All Figures Flashcards
FIG. 2.3 Protocol for determining the need for urine sediment microscopy in an asymptomatic population. (From Flanagan PG, Rooney PG, Davies EA, et al. Evaluation of four screening tests for bacteriuria in elderly people. Lancet. 1989;1(8647):1117–1119. © by The Lancet Ltd., 1989.)
FIG. 2.16 Urinary crystals. (A) Cystine. (B) Calcium oxalate. (C) Uric acid. (D) Triple phosphate (struvite).
FIG. 3.1 Recommended equipment setup for fluoroscopy. The x-ray source located beneath the table reduces the radiation exposure to the urologist. Locating the image intensifier as close to the patient as feasible reduces scatter radiation. Equipment setup will vary based on application.
FIG. 3.2 Intravenous excretory urogram (IVU) in a 40-year-old woman with the complaint of a mobile mass in the right lower quadrant with standing associated with bilateral flank and back pain that resolved in the supine position. (A) Supine IVU shows kidneys in the normal position, with normal ureters and proximal collecting systems. (B) Standing film shows significant displacement of both kidneys with the right kidney moving onto the pelvis as described by the patient.
FIG. 3.3 (A) Right ureteral calculus (arrow) overlying the sacrum is difficult to visualize on the plain film. (B) The right posterior oblique study fails to confirm the location of the ureteral calculus. (C) CT confirms this 6-mm calculus in the right ureter at the level of the third sacral segment.
FIG. 3.4 KUB demonstrating residual stone fragments (arrows) adjacent to a right ureteral stent 1 week after right extracorporeal shock wave lithotripsy.
FIG. 3.5 (A) Right retrograde pyelogram performed using an 8-Fr cone-tipped ureteral catheter and dilute contrast material. The ureter and intrarenal collecting system are normal. (B) Left retrograde pyelogram using an 8-Fr cone-tipped ureteral catheter. A filling defect in the left distal ureter (arrow) is a low-grade transitional cell carcinoma. The ureter demonstrates dilation, elongation, and tortuosity, the hallmarks of chronic obstruction.
FIG. 3.6 Patterns of backflow during retrograde pyelography. (A) Pyelotubular backflow. (B) Pyelosinus backflow. (C) Pyelolymphatic backflow.
FIG. 3.7 Loopogram in a patient with epispadius/exstrophy and ileal conduit urinary diversion. The plain film (A) shows wide diastasis of the pubic symphysis. After contrast administration via a catheter placed in the ileal conduit, free reflux of both ureterointestinal anastomoses is demonstrated (B). (C) A postdrain radiograph demonstrates persistent dilation of the proximal loop indicating mechanical obstruction of the conduit (arrows).
FIG. 3.8 Normal retrograde urethrogram demonstrating (A) the balloon technique for retrograde urethrography, (B) Brodney clamp (arrowhead) technique; note the bulbar urethral stricture (arrow), and (C) normal structures of the male urethra.
FIG. 3.9 The patient has undergone radical retropubic prostatectomy. (A) During bladder filling, contrast is seen adjacent to the vesicoureteral anastomoses (arrow). (B) The postdrain film clearly demonstrates a collection of extravasated contrast (arrow).
FIG. 3.10 A voiding cystourethrogram performed for the evaluation of recurrent urinary tract infection in this female patient. (A) An oblique film during voiding demonstrates thickening of the midureteral profile (arrows). (B) After interruption of voiding a ureteral diverticulum is clearly visible extending posteriorly and to the left of the midline (arrows).
FIG. 3.11 (A) Technetium99m-mercaptoacetyltriglycine (99mTc-MAG3) perfusion images demonstrate normal, prompt, symmetric blood flow to both kidneys. (B) Perfusion time-activity curves demonstrating essentially symmetric flow to both kidneys. Note the rising curve typical of 99mTc-MAG3 flow studies. Dynamic function images demonstrate good uptake of tracer by both kidneys and prompt visualization of the collecting systems. This renogram demonstrates prompt peaking of activity in both kidneys. The downslope represents prompt drainage of activity from the kidneys. Printout of quantitative data shows the differential renal function to be 47% on the left, 53% on the right. The normal half-life for drainage is less than 20 minutes when 99mTc-MAG3 is used. The Image 1 is 5 min on the left and 7 min on the right, consistent with both kidneys being unobstructed.
