Prostate Imaging: Key Concepts

• Plain radiography of the bladder is limited, but may detect lithiasis or air from emphysematous cystitis
• Voiding cystourethrogram (X-ray with contrast during urination) helps identify urethra and bladder abnormalities, and is valuable in pediatric cases.
• Cystogram is another imaging study where contrast dye is injected into the bladder and X-rays are taken to assess the bladder's structure, and helps visualize structural damage from traumatic bladder rupture
• Ultrasound (US) is the preferred bladder imaging tool because it is convenient, safe, inexpensive, and can diagnose various pathologies.

Bladder Ultrasound

• US cystodynamogram is the choice for initial voiding disorder investigations, evaluating function and structure during filling and voiding.
• The standard initial assessment for UTIs in children includes bladder ultrasound, plain abdominal X-ray, and US of the kidney.

Computed Tomography (CT)

• Considered a second-line imaging tool for bladder evaluation, and is often employed when US is insufficient.
• Common referrals for CT include urolithiasis (urinary stones) and hematuria (blood in urine).
• Key advantages include assessing precise stone location, especially at the uretero-vesical junction.
• CT evaluates stone burden (size and number), composition, and fragility, which are essential for treatment decisions.
• CT is valuable when stones in distal ureters and bladder are not detectable on ultrasound; CT urography (CTU) is reliable for detecting advanced bladder cancers. CTU is the gold standard for N involvement and distant metastases (M).
• CT can differentiate intraluminal blood clots from urothelial tumours in gross hematuria cases, providing essential diagnostic and treatment information.

Magnetic Resonance Imaging (MRI)

• This is a second-line modality for bladder imaging after ultrasound because it is more costly and the effectiveness of US.
• Gadolinium-enhanced MRI is accurate for determining the T stage (tumour invasion depth) of bladder cancer, making it the gold standard for this purpose.
• Initially, ultrasound (US) is for screening bladder conditions, CT is essential for staging bladder cancer and MRI helps evaluate the presence of cancer and examine the bladder's volume.
• Bladder masses are challenging to asses on ultrasound: Patient repositioning allows observation of mass movement, determining its nature.
• After MRI confirms bladder cancer, CT scans help determine the extent and spread for treatment planning.

Virtual Reality Imaging

• Employs 3D reconstructions from CT for detailed volume renderings and virtual endoscopy, to evaluate the entire urinary tract.
• CT images show a small pedunculated lesion on left bladder wall as a hypodense area so 3D reconstruction helps assess structures around it.
• Virtual Cystography provides diagnostic info, but cannot assist with biopsy or in situ diagnosis.

Clinical Point of View

• Fluorescence and normal cystoscopy remain the gold standard for diagnosing bladder lesions and cancer.
• Transitional epithelial cell carcinomas is a common bladder cancer, mostly in males.
• Risk factors include smoking and pigment manufacturing occupational exposure.
• Squamous cell carcinoma is a small percentage of bladder tumours, typically observed in Egypt due to schistosomiasis infections
• Hematuria is common, but patients can experience urinary symptoms such as dysuria.

Bladder Cancer Staging

• Differentiation involves invasive versus non-muscle invasive (Ta-T1 Stage vs T2, T3, T4), influencing treatment.
• After ultrasound, MRI identifies lesions, evaluates morphology, measures tumour and checks for node involvement
• T2-weighted MRI differentiates wall from fluid, while bladder wall appears hyperintense, improving visibility of the bladder layers.
• T2-weighted imaging is valuable without contrast, showing the bladder and urinary tract.
• The bladder T staging differences are shown by invasion and non-invasion of muscle walls.
• Confined to bladder in the T1-stage tumour

Bladder Tumour Types

• A sessile lesion is flat and broad-based, lacking a stalk, and may indicate invasive or higher-grade tumours.

Summary of tests

• Ultrasound is the first choice for evaluating bladder pathologies
• A voiding cystourethrogram is helpful with voiding disorders
• MRI is essential for evaluating the T stage
• CT is useful for staging bladder cancer
• Virtual cystography assesses bladder lesions

Urethra

• Ultrasound is not primarily used but radiography is beneficial
• Retrograde urethrography evaluates traumatic injuries, inflammatory conditions and male stricture diseases.
• Sonourethrography assesses thickness/length of the bulbar urethral structure.
• In women with urethral diverticula, voiding cystourethrography is frequently used
• However, MRI is more sensitive in detecting these conditions and is valuable for local staging of urethral tumors.
• While CT isn't suitable, MRI is an emerging secondary modality for urethral imaging.
• There are various Pitfalls to consider in the procedure.
• There is a potential of Fibroblastic stenosis

Potential risks

• Air bubbles can complicate diagnosis, crucial to empty urethra/bladder carefully.
• Vesicoureteral reflux, with contrast media flowing backwards, can indicate reflux.
• Fistulas or ruptures are detectable because contrast extends to areas it shouldn't. Retrograde urethrography is the first choice for traumatic injuries In the emergency department, CT scan can assess rupture of the urethra

Ultrasound

• MRI is next for pelvic pain and fever, use T2-weighted imaging.

