DAVID SUTTON PICTURES THE BLADDER AND PROSTATE ONLY FOR STUDY PURPOSE

1. 31
THE BLADDER AND
PROSTATE
DAVID SUTTON

2. DAVID SUTTON PICTURES
DR. Muhammad Bin Zulfiqar
PGR-FCPS III SIMS/SHL

3. • Fig. 31.1 Full-length film from an IVU series on a patient with bladder
extrophy treated with ureterosigmoidostomies. There is characteristic
separation of the symphysis pubis. The ureters have been anastamosed to
the sigmoid colon close to the midline. Reflux has predisposed to dilatation
of the distal ureters (black arrows) and the left kidney shows changes of
chronic pyelonephritis with cortical loss and calyceal clubbing. Contrast
opacified urine has drained into the sigmoid colon and passed forwards into
the rectum and retrogradely into the descending colon (white arrows).

4. • Fig. 31.2 Cystogram on an infant with prune-
belly syndrome. There is a typical capacious
flaccid bladder and absence of the prostate. A
urachal diverticulum is demonstrated
anteriorly (arrow).

5. • Fig. 31.3 Longitudinal (A) and transverse (B)
ultrasound showing a urachal cyst as a thin-
walled cylindrical echo-free area (arrow). The CT
(C) demonstrates analagous features with a small
area of calcification.

6. • Fig. 31.3 Longitudinal (A) and transverse (B)
ultrasound showing a urachal cyst as a thin-walled
cylindrical echo-free area (arrow). The CT (C)
demonstrates analagous features with a small area of
calcification.

7. • Fig. 31.4 MRI scan (transverse T2-weighted
images) showing a small left paraureteric
congenital bladder diverticulum (arrows).

8. • Fig. 31.5 Transverse image from a transrectal
ultrasound examination showing a normal left
seminal vesicle and a large right seminal vesicle
cyst.

9. • Fig. 31.6 Transverse ultrasound image showing
bladder wall thickening and echogenic clumps of
inflammatory debris within the urine in a patient
with severe cystitis.

10. • Fig. 31.7 Transverse ultrasound image (A) showing
gross focal thickening of the right posterolateral
bladder wall in a patient with acute Crohn's disease.
Similar features are seen on CT (B), which also shows
adherent swollen small bowel. An enterovesical fistula
is present with gas seen in the bladder.

11. • Fig. 31.8 Longitudinal ultrasound of the bladder (A)
showing localised wall thickening in tuberculous
cystitis (arrowhead) and dilated distal ureter (arrows).
Similar heaped-up appearance of the bladder mucosa
is seen on CT (B) around the ureteric orifice. The IVU
(C) also demonstrates the localised bladder wall
thickening, narrowing of the ureteric orifice and
dilatation of the distal ureter.

12. • Fig. 31.8 Longitudinal ultrasound of the bladder (A)
showing localised wall thickening in tuberculous
cystitis (arrowhead) and dilated distal ureter (arrows).
Similar heaped-up appearance of the bladder mucosa
is seen on CT (B) around the ureteric orifice. The IVU
(C) also demonstrates the localised bladder wall
thickening, narrowing of the ureteric orifice and
dilatation of the distal ureter.

13. • Fig. 31.9 Plain film (A) showing linear calcification along
the bladder wall and distal left ureteric walls. CT (B,
different patient) is highly sensitive for the demonstration
of bladder wall calcification and will also show the soft-
tissue wall thickening which may be gross and (as here)
associated with rectal wall thickening. (Courtesy of Dr
Shadley Fataar of the Royal Hospital, Muscat, Oman.)

14. • Fig. 31.10 Longitudinal ultrasound of the bladder
showing wall thickening and trabeculation
(replacement of normal smooth inner aspect by
regularly undulating appearance).

15. • Fig. 31.11 Bladder view from an IVU series in a patient
with bladder outflow obstruction due to prostatic
hyperplasia. The bladder is trabeculated and saccules
(arrows) are beginning to develop. The distal ureters are
showing some elevation in association with the prostatic
enlargement and the bladder wall disease has provoked
some fullness of the distal left ureter.

16. • Fig. 31.12 Longitudinal ultrasound of the
bladder showing gross sacculation, best seen
along the posterior wall, in a patient with
severe longstanding outflow obstruction.

