Measuring diagnostic accuracy of imaging parameters in pelvic lipomatosis

Cystitis glandularis: MR imaging characteristics in 27 patients

PURPOSE

To explore the diagnostic characteristics of cystitis glandularis (CG) using magnetic resonance imaging (MRI).

MATERIALS AND METHODS

A retrospective study was conducted on pathologically confirmed patients who underwent bladder MRI examination between January 2019 and November 2023. Image analysis was jointly conducted, with emphasis on lesion location, morphology, size, signal intensity, and pattern of enhancement, by two genitourinary radiologists with 22 and 15 years of experience, respectively.

RESULTS

A total of 27 patients with 27 lesions were included (median age 47 years, 24 males). The lesions were mostly located in the bladder trigone area (18/27). The lesions could be categorized as focal thickening (17/27), nodular (8/27), and diffuse thickening of the entire bladder (2/27) in morphological terms. On T2-weighted imaging (T2WI), 15 of 17 focal thickening lesions appeared as a slightly hyperintense thickened inner layer, with a higher signal in the center of the thickened inner layer, resembling a sandwich sign, and 6 of 8 nodular lesions were slightly hyperintense. On T1-weighted imaging (T1WI), 19 patients showed slight hypointensity. The lesions on DWI showed mainly high (5/27) and slightly high signal (21/27), with an average mean apparent diffusion coefficient (mADC) value of 2.171 ± 0.052 × 10-3mm2/s. Among the 23 patients who underwent dynamic contrast-enhanced (DCE) scanning, 18 lesions showed mild enhancement in the arterial phase (average 1.7 times comparing to unenhanced phase), and the degree of enhancement gradually increased in the venous and delayed phases (average 2.2 and 2.3 times compared to the unenhanced phase, respectively), showing a progressive enhancement pattern.

CONCLUSION

On MRI, the majority of CG manifest as focal thickening or nodules in the bladder trigone area, showing slight hyperintensity on T2WI, slight hypointensity on T1WI, and a progressive enhancement pattern, without significant restriction on DWI. Focal thickening lesions may exhibit a special sandwich sign.

Pelvic lipomatosis-a rare diagnosis and a challenging management: a case report and literature review

Pelvic lipomatosis (PL) involves nonmalignant excess fat growth in perirectal and perivesical areas, gaining recognition over three decades. This review addresses its clinicopathological aspects amid controversies, emphasizing the need for a comprehensive examination of current literature. This report outlines a 42-year-old man's diagnostic journey for persistent urological symptoms, ultimately identified as PL. PL, if untreated, adversely impacts the urinary system, affecting kidney function and causing systemic complications. Management involves accurate diagnosis through radiological methods and surgical intervention, aiming to alleviate symptoms and enhance affected individuals' quality of life.

Ultrasound Urodynamics: A Review of Ultrasound Imaging Techniques for Enhanced Bladder Functional Diagnostics

Purpose of Review

Invasive urodynamics are currently used to diagnose disorders of bladder function. However, due to patient discomfort as well as artifacts induced by catheters and non-physiologic filling, less invasive screening tools that can improve diagnostic information, such as ultrasound are required. The purpose of this review is to assess different modalities of ultrasound as applied to functional bladder imaging. This information will help guide future studies in the use of ultrasound during urodynamics.

Recent Findings

Recently, multiple studies have employed ultrasound to evaluate bladder volume, wall thickness, shape, vibrometry, elastography, compliance, biomechanics, and micromotion during urodynamics. These new techniques have used both 2D and 3D ultrasound techniques to evaluate bladder changes during filling. Continued research is needed to confirm ongoing findings prior to widespread incorporation into clinical practice.

Summary

This review demonstrates the potential use of ultrasound as an adjunct to urodynamics for the diagnostic evaluation of functional bladder disorders.

Ureteral reimplantation for the management of pelvic lipomatosis

Introduction

Pelvic lipomatosis is a rare benign disease characterized by urethral elongation, bladder deformity, and/or hydronephrosis. Conservative management is not effective, and urinary diversion is the most effective treatment option but is usually unacceptable for relatively young patients. Ureteral reimplantation seemed to be an appropriate modality under these conditions. We present one case in which pelvic lipomatosis was managed with ureteral reimplantation.

Patient presentation

A 45-year-old, previously healthy man presented with right flank pain. Pelvic CT and CT urography showed excessive pelvic fat, bilateral hydronephrosis, tortuous ureters, and a pear-shaped bladder, all of which indicated a diagnosis of pelvic lipomatosis. We performed laparoscopic bilateral urinary tract infection on this patient. At follow-up, bilateral hydronephrosis and flank pain were greatly relieved.

