INTERESTING IMAGE
Giant Urinary Bladder Stone Incidental Finding in
99m
Tc-DTPA Renography
Diego Villasboas-Rosciolesi, MD, Rodrigo Ca´rdenas-Perilla, MD, Amparo Garcı´a-Burillo, MD, and Joan Castell-Conesa, MD, PhD Abstract: A 27-year-old woman presented with a history of recurrent urinary tract infections in infancy and urinary incontinence secondary to lipomyelomeningocele. At the age of 7, she underwent bladder augmentation enterocystoplasty, requiring intermittent catheterization without urinary tract infections until present. A 99mTc-DTPA renography was performed to evaluate renal function, in which an abnormal tracer distribution was seen in urinary bladder, and furthermore, a retrograde cystography shows a giant bladder stone. Key Words: augmentation enterocystoplasty, giant bladder calculus, DTPA renography (Clin Nucl Med 2014;39: 667Y668)
Received for publication November 13, 2013; revision accepted February 12, 2014. From the Department of Nuclear Medicine, Hospital Universitari Vall d’Hebron, Barcelona, Spain. Conflicts of interest and sources of funding: none declared. Reprints: Diego Villasboas-Rosciolesi, MD, Department of Nuclear Medicine, Hospital Universitari Vall d’Hebron, Passeig de la Vall d’Hebron 129, 08035 Barcelona, Spain. E-mail: [email protected]. Copyright * 2014 by Lippincott Williams & Wilkins ISSN: 0363-9762/14/3907Y0667
Clinical Nuclear Medicine
& Volume 39, Number 7, July 2014
REFERENCES 1. Bilchik TR, Spencer RP. Bladder variants noted on bone and renal imaging. Clin Nucl Med. 1993;18:60Y67. 2. Mandell GA, Harcke HT. Extrinsic causes of vesical filling defects on scintigraphy. Clin Nucl Med. 1987;12:240Y247. 3. Stav K, Dwyer PL. Urinary bladder stones in women. Obstet Gynecol Surv. 2012;67:715Y725. 4. Papatsoris AG, Varkarakis I, Dellis A, et al. Bladder lithiasis: from open surgery to lithotripsy. Urol Res. 2006;34:163Y167. 5. Onur Demirkol M, Seymen H, Ihsan Ko¨lgesiz A, et al. Bone tracer uptake in urinary bladder stones. Clin Nucl Med. 2003;28:337Y339. 6. Webb M, Fong W. A large bladder calculus and severe vesicoureteric reflux as seen on Tc-99m MAG3 renography. Clin Nucl Med. 2002;27:803Y804. 7. Gallego Vilar D, Beltran Persiva J, Pe´rez Mestre M, et al. Giant bladder lithiasis: case report and bibliographic review. Arch Esp Urol. 2011;64:383Y387. 8. Shiu-Dong C, Ming-Chieh T, Ching-Chun L, et al. A case-control study on the association between bladder cancer and prior bladder calculus. BMC Cancer. 2013;13:117.
www.nuclearmed.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
667
Villasboas-Rosciolesi et al
Clinical Nuclear Medicine
& Volume 39, Number 7, July 2014
FIGURE 1. A 27-year-old woman presented with recurrent urinary tract infections (UTIs) in infancy and urinary incontinence secondary to lipomyelomeningocele. At the age of 7, she underwent bladder augmentation enterocystoplasty, requiring intermittent catheterization without UTIs until present. The patient turned to the emergency department for a new episode of UTI with fever (102.5-F) without voiding syndrome. On physical examination, she had right lumbar fist percussion with discomfort, abnormal urine sediment, and leukocytosis. 99mTc-DTPA renography 1 minute per frame is shown (A), with an asymmetric activity between the 2 renal parenchyma, less activity on the right one. The left kidney has a normal function and excretion. Tracer activity in urinary bladder is seen since the first minutes, with a large central photopenic area at the end of the study (black arrow). These photopenic defects should raise a differential diagnosis with extrinsic causes such as neoplasm (rhabdomyosarcoma, lymphoma, neurofibroma sacrococcygeal teratoma, and others), constipation (functional, neurogenic, Hirschsprung disease), pelvic abscess or hematoma, and metal objects (Harrington rod, belt buckle) and intrinsic causes such as neoplasm (sarcoma botryoides, neurofibroma, hemangioma), blood clot, calculus, ureterocele, and iatrogenic instrumentations (Foley catheter or cystoscope).1,2 Because of these findings, she underwent a retrograde cystography (B) where a giant bladder stone of 11 cm in onions skin (white arrow) accompanied by other smaller calcifications (arrowheads) were identified. Bladder stones in women counts for the 5% of all urinary bladder lithiasis; the risk factors had been described as follows: urinary stasis, infections, or foreign bodies (sutures, synthetic tapes, etc).3,4 Our patient has a urinary stasis due to neurogenic bladder and previous surgery. Most stones are asymptomatic; however, they could result in hematuria, recurrent infections, irritative symptoms, and anuria and could increase malignance bladder risk.3Y8 Diagnosis could be performed with abdominal x-ray, ultrasound and CT.3Y5
668
www.nuclearmed.com