FIG. 3.12 Delayed static images in the posterior and anterior projections demonstrate intestinal activity (arrow in A) and gallbladder activity (arrow in B), reflecting a normal mode of excretion of 99mTc-MAG3. Gallbladder activity, in particular, can cause false-positive interpretation when it overlies activity in the renal collecting system or is inappropriately included in the area of interrogation. Liver activity is variable and tends to be more pronounced in children and patients with renal insufficiency.
FIG. 3.13 Six different PET tracers used to evaluate an 83-year-old man with a T2b nodule and a prostate-specific antigen (PSA) level of 5.4, confirmed Gleason 5+4 prostate adenocarcinoma, and treated with intensity-modulated pelvic radiotherapy and androgen blockade. After PSA nadir of 0.11, biochemical recurrence occurred with PSA of 1.83 and negative conventional imaging. Patient was followed for 40 months under watch-and-wait strategy due to no identification of sites of recurrent disease despite increasing PSA up to 18.7 at the time of positive Ga-68 PSMA 11 and Ga-68 RM2 (both show retroperitoneal lymph nodes whereas all other studies are negative). (Image courtesy of Andrei Iagaru, MD, Stanford University.)
FIG. 3.14 Fluorine-18 fluorodeoxyglucose (18F-FDG) PET/CT is useful for staging and restaging of seminoma in patients treated with chemotherapy. This patient presented with a right-sided seminoma with bulky right-sided retroperitoneal lymph nodes. PET/CT after chemotherapy shows no uptake in the previously positive nodal region.
FIG, 3.15 (A) CT scanner with a single-row detector requires five circular passes around the patient to image a small area of the patient’s body. (B) With a 16-slice, multirow detector, the chest, abdomen, and pelvis can be imaged with five circular passes, easily obtained during a single breath hold. The thin slices offered by the 16-slice detector offer much greater detail of internal structures.
FIG. 3.16 (A) 3D colored reconstruction of the kidneys ureter and bladder from CT urogram. (B) Coronal reconstruction in a patient with a clear cell renal cell carcinoma in a complex renal cystic mass and enhancing mural nodule. (C) 3D reconstruction of the same patient with slight posterior rotation
FIG. 3.17 CT of the abdomen and pelvis demonstrating normal genitourinary anatomy. (A) The adrenal glands are indicated with arrows. The upper pole of the right and left kidneys is indicated with rk and lk, respectively. a, aorta; li, liver; p, pancreas; s, spleen; v, inferior vena cava.
(B) Scan through the upper pole of the kidneys. The left adrenal gland is indicated with an arrow. a, aorta; c, colon; d, duodenum; li, liver; lk, left kidney; p, pancreas; rk, right kidney; v, inferior vena cava.
(C) Scan through the hilum of the kidneys. The main renal veins are indicated with solid arrows, and the right main renal artery is indicated with an open arrow. a, aorta; c, colon; d, duodenum; li, liver; lk, left kidney; p, pancreas; rk, right kidney; v, inferior vena cava.
(D) Scan through the hilum of the kidneys slightly caudal to C. The left main renal vein is indicated with a solid straight arrow, and the left main renal artery is indicated with an open arrow. The hepatic flexure of the colon is indicated with a curved arrow. a, Aorta; c, colon; d, duodenum; li, liver; lk, left kidney; p, pancreas; rk, right kidney; v, inferior vena cava.
(E) Scan through the mid to lower polar region of the kidneys. a, Aorta; ac, ascending colon; d, duodenum; dc, descending colon; lk, left kidney; p, pancreas; rk, right kidney; rp, renal pelvis; v, inferior vena cava.
(F) CT scan obtained below the kidneys reveals filling of the upper ureters (arrows). The wall of the normal ureter is usually paper thin or not visible on CT. a, aorta; ac, ascending colon; dc, descending colon; v, inferior vena cava.
(G) Contrast filling of the midureters (arrows) on a scan obtained at the level of the iliac crest and below the aortic bifurcation. ac, Ascending colon; dc, descending colon; la, left common iliac artery; ra, right common iliac artery; v, inferior vena cava.
(H) The distal ureters (arrows) course medial to the iliac vessels on a scan obtained below the promontory of the sacrum. b, urinary bladder; la, left external iliac artery; lv, left external iliac vein; ra, right external iliac artery; rv, right external iliac vein.
(I) Scan through the roof of the acetabulum reveals distal ureters (solid arrows) near the ureterovesical junction. The bladder (b) is filled with urine and partially opacified with contrast material. The normal seminal vesicle (open arrows) usually has a paired bow-tie structure with slightly lobulated contour. a, Right external iliac artery; r, rectum; v, right external iliac vein.
