Wednesday, November 27, 2013

Procedure Guideline for Tumor Imaging with 18F-FDG PET/CT 1.0*

Tuesday, November 26, 2013

Biograph mCT Flow ---FlowMotion, the end of stop and go.

Diagnostic imaging is expected to deliver  definitive and timely answers to clinical  questions. And, in today’s increasingly competitive and rapidly changing healthcare environment, these answers must be provided in the safest and most efficient way possible. While every hospital and physician strives to deliver the best care, patient expectations for a comfortable, stress-free imaging experience continue to increase. To meet these growing demands for higher-quality and more patient-centered care, PET/CT must overcome the limitations defined by conventional stop-and-go technology.

Until now, PET examinations have been performed in sequential bed positions, alternating between acquisition and patient table motion. As such, planning and scanning have always been restricted by the fixed size of the detector array. Additionally, the inherent complexity of stop-and-go scanning has limited the routine use of advanced PET/CT imaging technology, and often resulted in higher dose, greater patient anxiety, lower efficiency and the potential for patient motion and related image degradation. Siemens understood the only way to break through the limitations of stop-and-go and enable further clinical advancements was to fundamentally change how PET imaging is performed. Powered by Siemens’ revolutionary Flow Motion™ technology, Biograph mCT Flow™ is the world’s first PET•CT system to eliminate the demand for stop-and-go imaging. Now with Biograph mCT Flow and Flow Motion, planning and scanning is based on a single continuous motion of the patient table.  With the new Biograph mCT Flow, physicians benefit from the finest* image resolution in every organ and every scan. Furthering the ability to understand disease, now you can also confidently rely on molecular imaging with accurate and reproducible quantification in all dimensions. Simple and precise range planning eliminates over-scanning and the associated radiation exposure, while simultaneously streamlining workflow. Biograph mCT Flow incorporates a host of proven solutions that support the use of the lowest possible dose, all while scanning patients faster than ever before. Finally, FlowMotion’s sense of continuous progress provides a more comfortable exam experience for patients.

Road to RSNA 2013: Molecular Imaging Preview

The field of molecular imaging and nuclear medicine continues to attract great enthusiasm for what many observers see as limitless possibilities for an expanding range of clinical applications.

Of particular note is Sunday's nuclear medicine poster session (CL-NMS-SUB, 1:00 p.m.-1:30 p.m., Room S503AB), which offers six studies on the roles of FDG and choline with PET/CT to assess various forms of cancer.

In the opening presentation, Dr. Erik Paulson, chairman of the department of radiology at Duke University School of Medicine, details the value of iodinated contrast and PET/CT. In addition, Dr. Andrea Rockall, a professor and a consultant radiologist with the Imperial College Healthcare NHS Trust, shows how to recognize typical findings on FDG-PET/CT in pelvic malignancies, as well as gynecologic and urologic cancers.

Monday, November 25, 2013


A 32-week prenatal sonogram of a male fetus followed for hydronephrosis reveals increasing bilateral hydronephrosis, a dilated bladder, and new-onset marked oligohydramnios. What is your recommendation?

Posterior urethral valves leading to bilateral hydronephrosis with oligohydramnios is the most likely etiology, and this situation potentially represents a rare urologic indication for induction of labor or fetal intervention.

1- Fetal lung maturity should be evaluated with a lecithin/sphingomyelin amniotic fluid ratio prior to a final recommendation.

2- If fetal surgical intervention is considered, fetal renal function should be estimated by the urinary sodium chloride, osmolality, and Beta 2 microglobulin obtained by fetal bladder aspiration.

3- A high-grade obstruction of a single system also requires a similarly rapid response. The outcomes for fetal intervention with respect to improvement of renal function are mixed.


This woman delivered a 7 lb, 3 oz otherwise healthy male infant. Postnatal sonography confirms the presence of unilateral hydronephrosis. What further evaluation do you recommend?

Careful physical examination with an emphasis on observing the infant’s active voiding is an important first step. The infant should be started on antibiotic prophylaxis as the incidence of urinary tract infection is approximately 3% to 4% in the first 6 months of life. A voiding cystourethrogram (VCUG) and nuclear renogram (DTPA or MAG 3) should also be scheduled. Recent work suggests a conservative approach to nuclear renography in patients with mild hydronephrosis.

