Magnelic Resonance Printed in the USA.
Imaging, Vol. 10. pp. 881-885, All rights reserved.
1992 Copyright
0
0730-725X192 $5.00 + .OLl 1992 Pergamon Press Ltd.
0 Original Contribution CINE MR VOIDING CYSTOURETHROGRAM IN ADULT NORMAL MALES R.K. GUPTA,* R. KA~OOR,~ H. POPTANI,* H. RASTOGI,* AND R.B. GUJRAL* *MR Section, Department
of Radiology and TDepartment of Urology, Sanjay Gandhi Post-Graduate Sciences, Lucknow - 226001, India
Institute of Medical
Cine voidingcystourethrogram was performed in 15 normal subjects using T,-weigbted Turbo FLASH sequence. It showed the sequence of emptying of bladder, detrusor muscle contraction, opening of the sphincters, and various parts of urethra. It was found to be a good noninvasive test to study the dynamics of lower urinary tract without disturbing the state of the physiology. Keywords: Magnetic resonance tine; Urinary bladder.
bladder has the function of storing urine and expelling the accumulated urine at a voluntary time. While urine is being stored, the bladder gives an indication of its distention, at first discreetly and later more forcefully. These two aspects of the bladder are due to complex series of anatomical, neurophysiological, and even psychological functions, any of which may be disturbed and cause symptoms. Video urodynamics is the gold standard for evaluating the pathophysiology of the urinary bladder.’ Sonography has also been performed but it has its limitations. ‘T3 We present the normal physiology of the lower urinary tract in adult males using tine MR. The potentials, shortcomings, and need to pursue it for future development is discussed.
MR examination was performed using a 2-T superconducting system (Siemen’s Helicon, Erlangen, Germany) operating at 1.5 T, with circularly polarized body coil. Initial localising slices were taken in sagittal plane using FLASH sequence (FA/TE/TR = 40/12/300) with contiguous interleaved 4-mm slices. Nine slices were obtained on a 256 x 256 matrix with oversampling with 400 mm field of view. The slice showing the bladder with its neck and urethra in its entire length was chosen for voiding study. A single pre-voiding 10 mm slice was taken in the selected position using turbo FLASH with 8/3/6.5, TI= 750 msec, 128 x 128 matrix, to confirm the final position. With same parameters 30 scans were taken on the same slice and the sequence was loaded. Each subject was told to urinate immediately after the start of the acquisition to avoid missing of any micturating event. Total time taken for acquisition of voiding data was 1 min and 10 sec. The images were run in tine mode and real time act of micturition was displayed (Fig. 1). In two subjects, we instructed them to stop micturating in between and to restart after a few seconds to look for the functioning of the sphincter. Volume of each slice was measured using area length measurement (ALM) (provided in the system software) and drawn as a function of time to see the bladder emptying pattern. Time taken for micturition by 12 individuals (n = 12) varied between 25 (n = 7)
The urinary
MATERIALS
AND RESULTS
Voiding cystourethrogram was studied in 15 normal volunteers using Ti weighted turbo FLASH sequence. 4,5Age of the subjects ranged between 20 and 40 yr. Subjects were told to retain urine until they found it difficult to hold. Each volunteer was positioned supine in the gantry when he developed a strong desire to micturate. The pelvis was centered with a light localizer. A plastic bottle was placed touching the glans to collect the voided urine.
Gandhi Post-Graduate Institute of Medical Sciences, P.B. 375, Raebareli Road, Lucknow - 226001, India.
RECEIVED10/18/91; ACCEPTEDS/6/92. Address correspondence to Dr. R.K. Gupta, MD, Incharge, MR Section, Department of Radiology, Sanjay 881
882
Magnetic Resonance Imaging 0 Volume 10, Number 6, 1992
(4
(B)
((3
0)
03
(Q
Fig. 1. M:id siagitl 11tine MR through the urinary bladder, bladder neck (arrow) and urethra (small arro%‘s) at (A) 0 set: 2.5 set, (( :) 5 set, :D) 7.5 set, (E) 10.0 set, and (F) 12.5 sec. (A) shows full bladder with closed bladder ne:ck; (B) op enin bladder . n’eck and .trethra with the initiation of act of micturition. (Figure continues)
Cine voiding cystourethrogram
0 R.K. GUPTA ET AL.
(1)
(J)
(W
(L)
883
Fig. 1 continued. (G) 15 set, and (H) 17.5 sec. (I) 20 set, (J) 22.5 set, (K) 25 set, and (L) 27.5 sec. (C)-(K) show gradual emp tying of the bladder; (L) residual urine with closed bladder neck at the end of micturition.