17. • Fig. 31.13 Transverse ultrasound image of the
bladder showing two posterior-lying
diverticula.

18. • Fig. 31.14 Bladder image from an IVU
examination showing a large right-sided
diverticulum (A). On the postmicturition film the
bladder has emptied but the narrow necked
diverticulum remains contrast filled (B).

19. • Fig. 31.15 CT scan demonstrating a large right
posterolateral diverticulum.

20. • Fig. 31.16 T1 -weighted MRI showing a large
right-sided bladder carcinoma (arrowheads)
and a small left-sided diverticulum (arrow)
containing a further deposit of carcinoma.

21. • Fig. 31.17 Full-length film showing right-sided
inguinal herniation of the distal right ureter
and part of the bladder.

22. • Fig. 31.18 Cystogram in a patient with gross ureteric
reflux and vesicovaginal fistula following previous
radiotherapy and pelvic surgery for pelvic malignancy.
Arrows indicate contrast within the vagina.

23. • Fig. 31.19 Coronal T,-weighted (A) and transverse STIR (B)
images from an MRI scan of the pelvis of a patient with an
extensive pelvic haemangioma in association with Klippel–
Trenaunay syndrome. There is a large lobulated mass over
the dome of the bladder which is continuous with further
dilated vessels running posteriorly in the left hemipelvis
and into the left buttock.

24. • Fig. 31.20 Longitudinal ultrasound of the
bladder showing a polypoidal bladder
carcinoma (A). Transverse ultrasound of the
bladder on a different patient (B) showing two
sessile deposits of carcinoma.

25. • Fig. 31.21 Transverse ultrasound of a large
sessile bladder carcinoma with calcific
encrustation appearing as intense superficial
echogenicity with marked distal acoustic
shadowing.

26. • Fig. 31.22 Plain film of the bladder area
showing irregular calcification over a bladder
carcinoma.

27. • Fig. 31.23 Bladder images from IVU studies. Bladder carcinoma is seen as one or
more filling defects with a variety of patterns. (A) A small slightly lobulated left-
sided filling defect. (B) Multiple irregular filling defects are seen related to the
dome and lateral walls of the bladder with a large basal filling defect. Bilateral
ureteric obstruction is developing, worse on the right where tumour can be seen
invading along the distal ureter. (C) Extensive irregular wall thickening is present,
particularly along the bladder base. Lytic bone metastases are seen affecting the
medial aspect of the right iliac bone and the lateral aspect of the left iliac bone
(arrows).

28. • Fig. 31.23 Bladder images from IVU studies. Bladder carcinoma is seen as
one or more filling defects with a variety of patterns. (A) A small slightly
lobulated left-sided filling defect. (B) Multiple irregular filling defects are
seen related to the dome and lateral walls of the bladder with a large
basal filling defect. Bilateral ureteric obstruction is developing, worse on
the right where tumour can be seen invading along the distal ureter. (C)
Extensive irregular wall thickening is present, particularly along the
bladder base. Lytic bone metastases are seen affecting the medial aspect
of the right iliac bone and the lateral aspect of the left iliac bone (arrows).

29. • Fig. 31.24 MRI scan on a young adult female with a
bladder base rhabdomyosarcoma. Coronal
postcontrast T 1 -weighted (A) and sagittal T2 -
weighted images (B) show a large heterogeneous mass
of tumour invading the anterior wall of the vagina.

30. • Fig. 31.25 Range of appearances of bladder calculi on plain films.
(A) Classical jackstone calculus. (B) Laminated calculus. (C)
Agglomerated calculi that have formed on catheter balloons in a
patient with bladder damage due to previous trauma (note
distortion of the bony pelvis). (D) Multiple small bladder calculi,
probably forming on fragments of prostatic tissue following a
previous transurethral resection of prostate. (E) Two years later the
same patient shows significant further growth of the small k
bladder calculi.

31. • Fig. 31.25 Range of appearances of bladder calculi on plain films.
(A) Classical jackstone calculus. (B) Laminated calculus. (C)
Agglomerated calculi that have formed on catheter balloons in a
patient with bladder damage due to previous trauma (note
distortion of the bony pelvis). (D) Multiple small bladder calculi,
probably forming on fragments of prostatic tissue following a
previous transurethral resection of prostate. (E) Two years later the
same patient shows significant further growth of the small k
bladder calculi.

