Routine Ultrasound in Acute Retention of Urine

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Slide 1 : 1 Routine Ultrasound in Acute Retention of Urine Mohammed H. AL-Durazi, FRCSEd, FRCSI, Hamad A. AL-Hellow, MBBS, MRCSI et al. Urology Unit, Surgical Department, Salmaniya Medical Complex
Slide 2 : 2 Introduction Benign prostatic hyperplasia (BPH) is one of the most common urological disorders affecting aging men. Patients presenting with clinical picture suggestive of BPH may harbor other urological or non urological abnormalities. Many urologists no longer carry renal or pelvic ultrasonography (US) for men with urinary retention secondary to BPH (1). It generally remains a matter of conjecture as to whether or not patients with BPH presenting with urinary retention will benefit from renal and pelvic US.
Slide 3 : 3 Objective To evaluate frequency of urological and non-urological abnormalities in routine urinary tract US for patients with acute urinary retention (AUR) due to BPH.
Slide 4 : 4 Patients and methods One hundred consecutive patients who presented to the urology unit in the period between Januarys and December 2001 with AUR secondary to BPH were included. Basic evaluation included detailed history, physical examination including digital rectal examination, urinalysis, renal profile & PSA. All patients had trans-abdominal US before undergoing transurethral resection of prostate (TUPR). The incidence of abnormalities (urological and non-urological) other than BPH was calculated.
Slide 5 : 5 Results One hundred patients were included in the study. Mean age was 67 years (54-96). Forty-one patients (41 %) had other urological abnormalities detected incidentally (Table 1). Six patients (6%) had non-urological conditions (Table 2).
Slide 6 : 6 Table1: incidentally discovered urological abnormalities * 2 new cases, 2 previously known but had negative last check cystoscopy
Slide 7 : 7 Table 2: Asymptomatic non-urological abnormalities
Slide 8 : 8 Results (cont.) All patients with bladder tumor had resection of the tumor (TURBT) in the same operative session. One patient with renal cell carcinoma had radical nephrectomy a week later. Five patients had bladder stone (one had multiple) with an average diameter of 3.0 cm (0.5-5.5 cm), all treated in the same session. Renal cysts were seen in 9 patients, all were asymptomatic except for one large symptomatic that measured 7.5 cm. All cases of hydronephrosis were mild except for one severe ureterohydronephrosis. Four patients with hydronephrosis (80%) had impaired renal function. Hypoechoic prostatic nodule was seen in 4 patients, all had high PSA level and all had carcinoma of the prostate confirmed by histological examination of the resected tissue.
Slide 9 : 9 Discussion Patients presenting with AUR secondary to BPH can harbor another abnormality that may be overlooked. So, should all men with retention and BPH have screening ultrasound? After review of the literature, it appears that routine imaging of the upper urinary tract for patients with urinary retention secondary to BPH is not warranted (4,5,6,7). Many advocate selective use of such imaging in patients with either hematuria, laboratory evidence of renal insufficiency, or a history of urinary tract infection, urolithiasis, previous urinary tract surgery, or congenital or acquired renal disease (6,2). Preoperative urography (IVP) used to be performed routinely as a preoperative assessment before prostatectomy (6). Marshall (1974) tested to value of IVP for patients with AUR before prostatectomy (5). Thirty-eight (19.7%) urological abnormalities were noted in 180 urograms performed. The use of ultrasound of the upper and/or lower urinary tract has been suggested as an alternative to IVP (7).
Slide 10 : 10 In many previous reports, a major justification quoted for the routine use of the IVP was the search for asymptomatic upper tract abnormalities, particularly “renal cancers” [renal carcinoma (RCC) and upper tract transitional cell carcinoma (TCC)]. One case of RCC was found in our study (1%). It was confined to the kidney and was excised completely. This would have been missed unless incidentally detected. Bundrick and Katz found 2 RCC and 1 TCC, among 180 patients screened, citing this unusually high yield of occult cancers to support their augment in favor of routine urography (9). In 1988, Brooks (7) stated, from a review of 17 series, that the incidence of asymptomatic RCC in men investigated for prostatism with IVP was 0.38% (17 out of 4466), a very low value. He also offered the counter-argument that this incidental finding would be of crucial importance as RCC discovered incidentally tends to be less advanced and gives rise to the expectation of longer survival. Several recent epidemiological and population-based studies report the incidence of incidentally detected RCC as 15-61 % of all cases of RCC (1). Many proved that incidentally discovered RCC have lower clinicopathological stage and statistically significant survival advantage (1,10).
