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27.01.2012 УЗИ Мочевого пузыря и предстательной железы. Гипертрофия предстательной железы, vesico-urachal diverticulum.

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Вижу гиперплазию простаты,

Вижу гиперплазию простаты, остаточную мочу....киста урахуса?

 
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ДГПЖ в зоне периуретральных

ДГПЖ в зоне периуретральных желез. Поэтому при относительно небольшом объеме такое количество ост.мочи. Образование -дивертикул мочевого пузыря ( киста урахуса-незаращение средней его части). Не вижу четкой  структуры стенки  дивертикула, имеющий все слои стенки мочевого пузыря, т.е. возможно ложный дивертикул- может быть вследствие повышенного давления, возникающего при мочеиспускании.  На скане с допплером- подозрение на полип?

 
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ДГПЖ. учитывая относительно

ДГПЖ. учитывая относительно небольшой обьем - 59 см3- дизурические жалобы - за счет гиперплазии в переходной зоне. 

уретра визуализируется не четко (точнее - не визуализируется). при этом расширен парапростатический отдел.

Дивертикул с полипом - по ходу пьесы. кста, слои стенки хорошо видны.

чем сердце успокоится - ПСА и ТУР.

 
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Источник :Диагностический

Источник :Диагностический ультразвук. Уронефрология. Практическое руководство А.В. Зубарев  2002 год. Страницы: 160-162: формы роста ДГПЖ :-)

 Кстати, увидеть все слои стенки дивертикула можно....при богатом воображении

 
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Vesicourachal дивертикул? 

Vesicourachal дивертикул? 

 
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гипер-гипо-гипер... и

гипер-гипо-гипер... и никакого воображения.

 
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ага, на предпоследнем скане

ага, на предпоследнем скане как раз видна хорошо стенка м.п., а вот убедительных стенок дивертикула -не видно. А как насчет гиперплазии переходной зоны :-))?

 
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(Тема не указана)

 
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то, что обведено вами- как

то, что обведено вами- как раз зона периуретральных желез :-))). Стенки дивертикула указали неубедительно. Сравните хотя бы с рядом расположенной трехслойной стенкой мочевого пузыря. 

С искренним уважением.

 
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Urachal Remnant Diseases:


Urachal Remnant Diseases: Spectrum of CT and US Findings

  1. Jeong-Sik Yu, MD,
  2. Ki Whang Kim, MD,
  3. Hwa-Jin Lee, MD,
  4. Young-Jun Lee, MD,
  5. Choon-Sik Yoon, MD and
  6. Myung-Joon Kim, MD

+ Author Affiliations


  1. 1From the Department of Diagnostic Radiology and the Research Institute of Radiological Science, Yonsei University College of Medicine, YongDong Severance Hospital, 146-92 Dogok-Dong, Gangnam-Gu, Seoul 135-270, South Korea. Presented as a scientific exhibit at the 1999 RSNA scientific assembly. Received March 21, 2000; revision requested June 8 and received June 28; accepted June 29. Address correspondence to J.S.Y. (e-mail: yjsrad97@yumc.yonsei.ac.kr).

Abstract

Computed tomography (CT) and ultrasonography (US) are ideally suited for demonstrating urachal remnant diseases. A patent urachus is demonstrated at longitudinal US and occasionally at CT as a tubular connection between the anterosuperior aspect of the bladder and the umbilicus. An umbilical-urachal sinus manifests at US as a thickened tubular structure along the midline below the umbilicus. A vesicourachal diverticulum is usually discovered incidentally at axial CT, appearing as a midline cystic lesion just above the anterosuperior aspect of the bladder. At US, it manifests as an extraluminally protruding, fluid-filled sac that does not communicate with the umbilicus. Urachal cysts manifest at both modalities as a noncommunicating, fluid-filled cavity in the midline lower abdominal wall located just beneath the umbilicus or above the bladder. Both infected urachal cysts and urachal carcinomas commonly display increased echogenicity at US and thick-walled cystic or mixed attenuation at CT, making it difficult to differentiate between them. Percutaneous needle biopsy or fluid aspiration is usually needed for diagnosis and therapeutic planning. Nevertheless, CT and US can help identify most disease entities originating from the urachal remnant in the anterior abdominal wall. Understanding the anatomy and the imaging features of urachal remnant diseases is essential for correct diagnosis and proper management.