32. • Fig. 31.25 Range of appearances of bladder calculi on plain
films. (A) Classical jackstone calculus. (B) Laminated
calculus. (C) Agglomerated calculi that have formed on
catheter balloons in a patient with bladder damage due to
previous trauma (note distortion of the bony pelvis). (D)
Multiple small bladder calculi, probably forming on
fragments of prostatic tissue following a previous
transurethral resection of prostate. (E) Two years later the
same patient shows significant further growth of the small
k bladder calculi.

33. • Fig. 31.26 Transverse ultrasound of the
bladder showing an echogenic spiculated
calculus with distal acoustic shadowing.

34. • Fig. 31.27 Cystogram performed via a suprapubic
catheter in a patient with major pelvic trauma and
anterior pelvic fractures. There is florid extravasation
from the bladder neck tear. Contrast remains
extraperitoneal. There is associated trauma to the
urogenital diaphragm and contrast extends inferiorly
into the perineum (arrow). The line of the urethra is
shown by the course of the urethral catheter.

35. • Fig. 31.28 (A) Intraperitoneal rupture, in this case visible
on IVU. III defined contrast extravasation is seen around
bowel loops immediately superior to the bladder (arrows).
(B) Cystogram showing intraperitoneal rupture with
contrast outlining the ceca! pole and the outer aspect of
the right side of the bladder dome.

36. • Fig. 31.29 CT cystogram. There is an extensive bladder
neck rupture. (A) The bladder cannot be distended, due to
the size of the rupture, and remains collapsed (arrow).
Contrast has flooded into the perivesical space anteriorly
and shows florid extension superiorly (B) in the
extraperitoneal space behind the anterior abdominal wall.

37. • Fig. 31.30 Bladder image from an IVU study
showing a heavily trabeculated neuropathic
bladder.

38. • Fig. 31.31 (A) Urinary diversion techniques: left,
ileal conduit; right, ureterosigmoidostomy. (B)
Reconstruction with an intestinal 'neobladder'
after cystectomy. (C) Cystoplasty techniques: left,
augmentation cystoplasty; right, substitution
cystoplasty. (D) Boari bladder flap technique.

39. • Fig. 31.31 (A) Urinary diversion techniques: left,
ileal conduit; right, ureterosigmoidostomy. (B)
Reconstruction with an intestinal 'neobladder'
after cystectomy. (C) Cystoplasty techniques: left,
augmentation cystoplasty; right, substitution
cystoplasty. (D) Boari bladder flap technique.

40. • Fig. 31.31 (A) Urinary diversion techniques: left, ileal
conduit; right, ureterosigmoidostomy. (B)
Reconstruction with an intestinal 'neobladder' after
cystectomy. (C) Cystoplasty techniques: left,
augmentation cystoplasty; right, substitution
cystoplasty. (D) Boari bladder flap technique.

41. • Fig. 31.31 (A) Urinary diversion techniques: left,
ileal conduit; right, ureterosigmoidostomy. (B)
Reconstruction with an intestinal 'neobladder'
after cystectomy. (C) Cystoplasty techniques: left,
augmentation cystoplasty; right, substitution
cystoplasty. (D) Boari bladder flap technique.

42. • Fig. 31.32 Stentogram 10 days after fashioning an ileal
conduit. Two stents have been positioned at the time of
surgery, running through the conduit and then into the two
ureters. Contrast has been injected via the stents to outline
the ureters and then, as the contrast flows antegradely, the
conduit. In this case very little contrast passes into the
conduit, as most is seen to extravasate at the level of the
uretroileal junction inferiorly into the pelvis.

43. • Fig. 31.33 Normal conduitogram (loopogram)
showing typical small bowel mucosa in the
conduit and free reflux into modestly dilated
ureters.

44. • Fig. 31.34 Barium enema (prone angled view) showing the
characteristic wide separation of the symphysis pubis seen
in bladder extrophy. The patient was treated in childhood
with bilateral ureterosigmoidostomies and has developed
large colonic adenomas at the site of insertion of the
ureters (arrows).

45. • Fig. 31.35 (A) Early cystogram following fashioning of an orthotopic
neobladder. Normal postoperative appearances. The two ureters are seen
entering the afferent loop, which drains into the main body of the
neobladder. No extravasation is seen, the anastamoses are intact. Both
urethral and suprapubic balloon catheters are still present. (B) Early
cystogram on a similar reconstruction. In this case the right ureter enters
the afferent loop somewhat lower than the left. There is a stent still
present in the left ureter running into the afferent loop because of
concerns about the integrity of the left-sided anastamosis. This is justified
because there is substantial extravasation from this anastamosis, running
superiorly into the left retroperitoneum (arrowheads).

