DOI:10.2214/AJR.05.1319
AJR 2007; 189:W292-W294
© American Roentgen Ray Society
Pseudoaneurysm of the Pudendal Arteries Complicating Cystoprostatectomy: Diagnosis with MDCT Angiography
Jennifer K. Chen1,
Pamela T. Johnson2 and
Elliot K. Fishman2
1 Johns Hopkins University School of Medicine, Baltimore, MD 21287-0801.
2 Russell H. Morgan Department of Radiology and Radiological Science, Johns
Hopkins University School of Medicine, 601 N. Caroline St., Room 3251,
Baltimore, MD 21287.
Received July 29, 2005;
accepted after revision October 6, 2005.
Address correspondence to P. T. Johnson
(pjohnso5{at}jhmi.edu).
WEB
This is a Web exclusive article.
Keywords: CT angiography • MDCT • pelvic imaging
Introduction
Cystoprostatectomy is frequently performed on patients with highly invasive
carcinoma of the prostate or transitional cell carcinoma of the bladder
[1]. Other less common
indications include severe radiation cystitis, urinary incontinence as the
result of a small fibrotic bladder, and uncontrollable hematuria. The common
complications of cystoprostatectomy include wound infection, anastomotic
insufficiency, pulmonary embolism, deep venous thrombosis, prolonged ileus,
and abscess [2]. We describe a
rare case in which cystoprostatectomy resulted in formation of a
pseudoaneurysm of the pudendal arteries. The diagnosis was made with 16-MDCT
angiography with 3D reconstructions.
Case Report
A 69-year-old man presented with gross hematuria, and his condition was
diagnosed as extensively infiltrating high-grade transitional cell carcinoma
of the bladder. Cystopanendos-copy confirmed the existence of a sessile tumor
in the bladder trigone. As a result of these findings, the patient underwent
cystoprostatectomy with ileal conduit reconstruction, and a flat in situ
urothelial carcinoma was found at the ureter margins. In the postoperative
period, the patient became hypotensive and oliguric, and the hemoglobin
concentration decreased to 7.9 g/dL. He had melanotic stools, and endoscopy
revealed two large bleeding gastric ulcers, which were fulgurated. Although
the hematocrit decreased again, the level stabilized after additional
transfusion. The patient remained afebrile and was discharged 15 days after
cystoprostatectomy.
Sixteen days after discharge, the patient was readmitted with recurrent
fevers despite use of antibiotics and antipyretic medication. He was treated
with IV antibiotics and underwent 16-MDCT (Sensation 16, Siemens Medical
Solutions). Scan parameters were 0.6-mm detector collimation, 0.75-mm slice
thickness, 225 mAs, 120 kVp, data reconstruction at 0.5-mm intervals.
Unenhanced, arterial, and delayed phase acquisitions were obtained. Arterial
phase images were obtained 25 seconds after IV injection of 120 mL of iohexol
(Omnipaque 350, GE Healthcare) at a rate of 3 mL/s. All data were transferred
to a workstation (Leonardo with InSpace software, Siemens Medical Solutions).
Three-dimensional volume-rendered and maximum-intensity-projection
reconstructions were made interactively.
MDCT revealed a tubular teardrop-shaped 4-cm pseudoaneurysm at the surgical
site near the surgical clips (Figs.
1A,
1B,
1C,
1D). The lesion appeared to
arise from the internal pudendal arteries, although it was difficult to
ascertain whether there was involvement of both vessels or only the right. A
10 x 14 cm hematoma surrounding the pseudoaneurysm was identified, and
there was evidence of active extravasation. The next day, a pelvic angiogram
confirmed the presence of a bilateral pseudoaneurysm of the internal pudendal
arterial branches, fed from a branch of the right obturator artery. The
patient underwent successful coil embolization. The fevers resolved, and 1
week later the patient underwent percutaneous drainage of the pelvic
collection. At the same time, CT confirmed successful embolization of the
pseudoaneurysm (Figs. 1E and
1F). After drain removal 2
weeks later, the patient made an uneventful recovery.
View larger version (139K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1A —69-year-old man after cystoprostatectomy for bladder cancer
and postoperative fever of unknown origin. Axial contrast-enhanced 16-MDCT
scan shows pelvic hematoma with 4-cm collection (arrow), compatible
with pseudoaneurysm.
|
|
View larger version (141K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1B —69-year-old man after cystoprostatectomy for bladder cancer
and postoperative fever of unknown origin. Coronal multiplanar reconstruction
shows cephalocaudal extent of pseudoaneurysm arising from perineal region and
large surrounding hematoma.
|
|
View larger version (87K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1C —69-year-old man after cystoprostatectomy for bladder cancer
and postoperative fever of unknown origin. Coronal 3D CT maximum intensity
projection confirms presence of 4-cm ovoid pseudoaneurysm arising from right
internal pudendal artery (arrow). It was difficult to ascertain on CT
whether left pudendal artery was involved. Pelvic arteriogram (not shown)
revealed bilateral pudendal artery involvement.
|
|
View larger version (146K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1E —69-year-old man after cystoprostatectomy for bladder cancer
and postoperative fever of unknown origin. Coronal multiplanar reconstruction
of unenhanced follow-up MDCT scan obtained 10 days after embolization shows
residual contrast material from previous studies in region of pseudoaneurysm
and surrounding hematoma.
|
|
View larger version (142K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1F —69-year-old man after cystoprostatectomy for bladder cancer
and postoperative fever of unknown origin. Coronal volume rendering of
contrast-enhanced follow-up MDCT scan obtained 10 days after embolization
shows no enhancement of pseudoaneurysm, confirming successful treatment. Large
surrounding hematoma is evident.
|
|
Discussion
Pseudoaneurysms occur when an arterial puncture site fails to seal and
forms a pulsatile hematoma [3].