LEARNING OBJECTIVES FOR TEST 5

After reading this article and taking the test, the reader will be able to:

  • Describe the basic embryologic and anatomic features of the urachus.

  • Identify the four types of congenital urachal anomalies and their CT and US features.

  • Recognize the manifestations of an infected urachal remnant versus urachal carcinoma at CT and US.

 

Introduction

The urachus, or median umbilical ligament, is a midline tubular structure that extends upward from the anterior dome of the bladder toward the umbilicus. It is a vestigial remnant of at least two embryonic structures: the cloaca, which is the cephalic extension of the urogenital sinus (a precursor of the fetal bladder), and the allantois, which is a derivative of the yolk sac (1). The tubular urachus normally involutes before birth, remaining as a fibrous band with no known function. However, persistence of an embryonic urachal remnant can give rise to various clinical problems, not only in infants and children but also in adults. Because urachal remnant diseases are uncommon and manifest with nonspecific abdominal or urinary signs and symptoms, definitive presurgical diagnosis is not easily made. Various abnormalities can be confusing unless one is familiar with the basic embryologic anatomy and imaging features of the subumbilical and prevesical region. Because computed tomography (CT) and ultrasonography (US) display cross-sectional images and the urachus in the anterior abdominal wall is located away from interfering intestinal structures, these modalities are ideally suited for demonstrating urachal anomalies (25).

In this article, we review the embryologic and anatomic features of the urachus. We also discuss and illustrate the spectrum of CT and US findings in both congenital urachal anomalies (patent urachus, umbilical-urachal sinus, vesicourachal diverticulum, urachal cyst) and acquired urachal remnant diseases (infection, neoplasm).

Embryology and Normal Anatomy

The allantois appears on about day 16 as a tiny, finger-like outpouching from the caudal wall of the yolk sac (1). The bladder develops from the ventral portion of the expanded terminal part of the hindgut, the cloaca, which is contiguous with the allantois ventrally (Fig 1). The cranioventral end of the bladder opens into the allantois at the level of the umbilicus; thus, the bladder initially extends all the way to the umbilicus. By the 4th or 5th month of gestation, the bladder descends into the pelvis and its apical portion progressively narrows to a small, epithelialized fibromuscular strand, the urachus (1). In late embryonic and fetal life and early postnatal life, the urachal portion, which is still microscopic, fails to grow; thus, its lumen remains narrow and is usually obliterated by fibrous proliferation. In one-third of adults, it may be visible at microscopic examination as a structure communicating with the lumen of the bladder; however, in terms of function it can be considered closed by the latter half of fetal life (6).

Figure 1.  Drawing illustrates the continuity of the ventral cloaca and the allantois in an 8-week-old fetus.

The urachus varies from 3 to 10 cm in length and from 8 to 10 mm in diameter. It is a three-layered tubular structure, the innermost layer being lined with transitional epithelium in 70% of cases and with columnar epithelium in 30%. The structure is surrounded by connective tissue and an outermost muscular layer in continuity with the detrusor muscle (6,7). Along its path from the bladder to the umbilicus, the urachus lies between the transverse fascia and the parietal peritoneum contained in the pyramidal, retropubic, preperitoneal perivesical space compartmental-ized by umbilicovesical fascia, along with the medial umbilical ligaments and the bladder (Fig 2). Occasionally, the urachus may merge with one or both of the obliterated umbilical arteries, and there may be a slight deviation to the right or left of the midline (8).

Figure 2.  Drawings of the lower anterior abdominal wall as seen from inside the peritoneal cavity (top) and in the transverse plane (bottom) show the urachus extending from the dome of the bladder to the umbilicus along with the medial umbilical ligaments (obliterated umbilical arteries) (mul), which lie within the perivesical space between the transverse fascia (tf) and the parietal peritoneum (pp) and are surrounded by the umbilicovesical fascia (uvf). eia = external iliac artery, eiv = external iliac vein, ieav = inferior epigastric artery and vein, ram = rectus abdominus muscle, vd = vas deferens.

