RPS 1609 - Genitourinary interventions

RPS 1609-1
Thermal ablation of central renal tumours performed with a retrograde cold pyeloperfusion technique
Purpose: To assess treatment safety and efficacy following thermal ablation of centrally located renal tumours performed with retrograde pyeloperfusion.
Methods: 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: The protocol was approved by the ethics committee.
Funding: No funding was received for this work.
RPS 1609-2
A minimally-invasive approach to symptomatic uterine fibroids: fibroids location as a predictor of treatment efficacy
Purpose: To retrospectively evaluate the comparing efficacy of MRgFUS and UAE in the treatment of different location-type uterine fibroids.
Methods: 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: Our study was conducted in accordance with the declaration of Helsinki.
Funding: No funding was received for this work.
RPS 1609-3
CT-guided biopsy of the adrenal gland in patients suspected of lung cancer
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: 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: Ethics committee approval obtained.
Funding: No funding was received for this work.
RPS 1609-4
Application of a novel image-processing method: digital variance angiography (DVA) in prostatic artery embolisation (PAE)
Purpose: To compare the performance of digital variance angiography (DVA) versus conventional digital subtraction angiography (DSA) for its utility in image-guidance during prostatic artery embolisation (PAE) of benign prostatic hyperplasia. DVA is a novel x?ray image processing algorithm for the visualisation of contrast motion.
Methods: We evaluated angiographic acquisitions of 15 patients (mean age 67.47, SD 9.76, range 42-82) undergoing PAE at our institution. For quantitative image-quality comparison, signal-to-noise ratio (SNR) of DSA and DVA image pairs were compared using multiple regions of interest (ROI) for each image. Qualitative image-quality evaluation was done in a randomised blinded trial by three experienced interventional radiologists using clinically relevant criteria (e.g. visibility of feeding- and collateral-branches, size of examinable arteries, and detectability of the prostatic artery). Fleiss? kappa-test was used to determine interrater agreement.
Results: DVA images provided 1.79 times higher SNR than DSA (median value, Q1-Q3 interval was 1.46-2-32). The visual evaluation indicated that DVA provided higher quality images than DSA since 90.6% of comparison evaluators preferred DVA over DSA images. The inter-rater agreement was 93.8% and Fleiss?s kappa was 0.38 (p<0.01).
Conclusion: In PAE, DVA-imaging enhances the visualisation of anatomical structures compared to DSA-imaging via significant SNR reduction. The new technology might improve the safety and efficacy of the intervention. As an additional advantage, the observed quality reserve of DVA might also reduce the radiation dose and the amount of contrast agent.
Limitations: A retrospective trial. Aspects of workflow, radiation-dose, and intervention time have to be investigated in an upcoming prospective trial comparing DVA versus DSA directly in the intervention room.
Ethics: This study was approved by our institutional ethics board.
Funding: No funding was received for this work.
RPS 1609-5
Uterine fibroid embolisation efficacy and safety: 15 years experience in an elevated turnout rate centre
Purpose: To evaluate the effectiveness and safety of UFE as an alternative to surgery in the treatment of uterine fibromatosis.
Methods: 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 ?m) 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: n/a
Funding: No funding was received for this work.
RPS 1609-6
The great migration: predicting intramural uterine fibroid migration after uterine artery embolisation
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: 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: n/a
Funding: No funding was received for this work.
RPS 1609-7
Investigating the clinical value of colour-coded pelvic parametric x-ray angiography for image guidance in prostatic artery embolisation for benign prostatic hyperplasia
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: 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: University hospital ethics committee approval obtained.
Funding: No funding was received for this work.
RPS 1609-8
Which women affected by uterine fibroids can be selected for MRgFUS treatment? Our experience
Purpose: To demonstrate that a careful selection of patients is important to predict the execution of treatment and a good result.
Methods: 228 women with uterine fibroids were submitted to c.e. MRI to evaluate the possibility of MRgFUS treatment. The ablation results were evaluated by the non-perfused volume (NPV) on contrast-enhanced MR images acquired after the treatment.
Results: 115 women out of 228 (50.4%) were considered suitable for treatment (good MRI features of the dominant fibroids and adequate acoustic window); 15 of them obtained an incomplete result and other treatments (a second MRgFUS, uterine artery embolisation (UAE), or surgery). The mean value of the NPV ratio was 67.4%, assessed immediately after the treatment. 113 patients out of 228 were not eligible for the treatment: 8/113 women had an abdominal scar, 39/113 patients showed interposition bowel, reverse uterine position, or inadequate acoustic window, and 66/113 had inappropriate features of the fibroids such as number, side (i.e. pedunculate position), big size, or high vascularisation.
Conclusion: MRgFUS is a mini-invasive treatment and it is well tolerated by patients. A correct selection is necessary to achieve a risk-free treatment and good clinical results.