These lesions become contained within a shell formed by the hematoma and
overlying tissue and commonly manifest as a thrill, bruit, hematoma, or marked
pain or tenderness [3]. In
cases of pudendal artery pseudoaneurysm, patients may also have penile
ecchymosis, perineal swelling, or hemorrhage into the perineum
[4]. Pudendal artery
pseudoaneurysms have been associated with endorectal prostate biopsy, blunt
pelvic trauma, ischial pressure wound with secondary infection, and
penetrating gluteal trauma
[4].
We report an unusual case of pseudoaneurysm secondary to cystoprostatectomy
that emphasizes the need for physicians to remain alert for signs of a
vascular lesion after pelvic surgery. The consequences of missing such lesions
include complications such as rupture, distal embolization, local skin
ischemia, neuropathy, and local pain
[3]. Sonography is most
commonly used in pseudoaneurysm diagnosis because it can depict the
characteristic blood flow pattern. One study
[5], however, has shown that
duplex sonography may have limitations in the detection of small
pseudoaneurysms of the proximal extremities and in correct localization of
identified lesions. Deep in the pelvic or perineal region, sonography can have
a limited acoustic window, and cross-sectional techniques may perform
better.
In this case, MDCT angiography was used to make the diagnosis. MDCT
angiography has many benefits, including being rapid, accurate, and relatively
operator independent [6]. MDCT
angiography is both less invasive and less expensive than conventional
angiography, the reference standard, although the latter offers the
opportunity for therapeutic intervention. In one study
[7], MDCT angiography had a
sensitivity of 95.1% and a specificity of 98.7% in the detection of vascular
lesions, including pseudoaneurysms, of the proximal parts of the extremities.
Although there are limited statistical data about the efficacy of MDCT
angiography with regard to vascular lesions of the pelvis, the findings in
this case suggest that MDCT angiography is a useful diagnostic imaging
technique for elucidating vascular abnormalities involving the smaller vessels
of the pelvis. Our findings are supported by a previous case report describing
the use of contrast-enhanced CT to good effect in the visualization of a
pudendal artery pseudoaneurysm
[8].
In summary, we report an unusual case in which cystoprostatectomy resulted
in formation of a pseudoaneurysm of the pudendal arteries. The findings in the
case illustrate the need for physicians to consider vascular complications
involving the perineum in patients undergoing bladder and prostate surgery who
have postoperative signs or symptoms of blood loss. The excellent resolution
afforded by 16-MDCT enabled detailed diagnostic evaluation sufficient for
pretreatment planning.
Acknowledgments
We thank Leo Lawler for his assistance in editing the manuscript.
References
- Gheiler EL, Wood DP Jr, Montie JE, Pontes JE. Orthotopic urinary
diversion is a viable option in patients undergoing salvage cystoprostatectomy
for recurrent prostate cancer after definitive radiation therapy.
Urology 1997; 50:580
–584[CrossRef][Medline]
- Leissner J, Stein R, Hohenfellner R, et al. Radical
cystoprostatectomy combined with Mainz pouch bladder substitution to the
urethra: long-term results. BJU Int 1999;83
: 964–970[CrossRef][Medline]
- Eisenberg L, Paulson EK, Kliewer MA, Hudson MP, DeLong DM, Carroll
BA. Sonographically guided compression repair of pseudoaneurysms: further
experience from a single institution. AJR1999; 173:1567
–1573[Abstract]
- Hanash KA, Al-Shammari M, Mokhtar AA, AlGhamdi A. Posttraumatic
pseudoaneurysm of the pudendal artery successfully managed with embolization.
J Urol 2002; 168:1498
–1499[CrossRef][Medline]
- Edwards JW, Bergstein JM, Karp DL, et al. Penetrating proximity
injuries: the role of duplex scanning—a prospective study. J
Vasc Technol 1993; 17:257
–261
- Novelline RA, Rhea JT, Rao PM, Stuk JL. Helical CT in emergency
radiology. Radiology 1999;213
: 321–339[Abstract/Free Full Text]
- Soto JA, Munera F, Morales C, et al. Focal arterial injuries of the
proximal extremities: helical CT arteriography as the initial method of
diagnosis. Radiology 2001;218
: 188–194[Abstract/Free Full Text]
- Yekeler E, Ziylan O, Erol B, Numan F, Ander H. Pseudoaneurysm of
the bulbourethral branch of the internal pudendal artery presenting as a
urethral pseudodiverticulum in a child. Pediatr Radiol2004; 34:435
–437[CrossRef][Medline]
CiteULike 
Complore 
Connotea 
Del.icio.us 
Digg 
Reddit 
Technorati What's this?
Top
Introduction
Case Report
