札幌医誌 4（5），344～354 （1953）

Pelvioprostatic Venography and Method of Estimating

Size of Prostate Gland

By

IwArrARo TozuKA， KAzuHiDE KuRoDA and KENzo ［1］oi｛iMorro

DepaTtment of DeTmatoJogy and UTogogy， 串卿oγoUniver吻（ゾMθ♂乞卿θ

Total exst・irpation of the organs is commonly perior iliac spine， exposure factors are 60 KV performed today upon the malignant tumors peqk， 40 milliamp．， 3”， 91 cm． of bladder and prostate・ lt is very important In something over half of all cases cystogra－ to know the grades of its invasion to thei’c phies were made． at the same time with 100 to adjascent tissues for adequate performances． 150 cc air inflation or injection of 20 cc of 10 In discussing this problem， some authors such per cent sodium jodati solution， and in some as De ．la Panai）， Ceccarelli2）， Abeshouse ＆ Ru－ cases Takahashi－Okoshi’s method of cystography ben3）， Fit4patrick and Or：c4，） and some others ’was also employed simultaneously・ After the have tried a procedure roentgenologically to exposure the incision is closed with two or three deエnonstrate the pelvic veins， injecting opaque silk sutures．一・ media into the v． dorsalis penis profunda． t t These studies have dealt， however， only with Interpretation of the Findings some cases of hypertrophy or malignant tumors of prostate and indicate lack of systematical By the technique above described pelviopro－ examinations． The present writers undertook static venog’ra’ Phy was performed of 17 cases to get some patte’cns of this venography， and with normal prostate， 7 with prostatic cancer， ca’rried through this procedure on fifty－one cases 2 with prostatic calculi， 8 with tuberculous and with such prostate as normal and insane， corning nontuberculous prostati’ti’s， 3 cases of bladder to some conclusions． The－aim of this report is tumors （cancer ］， papillom 2．）， and 2 ・other mis－ to describe their new obseTvations about cancer ’ cellaneous cases， 5’1 cases in all． The conclusive and other pathological conditions of the pro＄tate．． findings from them， disregarding some dQubtful matters， are as follows ： Techtmique 1） ’ln eases with nornial prostates， the veno・一 grams are as shown in Figs． 1， 2， ＆ 3． The Patients are positioned on the roentgen table opaque media injected into the v． dorsalis penis with the grid of Potter－Bucky． A slight incj，sion p：rodunda comes together into the plexus pu－ is made on the dorsal surface of penis， and the dendalis which is situated at the lower part of needle is inserted into the exposed vena dorsalis the pubic arch， then leaves in two ways， strea－ penis ptofunda， then 15 to 30 cc of 35 pei’ cen’t ming above into the plexus vesicalis and below Sugiuron or 70 per cent Pyraceton is rapidly into the v， pudenda interna ； the lattet two uni’te injected． During the i’n’ jectl’on of the ］ast 3 cc together in the v． hypogastrica， coni municating antero－posterior exposures are made． Center commonly vsTith v・ iliaca communis， and rarely is in the mid－line， at the level of the anterior－su一 with v． iliaca externa． Halfway within these

1） De la Pena， A．： Z． f． Urol． 44， 516 （1951）， 640 （1952）．

2） Ceecarelli， G．： Urologiea 17， 377 （1950）． 4） Fitzpatriek， R． J． ＆Orr， M．： J． Urol．， 68， 640 C 1952）． 3） Abeshouse， B． S． ＆ Ruben， M． E．： J． Urol． 68，

