Published online before print January 15, 2003, 10.1148/radiol.2263020255
(Radiology 2003;226:833-835.)
© RSNA, 2003
Pseudomass of the Bladder Neck after Prostatectomy: Report of Two Cases1
Ethan J. Halpern, MD and
Leonard G. Gomella, MD
1 From the Departments of Radiology (E.J.H.) and Urology (L.G.G.), Jefferson Prostate Diagnostic Center, Thomas Jefferson University, 132 S 10th St, Philadelphia, PA 19107-5244. Received March 18, 2002; revision requested May 29; revision received June 13; accepted July 23. Address correspondence to E.J.H. (e-mail: ethan.halpern@mail.tju.edu).
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ABSTRACT
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The authors reviewed ultrasonographic (US) images, cystoscopic findings, and biopsy results at the vesicourethral anastomosis in two patients suspected of having local recurrence after radical prostatectomy. A focal, masslike bulge was identified with US at the posterior aspect of the bladder neck, just above the anastomosis. This bulge mimicked the appearance of local recurrence of cancer; however, diagnostic studies, biopsy results, and clinical follow-up failed to demonstrate recurrent cancer. A review of the surgical technique led the authors to conclude that a pseudomass at the vesicourethral anastomosis may result from focal infolding of normal bladder mucosa.
© RSNA, 2003
Index terms: Prostate neoplasms, surgery, 844.458 • Prostate neoplasms, US, 844.12985, 844.39
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INTRODUCTION
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The vesicourethral anastomosis is expected to demonstrate a smooth, tapered appearance after prostatectomy. We have encountered two cases in which a focal, masslike bulge was seen near the posterior aspect of the bladder neck in patients treated with radical prostatectomy for clinically localized disease. Biopsy and cystoscopy of the mass demonstrated normal bladder mucosa. The anatomic relationships created during the procedure of radical prostatectomy lead us to believe that the technique employed for the vesicourethral anastomosis may create an apparent pseudomass secondary to a focal infolding of normal bladder mucosa. Our purpose is to alert others to this finding. It is the official policy of our institution that neither approval of the institutional review board nor informed consent was required for this retrospective case report.
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Case 1
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A 75-year-old white man presented 10 months after prostatectomy, and a rising prostate specific antigen (PSA) level was detected. Prior to prostatectomy, the patient had a PSA level of 20.9 ng/mL. A cancer with a Gleason score of 7 (3 + 4) was found at prostatectomy, and there was no evidence of positive surgical margins or nodal disease. The lowest postprostatectomy PSA level, at 3 months after surgery, was 0.43 ng/mL. By 10 months after surgery, the PSA level rose to 0.9 ng/mL. A bone scan was negative. Despite the negative results of a digital rectal examination, local recurrence was suspected, and transrectal ultrasonography (US) with a biopsy was requested.
Transrectal US demonstrated a focal 5 x 4 x 7-mm mass along the posterior bladder wall within 1 cm of the vesicourethral anastomosis (Fig 1). Color Doppler US evaluation demonstrated the presence of flow within this mass (Fig 2). Three core biopsy specimens were obtained from this mass, and several additional cores were obtained from the area of the anastomosis. No cancer was found. Biopsy specimens from the bladder mass yielded normal transitional urothelium. Subsequent cystoscopy demonstrated that the focal mass above the vesicourethral anastomosis consisted of a smooth bulge of normal bladder mucosa. The patient remains asymptomatic 15 months after the biopsy, with a PSA level remaining in the range of 0.7–0.9 ng/mL.
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Figure 1a. Transrectal US images in a 75-year-old man after prostatectomy. (a) Transverse and (b) longitudinal images demonstrate a focal mass (arrow) above the vesicourethral anastomosis. This posterior midline mass seen in b is within 1 cm of the vesicourethral anastomosis on this magnified image.
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Figure 1b. Transrectal US images in a 75-year-old man after prostatectomy. (a) Transverse and (b) longitudinal images demonstrate a focal mass (arrow) above the vesicourethral anastomosis. This posterior midline mass seen in b is within 1 cm of the vesicourethral anastomosis on this magnified image.
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Figure 2a. Color Doppler US images of the patient in Figure 1. (a) Transverse and (b) longitudinal color images demonstrate the presence of flow within a mass (arrows) near the neck of the bladder.
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Figure 2b. Color Doppler US images of the patient in Figure 1. (a) Transverse and (b) longitudinal color images demonstrate the presence of flow within a mass (arrows) near the neck of the bladder.
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Case 2
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A 71-year-old white man presented 6 years after radical prostatectomy, and a rising PSA level was detected. A cancer with a Gleason score of 6 (3 + 3) was removed at prostatectomy, and there was no evidence of positive surgical margins or nodal disease. His PSA level became undetectable in the postsurgical period. Five years after surgery, the PSA level was reported as less than 0.1 ng/mL. Approximately 6 months prior to biopsy, the PSA level rose from 0.7 to 1.2 ng/mL in 3 months. The PSA level was up to 2.2 ng/mL by the time a biopsy was performed. The bone scan and nuclear medicine study with antibody to prostate specific membrane antigen (ProstaScint; Cytogen, Princeton, NJ) were negative for recurrent disease. Local recurrence was suspected. To participate in a protocol involving local radiation to the surgical bed, the patient was referred for a US-guided biopsy of the vesicourethral anastomosis. Transrectal US evaluation demonstrated a focal 5 x 5 x 5-mm mass along the posterior bladder wall at the vesicourethral anastomosis (Fig 3). Two core biopsy specimens of this mass and multiple cores of the adjacent anastomosis failed to reveal any tumor. Fibromuscular tissue and transitional mucosa were identified. Subsequent cystoscopy demonstrated a focal bulge of normal bladder mucosa just above the vesicourethral anastomosis. The patient demonstrates no clinical evidence of cancer recurrence in the 18 months since this biopsy.