884
Magnetic Resonance Imaging 0 Volume 10, Number 6, 1992 v0L.m.) I
0
2.6
6.~
7.6
K).O 12.6
16.0
17.5 20.0
22.6 26.0 27.6
TIME IN SECONDS Fig. 2. Mean volume +l SD (n = 12) versus time demonstrates
initial volume, emptying time, and residual urine.
and 27.5 (n = 5) sec. Mean volume was plotted as a
the average maximal and mean flow of urine at the
function of time with + 1 SD from the different volumes of 12 volunteers (Fig. 2). The time taken in three volunteers was between 42.5 and 45 set, hence not included in the mean curve due to a large variation in the standard deviation. The mean curve with +I SD showed initial volume, residual volume, and ejection fraction of the urinary bladder. A plot was also made from the volume reduced after every slice to look for
bladder neck (Fig. 3). Average maximal flow rate ranged between 27.2 and 34.4 ml/set (normal range 20-40 ml/set, mean flow rate range 14.3-18.5 ml/set. Total micturition time varied between 25 and 45 sec. The uroflow was done using uroflow dentek UD-5500 in all the individuals and showed average maximal flow rate 26.0-33.3 ml/set and mean flow rate 14.217.5 ml/set.
10
12.5
15
Time (set) Fig. 3. Volume versus 2.5set flow rate of 27.2 ml/set.
increments:
It shows that the maximal urine passed is 68 ml in first 2.5 set, average maximal
Cine voiding cystourethrogram 0 R.K. GUPTA ET AL.
Opening of the internal sphincter, external sphincter, and contraction of detrusor muscle was seen. Total examination time per individual was 5-6 min. Time taken for its analysis was about 30 min.
885
ues which we could not do in the present study. We feel that it is a step in the direction of studying the pathophysiology of the lower urinary tract noninvasively, without modifying the physiology of the individual.
DISCUSSION REFERENCES Video urodynamics is the standard investigation for evaluating the functional problems of the urinary bladder. ’ As such the technique is invasive and carries a distinct risk of urinary infection. It creates an artificial situation to evaluate a physiological process. Therefore it becomes more difficult to correlate the results of the artificial testing situation with clinical symptomatology.6 Cine MR voiding cystourethrogram has given an anatomical and physiological picture of the complete act of micturition. Contraction of detrusor muscle, opening of the bladder neck and external sphincter, as well as a view of the whole urethra is very well displayed in dynamic mode. Our study gave a complete anatomical view of the lower urinary tract. In addition, the uroflow pattern, maximal and mean flow rate, total voiding time, residual volume, and pattern of bladder emptying as a function of time could be studied. To give a complete answer for voiding dysfunction problems, we also need detrusor muscle pressure val-
1. Saxton, H.M. Urodynamics: The appropriate modality
for the investigation of frequency, urgency, incontinence and voiding difficulties. Radiology 175:307-316; 1990. 2. Shapeero, L.G.; Friedland, G.W.; Perkash, I. Transrec-
3.
4.
5.
6.
tal sonographic voiding cystourethrography: Studies of neuromuscular bladder dysfunction. Am. J. Roentgenol. 141:83-91; 1983. Boothroyd, A.E.; Dixon, P. J.; Christmas, T. J.; Chapple, C.R.; Rickards, D. The ultrasound cystodynamogram a new radiological technique. Brit. J. Radiol. 63:331-332; 1990. Haase, A.; Matthaei, D.; Bartkowski, R.; Duhmke, E.; Leibfritz, D. Inversion recovery snapshot FLASH MR imaging. .I. Comput. Assist. Tomogr. 13:1036-1040; 1989. Haase, A. Snapshot FLASH MRI: Applications to T,, T,, and chemical shift imaging. Magn. Reson. Med. 13: 77-89; 1990. Wein, A.J. The pitfalls of urodynamics. In: A.R. Mundy, T.P. Stephenson, A.J. Wein (Eds.). Urodynamics: Principles, Practice and Application. Edinburgh: Churchill Livingstone; 1984: pp. 150- 153.
