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Complications of Prostate Cancer Treatment: Spectrum of Imaging Findings¹

¹ From the Departments of Radiology (C.M.Y., M.P.B., P.R.) and Surgery (Division of Urology) (M.P.B., E.S.R.), University of Pennsylvania Medical Center, One Silverstein, 3400 Spruce St, Philadelphia, PA 19104. Presented as an education exhibit at the 2003 RSNA scientific assembly. Received January 30, 2004; revision requested March 3 and received April 28; accepted May 5. All authors have no financial relationships to disclose. Address correspondence to M.P.B. (e-mail: marc.banner@uphs.upenn.edu).

View larger version (164K): [in a new window]   Figure 1.  Rectal injury during radical retropubic prostatectomy. The patient presented 3 months after surgery with pneumaturia and fecaluria. Voiding cystourethrogram demonstrates a rectovesical fistula (solid arrow) that originates from the region of the vesicourethral anastomosis (VUA). R = rectum.

View larger version (122K): [in a new window]   Figure 2a.  Intraoperative ureteral injury. (a) Pelvic computed tomographic (CT) scan shows a small urinoma (arrows) related to transection of the left ureter during pelvic lymph node dissection. The urinoma is seen adjacent to surgical clips. (b) Retrograde ureterogram shows contrast material extravasation (arrow) from the distal ureter into the urinoma. The obstructed left collecting system and ureter remain opacified from excretory urography performed the previous day. (c) Subsequent antegrade pyelogram demonstrates extravasation of contrast material at the site of ureteral transection (arrows), with no opacification of the distal ureter. The injury was surgically repaired and the ureter reimplanted into the bladder.

View larger version (112K): [in a new window]   Figure 2b.  Intraoperative ureteral injury. (a) Pelvic computed tomographic (CT) scan shows a small urinoma (arrows) related to transection of the left ureter during pelvic lymph node dissection. The urinoma is seen adjacent to surgical clips. (b) Retrograde ureterogram shows contrast material extravasation (arrow) from the distal ureter into the urinoma. The obstructed left collecting system and ureter remain opacified from excretory urography performed the previous day. (c) Subsequent antegrade pyelogram demonstrates extravasation of contrast material at the site of ureteral transection (arrows), with no opacification of the distal ureter. The injury was surgically repaired and the ureter reimplanted into the bladder.

View larger version (93K): [in a new window]   Figure 2c.  Intraoperative ureteral injury. (a) Pelvic computed tomographic (CT) scan shows a small urinoma (arrows) related to transection of the left ureter during pelvic lymph node dissection. The urinoma is seen adjacent to surgical clips. (b) Retrograde ureterogram shows contrast material extravasation (arrow) from the distal ureter into the urinoma. The obstructed left collecting system and ureter remain opacified from excretory urography performed the previous day. (c) Subsequent antegrade pyelogram demonstrates extravasation of contrast material at the site of ureteral transection (arrows), with no opacification of the distal ureter. The injury was surgically repaired and the ureter reimplanted into the bladder.

View larger version (152K): [in a new window]   Figure 3.  Postoperative lymphoceles. Pelvic CT scan demonstrates a small, right-sided lymphocele (arrow) and a large, bilobed left lymphocele (L) compressing the urinary bladder (B).

View larger version (78K): [in a new window]   Figure 4.  Catheter-related urethral stricture. Retrograde urethrogram obtained 2 months after radical retrograde prostatectomy demonstrates a stricture in the fossa navicularis (arrow).

View larger version (174K): [in a new window]   Figure 5a.  Encrusted bladder catheter. (a) Radiograph obtained 3 weeks after radical retrograde prostatectomy demonstrates a thin rim of peripheral calcification (arrows) on an inflated Foley catheter balloon within the urinary bladder. The tip of the catheter is also encrusted. Surgical clips are related to pelvic lymph node dissection. The balloon was deflated and the catheter uneventfully removed. (b) Radiograph of the pelvis obtained 9 months later shows a large bladder calculus that undoubtedly formed as a result of a nidus of calcific debris left behind when the Foley catheter was removed.