(I) Scan through the roof of the acetabulum reveals distal ureters (solid arrows) near the ureterovesical junction. The bladder (b) is filled with urine and partially opacified with contrast material. The normal seminal vesicle (open arrows) usually has a paired bow-tie structure with slightly lobulated contour. a, Right external iliac artery; r, rectum; v, right external iliac vein.
(J) Scan at the level of the pubic symphysis (open arrow) reveals the prostate gland (solid arrow). a, Right external iliac artery; m, obturator internus muscle; r, rectum; v, right external iliac vein.
FIG. 3.18 CT of the abdomen and pelvis in patient with an obstructing ureteral stone at the level of the ureterovesicle junction. (A) Level of the left upper pole. Mild renal enlargement, caliectasis, and perinephric stranding are apparent. (B) Level of the left renal hilum. Left pyelectasis with a dependent stone, mild peripelvic and perinephric stranding, and a retroaortic left renal vein are shown. (C) Level of the left lower pole. Left caliectasis, proximal ureterectasis, and mild periureteral stranding are present. (D) Level of the aortic bifurcation. The dilated left ureter (arrow) has lower attenuation than do nearby vessels. (E) Level of the upper portion of the sacrum. A dilated left ureter (arrow) crosses anteromedial to the common iliac artery. (F) Level of the midsacrum. A dilated left ureter (arrow) is accompanied by periureteral stranding. (G) Level of the top of the acetabulum showing a dilated pelvic portion of the left ureter (arrow). (H) Level of the ureterovesical junction. The impacted stone with a “cuff” or “tissue rim” sign that represents the edematous wall of the ureter. (Reprinted from Talner LB, O’Reilly PH, Wasserman NF: Specific causes of obstruction. In Pollack HM, et al., eds: Clinical urography, ed 2, Philadelphia, 2000, Saunders.)
Renal CT demonstrating normal nephrogenic progression. (A) Unenhanced CT scan obtained at the level of the renal hilum shows right (R) and left (L) kidneys of CT attenuation values slightly less than those of the liver (H) and pancreas (P). A, Abdominal aorta; M, psoas muscle; S, spleen; V, inferior vena cava. (B) Enhanced CT scan obtained during a cortical nephrographic phase, generally 25 to 80 seconds after contrast medium injection, reveals increased enhancement of the renal cortex (C) relative to the medulla (M). The main renal artery is indicated with solid arrows bilaterally. Main renal veins (open arrows) are less opacified with respect to the aorta (A) and arteries. D, Duodenum; P, pancreas; V, inferior vena cava. (C) CT scan obtained during the homogeneous nephrographic phase, generally between 85 and 120 seconds after contrast medium administration, reveals a homogeneous, uniform, increased attenuation of the renal parenchyma. The wall of the normal renal pelvis (RP) is paper thin or not visible on the CT scan. A, Abdominal aorta; V, inferior vena cava. (D) CT scan obtained during the excretory phase shows contrast medium in the RP bilaterally; this starts to appear approximately 3 minutes after contrast medium administration.
FIG. 3.21 A 45-year-old man underwent a 1.5T MRI with chemical shift imaging, which was consistent with left adrenal adenoma (red arrow). (A) In-phase (IP) T1-weighted image demonstrates a left adrenal mass with signal isointense to muscle. (B) Out-of-phase T1-weighted imaging shows drop out of signal in a left adrenal mass relative to the IP imaging. (C) Single-shot T2-weighted spin echo image reveals a left adrenal nodule with low signal intensity.
FIG. 3.20 Small renal cell carcinoma in the infrahilar lip of the right kidney is not easily seen on unenhanced image (A). On corticomedullary phase image (B), the lesion is subtly visible as a hyperenhancing focus within the renal medulla. On nephrographic (C) and pyelographic phase (D) images, the full extent of the lesion (arrow) within the medulla and cortex is depicted. (Reprinted from Brink JA, Siegel CL: Computed tomography of the upper urinary tract. In Pollack HM, et al., eds: Clinical urography, ed 2, Philadelphia, 2000, Saunders.)
FIG. 3.22 A 65-year-old woman with left side heterogeneous enhancing suprarenal lesion (ACC) with select images from a 1.5T abdominal MRI. (A) Moderately weighted T2 STIR images with a hyperintense signal (red arrow). (B) Heavily weighted T2 single shot fast spin echo isointense signal. These findings are all dependent on the degree of T2 weighting.