Imaging, Vol. 10. pp. 881-885, All rights reserved.
1992 Copyright
0
0730-725X192 $5.00 + .OLl 1992 Pergamon Press Ltd.
0 Original Contribution CINE MR VOIDING CYSTOURETHROGRAM IN ADULT NORMAL MALES R.K. GUPTA,* R. KA~OOR,~ H. POPTANI,* H. RASTOGI,* AND R.B. GUJRAL* *MR Section, Department
of Radiology and TDepartment of Urology, Sanjay Gandhi Post-Graduate Sciences, Lucknow - 226001, India
Institute of Medical
Cine voidingcystourethrogram was performed in 15 normal subjects using T,-weigbted Turbo FLASH sequence. It showed the sequence of emptying of bladder, detrusor muscle contraction, opening of the sphincters, and various parts of urethra. It was found to be a good noninvasive test to study the dynamics of lower urinary tract without disturbing the state of the physiology. Keywords: Magnetic resonance tine; Urinary bladder.
bladder has the function of storing urine and expelling the accumulated urine at a voluntary time. While urine is being stored, the bladder gives an indication of its distention, at first discreetly and later more forcefully. These two aspects of the bladder are due to complex series of anatomical, neurophysiological, and even psychological functions, any of which may be disturbed and cause symptoms. Video urodynamics is the gold standard for evaluating the pathophysiology of the urinary bladder.’ Sonography has also been performed but it has its limitations. ‘T3 We present the normal physiology of the lower urinary tract in adult males using tine MR. The potentials, shortcomings, and need to pursue it for future development is discussed.
MR examination was performed using a 2-T superconducting system (Siemen’s Helicon, Erlangen, Germany) operating at 1.5 T, with circularly polarized body coil. Initial localising slices were taken in sagittal plane using FLASH sequence (FA/TE/TR = 40/12/300) with contiguous interleaved 4-mm slices. Nine slices were obtained on a 256 x 256 matrix with oversampling with 400 mm field of view. The slice showing the bladder with its neck and urethra in its entire length was chosen for voiding study. A single pre-voiding 10 mm slice was taken in the selected position using turbo FLASH with 8/3/6.5, TI= 750 msec, 128 x 128 matrix, to confirm the final position. With same parameters 30 scans were taken on the same slice and the sequence was loaded. Each subject was told to urinate immediately after the start of the acquisition to avoid missing of any micturating event. Total time taken for acquisition of voiding data was 1 min and 10 sec. The images were run in tine mode and real time act of micturition was displayed (Fig. 1). In two subjects, we instructed them to stop micturating in between and to restart after a few seconds to look for the functioning of the sphincter. Volume of each slice was measured using area length measurement (ALM) (provided in the system software) and drawn as a function of time to see the bladder emptying pattern. Time taken for micturition by 12 individuals (n = 12) varied between 25 (n = 7)
The urinary
MATERIALS
AND RESULTS
Voiding cystourethrogram was studied in 15 normal volunteers using Ti weighted turbo FLASH sequence. 4,5Age of the subjects ranged between 20 and 40 yr. Subjects were told to retain urine until they found it difficult to hold. Each volunteer was positioned supine in the gantry when he developed a strong desire to micturate. The pelvis was centered with a light localizer. A plastic bottle was placed touching the glans to collect the voided urine.
Gandhi Post-Graduate Institute of Medical Sciences, P.B. 375, Raebareli Road, Lucknow - 226001, India.
RECEIVED10/18/91; ACCEPTEDS/6/92. Address correspondence to Dr. R.K. Gupta, MD, Incharge, MR Section, Department of Radiology, Sanjay 881
882
Magnetic Resonance Imaging 0 Volume 10, Number 6, 1992
(4
(B)
((3
0)
03
(Q
Fig. 1. M:id siagitl 11tine MR through the urinary bladder, bladder neck (arrow) and urethra (small arro%‘s) at (A) 0 set: 2.5 set, (( :) 5 set, :D) 7.5 set, (E) 10.0 set, and (F) 12.5 sec. (A) shows full bladder with closed bladder ne:ck; (B) op enin bladder . n’eck and .trethra with the initiation of act of micturition. (Figure continues)
Cine voiding cystourethrogram
0 R.K. GUPTA ET AL.
(1)
(J)
(W
(L)
883
Fig. 1 continued. (G) 15 set, and (H) 17.5 sec. (I) 20 set, (J) 22.5 set, (K) 25 set, and (L) 27.5 sec. (C)-(K) show gradual emp tying of the bladder; (L) residual urine with closed bladder neck at the end of micturition.