MCQ pedia urology

A 23-year-old pregnant female presents for evaluation of prenatally detected unilateral hydronephrosis. There is no oligohydramnios. What would be your consideration and recommendation to the patient?

Prenatal fetal hydronephrosis is the most commonly diagnosed fetal urologic abnormality. While the overall incidence of hydronephrosis on prenatal sonography is between 1% and 1.5%, the incidence of clinically significant hydronephrosis is between 0.2% and 0.4%. With normal amniotic fluid levels, close follow-up throughout the pregnancy and in the neonatal/newborn period as well as through the first year of life are required. The majority of cases of prenatal low-grade hydronephrosis may stabilize and resolve within the first year of life.

Sunday, November 24, 2013

Difficult Cases in Endourology

Wednesday, November 20, 2013

High-Yield Histopathology (2nd Ed.).pdf

Tuesday, November 19, 2013

Sir William Osler

He who studies medicine without books
            sails an uncharted sea,
but he who studies medicine without patients

           does not go to sea at all.

Monday, November 18, 2013

Clinically Oriented Anatomy (7th Ed.)

Friday, November 15, 2013

Thursday, November 14, 2013

Urinary Tract Infections and Catheter-Associated Urinary Tract Infections


A urinary tract infection (UTI) is an infection of the bladder, kidneys, ureters, or urethra that occurs when bacteria enter the urinary system. As a result of the infection, a person’s urine, which is normally sterile, will contain bacteria. This type of infection occurs more often in females versus males, due to the anatomy of the bladder and urethra.
A urinary catheter is a thin tube placed in the bladder to drain urine. Urine drains through the tube into a bag that collects the urine. Catheter-associated urinary tract infections (CAUTIs) are infections caused by bacteria that have entered the urinary tract during the catheter's insertion, through the catheter tube, or through the catheter’s external surface.
Common symptoms of UTIs may include burning during urination, burning and pain in the lower abdomen, fever, and cloudy or bloody urine. In some cases, a person may have a CAUTI and not experience any symptoms.
Some patients may be at higher risk for developing a UTI due to older age, poor hygiene, or poor hydration (not drinking enough fluids). Female sex, older age, method of catheterization, duration of catheterization, and quality of catheter care are risk factors for CAUTI. (citation)  It is important that both the patient and thehealthcare providers take the appropriate steps to help prevent an infection.

Tuesday, November 12, 2013

Saturday, November 9, 2013

A review of female ejaculation and the Grafenberg (G) spot.


A review of recent works related to the concept of female ejaculation, defined as a partial, infertile homologue to male ejaculation, indicated that we have insufficient evidence to accept or reject the concept on scientific grounds. The claim that "female ejaculate" is similar to semen from a vasectomized male is without foundation.

Although recent discussion of female ejaculation has tended to focus on whether or not the fluid sometimes expelled from the urethra upon orgasm is invariably urine, the Bartholin's glands are another potential source of orgasmic expulsions which could properly be called "female ejaculate."
"Grafenberg spot" is a neologism referring to an area which some women report is erotically sensitive when massaged via the anterior vaginal wall.

"Urethral sponge" is another term which seems to refer to this anatomical/phenomenological reality. The relationship between stimulation of this area and subsequent orgasmic expulsion has yet to be studied systematically.

The female prostate revisited: perineal ultrasound and biochemical studies of female ejaculate.



Many speculations have been made on the possible existence of a "female prostate gland" and "female ejaculation." Despite several reports on the subject, controversy still exists around the "female prostate" and whether such a gland might be the source of fluid emitted during orgasm (ejaculation).


To investigate the ultrasonographic, biochemical, and endoscopic features in two women who reported actual ejaculations during orgasm.


Perineal ultrasound studies, as well as biochemical characteristics of ejaculate and urethroscopy, have been performed in two women.


Two premenopausal women--44 and 45 years of age--who actually reported fluid expulsion (ejaculation) during orgasm have been investigated. Ultrasound imaging, biochemical studies of the ejaculated fluid, and endoscopy of the urethra have been used to identify a prostate in the female. Ejaculated fluid parameters have been compared to voided urine samples.


On high-definition perineal ultrasound images, a structure was identified consistent with the gland tissue surrounding the entire length of the female urethra. On urethroscopy, one midline opening (duct) was seen just inside the external meatus in the six-o'clock position. Biochemically, the fluid emitted during orgasm showed all the parameters found in prostate plasma in contrast to the values measured in voided urine.