FIG. 3.23 A 44-year-old man with prior abdominal ultrasound detecting an indeterminate renal mass underwent a 1.5T MRI with chemical shift imaging, which was consistent with left adrenal myelolipoma (red arrow). (A) T2 single-shot spin echo demonstrates a large left adrenal mass with signal isointense to abdominal fat. (B) T1 in-phase (IP) imaging demonstrates a left adrenal mass, which signals similar to the abdominal fat. (C) T1 out-of-phase imaging shows no drop of signal compared with IP imaging. (D) T1 fat-suppressed precontrast imaging shows loss of signal within the mass consistent with gross fat.
FIG. 3.24 A 63-year-old female s/p right nephrectomy for clear cell carcinoma with a metachronous right adrenal metastasis. (A) T1 in-phase imaging of the right adrenal mass (red arrow). (B) T1 out-of-phase imaging with drop in signal (red arrow) consistent with microscopic fat. (C) Fat-suppressed fast relaxation fast spin echo moderately weighted T2 image with hyperintense signal (red arrow).
FIG. 3.25 A 50-year-old man with a left side pheochromocytoma and select images from a 1.5T MRI. (A) Heavily weighted T2 single-shot fast spin echo with an isointense signal (not bright). (B) Moderately weighted T2 fat-suppressed fast recovery fast spin echo with hyperintense signal (bright). (C) T1-weighted precontrast images. (D) T1-weighted postcontrast images with marked early enhancement.
FIG. 3.26 A 31-year-old woman after left extracorporeal shock wave lithotripsy with a subcapsular hematoma and right-side pathology confirmed 3.5-cm clear cell carcinoma underwent a 1.5T MRI of the abdomen. (A) T1-weighted in-phase (IP) imaging of a right renal nodule with mild heterogeneity (red arrow) but primarily isointense signal intensity. Left kidney subcapsular hematoma with a rim of high signal intensity (blue arrow). (B) T1-weighted out-of-phase (OP) image shows diffuse signal dropout within the renal nodule consistent with microscopic fat. (C) T1-weighted fat-suppressed precontrast image with a low signal intensity of the right renal nodule (red arrow) and high signal intensity of the left subcapsular hematoma (blue arrow). Blood is high signal intensity on precontrast T1-weighted images. (D) T1 fat-suppressed postcontrast images of the right renal nodule with avid heterogeneous enhancement. Nonenhancing left subcapsular hematoma. (E) Diffusion-weighted imaging b-1000 demonstrates high signal intensity throughout the right renal nodule.
FIG. 162.9 Neuroendocrine/anaplastic carcinoma of the prostate: clinical and pathological features. Red arrow shows histologic section from liver mass biopsy. PSA, Prostate-specific antigen.
FIG. 162.8 Overall survival in the ALSYMPCA study. (Data from Parker C, Nilsson S, Heinrich D, et al.: Alpha emitter radium-223 and survival in metastatic prostate cancer. N Engl J Med 369:213–223, 2013.)
FIG. 162.7 Overall survival in the IMPACT study. (Data from Kantoff PW, Higano CS, Shore ND, et al.: Sipuleucel-T immunotherapy for castration-resistant prostate cancer. N Engl J Med 363:411–422, 2010.)
FIG. 162.6 Overall survival in the AFFIRM study. (Data from Scher HI, Fizazi K, Saad F, et al.: Increased survival with enzalutamide in prostate cancer after chemotherapy. N Engl J Med 367:1187–1197, 2012.)
FIG. 162.5 Overall survival in the COU-AA-301 study. (Data from de Bono JS, Logothetis CJ, Molina A, et al.: Improved survival from metastatic prostate cancer with abiraterone acetate. N Engl J Med 364:1995–2005, 2011.)
FIG. 162.4 Overall survival in the TROPIC study. CI, Confidence interval; HR, hazard ratio. (From de Bono JS, Oudard S, Ozguroglu M, et al.: Prednisone plus cabazitaxel or mitoxantrone for metastatic castration-resistant prostate cancer progressing after docetaxel treatment: a randomised open-label trial. Lancet 376:1147–1154, 2010.)
FIG. 162.3 Overall survival in the Southwest Oncology Group 9916 study. (Data from Petrylak DP, Tangen CM, Hussain MH, et al.: Docetaxel and estramustine compared with mitoxantrone and prednisone for advanced refractory prostate cancer. N Engl J Med 351:1513–1520, 2004.)
FIG. 162.2 Overall survival in the TAX 327 study. (Data from Tannock I, DeWit R, Berry W, et al.: Docetaxel plus prednisone or mitoxantrone plus prednisone for advanced prostate cancer. N Engl J Med 351:1502–1512, 2004.)