884
Magnetic Resonance Imaging 0 Volume 10, Number 6, 1992 v0L.m.) I
0
2.6
6.~
7.6
K).O 12.6
16.0
17.5 20.0
22.6 26.0 27.6
TIME IN SECONDS Fig. 2. Mean volume +l SD (n = 12) versus time demonstrates
initial volume, emptying time, and residual urine.
and 27.5 (n = 5) sec. Mean volume was plotted as a
the average maximal and mean flow of urine at the
function of time with + 1 SD from the different volumes of 12 volunteers (Fig. 2). The time taken in three volunteers was between 42.5 and 45 set, hence not included in the mean curve due to a large variation in the standard deviation. The mean curve with +I SD showed initial volume, residual volume, and ejection fraction of the urinary bladder. A plot was also made from the volume reduced after every slice to look for
bladder neck (Fig. 3). Average maximal flow rate ranged between 27.2 and 34.4 ml/set (normal range 20-40 ml/set, mean flow rate range 14.3-18.5 ml/set. Total micturition time varied between 25 and 45 sec. The uroflow was done using uroflow dentek UD-5500 in all the individuals and showed average maximal flow rate 26.0-33.3 ml/set and mean flow rate 14.217.5 ml/set.
10
12.5
15
Time (set) Fig. 3. Volume versus 2.5set flow rate of 27.2 ml/set.
increments:
It shows that the maximal urine passed is 68 ml in first 2.5 set, average maximal
Cine voiding cystourethrogram 0 R.K. GUPTA ET AL.
Opening of the internal sphincter, external sphincter, and contraction of detrusor muscle was seen. Total examination time per individual was 5-6 min. Time taken for its analysis was about 30 min.
885
ues which we could not do in the present study. We feel that it is a step in the direction of studying the pathophysiology of the lower urinary tract noninvasively, without modifying the physiology of the individual.
DISCUSSION REFERENCES Video urodynamics is the standard investigation for evaluating the functional problems of the urinary bladder. ’ As such the technique is invasive and carries a distinct risk of urinary infection. It creates an artificial situation to evaluate a physiological process. Therefore it becomes more difficult to correlate the results of the artificial testing situation with clinical symptomatology.6 Cine MR voiding cystourethrogram has given an anatomical and physiological picture of the complete act of micturition. Contraction of detrusor muscle, opening of the bladder neck and external sphincter, as well as a view of the whole urethra is very well displayed in dynamic mode. Our study gave a complete anatomical view of the lower urinary tract. In addition, the uroflow pattern, maximal and mean flow rate, total voiding time, residual volume, and pattern of bladder emptying as a function of time could be studied. To give a complete answer for voiding dysfunction problems, we also need detrusor muscle pressure val-
1. Saxton, H.M. Urodynamics: The appropriate modality
for the investigation of frequency, urgency, incontinence and voiding difficulties. Radiology 175:307-316; 1990. 2. Shapeero, L.G.; Friedland, G.W.; Perkash, I. Transrec-
3.
4.
5.
6.
tal sonographic voiding cystourethrography: Studies of neuromuscular bladder dysfunction. Am. J. Roentgenol. 141:83-91; 1983. Boothroyd, A.E.; Dixon, P. J.; Christmas, T. J.; Chapple, C.R.; Rickards, D. The ultrasound cystodynamogram a new radiological technique. Brit. J. Radiol. 63:331-332; 1990. Haase, A.; Matthaei, D.; Bartkowski, R.; Duhmke, E.; Leibfritz, D. Inversion recovery snapshot FLASH MR imaging. .I. Comput. Assist. Tomogr. 13:1036-1040; 1989. Haase, A. Snapshot FLASH MRI: Applications to T,, T,, and chemical shift imaging. Magn. Reson. Med. 13: 77-89; 1990. Wein, A.J. The pitfalls of urodynamics. In: A.R. Mundy, T.P. Stephenson, A.J. Wein (Eds.). Urodynamics: Principles, Practice and Application. Edinburgh: Churchill Livingstone; 1984: pp. 150- 153.