Data of the two women presented further underline the concept of the female prostate both as an organ itself and as the source of female ejaculation.

Orgasmic expulsions in women

Orgasm is in some women accompanied by the release of fluid from the external genitalia. This fluid can sometimes eject under pressure and thus resemble male ejaculation. It may presumably originate in the vagina, in the bladder (orgastic urination) or in the paraurethral (Skene's) glands, labeled by some authors as the female prostate. Analysis of the fluid samples showed it to be urine, secretion of Skene's glands or a mixture of both. The relationship of these expulsions to the stimulation of the vaginal G spot has been reported. Zaviacic et al. (1988) established in female volunteers undergoing digital stimulation of the G spot that in some women there is no expulsion, in some there is expulsion accompanied by orgasm and in some expulsions occur easily without orgasm or even without sexual arousal. Our own findings are based on the use of the sexological questionnaire SGZ, which contains items concerning the occurrence of "release of fluid" during orgasm or of "expulsion of fluid, similarly as in male ejaculation". We obtained data from 200 women treated for the neurosis and from 100 female health professionals and counselors. Organistic expulsions resembling male ejaculation were reported in 6% of both samples. Additional 13% had at least some experience with such expulsions. Release of fluid without ejaculation was reported by approximately 60% of females in both samples. 

We consider "female ejaculation" to be a rare phenomenon, which nevertheless deserves attention in sexological consultations. It should not cause feelings of shame, but should be accepted as a normal part of female sexual reaction.

The Female Prostate

Contrary to the statement by Borchert et al. (1) that “Women have no prostate … ,” women do have a prostate, the presence of which has clinical significance for the female and for our understanding of the expression of prostate- specific antigen (PSA) in women and its possible implications.
In 1672 the anatomist Regnier de Graaf described and illustrated a set of glands and ducts surrounding the female urethra that he called the female prostate. Subsequently, in 1880, Alexander Skene redirected attention to this structure, particularly to two paraurethral ducts (Skene's ducts) therein, and emphasized their importance in infection of the female genitalia.
Skene's paraurethral glands and ducts are homologous to the male prostate (2). Recent studies supporting this homology, as reviewed by Zaviačič et al. (3,4), are postmortem and detailed histological examinations of the urethras of 130 women, followed by biochemical and immunohistochemical studies that demonstrated expression of PSA and prostate-specific acid phosphatase (PSAP) in Skene's paraurethral glands and ducts. These studies unequivocally substantiate the existence of the female prostate.
The female homologue of the male prostate is of clinical significance not only as a focus for acute and chronic infection, but also as the origin of other pathologic entities, including adenocarcinoma (3,4), a cancer which shows, as does its male counterpart, localized expression of PSA and PSAP(3,4).
Thus, there is convincing evidence that prostatic tissue exists in the female, and that the term “female prostate” is both fully justified and preferable to the terminology Skene's glands and ducts. The latter incorrectly implies that some other structure of an extraprostatic nature, rather than the prostate itself, is involved. If the female prostate exhibits the immunopermissiveness observed in the male prostate (5), it may also serve as a site for viral latency and origin of infection in women with human immunodeficiency virus.
Of perhaps equal importance is the expression of PSA (6). The existence in women of the counterpart of the male prostate, shown to express PSA, may provide a note of caution in considering the molecular basis of the apparent anomalous expression of PSA in male and female nonprostatic tissues, e.g., in female breast (1). Given observations on the association of PSA detection in breast cancer with steroid hormone receptor positive tumors, one may envision (6) the existence of a complex regulatory gene network controlling the expression of PSA in several organs. Therefore, a given tissue (depending on the state of cellular differentiation) may express previously repressed genes after neoplastic transformation. Also, and not mutually exclusive, somatic mutations may lead to specific changes in PSA genes in cancer cell clones (6).