FIG. 162.1 Prostate cancer clinical states. PSA, Prostate-specific antigen. (Modified from Scher HI, Halabi S, Tannock I, et al.: Design and end points of clinical trials for patients with progressive prostate cancer and castrate levels of testosterone: recommendations of the Prostate Cancer Clinical Trials Working Group. J Clin Oncol 26:1148–1159, 2008.)
FIG. 161.2 Chemical structures of steroidal and nonsteroidal antiandrogens. (Figure 3 from Crawford ED, Schellhammer PF, McLeod DG, et al.: Androgen receptor targeted treatments of prostate cancer: 35 years of progress with antiandrogen. Urology 200[5]:955–956, 2018 [online journal]: https://www.ncbi.nlm.nih.gov/pubmed/29730201.)
FIG. 161.3 Mechanism of action of abiraterone and potential side effects. ACTH, Adrenocorticotropic hormone.
FIG. 161.1 Molecular biology of the androgen receptor (AR) and putative mechanism of resistance to AR blockade.
FIG. 160.3 Whole-pelvis radiotherapy after radical prostatectomy.
FIG. 160.2 Prostate bed–only salvage radiotherapy after radical prostatectomy.
FIG. 160.1 11C-acetate positron emission tomography scan in biochemical recurrence.
FIG. 159.7 Probabilities of cancer control after radical prostatectomy based on pathologic stage. ECE, extracapsular extension; N+, node positive; OC, organ confined; SVI, seminal vesicle invasion. (Modified from Bianco FJ Jr, Scardino PT, Eastham JA. Radical prostatectomy: long-term cancer control and recovery of sexual and urinary function [“trifecta”]. Urology 66[5 Suppl]:83–94, 2005.)
FIG. 159.6 Prostate cancer mortality as a factor of Gleason grade and age at diagnosis in men managed conservatively. Brown-shaded areas represent proportion of patients dying of prostate cancer. Light brown–shaded areas represent death from competing causes. Light-blue areas represent proportion of patients alive. (Modified from Albertsen PC, Hanley JA, Fine J. 20-year outcomes following conservative management of clinically localized prostate cancer. JAMA 293[17]:2095–2101, 2005.)
FIG. 159.5 Treatment trends in the Cancer of the Prostate Strategic Urologic Research Endeavor (CaPSURE) Registry for men with CAPRA score range 6–10. Error bars indicate 95% confidence intervals. (Modified from Cooperberg MR, Carroll PR. Trends in management for patients with localized prostate cancer, 1990–2013. JAMA 314[1]:80–82, 2015.)
FIG. 159.4 68Ga-PSMA-11 PET/MRI demonstrating right-sided uptake within the peripheral prostate (A) and in right pelvic side wall and external iliac lymph nodes (B,C). (Courtesy of Dr. Thomas Hope.)
FIG. 159.3 Axial T2-weighted magnetic resonance image shows tumor involving the seminal vesicle and bladder base and extending into the adjacent fat.
FIG. 159.2 Transrectal ultrasound examination demonstrates hypoechoic tumor in the left base (arrowhead) with likely extension into the ipsilateral seminal vesicle (arrow). (Courtesy of Dr. Katsuto Shinohara.)
FIG. 159.1 Transrectal ultrasound examination demonstrates increased flow on color Doppler study at the left posterior (upper panel, arrow) with corresponding hypoechoic area on gray-scale images (lower panel, arrow). Note the left lateral distortion and squaring of the capsule, suggesting extracapsular extension. (Courtesy of Dr. Katsuto Shinohara.)
FIG. 158.10 Perioperative TRUS image with inserted irreversible electroporation electrode (arrows), with corresponding whole-mounted prostate section and H&E slide. (From van den Bos W, Jurhill RR, de Bruin DM, et al. Histopathological outcomes after irreversible electroporation for prostate cancer: results of an ablate and resect study. J Urol 196(2):552–559, 2016b.)
FIG. 158.9 Electrode metrics. (A) Axial representation of probe placement geometry using probe insertion initiated in periurethral position with additional probes configured radially (blue dashed lines) from this point. The closest distance from each probe to the capsule or urethra (arrows) was no more than 5 mm. The distance between probe pairs (blue dashed lines) used for ablation was between 10 and 20 mm. (B) Distances between probes (d) and length of needle exposure within tissues (L) are obtained to provide data for initial energy settings. Measurements were obtained to confirm parallel orientation (d) and 5 mm or greater distance tip to capsule (arrows). (From Murray KS, Ehdaie B, Musser J, et al. Pilot study to assess safety and clinical outcomes of irreversible electroporation for partial gland ablation in men with prostate cancer. J Urol 196(3):883–890, 2016.)