Conclusion

Pelvic lipomatosis can be managed safely and effectively by urinary tract infection, but longer follow-up periods are needed to evaluate the long-term efficacy of this approach.

Bladder Sparing Extirpation of Pelvic Mass With Ureteral Reimplantation: A Case Report on Pelvic Lipomatosis Treatment

Pelvic lipomatosis is a proliferative disease characterised by excessive fat growth in retroperitoneal space leading to inadequate bladder drainage and ureteral compression. Cystitis glandularis, cystitis cystica, or cystitis follicularis can be found in the majority of patients with the disease. We report a case of a 63-year-old man diagnosed outside our hospital with pelvic lipomatosis after finding a pelvic mass behind the bladder causing severe bilateral hydronephrosis. A bladder-sparing excision of the pelvic lipomatosis mass with bilateral ureteric reimplantation was performed, thereby avoiding the need for urinary diversion. Our case supports the hypothesis that pelvic fat mass extirpation and ureteral reimplantation is an effective surgical treatment strategy for pelvic lipomatosis.

Pelvic lipomatosis with cystitis glandularis managed with cyclooxygenase-2 inhibitor: A case report

BACKGROUND

Pelvic lipomatosis (PL) is a rare benign condition with characteristic overgrowth of histologically benign fat and invasion and compression of pelvic organs, often leading to non-specific lower urinary tract symptoms (LUTS). Approximately 40% of patients with PL have cystitis glandularis (CG). The cause of PL combined with CG is poorly understood, and there is currently no effective treatment. Refractory CG with upper urinary tract obstruction even requires partial or radical bladder resection.

CASE SUMMARY

In this case, a patient suffering from PL with CG was treated by transurethral resection of bladder tumour (TUR-BT) and oral administration of celecoxib, a selective cyclooxygenase-2 (COX-2) inhibitor. The LUTS were alleviated, and the cystoscopy results improved significantly. Immunohistochemistry showed up-regulated COX-2 expression in the epithelium of TUR-BT samples, suggesting that COX-2 may participate in the pathophysiological process of PL combined with CG.

CONCLUSION

We report for the first time that celecoxib may be an effective treatment strategy for PL combined with refractory CG.

Diagnostic accuracy of CT imaging parameters in pelvic lipomatosis

PURPOSE

To predict the diagnosis of pelvic lipomatosis (PL) by assessing CT imaging parameters.

METHODS

Fifty clinically proven PL patients and 50 controls were included. Two radiologists recorded the types of bladder shapes and measured the following CT imaging parameters: (1) pelvic fat volume (PFV); (2) a set of morphological indices of bladder and rectosigmoid, including the ratio of craniocaudal to anterior-posterior length of bladder (CC/AP), angle between anterior and posterior wall (AAP), relative length of posterior urethra (rLPU), right and left angles between bladder and seminal vesicle (RABS and LABS), distance from verumontanum to anterior wall of rectum (DVR) and rectosigmoid morphological index (RMI). Secondary complications were also noted.

RESULTS

The results were evaluated by an unpaired t test, ROC analysis and logistic regression. All CT imaging parameters except RMI (p = 1.000) indicated a statistical difference between PL and controls (p < 0.01). The AUCs of these parameters were between 0.724 (for rLPU) and 0.993 (for AAP). The sensitivity and specificity were 94% and 98% for AAP and 92% and 94% for the combined model, respectively. 23 patients were pathologically diagnosed with cystitis glandular. The incidence of hydronephrosis in the PL group was higher than that in the control group (p < 0.01).

CONCLUSION

CT imaging parameters can predict the diagnosis of PL. The combined model of objective parameters including PFV, rLPU and DVR showed the best diagnostic performance for PL.

Difficult cystoscopy due to "Elongated" urethra- think of pelvic lipomatosis

Pelvic lipomatosis is a rare, proliferative disease with unknown etiology involving an overgrowth of normal fat in the pelvic retroperitoneal space. ^1-5 Cystitis glandularis or cystitis cystica can be observed in 75% of patients with pelvic lipomatosis. ⁵ We describe a 44-yr-old chronic smoker with suspicion of bladder mass who was referred to us following an inconclusive cystoscopy due to an "elongated” urethra and was later diagnosed to be a case of pelvic lipomatosis with cystitis cystica. Because the association of this condition with bladder adenocarcinoma and the possibility of obstructive uropathy later, we have kept the patient on close follow-up.

