British Journal of Urology (1979). 51. 391-399

Cavernosography in the Management of Prostatic Cancer

E. PROCA and M. LUCAN Department of Surgical Urology, Postgraduate Medical School, Bucharest, Romania

Summary-Cavernosograms were used in the investigation of 22 patients with prostatic cancer to determine the incidence of venous invasion. There were 21 patients with T3/T4 category tumours and one with a T2 tumour. All but one, a T 3 tumour, had the radiological features of periprostatic venous malignant thrombosis.

An attempt was made to correlate these findings with lymphography and tumour grade but no correlations could be made and the clinical relevance of these findings remains uncertain.

An accurate assessment of the local extent of the All patients underwent similar operative treat- tumour is essential in the clinical staging and ment, namely transperitoneal pelvic lymph- management of patients with prostatic carcinoma. adenectomy, transvesical prostatectomy and

Bandhari et al. (1968) claimed that obstruction bilateral orchiectomy. These patients were then and thrombosis of the periprostatic venous plexus given stilboestrol 100 mg daily for 20 days, then would be found in carcinoma of the prostate. Le 1 mg daily indefinitely. Gouillou et al. (1977) reviewed several un- conventional methods of investigation in prostatic carcinoma with special attention to prostatic phlebography; they suggested that venous occlusions indicated local extension of disease.

We report our experience with cavernosograms which have been used to study the periglandular venous pattern in patients with prostatic car- cinoma in order to detect evidence of local invasion. We have compared this technique with more conventional investigations.

Materials and Methods During a 2-year period (1976 to 1977) 98 patients were admitted to our department with a diagnosis of carcinoma of prostate. Twenty-two of these patients, unselected and consecutive, were in- vestigated as follows:

(i) Excretion urography. (ii) Transrectal needle biopsy.

(iii) Pedal lymphography. (iv) Cavernosography.

Clinical staging and grading were carried out according to the recommendations of Wallace et al. (1975).

Fig. 1 Case I. Total obstruction of periprostatic venous drainage. Lymphangiography indicating bilateral lymph node metastases. Surgical and histological confirmation of extra- glandular malignant invasion.

Received 10 May 1978. Accepted for publication 14 June 1979.

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398 BRITISH JOURNAL OF UROLOGY

Table

Number Clinical staging Grading Lymphangiography Cavernosogram

1 T3N + MO 3 + Technical failure 2 T 4 N + M + 3 + + 3 T3N + MO 3 + + 4 T3NOMO 2 - + 5 T4NOM + 2-3 - + 6 T 3 N x M + 1-2 - + 7 T3N X MO 1 - + 8 T4N X MO I ? + 9 T3N X MO 1 - -

10 T4N + MO 2-3 + + 11 T 3 N + M + 2-3 + + 12 T4N + MO 3 + + 13 T2N + MO 2 + 14 T3N + MO 1 + + I5 T4NOMO 1-2 - + 16 T3NOMO 1 - + 17 T3N + MO 1 + + 18 T3N + MO 3 + + 19 T4N + MO 1 + + 20 T4N + MO 1 + + 21 T4NOMO 1 ? + 22 T4N + MO 1 + + Lymphangiography: - Normal, + Node involvement. Cavernosogram: - Normal, + Periprostatic venous involvement.

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Fig. 2 Case 5 . Abnormal cavernosogram. Poor filling of venous return, especially on the left side. Narrow, bead-like chain veins. Extensive pelvic bone metastases.

Fig. 3 Case 17. Absence of right periprostatic venous drain- age and filling defects on the left, with venous shunts to the saphena magna.

399 CAVERNOSOGRAPHY IN THE MANAGEMENT OF PROSTATIC CANCER

Cavernosography was carried out under local anaesthesia. A No. 1 disposable needle was intro- duced into the corpus cavernosum on one side, just proximal to the glans. A few millilitres of local anaesthetic were then injected and a free flow, together with the lack of any local swelling, indicated correct placement of the needle; 20 ml of 60% Urografin were then injected via this needle and posterior/anterior views were taken, or direct visualisation on an image intensifier was used.

A compression dressing prevented subsequent local haematoma. There were no complications from this procedure.

The radiological criteria of venous invasion were as follows: (1) Pooling of dye in the corpus cavernosum and/ or retropubically. (2) Poor or absent periprostatic veins. (3) Lateral displacement of periprostatic veins. (4) “Bead-chain” periprostatic veins. ( 5 ) Venous shunts to the saphenous system. (6) Asymmetry of periprostatic veins.

Cavernosogram findings (positive and negative) were correlated with conventional clinical staging, histological grade and lymphangiography.

Results (Table) The cavernosograms were positive in 20 cases, there was one technical failure and one was negative. This correlated well with T category as 21 out of 22 patients were thought to have T3 or T4 lesions. The only patients with a T2 lesion had a positive cavernosogram, but normal lymphography and lymphadenectomy.

Seven patients with positive cavernosograms had normal lymphograms but 2 of these were subsequently found to have positive nodes on lymphadenectomy .

Two patients with positive lymphograms and cavernosograms had histologically normal pelvic lymph nodes.

The cavernosogram was positive in all grades of the tumour.

Discussion The value of the cavernosogram in the manage-

ment of prostatic carcinoma is uncertain. In previous reports, Drozdovsky ef al. (1976) obtained useful data for differential diagnosis, assessment of infiltration and detection of venous thrombosis associated with pelvic malignancy. Le Gouillou et al. (1977) considered it to be a relatively simple way of detecting the venous anomalies seen in malignancy.

The experience presented in this study is limited to mainly locally advanced prostatic lesions, 4 of which had distant metastases. In these lesions tumour category is more easily assessed by palpation. It would be of interest to assess this technique in less advanced prostatic carcinomas.

Cavernosography did not influence the management of patients in any way, as this was based on the results of more conventional in- vestigations.

It is concluded that insufficient information is available to determine the relevance of a positive cavernosogram in prostatic tumour staging. Without information that can only be obtained by a histological study of the corpora, it must be concluded that this technique adds little to the present methods of tumour staging.

References Bandhari, R. D., Devlesover. P., Grbgoir, W. and Schulmann,

C. (1968). L’exploration radiologique du reseau veineux prostatique et vesical par cavernographie. Acta Urologica Belgica, 36,429-436.

Drozdovsky, B. Y’., Dunchik, V. N. and Rsyb, A. F. (1976). Transrenal pelvic phlebography in the diagnosis of tumours of the prostate. Urologha i Nefrologha (Moskva),

Le Gouillou, M., Muguier, C., Joncheres, P. and Lange, J. (1977). Advantages in the investigation of prostatic carcinoma. Journal dUrologie et de Nephrologie (Paris), 83,

Wallace, D. M., Chisholm, G. D. and Hendry, W. F. (1975). TNM classification for urological tumours. British Journal of Urology, 47, 1-12.

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The Authors E. Proca, MD, Professor of Urological Surgery M. Lucan, Junior Registrar.

Requests for reprints to: E. Proca, 24 Christian Tell Street, 7000 Bucharest I , Romania.