Limitations: The radiological evaluation according to criteria in the literature for the MRgFUS treatment.
Ethics: n/a
Funding: No funding was received for this work.
RPS 1609-9
Results after endovascular uterine artery embolisation in the treatment of symptomatic leiomyoma
Purpose: To evaluate fibroid size using ultrasonography (US) and magnetic resonance imaging (MRI) after uterine artery embolisation (UAE) of leiomyoma.
Methods: 1,023 women with symptomatic leiomyoma were treated by bilateral transcatheter UAE. Angiography and embolisation were performed using 5F Cobra and Roberts uterine catheters by 355-1,000µm of PVA particles. The size of particles depended on the uterine artery diameter and anastomosis between the uterine and ovary arteries. The mean age was 29.5 years (range: 19-47).
Results: The moderate reduction of leiomyoma size was observed one month after UAE. The reduction of fibroid size after 1 month was 18.4% by US and 17.3% by MRI, after 3 months was 40.7% by US and 42.9% by MRI, after 6 months was 60.4% by US and 61.8% by MRI, after 12 months was 72.5% by US and 74.7% by MRI, and after 24 months was 70.8% by US and 72.2% by MRI. Doppler US-control showed a blood flow decrease during the first month after UAE; in 3 months, blood flow data was restored in uterine arteries. We also noticed a significant reduction or disappearance of clinical symptoms such as pain, menorrhagia, and pressure symptoms. The partial vascularisation of leiomyoma was only detected in one case 24 months after UAE.
Conclusion: UAE is an effective, minimal-invasive form of leiomyoma treatment. MRI and US are the modalities that can accurately estimate fibroid changes and blood flow in uterine arteries. The tendency of fibroid shrinkage after UAE is well-defined in the period from 1-24 months. After UAE, the blood supply of myometrium is restored according to US Doppler data in the period from 1-3 months.
Limitations: n/a
Ethics: n/a
Funding: No funding was received for this work.
RPS 1609-11
Pregnancy results: favourable outcomes and fertility perspectives in women treated by MRgFUS for uterine fibroids
Purpose: To discuss fertility perspectives in women treated by MRgFUS and to report pregnancy after this procedure.
Methods: 15 patients aged between 26 and 47 (mean age 36.4) affected by uterine fibroids who wanted to get pregnant were treated in our department with MRgFUS. This study evaluated the findings of 15 patients presenting with a difficulty to conceive and uterine fibroids smaller than 5.5 cm. We preliminarily excluded the other causes of infertility with a gynaecological evaluation. All patients had only one treatment. We made a c.e. MRI in order to control the non-perfused-volume immediately after treatment and then after 3, 6, and 12 months from the procedure.
Results: After 12 months from the treatment, 11 patients had complete reabsorption of the necrotic areas and 4 had partial reabsorption. 7 months later, the patients started the course to become spontaneously pregnant. 3 succeeded and 1 has already given birth at term to a healthy infant without any perinatal complications. Another patient with partial reabsorption of the necrotic area gave birth to a baby and another is now in her seventh month of pregnancy.
Conclusion: MRgFUS permits a significant reduction of the clinical symptomatology and is a valid alternative method to surgery in fertile women, without any complications in case of uterine implanting.
Limitations: A small group of patients.
Ethics: n/a
Funding: No funding was received for this work.
RPS 1609-12
Percutaneous thermal ablation of small renal tumours: a singe-centre experience
Purpose: Percutaneous ablation has been proven as a safe and effective treatment for small renal tumours. The treatment has been available in Israel for over 15 years. We will present the results of a single-centre experience, the largest ablation service in Israel.
Methods: A retrospective study of 199 percutaneous renal tumour ablations was conducted. All patients (mean age 68 (±12); 53/146 female/male) were treated using ablation (microwave ablation 42%, radiofrequency ablation 50%, and cryoablation 8%) during 2013-2019. The average tumour diameter was 25 mm (10-58 mm); 104 tumors were exophytic, 69 were endophytic, and 26 were mixed. In 85 of the cases (42%), a biopsy was performed prior to the ablation. The pathological report revealed that 38 (44%) were clear-cell RCC, 10 (12%) were papillary type RCC, 2 (2%) chromophobe type RCC, 12 (14%) oncocytic tumour, 14 (16%) non-diagnostic, and 9 (12%) other. The monitoring protocol after treatment included imaging after 1, 3, 6, and 12 months subsequent to treatment and later annually; the median follow-up time was 26 months (1-122).
Results: Evidence of tumour recurrence was observed in 25 patients (12.6%); 13 were treated successfully by another ablation session. Cases in which recurrence was observed were characterized by a tumour larger than 30 mm (10-56). 10 of the lesions were central (endophytic).
Conclusion: Percutaneous ablation is a safe and effective treatment for small renal tumours. 89% of long-term complete ablation may be reached. In cases of remnant tumour tissue or recurrence, ablation can be repeated with good results.
Limitations: A single-centre study.
Ethics: In process.
Funding: No funding was received for this work.
RPS 1609-13
Clinical and economic impact of transperineal laser ablation (TPLA) for treating focal unilateral prostate cancer
Purpose: To evaluate the therapeutic success, complications, and economic impact of transperineal US-guided focal laser ablation by US/MRI fusion software as a primary treatment for focal unilateral prostate cancer.