Slide 11 : 11 Undoubtedly it is important to detect upper tract dilatation so that surgery can be advised before renal damage occurs. Thus, there is a good argument to provide renal US to assess for hydronephrosis in patients with LUTS or patients with AUR. Hydronephrosis can occur long before biochemical derangement of renal parameters is apparent (11). In this study, 20% of patients with hydronephrosis had normal renal parameters. Though cystoscopy is the most reliable method of excluding bladder pathology (8), bladder tumors can be overlooked unless careful cystoscopic evaluation of the bladder is carried out at time of TURP. In his series, Matthews et al. (8) in1982 had 3 patients with bladder tumor discovered incidentally. Since all had hematuria and only one was discovered by US, he stated that US would seem to be unreliable method of diagnosing bladder tumor. In our series, all 4 cases of bladder tumor were accurately pointed to by US. The argument that hematuria can be a guide for bladder tumor (or renal tumor) is invalid in patients with AUR. This is because most urine retained after insertion of catheter is unreliable for hematuria. Moreover, the detection of bladder tumor may alter the type of anesthesia and the surgical approach.
Slide 12 : 12 Renal cysts and renal stones, which were most of the remaining abnormalities shown in US, did not call for any special alteration in the treatment. Certainly, all were addressed in later stage. US can accurately differentiate between a renal tumor and a cyst, a major limitation of IVP (1). The incidence of diverticula is generally 2.2% in patients with BPH and AUR (5). Some of the diverticula may be large to warrant surgery. Though, most would have been found at preliminary cystoscopy, the surgeon might need to change his surgical approach or do preoperative cystography. The detection of bladder calculi may influence the surgical technique. Many will only need cystolithotrisy with TURP, but some larger stones might need an open approach. Non-urological findings were found in 5 patients when the radiologist was interested to expand his area of examination, all were asymptomatic.
Slide 13 : 13 Conclusion In our study, 41 % of these with AUR secondary to BPH had another unexpected pathology. Certainly, that is an over estimate as trivial conditions like simple renal cysts and small renal stones were also included. However, five patients (5%) had malignancy unrelated to their prostate. Though number of patients in the study small, a significant fraction of them harbored a potentially life-threatening pathology. We think that evaluating a patient with BPH presenting with urinary retention is a good opportunity to assess him for such abnormalities. In addition, this imaging modality is noninvasive, quick, cost-efficient and devoid of the harmful reaction to the contrast media of the urogram. We think that routine ultrasonic evaluation of bladder and kidneys is warranted. However, data from larger series are needed to formulate a policy regarding such approach.
Slide 14 : 14 References J. Masood; T. Lane; B. Koye; M.T. Vandal; J.M. Barua and J.T. Hill. Renal cell carcinoma: incidental detection during routine ultrasonography in men presenting with lower urinary tract symptoms. BJU Int 2001; 88: 671-764. Grossfeld GD; Coakley FV. Benign prostatic hyperplasia: clinical overview and value of diagnostic imaging. Radiol Clin North Am 2000 Jan; 38(1): 31-47.    Roger S. Kirby; John D. McConnell. Fast Facts-Benign Prostatic Hyperplasia. 3ed ed. England: Health Press Limited, 1999: 20. Lee B. Talner. Routine Urography in Men with Prostatism. AJR 1986 Nov; 147: 960-961. Villis Marshall; Manmeet Singh; J. P. Blandy. Is Urography Necessary for Patients with Acute Retention of Urine Before Prostatectomy? Br J Urol 1974; 46: 73-76. O’Rielly P. H. Assessment Before prostatectomy. Br Med J 1987; 294: 1370-1371. P. Brooks. Prostatism, Intravenous Urography and Asymptomatic Renal Cancer. Br J Urol 1988; 62: 1-3. P. N. Matthews; J. B. Quayle; A. E. A. Joseph; J. E. Williams; K. W. Wilkinson; P. R. Riddle. The Use of Ultrasound in the Investigation of Prostatism. Br J Urol 1982; 54: 536-538 Bundrick TJ; Katz PG. Excretory urography in patients with prostatism. AJR 1986; 147: 957-959. Siow WY; Yip SK; Ng LG; Tan PH; Cheng WS; Foo KT. Renal cell carcinoma: incidental detection and pathological staging. J R Coll Surg Edinb 2000 Oct; 45(5): 291-295. Dalla-Palma L.; Bazzocchi M.; Pozzi-Mucelli RS.; Stacul F.; Rossi M.; Agostini R. Ultrasonography in the diagnosis of hydronephrosis in patients with normal renal function. Urol Radiol 1983; 5: 221-226.
Slide 15 : 15 Correspondence M. Durazi, Salmaniya Medical Complex Tel: (+973)-255555 Ext: 7728 e-mail mddurazi@hotmail.com P.O. Box 12 Kingdom of Bahrain.

 


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