46. • Fig. 31.36 IVU 1 year after fashioning an orthotopic
neobladder. There is no upper tract dilatation and the
ureters drain satisfactorily into the afferent loop; this drains
into the neobladder, which is nicely seen on the full length
film (A) and has a remarkably normal appearance. The
postmicturition film (B) shows satisfactory emptying of the
neobladder and reveals the characteristic mucosal pattern
of the constituent small bowel.

47. • Fig. 31.37 Full-length film from an IVU study on a patient 1 year
after fashioning a Mitrofanoff reservoir. The appearances are
satisfactory. The left pelvicalyceal system shows minimal fullness,
which will require monitoring; the right-sided collecting system
shows no dilatation at all. Incidental note is made of the complete
duplex system on the right, which will have increased the
complexity of the surgical procedure.

48. • Fig. 31.38 Bladder images from IVU studies on
two patients with Boari flap procedures: (A)
shows only prominence of the right superolateral
angle of the bladder in keeping with a small flap.
(B) shows a patient who required resection of a
substantial length of ureter and has a much
longer flap reconstruction.

49. • Fig. 31.39 Cystogram 1 0 days after radical prostatectomy.
There is a substantial right posterolateral leak at the level
of the anastamosis of the bladder on to the urethra, seen
on the posteroanterior (A) and steep right anterior oblique
(B) views. This requires conservative treatment with
catheter drainage for 1-2 weeks and then repeat
cystographic assessment

50. • Fig. 31.40 Longitudinal (A) and transverse (B)
ultrasound images of the bladder showing
moderate lobulated benign prostatic
enlargement with areas of calcification.

51. • Fig. 31.41 Transrectal ultrasound (transverse images) on
patients with benign prostatic hyperplasia. (A) shows marked
prostatic enlargement. The central gland shows a multinodular
appearance with a benign cyst (arrow) and gross enlargement.
This has displaced and compressed the more echogenic
peripheral zone. (B) shows more modest disease with less
central gland enlargement. A benign cyst (arrowhead) and an
adenomatous nodule (arrows) can be identified.

52. • Fig. 31.42 Bladder image from an IVU series
showing marked prostatic enlargement as a
smooth bladder-base mass. Some
trabeculation of the bladder wall is also
visible.

53. • Fig. 31.43 Transrectal ultrasound (transverse images) on
patients with clinical prostatitis. (A) shows periurethral
calcification but an otherwise essentially normal young
adult gland. (B) Older patient with some benign prostatic
enlargement. There is calcification at the junction of the
peripheral and central gland and a slightly motheaten
appearance to the central gland.

54. • Fig. 31.44 Transrectal ultrasound (transverse images) on patients with
prostatic cancer. (A) shows a tiny peripherally placed carcinoma as a
hypoechoic nodule (arrows) easily seen against the remainder of the
normal hyperechoic peripheral gland. (B) shows a larger area of reduced
echogenicity (arrowheads) replacing much of the left peripheral gland and
showing an ill-defined infiltrative margin towards the adjacent central
gland. It currently, however, still appears confined by the prostatic capsule.
(C) shows an extensive prostatic cancer seen as a sheet of echopoor
material that has replaced the normal peripheral gland and is infiltrating
anteriorly into the central gland.

55. • Fig. 31.44 Transrectal ultrasound (transverse images) on patients with
prostatic cancer. (A) shows a tiny peripherally placed carcinoma as a
hypoechoic nodule (arrows) easily seen against the remainder of the
normal hyperechoic peripheral gland. (B) shows a larger area of reduced
echogenicity (arrowheads) replacing much of the left peripheral gland and
showing an ill-defined infiltrative margin towards the adjacent central
gland. It currently, however, still appears confined by the prostatic capsule.
(C) shows an extensive prostatic cancer seen as a sheet of echopoor
material that has replaced the normal peripheral gland and is infiltrating
anteriorly into the central gland.

56. • Fig. 31.45 Transrectal ultrasound (transverse
image) showing multifocal echo-poor prostatic
cancer (two nodules identified by
arrowheads).

