Intravesical Prostatic Protrusion Does Not Influence the Efficacy of Prostatic Artery Embolization.

PURPOSE: To compare the outcomes of prostatic artery embolization (PAE) in patients with different intravesical prostatic protrusion (IPP) grades. MATERIALS AND METHODS: This retrospective single-center study included 128 patients (aged 50-86 years) who underwent PAE from 2013 to 2017. IPP grades were classified as follows: grade I (<10 mm), grade II (10-19 mm), and grade III (≥20 mm). Nineteen patients (14.8%) had grade I [mean IPP 7.8 mm, prostatic volume (PV) 64.1 cm3], 77 (60.2%) had grade II (mean IPP 14.9 mm, PV 87.0 cm3), and 32 (25%) had grade III (mean IPP 26.2 mm, PV 132.6 cm3), P < .01. The outcomes, including PV, international prostate symptom score (IPSS), and quality of life (QoL), were compared between the IPP grades at the 12-month follow-up. Clinical failure was defined as IPSS >7 or QoL >2. RESULTS: IPP decreased (I: -8.2%, II: -27.3%, and III: -38.7%, P = .01), and all other endpoints improved (P < .01). Adjusted covariance analysis, considering baseline PV as a confounding factor, showed no correlation between the 12-month outcomes and baseline IPP. Clinical failure was observed in 17/128 patients (13.3%) and was similar in prevalence among the IPP groups (P = .20). Minor complications occurred in 43 patients (33.6%) and major in 3 (2.3%). There were statistical differences in the complications between IPP grades II and III (P < .01). CONCLUSIONS: PAE was similarly effective in all the IPP grades at the 12-month follow-up, and there was no difference in the clinical failure between the groups. Complications in IPP grade III were more frequent than those in IPP grade II.

Angiographic Findings during Repeat Prostatic Artery Embolization.

PURPOSE: To describe mechanisms of prostate revascularization based on imaging findings during repeat prostatic artery embolization (PAE; rPAE). MATERIALS AND METHODS: This is a retrospective analysis of 10 rPAEs performed between October 2012 and September 2018 in patients with recurrent lower urinary tract symptoms (LUTS) after PAE (mean age, 68.2 y ± 4.5). Two interventional radiologists reviewed PAE and rPAE images and defined 6 patterns of revascularization. Correlation between embolization of the posterolateral (PL) prostatic branch during previous PAE and prostate revascularization on rPAE was assessed by Fisher exact test. One hemiprostate was excluded because no detectable revascularization was observed. RESULTS: All patients showed LUTS improvement after previous PAEs (P < .01 for 5 outcome measures) and had recurrence during follow-up. rPAEs were performed a mean of 40.9 months after previous PAEs (18-96 mo). Of 19 hemiprostates analyzed, 11 presented revascularization by 2 or more branches (57.9%). The PL branch (29.0%) and the recanalized main prostatic artery (25.8%) were the most frequent revascularizing branches observed, followed by distal branches of obturator (12.9%), internal pudendal (12.9%), superior vesical (12.9%), and contralateral arteries (6.5%). Embolization of the PL branch during previous PAE significantly reduced the incidence of revascularization by this branch (P = .002). CONCLUSIONS: Mechanisms of revascularization in rPAE are diverse and complex. Revascularization by the PL branch and recanalization of the previously embolized prostatic artery were the most frequent patterns observed. Embolization of the PL branch may reduce the incidence of prostate revascularization and LUTS recurrence after PAE.

Impact of 5-Alpha-Reductase Inhibitors Use at the Time of Prostatic Artery Embolization for Treatment of Benign Prostatic Obstruction.

PURPOSE: To compare the 12-month post-prostatic artery embolization (PAE) clinical outcomes of patients who were and were not taking 5-alpha-reductase inhibitors (5ARIs) at the time of PAE. MATERIALS AND METHODS: A retrospective review was conducted of patients who underwent PAE from 2010 to 2017 due to lower urinary tract symptoms, secondary to benign prostatic hyperplasia (BPH). One hundred fifty-five patients were included and divided in 2 groups; these groups did not present statistically significant differences in their baseline characteristics-those taking 5ARIs (Y-5ARIs, n = 40) and those not taking 5ARIs (N-5ARIs, n = 115). International Prostate Symptom Score (IPSS), the sub-item Quality of Life (QoL), and the incidence of clinical failure were used as primary endpoints. Secondary endpoints included mean prostate volume reduction and mean peak flow rate (Qmax) improvement. Clinical failure or recurrence was defined as absence of symptomatic improvement (IPSS ≥ 8 or QoL ≥ 3) or the need for invasive BPH treatment (PAE or transurethral resection of the prostate) during the 12-month follow-up period. RESULTS: After 12-month follow-up, IPSS, QoL, and prostatic volume were significantly lower compared to baseline in both groups, and Qmax showed a significant increase. No statistically significant differences were observed in outcomes between N-5ARIs and Y-5ARIs, and the clinical failure rate for both groups was approximately 20%. CONCLUSIONS: The use of 5ARIs did not show a detrimental effect on clinical outcomes of PAE, in either subjective (IPSS, QoL, and clinical failure) or objective (prostatic volume and Qmax) parameters.