Prostate

• Patients for imaging present with elevated PSA levels, urinary problems, or abnormal findings.

Ultrasound for Prostate

• Can detect disorders, prostate enlargement (BPH), and help diagnose male infertility.
• Transrectal ultrasound is preferred, but transabdominal too.

Sovrapubic approach

• Convex probe studies the area just above the pubic bone with the patient supine.
• Painless/non-invasive.

Transrectal approach

• Significantly better imaging versus suprapubic.
• Visualizes the prostate and evaluates the volume, and capsular profile
• It can detect calcifications which is common
• A biopsy is needed for TRUS in the prostate

Scanning technique

• Patient should lie supine for axial and sagittal images
• TRUS only needs a small urine to avoid artifacts and the patient should empty before exam
• Patients drink water 20 mins before exam for transabdominal approach
• Differentiate between inflammatory conditions, benign prostatic hyperplasia (BPH), and neoplastic (cancerous) conditions
• Ultrasound has good sensitivity for BPH if visualized; transrectal ultrasound is often necessary for a detailed assessment.

Inflammatory Conditions

• TRUS evident from the prostate level and circular shape of the probe; various concerning hyperechoic areas within the prostate
• Doppler shows inflammation; acute prostatitis causes high blood flow, which relates to inflammation and is an edema.
• Chronic prostatitis presents with pain, fibrosis, calcifications, or lymph nodes. For severe conditions like gonorrhea, and granulomatous disease is for tuberculosis.

Assessment

• Doppler determines inflammation, however if there isn't high blood flow, there is tumors.
• MRI modality better for soft tissues cancer like the prostrate.

Prostate Cancer/Multi-Parametric

• T1 and T2 weighted images,
• In T2-weighted MRI, seminal vesicles are seen with retroprostatic at the top which helps detect extracapsular extensions in the prostrate.
• 70% or prostate cancer stems in peripheral zone

Transition Zones

• Can appear the same in images and can be hard to assess but, 23% originates in this zone.
• External sphincter of the urethra, evaluates urethra is there is a disease
• In prostrate MRI there is multi -parametric, assessing different images
• Assessment with using weighted images
• Difficulties include diffusion/weighed to interoperate, they are useful.
• Show tumor and normal function of water is restricted with DWI images.

Combining T2

• Show the morphology of the morphology assess prostate cancer
• Pi-rads is used to assess prostate and give assessment, helps for the prostate volume.
• High risk for Gleason score contrast and has good sensitivity for the cancer

Assessment of cancer

• Used to categorize prostrate from cancerous likelihood's ranging 1 to 5.
• Breast for coronary ,helps by using these systems to help communication, they are used to asses.
• Lesions can reassure patents

Assessing for biopsy

• Trans rectal is mentioned earlier because there can be with ultrasound
• Multi-parametric MRI are fused together helps show were to use biopsy

MR guidance Biobsy

• Done with an MR room
• Endorectal and trans rectal, helps to prevent it from cancer

Prostate Test

• Used non to specify with fusion accuracy with combine helps with traumas for patients

PI-RADS Classification System

• Scores determine if there is anything they can do with biopsy
• Lesions show that there is a risk in following if its high or low/ if a follow up is needed

Testicular Diseases

• Includes Testicular Cancer (rare), accounting for just 1% of all neoplasms and 5% of all urological tumors.
• The range in caner is shown in 30% or 40% but affects the 40's

Testicular Assessment

• Modalities for Testcular are mainly Ultrasound,CT .MRI shows for Radiography, its a first line assessment
• Assessment inflammation,torsion and pathology's with help for identifying and MRI will give secondary further detail

Location of Testicular Mass on Ultrasound

• mass it can show 3.5cm to 4.5cm size on the testicular

In cases

• The assessment or suspicion of extrateticular is when mass is difficult to asseee, in clear assessment helps to determine.

Testicular Torsion

• Difficult diagnoses in the department
• Twisted or blood twist will happen in testicle
• In addition with young patients has acute pain

Assessment and Diagnosis

• Can clinical the assessment and require ultrasound to find surgery
• there is a chance of complete and incomplete
• Dopplers help blood flow
• In the teste will be not fully in position or affected

Testis and Edpidymis development

• Change in how heterogenous necrosis will react
• Is the most crucial when twisted, visualized and decrease with it or confirm diagnosis

Assess the knowledge of prostate imaging techniques. Questions cover MRI sequences, T1 and T2 weighted images, and the detection of tumor growth. Highlights the best imaging modality for staging prostate cancer.