Congenital Urachal Anomalies

Congenital urachal anomalies are twice as common in men as in women (9). There are four types of congenital urachal anomalies: patent urachus, umbilical-urachal sinus, vesicourachal diverticulum, and urachal cyst (Fig 3). A patent urachus is purely congenital and accounts for about 50% of all cases of congenital anomalies (10). An umbilical-urachal sinus (representing about 15% of cases), vesicourachal diverticulum (about 3%–5%), or urachal cyst (about 30%) may close normally after birth but then reopen in association with pathologic conditions that are often categorized as acquired diseases (7,1013). The majority of patients with urachal abnormalities (except those with a patent urachus) are asymptomatic. However, they may become symptomatic if these abnormalities are associated with infection.

Figure 3a.  Drawings illustrate the four types of congenital urachal anomalies. B = bladder, p = peritoneal cavity, r = rectum, s = symphysis pubis, umb = umbilicus.

If a persistent communication exists between the bladder lumen and the umbilicus, urine leakage is usually noted during the neonatal period. In about one-third of cases, this condition is associated with posterior urethral valves or urethral atresia (14). A definitive diagnosis can be made with sinography or cystography (15,16). Patent urachus as a tubular connection between the anterosuperior aspect of the bladder and the umbilicus is demonstrated at longitudinal US and occasionally at CT performed in infants during the bladder-filling stage (Fig 4). Some patients with patent urachus are asymptomatic, and sometimes an acquired obstructive lesion of the lower urinary tract may result in umbilical-urinary fistulas (7).

Figure 4a.  Patent urachus with superimposed infection in a 20-day-old infant. (a) Sagittal US image shows a hypoechoic tubular structure between the bladder (bl) and the umbilicus (umb) (arrowheads). (b, c) Unenhanced CT scans (b obtained at a lower level than c) show a fluid-filled tubular structure (arrowhead) extending from the bladder (bl) to the umbilicus (umb).

Figure 4b.  Patent urachus with superimposed infection in a 20-day-old infant. (a) Sagittal US image shows a hypoechoic tubular structure between the bladder (bl) and the umbilicus (umb) (arrowheads). (b, c) Unenhanced CT scans (b obtained at a lower level than c) show a fluid-filled tubular structure (arrowhead) extending from the bladder (bl) to the umbilicus (umb).

Figure 4c.  Patent urachus with superimposed infection in a 20-day-old infant. (a) Sagittal US image shows a hypoechoic tubular structure between the bladder (bl) and the umbilicus (umb) (arrowheads). (b, c) Unenhanced CT scans (b obtained at a lower level than c) show a fluid-filled tubular structure (arrowhead) extending from the bladder (bl) to the umbilicus (umb).

Umbilical-urachal sinus consists of blind dilatation of the urachus at the umbilical end. A small opening into the umbilicus is generally present and may result in periodic discharge (7,10). A thickened tubular structure along the midline below the umbilicus can be visualized at US (Fig 5a). It is usually associated with an infection of the urachal remnant and confirmed at sinography (Fig 5b).

Figure 5a.  Infected umbilical-urachal sinus in a 19-year-old man. (a) Sagittal US image shows a hypoechoic tubular structure (arrows) extending from the umbilicus (umb) (cursors) just beneath the anterior abdominal wall. The caudal end of this tubular structure is obliterated. (b) Cross-table lateral sinogram shows a blind sinus tract (arrows) with no communication with the bladder. The complex caudal end of the sinus tract (arrowheads) suggests superimposed infection and fistula formation through the anterior abdominal wall. umb = umbilicus.

Figure 5b.  Infected umbilical-urachal sinus in a 19-year-old man. (a) Sagittal US image shows a hypoechoic tubular structure (arrows) extending from the umbilicus (umb) (cursors) just beneath the anterior abdominal wall. The caudal end of this tubular structure is obliterated. (b) Cross-table lateral sinogram shows a blind sinus tract (arrows) with no communication with the bladder. The complex caudal end of the sinus tract (arrowheads) suggests superimposed infection and fistula formation through the anterior abdominal wall. umb = umbilicus.