View larger version (170K): [in a new window]   Figure 5b.  Encrusted bladder catheter. (a) Radiograph obtained 3 weeks after radical retrograde prostatectomy demonstrates a thin rim of peripheral calcification (arrows) on an inflated Foley catheter balloon within the urinary bladder. The tip of the catheter is also encrusted. Surgical clips are related to pelvic lymph node dissection. The balloon was deflated and the catheter uneventfully removed. (b) Radiograph of the pelvis obtained 9 months later shows a large bladder calculus that undoubtedly formed as a result of a nidus of calcific debris left behind when the Foley catheter was removed.

View larger version (152K): [in a new window]   Figure 6a.  Anastomotic leak. (a) Voiding cystourethrogram obtained 10 days after radical retrograde prostatectomy demonstrates bilateral small, poorly marginated VUA leaks (arrows). (b) Voiding cystourethrogram obtained 10 days later shows that the leaks have resolved.

View larger version (143K): [in a new window]   Figure 6b.  Anastomotic leak. (a) Voiding cystourethrogram obtained 10 days after radical retrograde prostatectomy demonstrates bilateral small, poorly marginated VUA leaks (arrows). (b) Voiding cystourethrogram obtained 10 days later shows that the leaks have resolved.

View larger version (154K): [in a new window]   Figure 7a.  Anastomotic stricture. (a) Retrograde urethrogram obtained 3 months after radical retrograde prostatectomy demonstrates a tight stricture at the VUA (arrow). The stricture was successfully dilated with a high-pressure balloon catheter. (b) Retrograde urethrogram shows that the "waist" deformity of the almost completely inflated balloon at the stricture site (arrow) was effaced with continued inflation of the balloon (not shown).

View larger version (135K): [in a new window]   Figure 7b.  Anastomotic stricture. (a) Retrograde urethrogram obtained 3 months after radical retrograde prostatectomy demonstrates a tight stricture at the VUA (arrow). The stricture was successfully dilated with a high-pressure balloon catheter. (b) Retrograde urethrogram shows that the "waist" deformity of the almost completely inflated balloon at the stricture site (arrow) was effaced with continued inflation of the balloon (not shown).

View larger version (170K): [in a new window]   Figure 8.  Penile clamp for postprostatectomy urinary incontinence. Anteroposterior radiograph of the pelvis in a patient with florid postprostatectomy urinary incontinence shows a Baumrucker clamp applied to the distal part of the penis.

View larger version (116K): [in a new window]   Figure 9a.  Collagen injections for postprostatectomy urinary incontinence. (a) Voiding cystourethrogram obtained after the patient voided demonstrates a round, smoothly marginated filling defect at the bladder base (arrow), a finding that represents injected collagen around the vesicourethral junction. (b) Transrectal ultrasonographic (US) image depicts the periurethral collagen deposit as a hypoechoic round mass. (c) Axial fast spin-echo T2-weighted MR image shows periurethral collagen as well-circumscribed masses with intermediate signal intensity posterolateral to the urethra (U). (d) Coronal fast spin-echo T2-weighted MR image shows two periurethral deposits of collagen with intermediate signal intensity just inferior to the VUA (arrow). The midline structure inferior to the collagen deposits is the penile bulb (P, base of corpus spongiosum). (e) On a contrast material-enhanced CT scan, the collagen appears as a hypoattenuating round nodule (arrow) within the avidly enhancing penile bulb. Periurethral collagen may have been inadvertently injected into the penile bulb. (Figs 9c-9e reprinted, with permission, from reference 16.)

