AJR 2005; 184:1889-1890
© American Roentgen Ray Society
Urethral Diverticulum: Diagnosis with Virtual CT Urethroscopy
Chen-Pin Chou1,
Jer-Shyung Huang1,
Chia-Cheng Yu2,
Huay-Ben Pan1,3 and
Fong-Dee Huang4
1 Department of Radiology, Kaohsiung Veterans General Hospital, 386 Ta-Chung 1st
Rd., Kaohsiung 813, Taiwan, Republic of China.
2 Department of Urology, Kaohsiung Veterans General Hospital, Taipei, Taiwan,
Republic of China.
3 National Yang-Ming University, School of Medicine, Taipei, Taiwan, Republic of
China.
4 Emergency Department, Kaohsiung Veterans General Hospital, Taipei, Taiwan,
Republic of China.
Received July 10, 2004;
accepted after revision August 26, 2004.
Address correspondence to C.-P. Chou
(r2207759{at}ms19.hinet.net).
Abstract
OBJECTIVE. A 26-year-old woman presented with urinary frequency.
Findings were negative on voiding cystourethrography. Cystourethroscopy failed
to reveal a urethral diverticulum. A new method of virtual CT urethroscopy was
performed using a 16-MDCT scanner. The orifice of the diverticulum was
identified clearly on 3D virtual urethroscopy. Intraoperatively, the
diverticulum was identified, with the orifice location compatible with that
seen on virtual urethroscopy.
CONCLUSION. Virtual CT urethroscopy provides more information than
conventional urethral examinations and is less invasive than conventional
urethroscopy.
Introduction
Recent advances in MDCT and 3D virtual endoscopy have led to a new
diagnosis technique for urinary tract disease
[1]. CT urethrography consists
of thin-section transverse images of voiding cystourethrography (VCUG) on high
scan speed. Virtual CT urethroscopy allows reformatted images to be viewed
interactively on a workstation. This imaging technique provides more
information than film radiography and is less invasive than conventional
urethroscopy.
A 26-year-old woman presented with urinary frequency and urgency on
micturition for 3 months. Physical examination revealed a tender mass anterior
to the wall of the vagina suggestive of infected urethral diverticulum.
Cystourethroscopy was performed after the infection was controlled, but it
failed to reveal the opening of urethral diverticulum. Findings were negative
on VCUG (Fig. 1A).
A new method of virtual urethroscopy was performed using a 16-MDCT scanner
(Somatom, Sensation 16, Siemens). After the patient emptied her bladder, a
12-gauge Foley catheter was inserted and 400 mL of diluted water-soluble
iodine contrast medium (Iopamiro 300 [iopamidol], Bracco Diagnostics) was
introduced. The Foley catheter was removed, and the patient assumed a prone
position on the CT table. The patient was asked to void during scanning. The
lower urinary tract was imaged with thin-section helical scanning
(collimation, 16 x 0.75 mm; reconstructed slice width, 1.0 mm; 512
x 512 matrix; 120 mA; 120 kVp; scanning time, 6 sec).
The helical CT volumetric data sets were transferred to a workstation
(Syngo, Siemens) with manufacturer-provided software that allows generation of
2D multiplanar reconstruction, 3D shaded-surface display, and virtual
endoscopy. With CT virtual endoscopic fly-through software, interactive
intraluminal navigation was performed from the urethra to the urinary bladder.
MR images also were obtained.
Results
The reconstruction coronal view allowed good visualization of the urethra,
horseshoe-shaped urethral diverticulum, and opening of the diverticulum
(Fig. 1B). The orifice of
diverticulum at the left side of urethral midportion was identified clearly
from the urethra to the urinary bladder on 3D virtual endoscopy
(Fig. 1C). A complex
hyperintense diverticulum surrounding the urethra was seen on axial
T2-weighted MR images (Fig.
1D). Intraoperatively, the orifice of the diverticulum was
identified, with the location compatible with that seen on virtual
urethroscopy. Transvaginal diverticulectomy was performed, and the urethral
defect was closed in layers.
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Fig. 1B. —26-year-old woman who presented with urinary frequency and
urgency on micturition for 3 months. CT reformatted coronal view shows
horseshoe-shaped urethral diverticulum near urinary bladder neck. Orifice of
diverticulum (arrow) also is seen.
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Fig. 1C. —26-year-old woman who presented with urinary frequency and
urgency on micturition for 3 months. Virtual CT urethroscopy image reveals
orifice (arrow) of diverticulum at left side and extraluminal mass
effect (arrowheads).
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Fig. 1D. —26-year-old woman who presented with urinary frequency and
urgency on micturition for 3 months. Coronal T2-weighted fast spin-echo image
shows hyperintense complex diverticulum (arrows) surrounding urinary
catheter (arrowhead).
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Discussion
Diverticula occur in approximately 0.6-6% of women
[2]. The diagnosis often is
delayed because the usual signs and symptoms of urethral diverticula are
nonspecific. Conventional radiographic techniques (i.e., VCUG and
positive-pressure urethrography) use contrast agents to visualize the
diverticular cavity [3].
Conventional radiographs are useful in evaluating the anatomy of the urethra
but are limited in the derangement of periurethral structures and soft-tissue
inflammatory reactions.
Conventional cystourethroscopy allows direct visualization of the
diverticulum orifice; however, the orifice may be missed, especially when an
inflammatory process or obstructed orifice exists
[4]. New MDCT provides a fast
scan speed; long scan-field, thin-section CT images; and simulated
visualization of organs equivalent to that with conventional endoscopy. Subtle
contrast medium communication of the urethra to diverticulum can be better
seen on CT.
Vining et al. [5] first
reported the use of virtual cystoscopy to detect bladder neoplasms in 1996. We
report the first case of virtual urethroscopy to diagnose urethra diverticulum
and identify its opening. Our results show that virtual cystourethroscopy can
visualize extraluminal anatomy and pathology better than conventional
cystourethroscopy. It also leads to less organ injury and patient pain and
discomfort than does rigid cystourethroscopy. Surgeons can use the virtual
images to plan surgery and determine diverticulum orientation on the
workstation rather than in the operating room. Additional studies with more
cases are needed to verify the clinical value of virtual CT urethroscopy.
References
- Song JH, Francis IR, Platt JF, et al. Bladder tumor detection at
virtual cystoscopy. Radiology2001; 218:95
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- Andersen MJ. The incidence of diverticula in the female urethra.
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female urethral diverticula. Int Urogynecol J Pelvic Floor
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- Romanzi LJ, Groutz A, Blaivas JG. Urethral diverticulum in women:
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J Urol 2000;164:428
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- Vining DJ, Zagoria RJ, Liu K, Stelts D. CT cystoscopy: an
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Abstract
Introduction