344 4巻5号 ’Tdzuka．Kuroda．Torimbto Pelvioprostatie Venogtaphy 345

eourSes， v． pudenda interna cornmunicates with Among our seven tumor cases， the lack of vesical v． obturatoria，” plexus vesicalis with v． hemor－ plexus was seen in both sides （1 case） asig．11）， rhoidalis． Venae ileolumbales and v． glutae in one side （3 cases） （Figs．12，8）． ln the case are at times to be discerned・ These venographic which showed the lack of plexus vesicalis of patterns are symmetrical in both sides； the both sides， plexus pudendalis was als6 lacking venous passages can be recognized more stri－ and direct anastomosis of deep dorsal vein of kingly when films are viewed in stereo． penis to inner pudendal vein was seen （Fig． 11）． Plexus pudendalis is a round， oval or irregular The angle made by veins of． plexus vesicalis network of veins and plexus vesicalis also con一’ of both sides was very great； that is within sisted of several strips of veins but the latter 100－1500． takes the form of a single vein before emptying 3） Prostatic hypertrophy： Vascularity of both into the v．．hypogastrica・ pudendal and vesical plexuses are more ＄canty The angle whieh is made by the veins of the and more slender than normal （Figs． 13， 14）． plexus vesicalis of the two sides is in general But the irregularity of vascularisation of plexus less than 90C， 700 ・is rnost common （Fig・ 4）， but vesicalis as shown in cases of prostatic cancer， in some exceptional c，ases？ the angles are wider， the so－called “thrombosis of veins” of Abeshouse－ coming up to 1000 or more， （Fjg． 5） （Table 1）． Ruben， was． rarely observed and also complete Yet there are some variations in the case of absence of this plexus was seen in only a few normal prostate， viz．， the smallness of plexus cases． This is probably because of the lack of pudendalis because oE to its seanty vascularity infiltration into the neighbouring tissues as seen （3 cases） （Fig． 6）， or entire absence of venogram in the cases of cancer． ln our experiences， only of one side （frequently seen in the left， 2 cases） one case out of ten did not demonstrate the （Fig． 7）． lf the opaque madia is injected erro－ vesical plexus and it was in one side only・ neously into the superficial dorsal vein of penis， The angles made by the veins plexus of both pelvioprostatic venogram． connot be taken but sides were more wide than normal in the cases the dye will demonstrate v． pudenda externa of prostatic hypertrophy as in the cases of the and communicating v． femoralis （Fig． 19）． cancer， but narrower than in the cases of true 2） ’ ln cases of prostatic cancer in coMparison・ cancer， viz．， they were between 900 and 1000， with cases of normal prostate， plexus pudendalis 90G in seven cases， 100” in 3， ten ca’ 唐?ｓ in all・ is scantier of vessels and smaller in size； its 4） Prostatic abscess． ln two caseS of this dis－ connecting plexus vesicalis shows fewer bran－ ease， where prostate glands attained the size of ches， is irregular in its distribution and commonly goose－eggs， the pudendal plexus got smaller and thin． ’the vesicalis were narrow and partially deficient When the tuエnor is small， the changes above in their vessels， but thrombosis of the veins as described are very slight and it is difficult to in prostatic cancer was not recognized in them find out the differences from the normal・ But （Flg・ 15）． The angle of vesical plexus was as when the tumor is extremely great， plexus a matter of course wide， ranging 100－1300． vesicalis on one or both sides （rarely plexu’s 5） Prostatic falc’uli・ Almost similar’ finding＄ pudendalis too）， can not be delineated， but direct as in prostatic hypertrophy were made ；． it was anastomosis of the deep dorsal vein of penis to definitely observed that the shadow of the cal－ internal pudenda1 vein would be observed， as culi lay between the vesical plexus of the twb a result of tumor exphnsion and invasion to sides and surrounding the shadow of the calculi the surrounding tissues． The relative paucity ran the vessels of the vesical plexus asig． 16）． of vessels， the lack of distention and areas of 6） Prostatitis of tuberculosi’sor of other nattire． irregular filling are very stTiking in the ca＄es Quite the same conditions were fourid in these of carcinoma of prostate （Figs． 8－12）． These find－ cases as in the normal． Nothing characteristic ings have also been observed by Ceccarelli and was seen． Abeshouse－Ruben． Abeshouse－Ruben thought 7）， 7esical ，teoplasmct．s． ln a case of vesical this phenomenon to be attributable to the throm－ papilloma with prostatic hypertrophy． ， defect of bosis of“veins and very suggestive of malignancy． the shadow of left vesical plekus was demon一 346 Tozuka．Kuroda．TQrimoto 一Pelvioprostati’c Venogiraphy オ：L砲晃医誌 1953