* 2014 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Giant Urinary Bladder Stone Incidental Finding in
99m
Tc-DTPA Renography
Diego Villasboas-Rosciolesi, MD, Rodrigo Ca´rdenas-Perilla, MD, Amparo Garcı´a-Burillo, MD, and Joan Castell-Conesa, MD, PhD Abstract: A 27-year-old woman presented with a history of recurrent urinary tract infections in infancy and urinary incontinence secondary to lipomyelomeningocele. At the age of 7, she underwent bladder augmentation enterocystoplasty, requiring intermittent catheterization without urinary tract infections until present. A 99mTc-DTPA renography was performed to evaluate renal function, in which an abnormal tracer distribution was seen in urinary bladder, and furthermore, a retrograde cystography shows a giant bladder stone. Key Words: augmentation enterocystoplasty, giant bladder calculus, DTPA renography (Clin Nucl Med 2014;39: 667Y668)
Received for publication November 13, 2013; revision accepted February 12, 2014. From the Department of Nuclear Medicine, Hospital Universitari Vall d’Hebron, Barcelona, Spain. Conflicts of interest and sources of funding: none declared. Reprints: Diego Villasboas-Rosciolesi, MD, Department of Nuclear Medicine, Hospital Universitari Vall d’Hebron, Passeig de la Vall d’Hebron 129, 08035 Barcelona, Spain. E-mail: [email protected]. Copyright * 2014 by Lippincott Williams & Wilkins ISSN: 0363-9762/14/3907Y0667
Clinical Nuclear Medicine
& Volume 39, Number 7, July 2014
REFERENCES 1. Bilchik TR, Spencer RP. Bladder variants noted on bone and renal imaging. Clin Nucl Med. 1993;18:60Y67. 2. Mandell GA, Harcke HT. Extrinsic causes of vesical filling defects on scintigraphy. Clin Nucl Med. 1987;12:240Y247. 3. Stav K, Dwyer PL. Urinary bladder stones in women. Obstet Gynecol Surv. 2012;67:715Y725. 4. Papatsoris AG, Varkarakis I, Dellis A, et al. Bladder lithiasis: from open surgery to lithotripsy. Urol Res. 2006;34:163Y167. 5. Onur Demirkol M, Seymen H, Ihsan Ko¨lgesiz A, et al. Bone tracer uptake in urinary bladder stones. Clin Nucl Med. 2003;28:337Y339. 6. Webb M, Fong W. A large bladder calculus and severe vesicoureteric reflux as seen on Tc-99m MAG3 renography. Clin Nucl Med. 2002;27:803Y804. 7. Gallego Vilar D, Beltran Persiva J, Pe´rez Mestre M, et al. Giant bladder lithiasis: case report and bibliographic review. Arch Esp Urol. 2011;64:383Y387. 8. Shiu-Dong C, Ming-Chieh T, Ching-Chun L, et al. A case-control study on the association between bladder cancer and prior bladder calculus. BMC Cancer. 2013;13:117.
www.nuclearmed.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
667
Villasboas-Rosciolesi et al
Clinical Nuclear Medicine
& Volume 39, Number 7, July 2014
FIGURE 1. A 27-year-old woman presented with recurrent urinary tract infections (UTIs) in infancy and urinary incontinence secondary to lipomyelomeningocele. At the age of 7, she underwent bladder augmentation enterocystoplasty, requiring intermittent catheterization without UTIs until present. The patient turned to the emergency department for a new episode of UTI with fever (102.5-F) without voiding syndrome. On physical examination, she had right lumbar fist percussion with discomfort, abnormal urine sediment, and leukocytosis. 99mTc-DTPA renography 1 minute per frame is shown (A), with an asymmetric activity between the 2 renal parenchyma, less activity on the right one. The left kidney has a normal function and excretion. Tracer activity in urinary bladder is seen since the first minutes, with a large central photopenic area at the end of the study (black arrow). These photopenic defects should raise a differential diagnosis with extrinsic causes such as neoplasm (rhabdomyosarcoma, lymphoma, neurofibroma sacrococcygeal teratoma, and others), constipation (functional, neurogenic, Hirschsprung disease), pelvic abscess or hematoma, and metal objects (Harrington rod, belt buckle) and intrinsic causes such as neoplasm (sarcoma botryoides, neurofibroma, hemangioma), blood clot, calculus, ureterocele, and iatrogenic instrumentations (Foley catheter or cystoscope).1,2 Because of these findings, she underwent a retrograde cystography (B) where a giant bladder stone of 11 cm in onions skin (white arrow) accompanied by other smaller calcifications (arrowheads) were identified. Bladder stones in women counts for the 5% of all urinary bladder lithiasis; the risk factors had been described as follows: urinary stasis, infections, or foreign bodies (sutures, synthetic tapes, etc).3,4 Our patient has a urinary stasis due to neurogenic bladder and previous surgery. Most stones are asymptomatic; however, they could result in hematuria, recurrent infections, irritative symptoms, and anuria and could increase malignance bladder risk.3Y8 Diagnosis could be performed with abdominal x-ray, ultrasound and CT.3Y5
668
www.nuclearmed.com
* 2014 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
