British Journal of Radiology (2007) 80, e119-e121
© 2007 British Institute of Radiology
doi: 10.1259/bjr/64765826
Pseudotumour in the bladder as a complication of total hip replacement: ultrasonography, CT and MR findings
S J Park, MD, PhD
1
H K Lee, MD
1
B H Yi, MD
1
J G Cha, MD
1
H C Kim, MD
2
K W Lee, MD
M E Kim, MD
and
G W Kwon, MD
1 Department of Radiology, Soonchunhyang University Bucheon Hospital, 1174, Jung-dong, Wonmi-gu, Bucheon-si, Gyeonggi-do, 420-021, and 2 Department of Diagnostic Radiology, College of Medicine, Soonchunhyang University, 23-20, Bongmyungdong, Cheonan, Choongnam 330-721, Departments of 3 Urology and 4 Anatomic Pathology, Soonchunhyang University Bucheon Hospital, 1174, Jung-dong, Wonmi-gu, Bucheon-si, Gyeonggi-do, 420-021, Republic of Korea
Correspondence: Dr Seong Jin Park, Department of Radiology, Soonchunhyang University Bucheon Hospital, 1174, Jung-dong, Wonmi-gu, Bucheon-shi, Gyeonggi-do, 420-021, Republic of Korea. E-mail: indawn{at}hanafos.com
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Abstract
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We report a pseudotumour in the urinary bladder following total hip replacement with review of the literature. Pseudotumour in the urinary bladder as a late complication of total hip replacement is an extremely rare condition. In this case, cross-sectional imaging modalities including sonography, CT and MR showed a hypervascular polypoid mass in the urinary bladder and adjacent wall thickening with a band connecting between the mass and the acetabulum. Histopathological diagnosis confirmed acute and chronic inflammation with calcification.
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Introduction
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Late complications of the urinary system secondary to total hip replacement are rare and include gross haematuria, urinary retention, ureterocutaneous fistula, vesicoacetabular fistula, formation of inflammatory pseudotumour in the pelvis, necrosis of the bladder and ureteral compression and stenosis [1–3]. Among these conditions, pseudotumour formation in the urinary bladder is an extremely rare condition [3]. We cannot find any radiological report about cross-sectional imaging findings describing this in the English literature. We present various radiological features of a pseudotumour in the bladder that occurred 4 years after total hip replacement.
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Case report
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A 39-year-old woman presented with intermittent gross haematuria for 1 month. The patient had had total hip replacement for avascular necrosis three times. The patient underwent right total hip replacement 7 years ago, revision operation 4 years ago and left total hip replacement 1 year ago for avascular necrosis of the femoral heads. Grey scale sonography showed a polypoid mass in the urinary bladder with adjacent wall thickening (Figure 1a
). She had no history of a predisposing condition for avascular necrosis, including steroid use. Colour Doppler sonography showed abundant flow signals in the polypoid mass and adjacent bladder wall. Plain radiography of the pelvis following sonography shows the metallic prostheses in the hip joints bilaterally, with no evidence of loosening or migrating cement in the pelvis. Pelvic MR images showed a polypoid mass with bright signal intensity on T2 weighted images and intermediate signal intensity on T1 weighted images in the right lateral wall of the urinary bladder and a band-like structure connecting the mass and the right acetabulum (Figure 1b–d). Multidetector CT (MDCT) showed a polypoid mass with homogeneously strong enhancement on arterial and portal phase. Late-phase axial and reconstructed coronal CT scans showed a well-marginated polypoid mass in the contrast-filled bladder (Figure 1e). Part of the CT scan is distorted by metallic artefact at the replaced hip joint level. Cystoscopy showed a protruding polypoid mass without sinus opening in the urinary bladder. Transurethral tumour resection was performed. Histopathological diagnosis confirmed an inflammatory granulation polyp showing acute and chronic inflammation with calcifications without evidence of acrylic cement. Post-operative cystography showed a small dimple at the operation site without a fistula tract between the urinary bladder and the right hip joint.
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Figure 1. A 39-year-old woman with a pseudotumour in the bladder as a complication of total hip replacement. (a) Grey scale sonography shows a polypoid mass in the urinary bladder with adjacent wall thickening. (b,c) T2 weighted axial pelvic MR images show a polypoid mass with bright signal intensity in the right lateral wall of the urinary bladder and a band-like structure between the mass and the right acetabulum. (d) Gadolinium-enhanced T1 weighted coronal image shows good enhancement of the bladder polyp and band. (e) Delayed multidetector (MD)CT in the axial plane shows a well-marginated polypoid mass in the contrast-filled bladder.