strated ： other ・cases of this disease have no char一 ’ the cystographic method of lchikawa－Okoshi－ acteristic venogram even in a case of cancer Kuroda （1952）｛i）， the cystourethrogram method situated over the most part of the b］adder wall of Thumann （1951）7） and of Boone （1952）S） these and infiltrating into all its layers （Fig． 17）． are examples． Except for the relatively perfect 8） Other rniscellaneous diseases． （i） ln a caSe of method of lchikawa－Okoshi－Kuroda， every meth－ sem｛noma which resulted in anuria because of od above－mentioned has its o wn deficiency in its retroperitoneal lymphatic metastases CFig・ 18）， fulfiiling our need． it was demonstrated that a round or oval dense The writers， therefore， adopted the above networks of Shadows we．re multiplied in the descエibed pelvioprostatic venography．in ordef minor p’ elvis・ This may be attributable ．to the to－estimate the size and weight of prostate as new vascularization roun．d the metastatic lym－ accurately as possible．一 The p：ostatic vertical， phnodes． （ii） A case of peni］e cahcer with the diarneter is anatomically the d．istance from the metastases to the ．inguinal and fetnoral lymphatic upper rim of pudendal venous plexus to the nodes． ln this case the pelviopttostatic venogram ． base of the bladder， and’ when the p， r6state iS did not belong to any particuJar pattern， but the neoplastic， the distance to its most projected ipjection of ．opaque media into the subcutaneous point into the bladder． Venographically by our dorsal vein． of penis revealed multiple branched method， in combination with pneumocystography fine network of veins i．n the left femQral paTt or with its variation of Tal〈ahashi－Okoshi， it is which have gotten edema because of metastases therefore reasonable for Qne to take the diameter （Fig・ 19）． （iii） A case of Recklinghausen’s disease of・the prostate to be the distance from the with partiaklefect of pubic bone ； the venography transition p6in亡of vesical and pudendal P工exus demonstrated asymmetrical vesical plexus and to the bladder base or to the apex of the prostatic internal pudendal veins of both sides （Fig・ 2Q）． projection into the bladder （Fig． ZC 1）． Measure－ There were side reactioエ1s to this procedure： ments have been made of this distance by the general heat feeling， metallic taste， and dumb combination radiography， just’ mentioned， in va－ pain in the pelvis at the time of dye injection rious’cases， copaparing with that of lchikawa－ were seen in almost all cases． Rarely nausea Okoshi一一Kurodars method published by Kuroda． C2 cases）， or slight u－rticaria （5 ca＄es）， were also ’ ln the obtained results， as shown in Table 2， experienced， but they were trans；tent． ［NTo post－ the vertical diameters of normal prostates， were operative distress caused by incision was seen less than 3 cm （the greatest 3．0 crn， the smaliest m any case． 1・5 cm， average 2．33±O．0428 cm）， in accord with Kuroda’s results obtatned by his method above mentioned， especially thQse of anteroposterio’r Another Ap， plication of pQsition （Table 3） ； in neoplastic cases， al］ were this Venography ’More than 3．0 a’nd less than 6．O cm， excepting In connection with rece：nt prog：ress in the two cancer cases of which the diameters were methods of surgical operation and antiandrogenic 2．6 cm； in the 8 cases of prostatic calculi and therapy for cancer and hypertrophy of the prostatitis， they were Jess than 4．0 cm． prostate， measu： ement of its size especially of In one case each of cancer and hypertrophY ・ en］arged one is one of the important things i’n of prostate gland， a compa’rison was made of deterMining the method of p：rostatectomy， in roentgenologic estimation and the actLi． al size of making prognosis and in following up the aine－ enucleated tumo’rs；the results were in goQd Iioration by t：ceatment． lt is now， therefo’re， accordance （Table 4）． widely attempted to estimate the size of the Thumann has devised a formula （R”x2＝W） prostate gland roentgenologically． The bag－ for estimating roentgenologically the’ weight of catheter method of Peirson and Wilson （1941）o”）， the hyperplastic prostate by means of measure一

5） Peirson， E． L． ＆ Wilson， S． A． ： 」． Urol． 45， S2 7） Thurnann， R． C．： Ain． J． Roentgenol． 65， 593

（194工．）． （195工）．

6） Kuroda， Kyoichi： Jap， J． Urol． 43， 8’3 （1952）． 8J Boone， R． W．： 」． UroL 67， 358 （1952）． 4巻5号 Tozuka・K：uroda・Torimotoこ一Pelvioprostatic Venography 347・ ments of horizontal and vertical diameters． ln shown in Table 4， and smaller than the results this case， the vertical diameter meanS the dis－ obtained by ThLumann’s cysto－urethrographic es－ tance from the impエint of verumontamlm on an anteroposterio：c cysto－u‘cethrog：cam to the most It is a pleasu：ce to record here a debt of grat一’timations． ・ superior extent of the prostatic mass a＄ seen itude ’co PrbfessQr S． Watanabe for his kind on it； when the imprint of the verumontanum・ instructttons and to the memberes of the De－ cann’ot be dttsce’rned accurately， then the ex－ partment of Radiology． for technical asistance． ternal sphincter i，s used as the distal extent， （Read before the 41 st Annual Meeting of the Jap－ substracting from the vertical diameter 1．5 cen－ anese Urologieal Assoeiation held in Fukuoka， Apri1 timeteirs， which is the average distance from 5一一6， 1953）， the uppec end of the external sphincter tQ the upper end of the veruinontantnn． The hoi’i－ Conclusions zontal diameter is found by measuring the dis－ The method of a pelvioprostatic venogrcaphy tance between each lateral rnargin of the pros－ and the patterns in normal and various p：rost－ tatic mass at its Widest pa：rt． ln this formula， atic diseases were described． R is the radius in centim．eters calculated f’rom the average diameter of the horjzontal and This ve’nography is suggested as an atixiliarY diagnostic inethod in the differentiation of intra－ vertical measurements， regarding the hyPer－ pelvic ：aeoplasmas and is useful for the rneasure－ plastic prostate as a ・sphere， oval o：c round ； W． ment ’of tlie size and weight of i“he prostate is the weight in grams of the prostatic adenoma． gland． The writers applied this formula on their venogram． The vert・ical diameter in the－present method is， as described above， somewhat differr Other Literature ent from Thuman． n’s・ The horizontal is the 1） Baston， O． V．： Ann． lnt． Med，， 16， 3S （1942）． same as taken by him． The theoretjcal was 2） Beneventi， F． R・ ＆ Norbaek， G． J．： J． Urol．， 62， compared with the actual weight of enucleated 663 （1949）． ） prostate in one． case of cancer and three cases りθ Gray， J． H．： Anatomy of the Human Body． 25 th of hypertrophy； it was found that they bore a Ed， （1’hila， 194E）・ close resemblance to each otheic， and that the ｛ t d：lfferences between them Nvas only 1－1．5 g as