57. • Fig. 31.46 Transrectal ultrasound (longitudinal
image) showing echopoor tumour in the
peripheral gland extending anteriorly into the
adjacent central gland and superiorly into the
seminal vesicle.

58. • Fig. 31.47 Transrectal ultrasound (transverse
image) showing echo-poor tumour infiltrating
throughout the prostate, predominantly the
right lobe, and extending laterally through the
capsule on the right into the periprostatic fat.

59. • Fig. 31.48 (A) Transverse T2 -weighted spin-echo (SE
2000/80) image demonstrating a chemical shift
artefact in the frequency direction (horizontal) with a
low-signal-intensity line at one edge of the bladder
wall (straight solid arrow) and a high-signal band in the
opposite wall (open arrow). (B) Bladder tumour
(histological stage T2) with an intact low-signal bladder
wall peripherally on a coronal intermediate-weighted
spin-echo (SE 1200/26) image. t = tumour; u = urine.

60. • Fig. 31.49 Extensive T3b bladder tumour shown on (A)
a transverse T 2 -weighted spin-echo (SE 3000/100)
image; (B) transverse (at the same anatomical level as
(A)) and (C) parasagittal T 2 -weighted spin-echo (SE
3000/100) images with fat suppression. The tumour
(curved arrow) is infiltrating through the bladder wall
(straight arrows), which is better appreciated on the fat
suppression scans. p = prostate.

61. • Fig. 31.49 Extensive T3b bladder tumour shown on (A)
a transverse T 2 -weighted spin-echo (SE 3000/100)
image; (B) transverse (at the same anatomical level as
(A)) and (C) parasagittal T 2 -weighted spin-echo (SE
3000/100) images with fat suppression. The tumour
(curved arrow) is infiltrating through the bladder wall
(straight arrows), which is better appreciated on the fat
suppression scans. p = prostate.

62. • Fig. 31.50 Enhancing bladder carcinoma (t) in the posterolateral
part of the bladder on a transverse T,-weighted spin-echo (SE
740/40) postgadolinium- DTPA image. Note the three layers—
unopacified urine (u), signal void posteriorly in the bladder due to
the superparamagnetic effect of high concentrations of gadolinium-
DTPA, with a high-signal layer in between due to the paramagnetic
effect of normal concentrations of gadolinium-DTPA. Also note the
heterogeneity of signal within the middle layer due to urine flow. r
= rectum; arrows = fluid levels.

63. • Fig. 31.51 Multiple confined bladder tumours (t) on
transverse T 1 -weighted spin-echo (SE 740/40) (A) pre-
and (B) early postgadolinium-DTPA images. Note the
enhancing tumour anterolateral to the left is well visualised
but the posterior-based lesions are obscured due to the
high-signal effect of normal concentrations of gadolinium-
DTPA. r = rectum; s = seminal vesicles; u = urine.

64. • Fig. 31.52 Histological stage T3b bladder carcinoma (curved open
arrow) on transverse (A) T,-weighted spin-echo (SE 700/40) and
(B) moderately T-2 -weighted spin-echo (SE 180/80) images. The
intraluminal component of the tumour is wel shown in (A) buthe
destruction of the low-signal blader wall (straight arrow) is better
demonstrated in (B) Left-sided pelvic lymphadenopathy (n) shown
in (A) is obscured in (B). b = bladder; r = rectum.

65. • Fig. 31.53 Extensive stage T3b bladder tumour (straight
arrows) with bilateral obstructive uropathy on (A)
transverse and (B) parasagittal T 2 -weighted spin echo (SE
3500/100) images with fat suppression. The dilated ureters
(u) are clearly shown to contain high signal urine with no
spread of the transitional cell carcinoma into the ureters.
This was suggested on CT (not shown). There is also ascites
(curved arrows) present.

66. • Fig. 31.54 Metastatic transitional cell bladder
carcinoma on a transverse T-1 -weighted spin-echo
(SE 520/15) image showing a soft-tissue mass in the
perineum (arrow) involving the left corpus
cavernosum and left inferior pubic ramus.