View larger version (190K): [in a new window]   Figure 9b.  Collagen injections for postprostatectomy urinary incontinence. (a) Voiding cystourethrogram obtained after the patient voided demonstrates a round, smoothly marginated filling defect at the bladder base (arrow), a finding that represents injected collagen around the vesicourethral junction. (b) Transrectal ultrasonographic (US) image depicts the periurethral collagen deposit as a hypoechoic round mass. (c) Axial fast spin-echo T2-weighted MR image shows periurethral collagen as well-circumscribed masses with intermediate signal intensity posterolateral to the urethra (U). (d) Coronal fast spin-echo T2-weighted MR image shows two periurethral deposits of collagen with intermediate signal intensity just inferior to the VUA (arrow). The midline structure inferior to the collagen deposits is the penile bulb (P, base of corpus spongiosum). (e) On a contrast material-enhanced CT scan, the collagen appears as a hypoattenuating round nodule (arrow) within the avidly enhancing penile bulb. Periurethral collagen may have been inadvertently injected into the penile bulb. (Figs 9c-9e reprinted, with permission, from reference 16.)

View larger version (165K): [in a new window]   Figure 9c.  Collagen injections for postprostatectomy urinary incontinence. (a) Voiding cystourethrogram obtained after the patient voided demonstrates a round, smoothly marginated filling defect at the bladder base (arrow), a finding that represents injected collagen around the vesicourethral junction. (b) Transrectal ultrasonographic (US) image depicts the periurethral collagen deposit as a hypoechoic round mass. (c) Axial fast spin-echo T2-weighted MR image shows periurethral collagen as well-circumscribed masses with intermediate signal intensity posterolateral to the urethra (U). (d) Coronal fast spin-echo T2-weighted MR image shows two periurethral deposits of collagen with intermediate signal intensity just inferior to the VUA (arrow). The midline structure inferior to the collagen deposits is the penile bulb (P, base of corpus spongiosum). (e) On a contrast material-enhanced CT scan, the collagen appears as a hypoattenuating round nodule (arrow) within the avidly enhancing penile bulb. Periurethral collagen may have been inadvertently injected into the penile bulb. (Figs 9c-9e reprinted, with permission, from reference 16.)

View larger version (148K): [in a new window]   Figure 9d.  Collagen injections for postprostatectomy urinary incontinence. (a) Voiding cystourethrogram obtained after the patient voided demonstrates a round, smoothly marginated filling defect at the bladder base (arrow), a finding that represents injected collagen around the vesicourethral junction. (b) Transrectal ultrasonographic (US) image depicts the periurethral collagen deposit as a hypoechoic round mass. (c) Axial fast spin-echo T2-weighted MR image shows periurethral collagen as well-circumscribed masses with intermediate signal intensity posterolateral to the urethra (U). (d) Coronal fast spin-echo T2-weighted MR image shows two periurethral deposits of collagen with intermediate signal intensity just inferior to the VUA (arrow). The midline structure inferior to the collagen deposits is the penile bulb (P, base of corpus spongiosum). (e) On a contrast material-enhanced CT scan, the collagen appears as a hypoattenuating round nodule (arrow) within the avidly enhancing penile bulb. Periurethral collagen may have been inadvertently injected into the penile bulb. (Figs 9c-9e reprinted, with permission, from reference 16.)

View larger version (173K): [in a new window]   Figure 9e.  Collagen injections for postprostatectomy urinary incontinence. (a) Voiding cystourethrogram obtained after the patient voided demonstrates a round, smoothly marginated filling defect at the bladder base (arrow), a finding that represents injected collagen around the vesicourethral junction. (b) Transrectal ultrasonographic (US) image depicts the periurethral collagen deposit as a hypoechoic round mass. (c) Axial fast spin-echo T2-weighted MR image shows periurethral collagen as well-circumscribed masses with intermediate signal intensity posterolateral to the urethra (U). (d) Coronal fast spin-echo T2-weighted MR image shows two periurethral deposits of collagen with intermediate signal intensity just inferior to the VUA (arrow). The midline structure inferior to the collagen deposits is the penile bulb (P, base of corpus spongiosum). (e) On a contrast material-enhanced CT scan, the collagen appears as a hypoattenuating round nodule (arrow) within the avidly enhancing penile bulb. Periurethral collagen may have been inadvertently injected into the penile bulb. (Figs 9c-9e reprinted, with permission, from reference 16.)