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Figure 3a. Transrectal US images in a 71-year-old man after prostatectomy. (a) Transverse and (b) longitudinal images demonstrate a focal mass (arrow) just above the vesicourethral anastomosis.
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Figure 3b. Transrectal US images in a 71-year-old man after prostatectomy. (a) Transverse and (b) longitudinal images demonstrate a focal mass (arrow) just above the vesicourethral anastomosis.
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Discussion
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Transrectal US of the postprostatectomy patient is requested most often for evaluation of a palpable mass. In the appropriate clinical setting, however, US may be requested on the basis of an elevated PSA level and suspected local recurrence. The normal postprostatectomy US appearance of the vesicourethral anastomosis is described as smooth and tapered from the bladder neck to the urethral sphincter (1). A radical prostatectomy should remove the entire prostate and the seminal vesicles, with no residual tissue in the prostatic bed. The more superior and lateral portions of the seminal vesicles may not be removed at surgery and are often noted on imaging studies obtained after prostatectomy.
Tumor recurrence in the prostate bed may appear as a solid, complex, or cystic lesion (2). Early recurrence may be difficult to distinguish from postoperative scarring. Local recurrence may appear at US as a focal hypoechoic nodule, as an asymmetric thickening or fullness of the anastomosis, or as a loss of the retroanastomotic fat plane (3–5). Hypervascularity is often present in recurrent lesions. Color Doppler imaging has been demonstrated to improve the sensitivity of US detection of recurrent cancer after radical prostatectomy (6). Although local recurrence is most frequent in the perianastomotic area, a recurrent tumor may involve other adjacent structures. In one recent study, the area of the bladder neck was the second most common site for local recurrence (7).
We report two cases of focal masses in the bladder neck that represent normal bladder mucosa. These masses do appear to project into the bladder to a greater degree than the recurrent cancers described in prior reports. Nonetheless, the location of the masses in our cases is similar to that of recurrent cancers in prior cases (6, fig 4; 7, figs 4, 5). Furthermore, the mass in Figure 2 clearly demonstrates suspicious flow at color Doppler evaluation (similar to that in 6, fig 4b). In retrospect, however, our biopsy and cystoscopy studies demonstrated that the apparent masses represent bunched-up bladder mucosa.
The explanation for our findings was evident after reviewing the radical prostatectomy procedure. A variable amount of the bladder neck may be removed during prostatectomy. The amount of bladder neck removed depends on the location of the cancer within the prostate and the personal preference of the surgeon. To reanastomose the bladder to the distal urethra, sutures are placed into the neck of the bladder to taper the bladder neck to the diameter of the urethra. In addition, everting stitches may be placed to allow mucosal apposition of the urethra to the bladder. Infolding of redundant mucosa in the area of the bladder neck is the likely explanation for the US appearance of a pseudomass at the bladder neck. Our review of the surgical technique used to suture the anastomosis suggests that it is reasonable to expect heaped up bladder mucosa along the posterior bladder neck just above the anastomosis. The detection of Doppler flow in normal bladder mucosa is not surprising, since the examination was performed with a high-frequency transrectal probe (EC10C5 probe on a Sequoia 512 system; Siemens Medical Systems, Mountain View, Calif) operating at a Doppler frequency of 9 MHz.
To our knowledge, postprostatectomy pseudomass of the bladder neck has not been reported as a normal finding after prostatectomy. In a postprostatectomy patient, the US finding of a mass in the bladder neck often prompts the physician to perform a core biopsy for recurrent disease. Our experience suggests that in some cases, such masses may represent a normal postoperative finding. The surgical technique used to suture the bladder neck anastomosis after radical prostatectomy may result in an apparent pseudomass secondary to a focal infolding of bladder mucosa. In some cases, it may not be possible for US to distinguish postoperative infolding of the bladder mucosa from recurrent neoplasm. A review of the surgical details of the vesicourethral anastomosis may be helpful in such cases. Additional imaging with magnetic resonance imaging may be useful to distinguish between recurrence in the surgical bed and postoperative redundancy of the bladder mucosa. In some cases, cystoscopy may be required to exclude a bladder neoplasm or recurrent prostate cancer and to avoid unnecessary biopsy procedures.
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FOOTNOTES
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Abbreviation: PSA = prostate specific antigen
Author contributions: Guarantors of integrity of entire study, E.J.H., L.G.G.; study concepts, E.J.H., L.G.G.; study design, E.J.H.; literature research, E.J.H.; clinical studies, E.J.H.; data acquisition and analysis/interpretation, E.J.H.; manuscript preparation, definition of intellectual content, editing, revision/review, and final version approval, E.J.H., L.G.G.
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J. B. Summers, J. Kaminski, E. J. Halpern, and L. Gomella
Urinary Bladder Pseudomass as a Postoperative US Finding [letter] * Drs Halpern and Gomella respond:
Radiology,
October 1, 2003;
229(1):
291 - 291.
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