Table 1唱 ノlngles Mα〔le by tlte Veins（ゾレセs乞。α‘Plexus（ゾBo渉んSぜ（les tinレ窃7¶iozcs Prosta，t’io Di・geαses

No． o’t’ Diagnosis ， Angles eaSes ，55－60 65 70 75 SO E5 90 9，5 100 IIO J20 ］40 150 Undetermined＋＋ 1 Caneer 702277 1 （1） （1） （1） 1 1 Hypert／ opby 7 2（1） Abseess （1） 1

Calculus 1 1

0μ Prostatitis“i’ 1 1 3

のβ の四 Normal i 1 6 2 4

45

＋ lneluding tubereulosis ’ Braeket O means the ease whieh showed the defee’t o：E the plexus in one side， The an．crle was calcu］ated on tbe assumption that it existed symmetrically in the opposite q．i’de． 一F＋ Undetermined rneans eases which showed’the defect on both sides． 348 T…ka●K・・Od・’T・・im・t・一’一P・1・i・P…t・li・V…graphy 札幌医誌1953

Table 2 Venogγαphio Meαszareme？zts qプ疏θVeTticα11）iαmeter〔ゾ漉θPγost．αte伽麗sレ窃短。㊥6s l）おθ．αsθ8

No． of Diagnosis サ Diameter em． eases 1．1－2，0 2，1一？．O 3．1－4，0 4，1一一5．0 5．1－6．0 More than 6．1 20e Caneer 4 2

りσ Hypertrophy 7 －1 Abseess 2 1

Caleuli 1． 1 ユりμ4 Prostatits＋ 7 0θ2 2 Normal 16 37

＋工neluding tuberculosis of the prostate

Tab童e 3 Compαrison（ゾ悔短oz58 Roentgenologic Meαsu？’ements qプ碗γ彪。α♂ diameter of the Normag PTostate Glands

No． of Vertieal diameter cm． Methods and Authors ’ eases shortest longest L Average

Peirson－Wilson C 1941） 14 3．1

Aetual length 3 1 ユ．7 2．30±O，0625 22の召23コ 98990 34 1．7 Rectal血etbod コ 2．24士0．067

K二uroda （1952） 3 1 1．7 Urethra1 method ロ 2．26±O．0609

9σ 1 1．7 Antero－posterior metbod ロ 2．36±O．0182

3 1 2．0 2．．47士0．054 Oblique method ロ

Tozuka－Kuroda－Torimoto ユ6 1．5 3，0 2．33土0．054 （present paper） C1953）

Tdble 4 Cb即翻S伽げ疏θ：rheore．ticα〔々伽θS O窃娩♂αオθd力伽Ol‘γVenogrαpuhy ”伽伽孟伽αzSOfee．侃d va吻ん拶け’伽翫zeogeαte．Cl． Prostates

， 1 HorizontalVertical Weight Cases diIrmeter epa’ 1’dihin6tt／t’ CM’ Remarks ’ gr．

Prostatie Theoretieal Z5 5．5 16 Total 1 caneer 6S ys， Ac七ual 2．3 5．0 17 prostateetomy

Prostatic ’TheoreLieal 4．9 or，5 ？，4 Retropubie 0劃 hypertropby 0ゆ 63 ys， Aet－ual 4 5．1 32 prostateetomy