67. • Fig. 31.55 Pelvic lymphadenopathy (n) demonstrated
on T 1 -weighted spin-echo (SE 740/40) images in (A)
coronal and (B,C) transverse planes in different
patients. The soft-tissue signal from the
lymphadenopathy contrasts well with the signal void
from flowing blood within adjacent vessels and high
signal from surrounding fat. b = bladder; p = psoas
muscles; t = bladder tumour; arrow = dilated left ureter
filled with low-signal urine.

68. • Fig. 31.55 Pelvic lymphadenopathy (n) demonstrated on T
1 -weighted spin-echo (SE 740/40) images in (A) coronal
and (B,C) transverse planes in different patients. The soft-
tissue signal from the lymphadenopathy contrasts well with
the signal void from flowing blood within adjacent vessels
and high signal from surrounding fat. b = bladder; p = psoas
muscles; t = bladder tumour; arrow = dilated left ureter
filled with low-signal urine.

69. • Fig. 31.56 Resected stage T1/T2 bladder tumour
with a focal area of wall thickening (straight
arrows) and ulcer crater (curved arrow) with no
residual tumour on a coronal T2 -weighted spin-
echo (ESE 3000/100) image with fat suppression.
(1.5 T IGE Horizon using a phased-array pelvic
coil.)

70. • Fig. 31.57 Cyst of Cowper's gland (c) on spin-echo (A)
sagittal intermediate- weighted (SE 1100/26) and (B)
transverse T 2 -weighted (SE 2000/80) images. Note
that the urethra is well visualised between the anterior
and posterior parts of the cyst in (A). b = bladder; p =
prostate; r = rectum; s = symphysis pubis; v = seminal
vesicles; straight arrow = urethra; curved arrow = bulb
of penis.

71. • Fig. 31.58 Stage T3a prostate carcinoma
(arrow) posterolateral to the right in the
peripheral zone infiltrating through the
capsule into the adjacent neurovascular
bundle. p = peripheral zone; c = central gland.

72. • Fig. 31.59 1,111 ,,,use T2 -weighted spin-echo
(SE -uuu 80) image through the prostate of an 80-year-
old patient. Note that there is no differentiation
between the central and peripheral zones due to
benign prostatic hypertrophy. p = prostate; r = rectum;
s = symphysis pubis; arrows, periprostatic venous
plexus.

73. • Fig. 31.60 Benign prostatic hypertrophy (p)
on a fat-suppressed corona! T2 -weighted
spin-echo (FSE 3500/100) image. Arrows =
periprostatic venous plexus. (1.5 T IGE Horizon
using a phased-array pelvic coil.)

74. • Fig. 31.61 Multifocal prostatic carcinoma (curved
arrows) in the left peripheral zone with
associated benign prostatic hypertrophy on a
transverse T2-weighted spin-echo (FSE 4000/104)
image. Note the area of high signal (straight
arrow) in the more posteriorly placed tumour
due to haemorrhage from recent biopsy.

75. • Fig. 31.62 Prostatic carcinoma (stage T2) in the
right peripheral zone (arrow) abutting onto the
capsule on a fat-suppressed transverse
T-2 weighted spin-echo (TSE 350/10) scan. Note
the coincidental benign prostatic hypertrophy.
(1.5 T Philips Gyroscan using the body coil.)

76. • Fig. 31.63 Stage T4a prostatic carcinoma (arrow)
infiltrating the bladder base on a fat-suppressed
coronal T 2 -weighted spin-echo (TSE 3500/100)
image. This tumour was not detected on
transrectal ultrasound examination (not shown).
(1.5 T Philips Gyroscan using the body coil.)

77. • Fig. 31.64 (A,B) Mucin-secreting adenocarcinoma of
the prostate (straight arrows) extending through the
capsule with a large right pelvic nodal metastasis (n)
on transverse T2 -weighted spin-echo (SE 2000/100)
images. Note the similar high signal from the primary
prostatic tumour and nodal disease.

78. • Fig. 31.65 Stage T3a prostatic carcinoma extending
through the capsule (arrow) posterolaterally to the left
with involvement of the adjacent neurovascular bundle
on a fat-suppressed transverse T 2 -weighted spin-echo
(TSE 5000/11 7) image. (1.5 T IGE Horizon using a
phased-array pelvic coil.)

79. • Fig. 31.66 Recurrent rectal carcinoma (t)
infiltrating an enlarged prostate (p) from benign
prostatic hypertrophy. b = bladder, curved open
arrow = perforation into the perirectal fat space;
straight arrows = thickened left perirectal fascia.