Cystography

CYSTOGRAPHY (from Greek kystis-bladder and grapho-I draw), a method for examining the urinary bladder, which makes it possible to obtain a clear visualization of the contours of its cavity; it consists of taking an X-ray photograph after filling the bladder with a contrast substance. C. was first applied in Germany in 1905 by Wulf and Albers-Schoenberg, who used bismuth emulsion as the contrast medium. In the same year, Voelcker and Lichtenberg proposed using collargol for C. In 1909, Perthes described a diverticulum discovered by C., and in 1912, Legueu and Papin proposed C. as a method for diagnosing bladder tumors. C. became more widely used after the appearance in 1921 of the work of Sgalitzer, who studied the physiological changes in the contours of the bladder by means of C. and showed the possibility of obtaining on the X-ray image not only the lateral, but also the anterior and posterior walls of the bladder. The technique of C. consists of a standard X-ray examination of the bladder after filling it through a catheter until the urge to urinate appears (150-200 cm³) with a 10-12% solution of sodium bromide or iodide, a 5-7% solution of collargol, a 5% solution of abrodil (sergosin) or air (pneumocystography). The success of C. depends to a large extent on the choice of contrast substance. In cases where it is necessary to obtain sharply defined contours of the bladder cavity, the use of liquid contrast substances is indicated. In cases where the nature of the suspected disease requires highlighting fine details of pathological changes, pneumocystography should be performed. C. with bromine is not entirely indifferent to patients - the introduction of large amounts of sodium bromide often causes quite a significant reaction from the mucous membrane in the form of dysuria phenomena, especially in cases where the amount of bromine required to stretch the bladder cavity is large and its complete removal after the photograph for some reason (diverticulum) is difficult. Therefore, as a rule, the bladder should be thoroughly washed with warm physiological solution immediately after taking the photograph. C. with air is free from the possibility of such a complication, but it must be admitted that the photographs obtained by this method are significantly inferior in contrast to photographs with the bladder filled with liquid contrast substances. To obtain an accurate spatial representation of the bladder cavity, photographs must be taken in three mutually perpendicular directions - cranio-caudal, lateral, and anteroposterior. The first direction is technically unfeasible and is replaced by the axial direction, for which the patient sits on the plate with the trunk tilted back at 135°, and the tube is placed vertically above the pubis. The lateral direction - technically difficult - is replaced by the oblique direction, and the photograph is taken twice - in the position on the right and left sides. The patient is placed with the trunk and pelvis tilted at 45° relative to the plate placed under the pelvis. The rays are directed vertically to the midpoint of the line connecting the iliac spine to the midline connecting the navel to the pubis. In the anteroposterior direction, the patient lies on his back on the cassette, the upper edge of which is at the level of S_n. The central ray of the tube falls two transverse fingers above the pubis. A well-filled normal urinary bladder appears on the X-ray in the anteroposterior direction as a smooth spherical shadow emerging from the pelvic cavity above the pubic symphysis (see separate table, fig. 1). As the fluid is released, the upper convex border of the bladder becomes concave, the entire bladder flattens and first takes an oval shape, and then resembles a soup bowl (schussel-formig). According to Sgalitzer's studies, the bladder photographed in the lateral position has the shape of a triangle, the anterior wall of which is adjacent to the anterior abdominal wall and the pubic bone, and the posterior wall is directed toward the peritoneum. In individual cases, the angle formed by the anterior and posterior walls of the bladder is flattened, and the bladder takes the shape of an irregular quadrangle. A similar image is obtained with maximum filling of the bladder. As the fluid is released, the anterosuperior angle is smoothed out and the posterior wall becomes dome-shaped. The anteroinferior wall and the posterior wall form an acute angle, which does not change depending on the filling of the bladder and is the lowest point of the bladder. The urethral opening is located at the border of the lower and middle thirds of the anterior wall of the bladder. In the normal state of the neuromuscular apparatus of the bladder, its contours are strictly defined, completely equal and smooth. There is no leakage of contrast fluid into the physiological openings of the bladder, the urethra, and the ureters. With impaired innervation of the bladder, as well as with other extravesical factors causing difficulty in normal emptying of the bladder (narrowing of the canal, hypertrophy of the prostate), changes occur in the wall of the bladder in the form of the formation of trabeculae and false diverticula. As a result, the contours of the bladder wall change: they become uneven, with the formation of a series of more or less large bay-like protrusions, and the configuration of the bladder changes (see separate table, fig. 2). The close proximity of the bladder to the female genital organs is the reason that the displacement of the latter from their normal location, as well as the inflammatory and neoplastic processes arising in them, cause changes in the normal picture in C. The bladder can take an elongated shape or be displaced upward, downward, and to the side. A number of pathological factors of both congenital and acquired nature, such as: congenital aplasia of the ureteral musculature, atony of its bladder opening as a result of long-standing cystitis, disorders of the central nervous system, can be the cause of the development of the vesicoureteral reflex, and then a characteristic picture of the leakage of contrast fluid into the ureter is obtained on the cystogram. In case of suspicion of such reflux (clinically - pain in the kidney area during the urge to urinate or during the act of urination), a photograph of the bladder should be taken in the anteroposterior direction, with the urethra compressed and the patient asked to urinate. The contrast fluid, deprived of an outlet from the bladder in the presence of pathological changes in the vesicoureteral opening, rushes upward along the ureter and creates a characteristic cystogram for reflux. In case of insufficiency

