RPS 1609 - Genitourinary interventions

Purpose:

To assess treatment safety and efficacy following thermal ablation of centrally located renal tumours performed with retrograde pyeloperfusion.

Methods and materials:

From November 2011-December 2018, 54 patients (17 females, 37 males, mean age 69, range 41-89) underwent 64 renal ablations for centrally located renal tumours, 58/64 (90.6%) renal cell carcinomas (RCC), 5/64 (8%) oncocytomas, and one metastasis. Inclusion criteria consisted of biopsy-proven renal masses <4 cm (T1a); the average lesion size was 32.5 mm (range 16-67 mm). 7 mono-renal patients underwent 13/64 (13%) procedures. Microwave (MWA), radiofrequency (RFA), or their combination were the ablation techniques of choice, 33/64 RFA (52%), 29/64 (45%) MWA, and 2/64 (3%) MWA+RFA. All treatments were performed with ultrasound- and CT-guidance under general anaesthesia and a simultaneous retrograde cold pyeloperfusion technique in a dedicated angiography room setting.

Results:

The primary technical success overall was reached in 57/64 cases (89%). Primary technical efficacy at 1 month overall was reached in 48/64 (75%) lesions. 12 lesions underwent a second treatment, with a secondary efficacy of 54/64 (84%). 2/54 (4%) underwent nephrectomy. At a median follow-up of 26.5 months, 3/54 patients died of unrelated events. The mean procedure duration overall was 32 minutes (range 2-160 minutes). Adverse events (AEs) were reported in 15/64 lesions (23%), 5/64 (8%) major AEs and 10/64 (16%) minor AEs.

Conclusion:

Percutaneous thermal ablation of central renal tumours associated with protective pyeloperfusion is a safe and effective treatment option allowing for kidney function preservation and radical results in a large majority of cases. This technique can be useful for avoiding nephrectomy in mono-renal patients.

Limitations:

The retrospective nature of the study.

Ethics committee approval

The protocol was approved by the ethics committee.

Funding:

No funding was received for this work.

Purpose:

To retrospectively evaluate the comparing efficacy of MRgFUS and UAE in the treatment of different location-type uterine fibroids.

Methods and materials:

71 women consecutively treated for symptomatic uterine fibroids were enrolled in our study. Primary (clinical) and secondary (imaging efficacy evaluation) outcomes were evaluated. Pre-procedural and 1-year post-treatment MRI examinations were analysed.

Results:

27 patients were treated by UAE. The overall success rate was 94.63%. The response rate was 100% in submucosal groups and 87.5% and 72.73% in intramural and transmural groups, respectively. A significant difference was observed between transmural and both submucosal and intramural post-treatment severity scores (p=0.006 and 0.017, respectively), while no differences were observed between submucosal and intramural groups (p=0.33). No difference was found between the three groups in the Kaplan-Meier analysis (Log-rank: p= .74). 44 patients were treated with MRgFUS. The overall success rate was 83.01%. Notably, RR was 66.67% in the submucosal group, and 64.71% and 55.56% in intramural and transmural groups, respectively. A significant difference was observed between transmural and both submucosal and intramural post-treatment scores (p=0.016 and 0.017, respectively), while no differences were observed between submucosal and intramural groups (p=0.637). A significant difference was found between the three groups according to the Kaplan-Meier analysis (Log-rank: p=0.001).

Conclusion:

MRgFUS and UAE are highly effective techniques in the treatment of symptomatic uterine fibroids. Fibroid type analysis should be considered for adequate treatment planning, especially for FUS treatment, which finds the primary indication for submucosal fibroids.

Limitations:

The single-centre analysis and the retrospective analysis.

Ethics committee approval

Our study was conducted in accordance with the declaration of Helsinki.

Funding:

No funding was received for this work.

Purpose:

To confirm adrenal metastasis of suspected lung cancer and for molecular tumour characterisation, a biopsy is required. CT-guided biopsy offers 3D visualisation of adjacent anatomical structures in real-time and a detection of complications.

Methods and materials:

A retrospective analysis of all CT-guided biopsies of the adrenal glands performed from 2016-2018 at Thoraxklinik Heidelberg to evaluate outcome and complications and to identify potential risk factors.

Results:

53 CT-guided biopsies were performed in 50 patients (24 left/29 right). No transrenal, transsplenic, transpancreatic, or transpulmonal path was chosen. Anticoagulation was paused according to the guidelines in 16/22 cases. No major complications like death, abscess, pneumothorax, or Hb-relevant bleeding occurred. In 22 patients, a small local haematoma with a median size of 6 ml without further treatment was observed. 20 patients reported pain within the first hours after the intervention, which was easily treated with metamizole. 1 of those 15 patients with a transhepatic pathway showed an incidental arterioportal fistula in a follow-up CT, which did not require further action. The intervention duration from local anaesthesia to the control scan was a median 16 minutes, with a range of 7-35 minutes, and was well tolerated by the patients. Malignancy was confirmed in 92%. In 2 cases, an adenoma was detected; one lesion showed high FDG-uptake and the other high density on CT. In 2 cases, a definite determination was not possible.

