocystogram were made on the first visit (fig. 3, A and B). After 2 months of hormonal therapy• the serum acid phosphatase level decreased to 0.6, while the

Case 1. A 60-year-old man with benign prostatic hypertrophy underwent conventional retrograde urethrography and double contrast retrograde urethrocystography (fig. 2). The smooth and even nature of compression and displacement are much more finely depicted in the double contrast retrograde urethrocystogram and indicate a benign lesion. The bladder neck is displaced and transformed into an umbrella-like structure. Subsequently, retropubic prostatectomy was performed

B

INJECTIN STREAM

--PENDULOUS URETHRA

Fm. 1. A, normal double contrast retrograde urethrocystogram. B, labeled schematic drawing of normal double contrast retrograde urethrocystogram. J

Fm. 2. Benign prostatic hypertrophy. A, retrograde urethrogram. B, double contrast retrograde urethrocystogram reveals continuous and regular compression and displacement at bladder neck and prostatic urethra.

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FIG. 3. Stage IV prostatic carcinoma. A, retrograde urethrogram. B, double contrast retrograde urethrocystogram reveals moth-eaten defects and irregular compression at bladder neck. C, double contrast retrograde urethrocystogram after 2 months of hormonal therapy.

alkaline phosphatase increased to 56 King- togram at this time. Note that only the irregularly Armstrong units. Another double contrast retro- broken down bladder neck in the double contrast grade urethrocystogram was made at this time (fig. retrograde urethrocystogram shows the malignant 3, C). Note that only the double contrast retro- lesion infiltrating this region (fig. 4, B). Note also grade urethrocystogram gives the impression of the that the bladder neck has begun to reform its shape malignant lesion. The bladder neck is irregularly after 1 month of hormonal therapy (fig. 4, C). displaced and has moth-eaten defects (fig. 3, B). Case 4. A 63-year-old man had stage II prostatic However, this malignant sign disappeared after carcinoma. On his initial examination the acid hormonal therapy (fig. 3, C). phosphatase level was 7.0 King-Armstrong units Case 3. A 74-year-old man had stage III to IV and the alkaline phosphatase was 6. 7. A retrograde prostatic carcinoma. The serum acid phosphatase urethrogram and a double contrast retrograde level was 12 and the alkaline phosphatase was 20 urethrocystogram were made at this time (fig. 5, A King-Armstrong units on initial laboratory exami- and B). The acid phosphatase level decreased to nation. A retrograde urethrogram and a double 0.8 King-Armstrong units after 1 month of hormocontrast retrograde urethrocystogram were made nal therapy. A double contrast retrograde ureat this time (fig. 4, A and B). After 1 month of throcystogram made at this time is shown in figure hormonal therapy the acid phosphatase level de- 5, C. In this case although there is a spreading sign creased to 0.8 King-Armstrong units but the alka- at the prostatic urethra in the retrograde urethroline phosphatase remained at 21. Figure 4, C gram only the moth-eaten defects seen in the shows the double contrast retrograde urethrocys- double contrast retrograde urethrocystogram con-

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FIG. 4. Stage III to IV prostatic carcinoma. A, retrograde urethrogram. B, double contrast retrograde urethrocystogram reveals bladder neck broken down, delineating malignant lesion. C, double contrast retrograde urethrocystogram after 1 month of hormonal therapy.

firm malignancy. Figure 5, C shows the moth-eaten defects at the prostatic urethra beginning to disappear after hormonal therapy. Subsequently, total retropubic prostatectomy was performed and intraoperative macroscopic and postoperative histopat~ological findings confirmed the clinical diagnosis. DISCUSSION

Retrograde urethrography and evacuation cystourethrography are important tests in the evaluation of male urethral lesions. Retrograde urethrography is currently the most widely used study in the urological outpatient clinics. However, both of these techniques have the same The bladder outlet and the prostatis urethra immedito it are often co-;Ter2d the

contrast medium injected into the bladder in the urethrogram obtained by these methods. The method of Flocks in combining the air cystogram and retrograde urethrogram has done much to promote visualization of the prostatic urethra and the bladder outlet. However, this method clearly depicts the prostatic urethra but not always the bladder outlet since the contrast medium injected into the bladder may diffuse back to cover and overlap with that depicting the bladder outlet, making it unavailable for detailed evaluation of the lesion involving this region. This impediment can be avoided by making the exposure with the patient in a head-down position. In this way the contrast medium may accumulate at the dome of the the bladder

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FIG. 5. Stage II prostatic carcinoma. A, retrograde urethrogram with sign of compression at prostatic urethra. B, double contrast retrograde urethrocystogram reveals moth-eaten defects at prostatic urethra in addition to compressing sign. C, double contrast retrograde urethrocystogram after 1 month of hormonal therapy.

For the far advanced clinical prostatic carcinoma, when the complete prostatic gland and the bladder outlet have been involved or have been transformed into a mass of bony hard body, conventional urethrography might be able to detect and to differentiate it from the benign lesion. However, when the malignant lesion is still comparatively small and is still localized within the prostatic tissue or is infiltrating only a small area of the bladder outlet, which is prone to be covered, the detection of it is sometimes difficult and is apt to be overlooked with conventional urethrography. However, there would be no difficulty in detecting and differentiating such a lesion with the use of the double contrast retrograde urethrocystography method, since it visualizes and provides not only

the signs of compression and displacement but also the nature of these signs. From our clinical experiences to date the modes of compression and displacement caused by benign prostatic hypertrophy are continuous, thinning and spreading out regularly and evenly without interruption and any uneven defect, while those caused by prostatic carcinoma are interrupted, irregular, with motheaten and granular defects. It is true that the diagnosis of prostatic carcinoma can be established with the findings of rectal prostatic palpation, serum acid phosphatase level, 4 local biopsy and so forth without taking into account the value of roentgenography. Nevertheless, as the rate of occurrence of prostatic carcinoma has recently drawn increasing attention

RADIOLOGIC DETECTION OF PROSTATIC CARCINOMA

among urologists, this double contrast retrograde urethrocystography would do much to promote a more definite and accurate x-ray diagnosis. REFERENCES

1. Emmett, J. L. and Witten, D. M.: Clinical Urology, 3rd ed. Philadelphia: W. B. Saunders Co., vol. I, p. 63, 1971. 2. Emmett, J. L. and Witten, D. M.: Clinical Urology, 3rd ed. Philadelphia: W. B. Saunders Co., vol. I, p. 67, 1971. 3. Campbell, M. F. and Harrison, J. H.: Urology, 3rd ed.

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Philadelphia: W. B. Saunders Co., vol. 2, p. 1173, 1970. 4. Campbell, M. F. and Harrison, J. H.: Urology, 3rd ed. Philadelphia: W. B. Saunders Co., vol. 2, p. 1162, 1970. COMMENT The authors have convincingly illustrated the value of their modification of the standard technique of air cystography and retrograde urethrography. The new method indeed provides superior visualization of the bladder neck and prostatic urethra. S.SJS.