Figure 1. X-ray of a normal urinary bladder filled with sodium bromide solution.

Figure 2. X-ray of a trabecular urinary bladder in a disease of the central nervous system.

Figure 3. X-ray in case of insufficiency of the internal sphincter.

Figure 4. Filling defect in bladder cancer.

Figure 5. Filling defect in bladder papilloma.

Figure 6. Two diverticula of the urinary bladder.

With cystography, it is possible to detect bulging of the bladder wall in the form of a cavity extending to the pubic symphysis (see separate table, fig. 3) when examining the closure apparatus of the bladder (internal sphincter) at the middle of its lower contour. Cystography occupies a modest place in practical urology, since direct examination of the bladder cavity by cystoscopy gives significantly better results. It is indicated only when cystoscopy cannot be performed (marked narrowing of the urethra or significant enlargement of the prostate, significant bleeding, spasmodic contractions of the bladder that prevent the introduction of a cystoscope or obtaining a sufficiently clear medium for cystoscopy). Additionally, cystography is indicated in individual cases of bladder tumors and bladder diverticula. In bladder tumors, cystography makes it possible to determine their nature, i.e., the presence or absence of infiltrating growth. In the latter case, we have not only proliferation of the tumor into the bladder cavity (see separate table, fig. 5), but also a change in the configuration of its wall (see separate table, fig. 4). Blanc and Negro give the following scheme: Pericystography according to Rosenstein is of great service in determining the infiltrating growth of a tumor, making it possible to see not only the contours of the bladder cavity but also the bladder wall itself in frontal section. For this purpose, after emptying the bladder, a needle is inserted strictly along the white line of the abdomen, immediately above the pubis, to a depth of 5-6 cm, and 500 cm³ of oxygen is introduced into the perivesical space. After this, the bladder is inflated with 150 cm³ of air through a catheter and a radiograph is taken. The normal bladder appears as a thin, even strip throughout its entire length. In the presence of an infiltrating tumor, the bladder wall undergoes changes that are clearly visible on the radiograph. In bladder diverticula, cystoscopic examination only gives us an indication of the presence of the disease-the entrance to the diverticulum is visible. An idea of the size and relationship of the diverticulum to adjacent organs can only be obtained on the basis of cystography. In this case, examination in all three directions is necessary. When the opening of the diverticulum is located in the area of the bladder base, cystography should be combined with intravenous pyelography to clarify the topographic relationships between the diverticulum and the ureter (see Bladder, bladder diverticula).