Conclusion:

CT-guided biopsy of the adrenal gland is a safe, fast, and reliable method to verify and characterise metastases in patients suspected of lung cancer. Pathways, patient positioning, investigator experience, and procedural manoeuvres are essential and will be communicated.

Limitations:

A relatively small number of procedures.

Ethics committee approval

Ethics committee approval obtained.

Funding:

No funding was received for this work.

Purpose:

To evaluate the effectiveness and safety of UFE as an alternative to surgery in the treatment of uterine fibromatosis.

Methods and materials:

255 patients (aged 26-55) with symptomatic UF, indicated for surgery, followed in our centre (2000-2014), with single or multiple fibroids, and pain and/or functional/compressive disorders underwent embolisation; an injection of PVA particles (150-900 μm) from the distal portion of uterine arteries (ascending section). The primary end-point was a flow-stop distally to the injection site, disappearance of the lesion design, and the preservation of flow in the main trunk of UA. The secondary end-point was the control of pain and functional/compressive disorders during follow-up (2-7 years).

Results:

The procedure was performed bilaterally in 250 patients (98%). The mean duration was 47 min (average fluoroscopy: 10-50 min).

Post-embolisation pelvic pain (according to a VAS score) was on average 2.2 at discharge (24h). Follow-up at 2 years showed a resolution of menstrual disorders in 78% of patients and improvement in 14%, pain disappeared in 66%, significant improvement of menstrual flow and HCT/HB levels, and adecrease in total uterine (57.7%)/dominant fibroid (76.1%) volume. There was recurrence in 18 patients.

Conclusion:

UFE represents an excellent alternative to surgical treatment. It is safe, tolerable, and effective both in the short and long term, with evident advantages in economic and social terms.

Limitations:

A retrospective study without randomisation.

Ethics committee approval

n/a

Funding:

No funding was received for this work.

Purpose:

To analyse pre-UAE MR images with a view to predicting migration of intramural fibroids post-UAE to better advise patients of the procedural risks.

Methods and materials:

We retrospectively reviewed all patients referred for UAE for symptomatic fibroids at our institution over one year. Patients without a pre-procedural MRI and a six-month post-procedural MRI were excluded from the study. Both pre- and post-UAE images were independently reviewed by two radiologists with subsequent consensus review. In each, dominant intramural fibroids were identified and the following measurements taken: a) 3-dimensional maximal measurements, b) the shortest distance between the fibroid and the endometrial wall, and c) the shortest distance between the fibroid and the serosal wall. Paired sample t-tests and two-sample t-tests were used to compare between pre- and post-UAE variations and between migrated and non-migrated intramural fibroids, respectively.

Results:

35 dominant intramural fibroids were identified, of which, 8 migrated to become submucosal fibroids, while 5 were either partially or completely expelled. All migrating fibroids had a pre-UAE minimum distance from the endometrium of 1-2.4 mm and a maximum fibroid diameter greater than 5.1 cm, and none of the non-migrating fibroids had both these characteristics together.

Conclusion:

Not only is it distressing to patients to have post-procedural pain and bleeding, but fibroid migration could also increase infection risks and affect fertility. Our study found that intramural fibroids with a minimum endometrial distance less than 2.4 mm and a maximum fibroid diameter greater than 5.1 cm have a high likelihood of migrating after UAE.

Limitations:

Small sample size and low statistical power.

Ethics committee approval

n/a

Funding:

No funding was received for this work.

Purpose:

A major challenge in prostatic artery embolisation (PAE) is an adequate and distinct visualisation of the feeding prostatic vessels and other branches of the internal iliac arteries. Novel colour-coded parametric images calculated from raw angiographic image data provide additional information compared to common digital subtraction angiography (DSA). Our objective was to investigate the clinical value of parametric images in a PAE setting.

Methods and materials:

We retrospectively examined the selective internal iliac artery image series of 26 patients (mean age: 67.47; SD: 9.76; range: 42-82) undergoing PAE. We generated 230, parametric, colour-coded-delay-angiograms (CDAs) from raw image data obtained from a latest-generation angiography system. Three experienced interventional radiologists evaluated the image quality using a 5-point-Likert scale based on clinically relevant criteria (e.g. the identification of dominant feeding arteries, stenoses, and non-target collaterals).

Results:

Subjective image quality was evaluated with mean scores of 4.16 (range 3-5; std.deviat.+-0.73), significantly higher for DA compared to the mean scores of 3.43 (range 2-5; std.deviat.+-1.80) for standard DSA. Evaluators agreed CDAs provided more information than the simple BW angiograms (87%), the image would be useful to select the dominant feeding artery (93%), and the functional stenoses of the branches could also be determined (84%). The inter-rater agreement, Fleiss’ kappa, and significance were 81%, 0.19, p<0.05, 85%, 0.32, p<0.01, and 79%, 0.11, p<0.05, respectively.

Conclusion:

Parametric delay images calculated from x-ray angiography series provide more information than standard angiograms and hold additional information about the branches of the internal iliac artery. Decision-making based solely on CDAs will require an appropriate prospective safety assessment.

Limitations:

Colour-coded-parametric-angiography has to be tested in upcoming prospective trials to prove our results for real-time image guidance.

Ethics committee approval

University hospital ethics committee approval obtained.

Funding:

No funding was received for this work.