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Discussion
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To our knowledge, this is the first report in the English literature illustrating the radiological features, including sonography, MDCT and MR, of pseudotumour formation in the urinary bladder after total hip replacement. In previous reports, the pathogenesis of late complications of total hip replacement has been shown to be bone cement being extruded through an acetabular defect into the pelvic cavity at the time of surgery, with subsequent thermal damage to the adjacent organ resulting in an inflammatory reaction. These processes can form a fistula between the hip joint and adjacent organs, chiefly the urinary bladder, or pseudotumour formation in the pelvic cavity and the urinary bladder [3–4]. Infiltration of cement into the pelvis during fixation of the prosthesis may cause a severe inflammatory reaction with oedema and necrosis of the bladder wall, resulting from thermal damage by polymerization to the methylmethacrylate. Finally, inflammation or abscesses of the hip joint extend to the skin and to the bladder [2]. This is a case of inflammatory mass formation in the urinary bladder wall combined with a fibrous tract between the acetabulum and the bladder. In a previous report, a histopathological study of pseudotumour formation as a late complication of total hip replacement revealed only inflammatory cells and small abscess formation in the bladder mass, but this was associated with bone cement penetrating into the bladder wall as revealed by partial cystectomy [3]. In a previous report of a foreign body in the bladder due to migrating bone cement, sonography revealed a fingertip sized mass with acoustic shadow in the bladder wall. An acoustic shadow is usually caused by bone cement in the mass [4]. However, in this case, sonography showed a hypervascular polypoid mass with adjacent wall thickening. Histopathologically, the mass contained small calcifications, not bone cement. Calcifications and bone cement usually show similar radiological features, including echogenic spots with posterior shadowing on sonography and signal void on MRI. A connecting band between the acetabulum and the mass is poorly depicted by sonography because of its deep location and shadow from the adjacent pelvic bone. In previous reports, there has been a stone-like radio-opaque nodule in the urinary bladder on plain radiography or a filling defect in the opacified bladder on cystography. But no radio-opaque nodule in the pelvic cavity from the acetabulum can be found in our case. MR images clearly depicted a polypoid mass with a communicating band between the acetabulum and lateral bladder wall. The mass and band showed similar signal intensity: homogeneous high signal intensity on the T2 weighted image and intermediate signal intensity on the T1 weighted image. This high signal intensity on the T2 weighted image was due to a high water composition from acute inflammation. The subsequent MDCT was limited in evaluating pelvic abnormalities in patients with hip replacement using a metallic prosthesis, because metallic artefact from the prosthesis distorted many slices of pelvic MDCT scans at the replaced hip joint level, as in this case. As such, MRI was more useful in evaluation of the pseudotumour in the urinary bladder and the communicating band than MDCT scan. Especially, in this case, axial and coronal T2 weighted MR scans are most useful in the diagnosis of pseudotumour and band after hip replacement.
In conclusion, the radiological findings of pseudotumour, acute and chronic inflammatory granuloma in the bladder as a complication of total hip replacement are a well-defined and hypervascular polypoid mass on grey scale and colour Doppler ultrasound, a well-enhancing mass on pelvic CT scan and a hypointense polypoid mass with a fine band communicating between the acetabulum and the bladder on T1 and T2 weighted MRI.
Received for publication August 2, 2005.
Revision received September 26, 2005.
Accepted for publication December 9, 2005.
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References
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- Lem S, Nolan RL. Complications of hip arthroplasty simulating pelvic or bladder pathology: sonographic and radiographic findings. Abdom Imaging 2000;25:440–3.[CrossRef][Medline]
- Gallmetzer J, Gozzi C, Herms A. Vesicocutaneous fistula 23 years after hip arthroplasty. Urol Int 1999;62:180–2.[CrossRef][Medline]
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- Nonomura M, Kanaoka T, Soeda A, Matsuo M. A case of a methylmethacrylate foreign body in the bladder wall. Int J Urol 1994;1:278–80.[CrossRef][Medline]
- Schneider HJ, Mufti GR. Vesico-acetabular fistula after total hip replacement. Br J Urol 1993;71:754[Medline]
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Abstract
Introduction