Diagnosis and management of biliary complications in pediatric living donor liver transplant recipients.

The incidence of biliary complications (BCs) after living donor liver transplantation (LDLT) can reach 40%. Published data on the pediatric population are limited, and treatment protocols vary. Our aim was to describe the clinical scenario for BCs and treatment approaches after LDLT. Between October 1995 and December 2012, 489 pediatric LDLT procedures were performed. BCs developed in 71 patients (14.5%). Biliary strictures (BSs) developed in 45 (9.2%) patients, and bile leaks (BLs) developed in 33 patients (6.7%). The BL diagnosis was clinical in all cases, and 69.7% of the patients underwent surgery. Nearly half of the BS cases had clinical features or suggestive ultrasound findings. Liver biopsy findings suggested BSs in 51.7%. Percutaneous transhepatic cholangiography was performed in 95.6% of the BS patients. The success rate was 77% [mean number of percutaneous biliary interventions (PBIs) = 3.9 ± 1.98, median drainage time = 8 months]. In conclusion, BL patients can be managed with conservative therapy, even though most of these patients will ultimately be treated with surgery. Diagnosing a BS requires a high degree of clinical suspicion because the available resources for its identification can fail in up to 50% of cases. A higher number of PBIs and the use of a drainage catheter for a longer time may be required to achieve better results with this technique.

Portal vein obstruction after liver transplantation in children treated by simultaneous minilaparotomy and transhepatic approaches: initial experience.

Portal vein thrombosis is a complication that occurs anytime after liver transplantation and can compromise the patient and graft survival. We describe a combined technique for PV recanalization in cases of PV obstruction after liver transplantation. Four children (1%), of 367 subjected to liver transplantation from June 1991 to December 2008, underwent PV recanalization through a combined approach (transhepatic and minilaparotomy). All children received left lateral hepatic segments, developed Portal vein thrombosis (n=3) and stenosis (n=1), and presented with symptoms of portal hypertension after transplantation. PV recanalization was tried by transhepatic retrograde access, and a minilaparotomy was performed when percutaneous recanalization was unsuccessful. Three patients underwent a successful portal recanalization and stent placement with the combined technique. In one patient, the recanalization was unsuccessful because of an extensive portomesenteric thrombosis. The other three children had the portal flow reestablished and followed with Doppler US studies. They received oral anticoagulation for three consecutive months after the procedure and the clinical symptoms subsided. In case of PV obstruction, the combined approach is technically feasible with good clinical and hemodynamic results. It' is a minimally invasive procedure and can be tried to avoid or delay surgical treatment or retransplantation.

Midterm and long-term results of percutaneous endovascular treatment of venous outflow obstruction after pediatric liver transplantation.

PURPOSE: To evaluate retrospectively the midterm and long-term results of percutaneous endovascular treatment of venous outflow obstruction after pediatric liver transplantation. MATERIALS AND METHODS: During a 9-year period, 18 children with obstruction of a hepatic vein (HV) or inferior vena cava (IVC) anastomosis underwent percutaneous transluminal angioplasty (PTA) with balloon dilation or stent placement in case of PTA failure after liver transplantation. Patients' body weights ranged from 7.7 kg to 42.6 kg (mean, 18.8 kg +/- 9). Potential predictors of patency were compared between balloon dilation and stent placement groups. RESULTS: Forty-two procedures were performed (range, 1-11 per patient; mean, 2). Technical and initial clinical success were achieved in all cases. Major complications included one case of pulmonary artery stent embolization and one case of hemothorax. Three children (25%) with HV obstruction were treated with PTA and nine (75%) were treated with stent placement. Three children with IVC obstruction (75%) were treated with PTA and one (25%) was treated with a stent. There were two children with simultaneous obstruction at the HV and IVC; one was treated with PTA and the other with a stent. Cases of isolated HV stenosis have a higher probability of patency with balloon-expandable stent treatment compared with balloon dilation (P < .05). Follow-up time ranged from 7 days to 9 years (mean, 42 months +/- 31), and the primary assisted patency rate was 100% when stent placement was performed among the first three procedures. CONCLUSIONS: In cases of venous outflow obstruction resulting from HV and/or IVC lesions after pediatric liver transplantation, percutaneous endovascular treatment with balloon dilation or stent placement is a safe and effective alternative treatment that results in long-term patency.