In vesicourachal diverticulum, the urachus communicates only with the bladder dome. This condition results when the vesical end of the urachus fails to close. Vesicourachal diverticulum is asymptomatic in most cases and is usually discovered incidentally at axial CT performed for unrelated reasons, appearing as a midline cystic lesion just above the anterosuperior aspect of the bladder (Fig 6a, 6b) (17). US readily demonstrates an extraluminally protruding, fluid-filled sac that does not communicate with the umbilicus (Fig 6c). This lesion tends to be found in patients with chronic bladder outlet obstruction and may be complicated by urinary tract infection, intraurachal stone formation, and an increased prevalence of carcinoma after puberty (18). In infants, vesicourachal diverticulum is commonly accompanied by prune-belly syndrome (9).

Figure 6a.  Vesicourachal diverticulum as an incidental finding in a 58-year-old man. (a, b) Axial CT scans (a obtained at a lower level than b) demonstrate a small, anterosuperior outpouching (arrow) representing a urachal diverticulum arising from the apex of the bladder (bl). The umbilicovesical fascia (arrowheads in b) allows localization of the urachus in the extraperitoneal perivesical space. (c) Sagittal US image shows a localized hypoechoic outpouching (arrow) communicating with the uppermost portion of the bladder (bl), thereby helping confirm the CT findings.

Figure 6b.  Vesicourachal diverticulum as an incidental finding in a 58-year-old man. (a, b) Axial CT scans (a obtained at a lower level than b) demonstrate a small, anterosuperior outpouching (arrow) representing a urachal diverticulum arising from the apex of the bladder (bl). The umbilicovesical fascia (arrowheads in b) allows localization of the urachus in the extraperitoneal perivesical space. (c) Sagittal US image shows a localized hypoechoic outpouching (arrow) communicating with the uppermost portion of the bladder (bl), thereby helping confirm the CT findings.

Figure 6c.  Vesicourachal diverticulum as an incidental finding in a 58-year-old man. (a, b) Axial CT scans (a obtained at a lower level than b) demonstrate a small, anterosuperior outpouching (arrow) representing a urachal diverticulum arising from the apex of the bladder (bl). The umbilicovesical fascia (arrowheads in b) allows localization of the urachus in the extraperitoneal perivesical space. (c) Sagittal US image shows a localized hypoechoic outpouching (arrow) communicating with the uppermost portion of the bladder (bl), thereby helping confirm the CT findings.

A urachal cyst develops if the urachus closes at both the umbilicus and the bladder but remains patent between these two endpoints. It occurs primarily in the lower one-third of the urachus and less frequently in the upper one-third (19). Urachal cysts are usually small but vary considerably in size (9). They become symptomatic when they enlarge but are sometimes found as incidental masses during routine examination (20). CT or US shows a fluid-filled cavity in the midline lower abdominal wall (12,16,2123). Eggshell calcification of the cyst wall is rarely reported (24). As with other urachal anomalies, infection is the most common complication of urachal cyst, and the majority of cysts are infected at the time of diagnosis (12,19,21,25,26). Superinfected urachal cyst manifests as wall thickening and demonstrates an attenuation higher than that of water at CT and soft-tissue components and mixed echogenicity at US (Fig 7).

Figure 7a.  Infected urachal cyst in a 55-year-old man. (a) Transverse US image shows a complex cystic lesion lying along the course of the urachus midway between the bladder and the umbilicus (arrows). The lesion demonstrates mixed internal echogenicity, a thick outer wall, and a shaggy inner margin. (b) Contrast material-enhanced CT scan shows a strongly enhancing, thick-walled cystic lesion with perilesional infiltration just beneath the abdominal wall in the midline (arrowheads).

Figure 7b.  Infected urachal cyst in a 55-year-old man. (a) Transverse US image shows a complex cystic lesion lying along the course of the urachus midway between the bladder and the umbilicus (arrows). The lesion demonstrates mixed internal echogenicity, a thick outer wall, and a shaggy inner margin. (b) Contrast material-enhanced CT scan shows a strongly enhancing, thick-walled cystic lesion with perilesional infiltration just beneath the abdominal wall in the midline (arrowheads).

 

 
 

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