FIG. 158.8 Laser fiber in cooling catheter (A), perineal template with endorectal coil and titanium catheter (B), overlay of template grid on MRI (C), and laser workstation (D). (From Eggener SE, Yousuf A, Watson S, et al. Phase II evaluation of magnetic resonance imaging guided focal laser ablation of prostate cancer. J Urol 196(6):1670–1675, 2016.)
FIG. 158.7 Images of a 67-year-old male patient with a Gleason score of 3 + 4 = 7 in his right transition zone. (A) Real-time MRI-temperature map acquired during focal laser ablation. (B) Anatomical MRI of the prostate (delineated in blue) with the Arrhenius-based damage-estimation zone as orange overlay. (C) Postablation axial T1-weighted contrast-enhanced image. The prostate is delineated in blue, and the nonenhancing necrotic tissue is in green. (D) Whole-mount H&E stain of the prostate. The necrotic tissue is delineated in green, the perinecrotic tissue in yellow, and vital tumor in blue. (From Bomers JGR, Cornel EB, Futterer JJ, et al. MRI-guided focal laser ablation for prostate cancer followed by radical prostatectomy: correlation of treatment effects with imaging. World J Urol 35(5):703–711, 2017. Open Access via Creative Commons Attribution 4.0 International License: http://creativecommons.org/licenses/by/4.0/)
FIG. 158.6 Treatment with magnetic resonance imaging–guided transurethral ultrasound ablation. ECD, endorectal cooling device; UA, ultrasound applicator. (Chin JL, Billia M, Relle J, et al. Magnetic resonance imaging-guided transurethral ultrasound ablation of prostate tissue in patients with localized prostate cancer: a prospective phase 1 clinical trial. Eur Urol 70(3):447–455, 2016.)
FIG. 158.5 54-year-old male patient with PSA 7.7 and biopsy-proven Gleason 3+3 prostate carcinoma. (A) Saturation biopsy map showing positions of 26 cores taken. Core 3 and 23 were positive for Gleason 3+3 prostate carcinoma (arrows), measuring 3 mm and 4 mm in the mid-cores, respectively. (B,C) Pretreatment axial T2-weighted fast spin-echo MR image (TR/TE, 3300/90) and corresponding axial DWI (TR/TE, 105/6000, b = 2000 mm/s2) showing well-demarcated lesion in left posterior peripheral zone at mid-gland level corresponding to core 23 (arrow). It also shows suspicious type 3 curve on DCE MRI (not shown). The other lesion in the right posterior peripheral zone was not visualized. (D,E) Intraoperative MRgFUS image showing focused ultrasound beam path overlaid on treatment plan for left posterior peripheral zone lesion (E) with real-time thermal map (D). (F) Immediate post-treatment T1-weighted postcontrast MR image (TR/TE, 400/6) showing nonperfused devascularized ablated volumes in bilateral peripheral zones (arrows). (G) One-month post-treatment T1-weighted postcontrast MR image (TR/TE, 400/6) showing persistence of nonperfused devascularized ablated volumes in bilateral peripheral zones (arrows). (H) Axial T2-weighted fast spin-echo MR image (TR/TE, 3300/90) on 2-year follow-up showing loss of volume with fibrosis in treated area (arrow). (From Tay KJ, Cheng CWS, Lau WKO, et al. Focal therapy for prostate cancer with in-bore MR-guided focused ultrasound: two-year follow-up of a phase I trial—complications and functional outcomes. Radiology 285(2):620–628, 2017.)
FIG. 158.4 Focal cryoablation procedure. (A) Biplanar ultrasound probe is placed in the rectum. (B) Variable length cryoprobes are set to prostate measurements. (C,D) An anterior ablation pattern is being used here with four probes in the anterior prostate. (E) The ice in the anterior prostate. The leading ice edge has a hyperechoic rim and can be monitored easily. (F) Console readout showing lethal temperature in the anterior apex and safe temperatures in the external sphincter (ES) and the right neurovascular bundle (RNVB). The full video may be viewed at http://www.liebertpub.com/videourology. (From Tay KJ, Polascik TJ. Anterior prostate cancer cryoablation: a technique in prostate focal therapy, Videourology 31:2, 2017.)
FIG. 158.3 Patterns of ablation.