View larger version (139K): [in a new window]   Figure 10a.  Recurrent tumor after radical retropubic prostatectomy. (a) Axial spin-echo T1-weighted MR image obtained with an endorectal coil shows an oval mass (m) with intermediate signal intensity posterolateral to the bladder base. (b) Axial fast spin-echo T2-weighted MR image shows the mass (m) with high signal intensity. Recurrent prostatic adenocarcinoma was diagnosed at transrectal US-guided needle biopsy.

View larger version (137K): [in a new window]   Figure 10b.  Recurrent tumor after radical retropubic prostatectomy. (a) Axial spin-echo T1-weighted MR image obtained with an endorectal coil shows an oval mass (m) with intermediate signal intensity posterolateral to the bladder base. (b) Axial fast spin-echo T2-weighted MR image shows the mass (m) with high signal intensity. Recurrent prostatic adenocarcinoma was diagnosed at transrectal US-guided needle biopsy.

View larger version (127K): [in a new window]   Figure 11a.  Postprostatectomy urinary incontinence and a normally functioning AUS. (a) Anteroposterior radiograph of the pelvis demonstrates an inflated sphincter cuff (arrow), a connecting tube, a reservoir (R) filled with contrast material, and a radiopaque pump within the scrotum. (b) Voiding cystourethrogram demonstrates the expected appearance of the AUS with the sphincter cuff inflated, which impedes the passage of contrast material (and urine) beyond the cuff. (c) Anteroposterior radiograph of the pelvis shows the scrotal pump being squeezed, which deflates the sphincter cuff to allow micturition. (d) Voiding cystourethrogram demonstrates unimpeded passage of contrast material (arrow) through the deflated cuff. (e) Pelvic CT scan demonstrates the AUS cuff surrounding the urethra. Tubing is seen to the right of the cuff and in the scrotum.

View larger version (147K): [in a new window]   Figure 11b.  Postprostatectomy urinary incontinence and a normally functioning AUS. (a) Anteroposterior radiograph of the pelvis demonstrates an inflated sphincter cuff (arrow), a connecting tube, a reservoir (R) filled with contrast material, and a radiopaque pump within the scrotum. (b) Voiding cystourethrogram demonstrates the expected appearance of the AUS with the sphincter cuff inflated, which impedes the passage of contrast material (and urine) beyond the cuff. (c) Anteroposterior radiograph of the pelvis shows the scrotal pump being squeezed, which deflates the sphincter cuff to allow micturition. (d) Voiding cystourethrogram demonstrates unimpeded passage of contrast material (arrow) through the deflated cuff. (e) Pelvic CT scan demonstrates the AUS cuff surrounding the urethra. Tubing is seen to the right of the cuff and in the scrotum.

View larger version (158K): [in a new window]   Figure 11c.  Postprostatectomy urinary incontinence and a normally functioning AUS. (a) Anteroposterior radiograph of the pelvis demonstrates an inflated sphincter cuff (arrow), a connecting tube, a reservoir (R) filled with contrast material, and a radiopaque pump within the scrotum. (b) Voiding cystourethrogram demonstrates the expected appearance of the AUS with the sphincter cuff inflated, which impedes the passage of contrast material (and urine) beyond the cuff. (c) Anteroposterior radiograph of the pelvis shows the scrotal pump being squeezed, which deflates the sphincter cuff to allow micturition. (d) Voiding cystourethrogram demonstrates unimpeded passage of contrast material (arrow) through the deflated cuff. (e) Pelvic CT scan demonstrates the AUS cuff surrounding the urethra. Tubing is seen to the right of the cuff and in the scrotum.