5 」 9e 0召 0召 ？rostatie Theoretical 5 6．0 FD 一 4 00 hypertrophy ditto 69 ys． Actual

？rostatic Theoretieal 4．6 3．7 17．5 4 hyper七rophy ditt・o 73 ys． Actual 14 ．

噸 〈Reeeived Aug． ］O， 1953）

十 4巻5号 ToZuka．Kuroda・Torimoto Pelvioprostatic Venography 349

灘

騒

鱗

Fig． 1 Normal Prostate．

騰懸 鵠灘

縷雌

F唱b呉ぬ

韓一 曝 ：髭

「ヌρ灘岬鱗1覧嘩夏、 、聾、醇肇警竃郷機．

Fig． 311．Normal prostate． Fig． 2 Normal prostate．

． 350， Tozuka．Kuroda．TorirnotQ Pelvioprostatie Venography 札幌医誌1953

綴織苧棚訟藤織 騨、壷

撚鱈’灘灘擁 、、贈蕪F蒸rひ』－

磯 灘 礫

難．， 鐸羅灘暫三輝同

Fig． 4 Normal prostate． The same ease as Fig． S Norma］ pros tate， but the angle of Fig． 1． The two straight lines on the platenshow plexus vesicalis is exceptionally great， the angle made by the veins of the plexus vesicalis．

Fig。6 Pros七ate norma1， but．七he venogram Fig． 7 Normal prostate， showing eomplete reveals the smallness of plexus pudendalis absence of’veno．crram of left side， beeause of its scanty vascularity． 4雀5号 Tozuka，Kuroda・TorimQto 一Pelvioprostatic Venography 351

Fig． 8 Prostatic caneer． Lack of vesieal Fig． 9 Prostatic eancer． plexus of left side is shown，

灘 麟 無異享叢』慮翫蕪1 纏競鞍繍毫ヒt’t燕・’

L

・雛

無乙 職漁

轟「

y．L”F’，・ 懸 欝 鐵妙，穏 堅剛 ＝強電 ’埠螂℃陶㌧ 》・τ・嵯 矧晒 鐸 － 幣．

浴|蔀国璽鍵．．・ as繁鐘 ．t、 欝撃㌔1宏「

・彗 欝

Fig． 10 Prostatie eancer． Fig． 11 Prostatie cancer， venogram reveals lack of vesieal plexus of both sides．

嗣

1 352 Tozuka．Kuroda・Torimoto Pelvioprostatic Venography オ…しi幌医誌 1953 欝欝 鍵 鍵滋毒臨寧 試姦 モらくド リ ハ

．…

k、ソ・轟チ鱒・1 ’綴9

識一 雛・ 欝1、読，患ジ

z．llk’・sew’t7”’U’i

難 難 醐 ．、ζト． 講義．・

郷．

柳醜廃、繋 輪・ 難i総懸

Fig． 12 ，？rostatie cance． The right vesieal Fig・ 13 ？rostatie bypertrophy． plexus is not delineated．

欝 i難灘「 難

． 欝

／／ ｛・

嘆1畢

盤州甑鍵 一κ 欝 灘壌・

・∵‘t『 ｡蔓，、 灘i． 灘雛欝 融三三 Fig． 14 Prostatie hypertrophy． Fig．15 Prosta七ic abscess． ’

4巻5一号 Tozuka・Kuroda．Torimoto ？elvioprostatic Venography 353

．

覧

灘鰍

鞍

懸 i懸 、争覇

鍵饗 醜蘇，，無， 轡． 鷺 讐

盤穿

Fig． 16 ？rQstatie calculi． Fig． 17 Carcinoma of the urinary bladder infiltrating most of tbe vesical wall but with normal prostate．

し

t 講

轟ζ

鞍 蓼

騰♂． 窒棒；．ヘゴ・’

Fig． 19 ？enile cancer． Opaque media was Fig． 18」・．Seminoma of the：testis with’retro－ injeeted into the subcutaneous dorsal vein peritoneal lymphatic metastases． ofl｛epenis．

一 ．

ゴ 354 Tozuka．Kuroda・TQrimQtQ PelvioprQsta七ic Venography 札幌医誌ユ953

．

簿

鞍鮮籍 「 」弓．’

．

’

き

繍撰 懸鰹、、 灘＼ 雛聯．灘韓

Fig． ZO Reeklinghausen’s disease with partial defeet Qf pubie bone，

糊鑓鞍ポ 嘱 噛『b 譲罐5，気！ 三脚

議

籔 ・「 ．

Fig． Z l Prostatic hypertrophy． Demonstra一一 ting how the measurements may be made of the vertieal and horizontal diametevs．

’