Robotic Management of Pelvic Lipomatosis-Experience with Difficulties Encountered and the Techniques to Successful Outcomes

Background

Pelvic lipomatosis (PL) is a rare condition characterized by diffuse pelvic overgrowth of nonmalignant but infiltrative adipose tissue in perivesical and perirectal space.

Objective

To share our robotic experience and difficulties encountered and suggested techniques to overcome them successfully. It is the first series from India.

Design, setting, and participants

A prospective observational study was conducted. All consecutive patients diagnosed with PL between 2016 and 2019 underwent robotic-assisted wide bladder fat extirpation and bilateral ureteral reimplantation (extravesical refluxing type) with double J stenting and were evaluated prospectively.

Outcome measurements and statistical analysis

Demographics, serum creatinine level, radiographic features, postoperative complications, and patient-reported outcomes were evaluated. Continuous variables are presented as median and range, as the sample size is very small.

Results and limitations

We encountered a total of five patients with PL. The median console time was 126 (range 120–130) min, with a median estimated blood loss of 120 (range 100–150) ml. Postoperative complications were Clavien-Dindo grade I in three cases, and the median hospital stay was 2 d. Distal ureteric margins showed subepithelial edema with submucosal fibrosis, and bladder fat biopsies were reported as adipose tissue with hemorrhage. At initial 3-mo and annual follow-ups, all patients had normal serum creatinine and there was no evidence of disease recurrence. Limitations of our study are the very small sample size (a low incidence of PL) and short follow-up time period (the question of how long the surgical effect will be sustained due to abnormal proliferation of fat cells remains unanswered).

Conclusions

Robotic management of wide bladder fat extirpation and bilateral ureteral reimplantation with double J stenting has a good success rate and good outcome in PL.

Patient summary

Pelvic lipomatosis is a very rare condition. Robotic management in treating the condition has good outcome for the patient. Here, we have discussed the difficulties encountered in treating the condition and the techniques used to overcome them.

Surgical treatment for pelvic lipomatosis using a bladder-sparing technique: A STROBE-compliant study

The aim of this study was to report the experience and long-term efficacy of a novel surgical treatment for pelvic lipomatosis (PL) using a combination of pelvic fat mass extirpation and ureteral reimplantation.Data of 8 patients with PL who underwent pelvic fat mass extirpation and ureteral reimplantation at our hospital from September 2010 to March 2018 were retrospectively reviewed. Demographics, serum creatinine level, radiographic changes, perioperative complications, and patient-reported outcomes were evaluated.Surgeries were performed successfully without severe perioperative complications in all 8 patients. Median operating time was 150 minutes with a median estimated blood loss of 75 mL. Patients were discharged after a median of 8.5 postoperative days. Imaging studies at the first follow-up revealed varying extents of alleviation of hydronephrosis and 3 patients' urinary symptoms were gradually relieved after surgery. During a median follow-up of 48.5 months (range, 10-100 months), all patients exhibited excellent surgical outcomes without evidence of disease progression, except 1 patient who underwent radical cystectomy with Bricker ileal conduit surgery due to hydronephrosis recurrence in the 49th postoperative month.Based on these cases, pelvic fat mass extirpation and ureteral reimplantation is a safe and effective surgical treatment for PL.

Use of Ultrasound Urodynamics to Identify Differences in Bladder Shape Between Individuals With and Without Overactive Bladder

OBJECTIVES

The objective of this study was to identify differences in bladder shape changes between individuals with overactive bladder (OAB) and unaffected individuals during ultrasound urodynamics.

METHODS

A prospective urodynamic study was performed with concurrent transabdominal ultrasound (ultrasound urodynamics) on individuals with and without OAB based on validated International Consultation on Incontinence Questionnaire - OAB survey scores. Three-dimensional ultrasound images were acquired at 1-minute increments during filling and used to measure bladder diameters in the height, width, and depth orientations. The engineering strain for each diameter was compared between participants with OAB and controls during urodynamic filling. The height-to-width ratio at capacity was used to determine if individuals were shape outliers.

RESULTS

A total of 22 subjects were enrolled, including 11 with OAB and 11 without OAB. During urodynamic filling in both groups, the greatest degree of geometric strain was found in the height orientation, indicating that bladders generally fill in a craniocaudal shape. The mean ± SD height-to-width ratio of the control group was 1.06 ± 0.12 yielding a 95% confidence interval of 0.82 to 1.30. Five (45.5%) of 11 OAB subjects had height-to-width ratios outside this interval as compared with none of the control subjects, identifying a potential shape-mediated subgroup of OAB.