Consider also, as initially pointed out by Longo (7), the forensic implications for alleged cases of rape. In the absence of knowledge of the female prostate and of the possible presence of PSA and PSAP in the normal female ejaculatory fluid, the identification of these supposedly male-specific markers in vaginal secretions may have been “. . . a fait accompli” (7) to the accused, but possibly innocent, perpetrator. Indeed, judicial miscarriage may have easily occurred when, for example, PSAP has been considered adequate for the identification of sperm spots and its potential origin from the prostate of the female victim was not taken into account. Therefore, the presence of PSA and/or PSAP for the confirmation of spermatic secretion in the absence of spermatozoa has no forensic value. This knowledge of PSAP originating from the female ejaculate was instrumental in the recent acquittal of an alleged rapist in Europe. In this regard, forensic DNA analysis can be expected to play a significant role in the near future.

Friday, November 8, 2013

Apoptosis and proliferation in human undescended testes

This study showed that the reduced fertility associated with undescended testes
cannot be explained by either reduced proliferation or increased apoptosis of
testicular germ cells at the time of surgical intervention. It remains possible that the
testis simply has fewer germ cells, or that abnormalities in germ cell turnover occur
before 6months of age.
Ofordeme KG, Aslan AR, Nazir TM, Hayner-Buchan A, Kogan BA. BJU Int
2005; 96: 634–8

Predictive factors of ultrasonographic involution of prenatally detected multicystic dysplastic kidney

There is an increasing incidence of diagnosis of many conditions, such as MCDK,
by antenatal US, and it is therefore important to understand the natural history of
such conditions. This study has shown similar rates of complete involution of
MCDK to those reported previously, although at a slower rate. The only factor
apparently predictive of involution was length at diagnosis, but this finding needs to
be reproduced in larger studies if it is going to be used to counsel parents more
Rabelo EAS, Oliveira EA, Silva GS, Pezzuti IL, Tatsuo ES. BJU Int 2005; 95:

An objective assessment of the results of hypospadias surgery

This interesting study strengthens the evidence that the Snodgrass repair can
produce a very good cosmetic result, perhaps even better than other techniques.
This study’s strength lies in the use of independent assessors, blinded to surgical
technique, to objectively evaluate cosmesis. However, this is only one facet in the
evaluation of penile appearance post hypospadias repair. A complete assessment
would include complication rates and, ideally, the patient’s own assessment of the
appearance. Most of the children undergoing this surgery would have been
circumcised as part of the repair, and there was no discussion as to the potential role
of the foreskin in cosmetic outcome. As the authors conclude, an ideal study to
compare cosmesis would be a multicentre, randomized, prospective trial involving
several surgeons, which is probably not feasible.
Ververidis M, Dickson AP, Gough DCS. BJU Int 2005; 96: 135–9

Inguinal hernia in female infants: a cue to check the sex chromosomes?

This study reaffirms that Complete androgen insensitivity syndrome CAIS should be considered in all girls who present with inguinal hernias. The options of assessment by gonadal inspection, gonadal biopsy,
ultrasound and karotyping are all considered, without reaching any real conclusion or suggestions. Common practice is to attempt to visualize the ovary or fallopian tube in all females undergoing inguinal herniotomy. If this is not possible, blood would be routinely sent intra-operatively for a subsequent karyotype to be performed.
Deeb A, Hughes IA. BJU Int 2005; 96: 401–3

Circumcision for the prevention of urinary tract infection in boys: a systematic review of randomised trials and observational studies

Circumcision, as a prophylactic measure for ‘medical conditions’, remains controversial.
This stringent and well-structured review finds that circumcision leads to a
decreased rate of urinary tract infections in boys. The authors acknowledge that it is
let down by the poor quality of the studies analysed, but few would disagree with
the paper’s findings. The interpretation of these findings, and how this should
influence clinical practice, is a more interesting topic.
This is well demonstrated by the conflicting perspectives published with the
article. Schoen’s |1| interpretation, a US author, is that this study backs routine
newborn circumcision for all boys, suggesting that the author’s summary is
‘analogous to postponing immunization of an infant until the child is exposed to
the pathogen or is diagnosed with the disease’. In contrast,Malone |2|, a UK author,
agrees with Sing-Grewal et al. that circumcision should be reserved for those boys
with recurrent UTI or those at increased risk of UTI.
Sing-Grewal D, Macclessi J, Craig J. Arch Dis Child 2005; 90: 853–8

Thursday, November 7, 2013

Sunday, November 3, 2013

Acute urinary retention in children.



Acute urinary retention in children is a relatively rare entity. There are a variety of causes that are poorly defined in the literature. We review our cases of acute urinary retention in children at three major pediatrics centers in Iran.