FIG. 158.2 (A) Unifocal prostate cancer. (B) Multifocal prostate cancer with clear index lesion and one or more separate secondary tumor foci with smaller volumes (most common). (C) Multifocal cancer with unclear index tumor. (From Perera, Krishnananthan N, Lindner U, Lawrentschuk N. An update on focal therapy for prostate cancer. Nat Rev Urol 13(11):641–653, 2016.)
FIG. 158.1 Emerging and established hallmark capabilities and enabling characteristics of cancer. (Modified from Hanahan D, Weinberg RA. Hallmarks of cancer: the next generation. Cell 144(5):646–674, 2011.)
FIG. 157.9 Axial view of MRI T2 image showing hydrogel positioned between the prostate/seminal vesicles and the rectum.
FIG. 157.8 Brachytherapy postimplant computed tomography (CT) (A) and T2 magnetic resonance imaging (MRI) (B) axial images. Seeds are well-visualized on CT, but prostate delineation is obscured by seed artifact. MRI imaging allows for improved prostate delineation. Image sets are spatially registered/fused for accurate correlation between dose and normal anatomy. The prostate (red), urethra (yellow), and rectum (light green) are shown. 100% and 150% prescription isodose lines are shown in green and blue, respectively.
FIG. 157.7 (A) Off-axis view of a brachytherapy treatment plan showing needle paths and seed locations. The prostate (red), rectum (blue), and urethra (green) are shown. Note peripheral loading of seeds to minimize the dose to the central urethra. (B) Axial view of brachytherapy treatment plan superimposed on TRUS image. Seeds that have been placed are denoted by green triangles with lines. The grid coordinates superimposed on the TRUS correlate with the holes in the template grid and allow the treatment team to communicate regarding specific seeds/needles.
FIG. 157.6 Dose-depth characteristics of protons and photons. Protons have improved skin- and tissue-sparing properties, as a result of the Bragg peak. However, because of the narrow effective range of the Bragg peak differing from the thickness of most tumors, clinical treatments modulate the protons to create a spread-out Bragg peak (SOBP). (From Leeman JE, Romesser PB, Zhou Y, et al. Proton therapy for head and neck cancer: expanding the therapeutic window. Lancet Oncol 18[5]:e254–e265, 2017.)
FIG. 157.5 Lateral view of a transrectal ultrasound probe (TRUS) held within a stepper cradle (black). The patient is in the high lithotomy position. The template grid is positioned against the perineum, and either needles (low-dose-rate) or catheters (high-dose-rate) are placed through the grid into the prostate. (From Morton GC. The emerging role of high-dose-rate brachytherapy for prostate cancer. Clin Oncol 17[4]:219–227, 2005.)
FIG. 157.4 Sagittal view of a treatment plan utilizing a rectal balloon.
FIG. 157.3 Modern linear accelerator with imaging capability. (A) The radiation treatment beam is shaped by a collimator contained within the treatment head (top). The panel (right) contains a kilovoltage unit for generating cone-beam computed tomography (CT) images. Two moveable imaging panels are present. The imager panel (left) is for capturing kilovoltage two-dimensional or cone-beam images (obtained by rotating the entire unit around the patient), whereas the unit on the bottom (opposite from the treatment head) allows for megavoltage imaging confirmation of beam shape in addition to three-dimensional CT reconstruction. The patient lies on the carbon-fiber treatment couch (black), which can be moved in three dimensions (x, y, z), and rotated in all directions (pitch, yaw, roll). (B) Example of cone-beam alignment images. Planning (simulation) images (light gray panels) are overlain with a cone-beam image acquired before each treatment (dark gray panels). Internal anatomy is aligned between the two image sets, and the treatment couch is moved accordingly (i.e., table correction). (C) Example of a fiducial marker-based alignment. Fiducial (typically gold) markers within the prostate allow for either orthogonal two-dimensional (shown) or three-dimensional on-board CT imaging alignment of prostate before each daily treatment session. (A, Used with permission from Elekta Inc.)
FIG. 157.2 Axial (A) and sagittal (B) views of an intensity-modulated radiation treatment plan (IMRT) showing prostate (solid red), bladder (base, solid yellow), and rectum (solid brown). Dose lines (isodoses) are shown in thin colored lines (key in upper left of image). Prescription dose isodose line (78 Gy, thick red) includes a margin around the prostate, with less margin posteriorly to minimize rectal dose. Note skin sparing, and concavity of posterior dose lines achieved by IMRT.