Methods: 24 patients with newly diagnosed, histopathologically-proven, focal unilateral prostate cancer were treated with US-guided transperineal focal laser ablation as a primary treatment. The inclusion criteria were no previous prostate treatment, a PSA level ?20, a Gleason score ?7, and stage ? T2b N0M0 with 3T multi-parametric MRI-visible index lesion (PIRADS ? 4). After the ablation, a 3T mpMRI of the prostate was obtained. Follow-up consisted of mpMRI at 1, 3, 6, and 12 months and a US/MRI fusion-guided biopsy at 6 and 12 months.
Results: 24 patients were successfully treated with transperineal US-guided focal laser ablation. No complications occurred. The IPSS and SHIM did not significantly change after treatment. The mean operation time was 38.2 minutes (range 32.6-42.5), the mean ablation time was 21.7 minutes (range 18.3-26.8), the mean energy deployed was 3606J (range 3212-3804), the mean hospital stay was 113 minutes (range 55-178), and the mean catheterisation time was 261 minutes (range 95-412). At the 6- and 12-month follow-up, prostate mpMRI and US/MRI fusion-guided biopsy showed neither evidence of local residual disease nor recurrence.
Conclusion: Transperineal US-guided focal laser ablation as a primary treatment for prostate cancer has shown encouraging results. Ten-year follow-up with an international registry is intended to confirm oncological long-term prostate cancer with index lesion control.
Limitations: A small number of treated patients, short follow-up, and our first experience with this technique.
Ethics: Protocol approved by the ethical committee of Policlinico Tor Vergata (Rome).
Funding: No funding was received for this work.
RPS 1609-14
Decision-making between radiofrequency and cryoablation based on tumour size, central location, and nearness to the collecting system for the management of cT1 RCC: a comparative study of 408 patients
Purpose: To evaluate our decision-making between RFA and CA based on tumour size, central position, and nearness to the collecting system on technical efficacy and oncologic outcomes for cT1 RCC.
Methods: All cT1 RCC from 2005-2019 were included. Patients treated before 2013 were included in the RFA group and patients treated after 2013 were included in the CA or RFA group, where CA was performed for large (?35 mm) central tumours or RCC with a nearness to the collecting system, while RFA was performed for smaller (<35 mm) and non-central RCC. The IPTW based on clinical and tumour features was applied. The primary success was compared using logistic regression, while local recurrence-free survival was compared using Cox proportional hazards regression. Clavien complications and the change in renal function (MDRD) were also evaluated.
Results: Data from 408 patients were analysed. The primary success rate was higher in the CA or RFA group compared to the RFA group (97.1% vs 87.1%, p<0.001). Local recurrence-free survival was better in the CA or RFA group compared to the RFA group (HR=0.49; 95%CI: 0.28-0.84; p=0.01). Survival without metastases was not different (p=0.65). The incidence of Clavien grade ?2 adverse events (p=0.30) and the change of renal function (p=0.35) was similar.
Conclusion: Our decision-making between CA and RFA achieved a better primary success rate and local recurrence-free survival compared to RFA alone, with excellent oncologic outcomes for RFA in selected patients and also for large and central RCC mainly treated with CA.
Limitations: The retrospective design.
Ethics: Institutional review board approval was obtained to review the medical records of patients who underwent ablation of RCC at Necker University Hospital.
Funding: No funding was received for this work.
RPS 1609-15
Adrenal glands haemorrhages: embolisation in an acute setting
Purpose: Acute adrenal haemorrhages are a rare event compared to other abdominal visceral injuries because of the anatomic localisation of the adrenal glands. The main causes are trauma and ruptured neoplasms.
This manuscript reports on a single-centre experience of transarterial embolisations of adrenal haemorrhages in an emergency setting.
Methods: In this retrospective analysis from 2010 to date, 17 patients (12 men and 5 women, mean age: 59.8 years) presenting with adrenal bleedings were treated by endovascular embolisation.
The aetiology was traumatic in 7 cases, ruptured neoplasm in 8 cases, and spontaneous in 2 patients assuming oral anticoagulant therapy.
After thin slice contrast-enhanced CT, a super-selective embolisation was conducted with different embolising agents according to the type of vessel lesion and operator preference.
Results: Technical success rate, considered as an interruption of adrenal bleeding detectable at angiography, was 94.1%.
Clinical success rate, considered as haemodynamic stability restoration within 24 hours from the procedure, was 82.3%.
The vessels involved were the superior adrenal artery in 5 patients, the middle adrenal artery in 8 patients, the inferior adrenal artery in one patient, and more than one adrenal artery in 3 patients.
No procedure-related major complications occurred and no patients had infarctions, necrosis, abscess formation, or required long-term steroid supplementation.
Conclusion: Acute adrenal haemorrhages can be safely and effectively managed by catheter-directed embolisations. The source of bleeding has to be carefully investigated at CT and angiography as adrenal glands present with a wide and complex vascular arterial network.
Limitations: This is a retrospective analysis and therefore bias selections should be considered. The number of patients is small, however, this is due to the low frequency of the scenario.
Ethics: n/a
Funding: No funding was received for this work.


Bora Peynircioğlu (Turkey)

Richard Nolz (Vienna/AT)

European Society of Radiology

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