CONCLUSIONS

Three-dimensional ultrasound urodynamics can be used to identify differences in bladder shape comparing individuals with and without OAB. This method may be used to identify a subset of OAB patients with abnormal bladder shapes which may play a role in the pathophysiology of their OAB symptoms.

Multimodality Imaging Review of Anorectal and Perirectal Diseases with Clinical, Histologic, Endoscopic, and Operative Correlation, Part II: Infectious, Inflammatory, Congenital, and Vascular Conditions

A broad spectrum of pathology affects the rectum, anus, and perineum, and multiple imaging modalities are complementary to physical examination for assessment and treatment planning. In this pictorial essay, correlative imaging, endoscopic, pathologic, and operative images are presented for a range of rectal, perirectal, and perineal disease processes, including infectious/inflammatory, traumatic, congenital/developmental, vascular, and miscellaneous conditions. Key anatomic and surgical concepts are discussed, including radiological information pertinent for surgical planning, and current operative approaches of these anatomic spaces to assist radiologists in comprehensive reporting for gastroenterologists and surgeons.

Urodynamic characteristics of pelvic lipomatosis with glandular cystitis patients correlate with morphologic alterations of the urinary system and disease severity

AIMS

To explore urodynamic characteristics and their clinical value in pelvic lipomatosis (PL) patients.

METHODS

We reviewed the clinical information of 84 PL patients. A voiding pressure-flow study was used to classify patients into nonoutlet obstruction (NOO), latter-half-section obstruction (LHSO), or whole-section bladder outlet obstruction (BOO) groups. Urinary morphologic features were measured by imaging examination and cystoscopy.

RESULTS

A unique LHSO that presented as sudden increasing detrusor pressure (Pdet) and decreasing flow rate in the latter half of voiding was observed for 52.4% (44 of 84) patients. Overall, 27.4% (23 of 84 patients) were diagnosed with BOO with whole-section increasing Pdet and decreasing flow rate. According to the morphologic feature analyses, the NOO patients had the largest angle of anteroposterior vesical walls (P < 0.001) and the least severe thickened bladder trigone (P = 0.015). The external compression at the bladder neck and thickened bladder trigone caused a prolonged and strictured bladder outlet tract (see the Supplementary video). There were 0, 5, and 4 urinary diversions performed in the NOO, LHSO, and BOO groups at diagnosis (P = 0.055). No patients in the NOO group, seven in the LHSO group, and two patients in the BOO group had disease progression at follow-up. Two LHSO patients and one BOO patients without hydronephrosis at diagnosis developed to hydronephrosis during follow-up.

CONCLUSIONS

Morphologic alterations of the urinary system of PL patients lead to unique LHSO or BOO on UDS. The presences of LHSO and BOO are associated with disease severity and progression.

Value of Multimode Sonography for Assessment of Pelvic Lipomatosis Compared With Computed Tomography

OBJECTIVES

To assess imaging features of pelvic lipomatosis with a multimode sonographic technique, including 2-dimensional (2D) grayscale sonography, 3-dimensional (3D) sonography, and transrectal sonography, and compare its diagnostic features with those of computed tomography (CT).

METHODS

In this study, 7 patients with different clinical manifestations were incidentally discovered by 2D sonography and followed by 3D and transrectal sonography before CT was performed for comparison. The urinary tract morphologic characteristics, bladder shape, and amount and distribution of perivesical or perirectal fatty tissue in all 7 patients were evaluated by both imaging modalities. Ten healthy participants were recruited and imaged as a control group.

RESULTS

The following sonographic features were shown in all 7 patients: (1) bilateral hydroureters and hydronephrosis on 2D sonography; (2) bladder shifting anteriorly and superiorly on 2D sonography; (3) nonvisualization of the prostate through the bladder window on transabdominal scanning and nonvisualization of the bladder when the prostate was scanned by transrectal sonography; (4) bladder elongation in the craniocaudal dimension, which appeared as a gourd or pear shape on 3D sonography; and (5) excessive fat accumulation between the prostate and rectum as well as in perivesical or perirectal regions on 2D and transrectal sonography. Computed tomography in these patients confirmed the sonographic findings, with evidence of hydronephrosis, bladder location shift and elongation, and excessive fitty tissue with extrinsic compression.

CONCLUSIONS

This preliminary study has shown that the application of a multimode sonographic technique (ie, 2D, 3D, and transrectal sonography) can provide unique evidence and imaging features of pelvic lipomatosis, which are comparable with CT for making a suggestive diagnosis of pelvic lipomatosis. Thus, multimode sonography may be the modality of choice for assessment of patients with a suspicion of lipomatosis.