View larger version (141K): [in a new window]   Figure 11d.  Postprostatectomy urinary incontinence and a normally functioning AUS. (a) Anteroposterior radiograph of the pelvis demonstrates an inflated sphincter cuff (arrow), a connecting tube, a reservoir (R) filled with contrast material, and a radiopaque pump within the scrotum. (b) Voiding cystourethrogram demonstrates the expected appearance of the AUS with the sphincter cuff inflated, which impedes the passage of contrast material (and urine) beyond the cuff. (c) Anteroposterior radiograph of the pelvis shows the scrotal pump being squeezed, which deflates the sphincter cuff to allow micturition. (d) Voiding cystourethrogram demonstrates unimpeded passage of contrast material (arrow) through the deflated cuff. (e) Pelvic CT scan demonstrates the AUS cuff surrounding the urethra. Tubing is seen to the right of the cuff and in the scrotum.

View larger version (152K): [in a new window]   Figure 11e.  Postprostatectomy urinary incontinence and a normally functioning AUS. (a) Anteroposterior radiograph of the pelvis demonstrates an inflated sphincter cuff (arrow), a connecting tube, a reservoir (R) filled with contrast material, and a radiopaque pump within the scrotum. (b) Voiding cystourethrogram demonstrates the expected appearance of the AUS with the sphincter cuff inflated, which impedes the passage of contrast material (and urine) beyond the cuff. (c) Anteroposterior radiograph of the pelvis shows the scrotal pump being squeezed, which deflates the sphincter cuff to allow micturition. (d) Voiding cystourethrogram demonstrates unimpeded passage of contrast material (arrow) through the deflated cuff. (e) Pelvic CT scan demonstrates the AUS cuff surrounding the urethra. Tubing is seen to the right of the cuff and in the scrotum.

View larger version (138K): [in a new window]   Figure 12.  AUS cuff erosion. Voiding cystourethrogram shows leakage of contrast material around a sphincter cuff (arrows), a finding that indicates cuff erosion through the periurethral soft tissues into the urethral lumen. Contrast material is also seen in the bladder and prostatic fossa.

View larger version (114K): [in a new window]   Figure 13.  Residual seminal vesicles after radical retropubic prostatectomy in a patient with an increasing PSA level. T2-weighted MR image obtained with an endorectal coil demonstrates residual seminal vesicles (arrow) as well as metallic clip artifacts.

View larger version (148K): [in a new window]   Figure 14.  Bladder neck contracture in a patient with brachytherapy seeds in the prostate. Simultaneous voiding cystourethrogram (performed through a suprapubic catheter) and retrograde urethrogram demonstrate a short bladder neck contracture (arrow).

View larger version (174K): [in a new window]   Figure 15.  Prostatorectal fistula in a patient who had undergone brachytherapy 1 year earlier and presented after having passed radioactive seeds from the rectum. Voiding cystourethrogram demonstrates a large prostatorectal fistula (arrow), with only four seeds remaining in situ. Left vesicoureteral reflux is also seen. P = prostatic fossa, R = rectum.

View larger version (174K): [in a new window]   Figure 16a.  Radiation-induced prostatosymphyseal sinus tract after transurethral prostatectomy. (a) Sagittal fast spin-echo T2-weighted MR image demonstrates a sinus tract from the prostatic fossa (containing a Foley balloon) to the pubic symphysis. (b) Voiding cystourethrogram also shows the sinus tract (arrow) as well as a contrast material-filled prostatic fossa, the anatomic residua of previously performed transurethral prostatic resection for benign disease. (c) CT scan (soft-tissue window) demonstrates a collection of contrast material and air extending from the pubic symphysis into the anterior abdominal wall. B = enhanced urinary bladder. (d) CT scan (bone window) demonstrates air tracking into the region of the pubic symphysis (arrows). The urinary bladder (B) contains a Foley catheter and is collapsed.