Between 1996 and 2003, children (up to 14 years old) who had been referred due to acute urinary retention were examined. Urinary retention was defined as inability to empty the bladder volitionally for more than 12 hours with a urine volume greater than expected for age or a palpably distended bladder. All data from the patients' past medical history, physical examination, and laboratory and radiographic assessments were collected. Also, cystourethroscopy and urodynamic procedures had been carried out according to patient's conditions. Patients with secondary urinary retention, including those with surgical history, immobility or chronic neurological disorders, mental retardation, and drugs or narcotics consumption were excluded from study.


There were 86 patients meeting the inclusion criteria, consisting of 58 males with a median age of 4 years (range 1 month to 14 years) and 58 females with a median age of 4 years (range 4 month to 14 years). Etiologies were lower urinary tract stone in 27.9%, neurological disorders in 10.4%, trauma in 10.4%, local inflammatory causes in 9.1%, urinary tract infection in 7.4%, ureterocele in 7.4%, benign obstructing lesions in 5.8%, iatrogenic in 5.8%, constipation in 4.6%, imperforated hymen in 3.5%, and large prostate utricle, urethral foreign body, and rhabdomyosarcoma each in 1 case (1.1%).


The most common cause of acute urinary retention was lower urinary tract stone in our pediatric cases. Ureterocele and stone were the main findings in girls and boys, respectively, and urinary retention in boys was twice as prevalent as that in girls.


Fowler’s Syndrome affects young women after the menarche, who develop painless retention at high bladder volumes, often following apparently unconnected precipitating events, such as minor surgery. Often, history of prior LUTS is minimal and most of the women will not report any prior urinary tract problems. It is estimated that around 40% of women affected have Polycystic Ovary Syndrome. It is important to exclude occult or undiagnosed neurological problems as a cause. The scientific explanation for the underlying sphincter problem in Fowler’s syndrome is not understood. It has been hypothesized that changes in the ion channels of the skeletal muscles of the urinary sphincter may be affected by the hormonal environment of the menarche (“hormonal channelopathy”) leading to abnormal communication directly between muscle cells (ephaptic transmission). As a consequence, the sphincter becomes overactive and hypertrophic, and reacts excessively to direct stimulation.
Diagnostic criteria include: UR of at least 1 liter on at least one occasion; exclusion of other causative factors; raised maximum urethral closure pressure on urethral pressure profilometry; increased sphincter volume on ultrasound or MRI assessment; and; a characteristic urethral sphincter EMG. Difficulties with IC can be profound—insertion of the catheter can be straightforward but then discomfort may develop, as if the sphincter were gripping the catheter, leading to consequent difficulty on catheter withdrawal. Flow rate patterns tend to be interrupted. Small volumes often are passed by micturition, leaving substantial PVR.
The most specific diagnostic test for Fowler’s Syndrome is a urethral sphincter EMG (USEMG), which differs from the pelvic floor EMG generally used for neurourological patients. In USEMG, the EMG needle is placed to one side of midline in the anterior vaginal wall, at the mid-urethral point, and advanced on to the dorsal aspect of the urethra. The neurophysiologist undertaking the test has to pay special attention to the audio signal being generated by the EMG, which confirms successful entry into the sphincter zone. The diagnostic parameter for Fowler’s Syndrome is an audio signal likened to the sound of whale noises in the ocean. Pelvic floor EMG often is non-diagnostic in this patient group.

Management of Fowler’s syndrome is specialized, and a sympathetic approach and consideration of psychological elements are essential. Strong efforts should be made to reduce the polypharmacy that many of these patients have, particularly attempting to discourage use of opiate drugs. For those patients manifesting the characteristic EMG signal who are unable to tolerate IC, the treatment of choice is sacral nerve stimulation (SNS), which can achieve normal voiding in a significant proportion of women affected. Management is difficult in patients without the characteristic EMG signal, or those patients where the SNS percutaneous needle electrode test fails to elicit a significant improvement in symptoms. Suprapubic catheter placement is generally unsatisfactory in younger women. No drug treatment has yet been established as deriving any substantive benefit. Botulinum injection into the urethral sphincter has not been tested on a systematic randomized basis. Ultimately, reconstructive surgery using a continent diversion (Mitrofanoff procedure) may be necessary.

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