FIG. 157.1 Dose-volume histogram (DVH) of conventionally fractionated, intensity-modulated radiation treatment plan. Both volume (y-axis) and dose (x-axis) are typically evaluated and shown as percentages of total. Prescription dose is 78 Gy. Note that this plan has nearly 100% of target volume (PTV) receiving prescribed dose, yet there is steep fall-off in target volume coverage beyond 78 to 80 Gy. This is typical for conventionally fractionated plans to avoid excessive dose within the prostate and immediate adjacent tissues. In contrast, stereotactic body radiation plans (see the Stereotactic Body Radiotherapy section in text) often have portions of target volume intentionally receiving a higher-than-prescribed dose, with the rationale of increasing the dose to the intraprostatic tumor.
FIG. 156.27 Final dissection of a standard pelvic lymph node template. The proximal and distal extent of the lymph node packet are clipped and divided, taking great care to avoid injury to the obturator nerve and vessels, as well as the accessory obturator vein. (Copyright Li-Ming Su, MD, University of Florida, 2009.)
FIG. 31.4 (A) Renal arteriography revealing at least three pseudoaneurysms 2 days after a right robotic partial nephrectomy for a 6-cm midpole renal mass. (B) Selective coil embolization revealing resolution of the bleeding pseudoaneurysms.
FIG. 31.3 Segmental renal arterial pseudoaneurysm. Arterial phase of a contrast computed tomography image revealing an arterial blush in a patient 2 days after a left laparoscopic partial nephrectomy. Source: (From Tare D, Maria P, Ghavamian R. Vascular complications in laparoscopic and robotic urologic surgery. In: Ghavamian R, ed. Complications of laparoscopic and robotic urologic surgery. 1st ed. New York: Springer, 2010:45-58.)
FIG. 31.2 Capacitive coupling. (A) Charge surrounding the activated monopolar electrode is conducted back to the all-metal cannula and dispersed by the abdominal wall. (B) The electrosurgical instrument is being used through a metal cannula that has been anchored to the skin with a nonconductive plastic grip; accordingly, the electrical field cannot be conducted to the abdominal wall because the plastic retainer acts as an insulator; a stronger electrical charge is thus conducted to any other tissue in contact with the cannula.
FIG. 31.1 (A) The fourth arm of the robot is utilized to gain temporary partial control. (B) The defect is repaired with a 5.0 running suture with excellent visualization and control. (C) Final repair with some luminal narrowing but proximal and distal filling of the vein with the sequential pneumatic device confirming flow. Source: (From Tare D, Maria P, Ghavamian R. Vascular complications in laparoscopic and robotic urologic surgery. In: Ghavamian R, ed. Complications of laparoscopic and robotic urologic surgery. 1st ed. New York: Springer, 2010:45–58.)
FIG. 30.10 Recommended surgical approach for nonmetastatic primary adrenocortical carcinoma. 18 FDG, [18F]fluorodeoxyglucose. Source: (From Gaujoux S, Mihai R; Joint Working Group of ESES and ENSAT: European Society of Endocrine Surgeons (ESES) and European Network for the Study of Adrenal Tumours (ENSAT) recommendations for the surgical management of adrenocortical carcinoma. Br J Surg 2017;104(4):358-376.)
FIG. 30.9 Testing algorithm for ruling out hypercortisolemia secondary to an adrenal mass. In case of a positive result during late-night salivary cortisol or 24-hour urinary free cortisol evaluations, repeat testing is often prudent. DST, Dexamethasone suppression test; UFC, urinary free cortisol.
FIG. 30.8 Summary of evaluation of adrenal mass using modern cross-sectional imaging. CT, Computed tomography; HU, Hounsfield units; MR, magnetic resonance.
FIG. 30.7 Preoperative medical management in patients with pheochromocytoma. bid, Twice a day; BP, blood pressure; HR, heart rate; IV, intravenous; PO, by mouth; SBP, systolic blood pressure; tid, three times a day. Source: (Modified from Pacak K. Preoperative management of the pheochromocytoma patient. J Clin Endocrinol Metab 2007;92:4069-4079.)
FIG. 30.6 Primary aldosteronism diagnosis and treatment algorithm. CT, Computed tomography; FH, familial hyperaldosteronism; PA, primary aldosteronism; PAC, plasma aldosterone concentration; PRA, plasma renin activity.
FIG. 30.5 Subtypes of primary aldosteronism. Source: (Modified from Young WF. Primary aldosteronism: renaissance of a syndrome. Clin Endocrinol [Oxf] 2007;66:607-618.)
FIG. 30.4 Clinically relevant causes of excess cortisol production. ACTH, Adrenocorticotropic hormone; CRH, corticotropin-releasing hormone.