View larger version (144K): [in a new window]   Figure 16b.  Radiation-induced prostatosymphyseal sinus tract after transurethral prostatectomy. (a) Sagittal fast spin-echo T2-weighted MR image demonstrates a sinus tract from the prostatic fossa (containing a Foley balloon) to the pubic symphysis. (b) Voiding cystourethrogram also shows the sinus tract (arrow) as well as a contrast material-filled prostatic fossa, the anatomic residua of previously performed transurethral prostatic resection for benign disease. (c) CT scan (soft-tissue window) demonstrates a collection of contrast material and air extending from the pubic symphysis into the anterior abdominal wall. B = enhanced urinary bladder. (d) CT scan (bone window) demonstrates air tracking into the region of the pubic symphysis (arrows). The urinary bladder (B) contains a Foley catheter and is collapsed.

View larger version (129K): [in a new window]   Figure 16c.  Radiation-induced prostatosymphyseal sinus tract after transurethral prostatectomy. (a) Sagittal fast spin-echo T2-weighted MR image demonstrates a sinus tract from the prostatic fossa (containing a Foley balloon) to the pubic symphysis. (b) Voiding cystourethrogram also shows the sinus tract (arrow) as well as a contrast material-filled prostatic fossa, the anatomic residua of previously performed transurethral prostatic resection for benign disease. (c) CT scan (soft-tissue window) demonstrates a collection of contrast material and air extending from the pubic symphysis into the anterior abdominal wall. B = enhanced urinary bladder. (d) CT scan (bone window) demonstrates air tracking into the region of the pubic symphysis (arrows). The urinary bladder (B) contains a Foley catheter and is collapsed.

View larger version (101K): [in a new window]   Figure 16d.  Radiation-induced prostatosymphyseal sinus tract after transurethral prostatectomy. (a) Sagittal fast spin-echo T2-weighted MR image demonstrates a sinus tract from the prostatic fossa (containing a Foley balloon) to the pubic symphysis. (b) Voiding cystourethrogram also shows the sinus tract (arrow) as well as a contrast material-filled prostatic fossa, the anatomic residua of previously performed transurethral prostatic resection for benign disease. (c) CT scan (soft-tissue window) demonstrates a collection of contrast material and air extending from the pubic symphysis into the anterior abdominal wall. B = enhanced urinary bladder. (d) CT scan (bone window) demonstrates air tracking into the region of the pubic symphysis (arrows). The urinary bladder (B) contains a Foley catheter and is collapsed.

View larger version (164K): [in a new window]   Figure 17.  Radiation-induced osteitis in the same patient as in Figure 16. Anteroposterior radiograph of the pelvis shows osteopenia with patchy sclerosis due to radiation-induced osteitis around the pubic symphysis (arrows).

View larger version (134K): [in a new window]   Figure 18.  Misplaced brachytherapy seeds. Axial T1-weighted MR image obtained with an endorectal coil demonstrates brachytherapy seeds within the prostate. Several extraprostatic seeds are present in the perirectal fat (arrows). (Courtesy of Evan S. Siegelman, MD, Department of Radiology, University of Pennsylvania Medical Center, Philadelphia.)

View larger version (114K): [in a new window]   Figure 19a.  Calcified debris after cryoablation of the prostate. (a) Anteroposterior radiograph of the pelvis shows faintly calcified debris (arrows) in the region of the prostatic fossa behind the pubic symphysis. (b) Voiding cystourethrogram shows a large filling defect within the prostatic fossa (arrows), a finding that corresponds to the calcified necrotic debris.

View larger version (78K): [in a new window]   Figure 19b.  Calcified debris after cryoablation of the prostate. (a) Anteroposterior radiograph of the pelvis shows faintly calcified debris (arrows) in the region of the prostatic fossa behind the pubic symphysis. (b) Voiding cystourethrogram shows a large filling defect within the prostatic fossa (arrows), a finding that corresponds to the calcified necrotic debris.

View larger version (153K): [in a new window]   Figure 20.  Prostatorectal fistula after cryoablation of prostatic carcinoma. Voiding cystourethrogram shows a prostatorectal fistula. The rectum (R) enhanced shortly after the prostatic fossa (P) filled with contrast material. The clips were used for pelvic lymph node dissection.