Splenic artery embolization changes the management of blunt splenic injury: an observational analysis of 680 patients graded by the revised 2018 AAST-OIS.

BACKGROUND: This study aimed to evaluate the management of blunt splenic injury (BSI) and highlight the role of splenic artery embolization (SAE). METHODS: We conducted a retrospective review of all patients with BSI over 15 years. Splenic injuries were graded by the 2018 revision of the American Association for the Surgery of Trauma-Organ Injury Scale (AAST-OIS). Our hospital provide 24/7 in-house surgeries and 24/7 in-house interventional radiology facility. Patients with BSI who arrived hypotensive and were refractory to resuscitation required surgery and patients with vascular injury on abdominal computed tomography were considered for SAE. RESULTS: In total, 680 patients with BSI, the number of patients who underwent nonoperative management with observation (NOM-obs), SAE, and surgery was 294, 234, and 152, respectively. The number of SAEs increased from 4 (8.3%) in 2001 to 23 (60.5%) in 2015 (p < 0.0001); conversely, the number of surgeries decreased from 21 (43.8%) in 2001 to 4 (10.5%) in 2015 (p = 0.001). The spleen-related mortality rate of NOM-obs, SAEs, and surgery was 0%, 0.4%, and 7.2%, respectively. In the SAE subgroup, according to the 2018 AAST-OIS, 234 patients were classified as grade II, n = 3; III, n = 21; IV, n = 111; and V, n = 99, respectively.; and compared with 1994 AST-OIS, 150 patients received a higher grade and the total number of grade IV and V injuries ranged from 96 (41.0%) to 210 (89.7%) (p < 0.0001). On angiography, 202 patients who demonstrated vascular injury and 187 achieved hemostasis after SAE with a 92.6% success rate. Six of the 15 patients failed to SAE preserved the spleen after second embolization with a 95.5% salvage rate. CONCLUSIONS: Our data confirm the superiority of the 2018 AAST-OIS and support the role of SAE in changing the trend of management of BSI.

Comparison of outcomes of proximal versus distal and combined splenic artery embolization in the management of blunt splenic injury: a report of 202 cases from a single trauma center.

BACKGROUND: To compare the outcomes of blunt splenic injuries (BSI) managed with proximal (P) versus distal (D) versus combined (C) splenic artery embolization (SAE). METHODS: This retrospective study included patients with BSI who demonstrated vascular injuries on angiograms and were managed with SAE between 2001 and 2015. The success rate and major complications (Clavien-Dindo classification ≥ III) were compared between the P, D, and C embolizations. RESULTS: In total, 202 patients were enrolled (P, n = 64, 31.7%; D, n = 84, 41.6%; C, n = 54, 26.7%). The median injury severity score was 25. The median times from injury to SAE were 8.3, 7.0, and 6.6 h for the P, D, and C embolization, respectively. The overall haemostasis success rates were 92.6%, 93.8%, 88.1%, and 98.1% in the P, D, and C embolizations, respectively, with no significant difference (p = 0.079). Additionally, the outcomes were not significantly different between the different types of vascular injuries on angiograms or the materials used in the location of embolization. Splenic abscess occurred in six patients (P, n = 0; D, n = 5; C, n = 1), although it occurred more commonly in those who underwent D embolization with no significant difference (p = 0.092). CONCLUSIONS: The success rate and major complications of SAE were not significantly different regardless of the location of embolization. The different types of vascular injuries on angiograms and agents used in different embolization locations also did not affect the outcomes.

A Specific Cystography Pattern Can Predict Postprostatectomy Incontinence.

BACKGROUND: Postprostatectomy incontinence (PPI) is one of the most bothersome complications of radical prostatectomy. A postoperative image survey may better predict PPI than a preoperative survey. OBJECTIVE: The aim of this study was to determine whether postoperative cystography bladder patterns can predict PPI at short- and long-term follow-up. METHODS: In total, 180 patients who underwent robot-assisted radical prostatectomy (RARP) from September 2008 to September 2014, and who were followed for at least 6 months, were enrolled in this study. All patients underwent cystography within 2 weeks after RARP before Foley catheter removal, and all parameters were analyzed to evaluate the relationship with PPI at 1, 6, 12, and 24 months post-RARP. Patients were also divided into four bladder neck level groups, according to the relative position of the bladder neck to the pubic symphysis. RESULTS: A total of 119 patients were followed for at least 48 months after RARP. Cystography patterns were analyzed, including the downward bladder neck, bladder height, bladder width, height to width ratio, and bladder neck angle. A more downward bladder neck and a sharper bladder neck angle were significant predictors of PPI at 1, 6, 12, and 24 months after RARP. Patients with a larger bladder height or height to width ratio (prolate bladder shape) tended to have poor outcomes regarding PPI. Clinicians can also use a bladder neck level classification to rapidly predict the outcome of PPI. CONCLUSIONS: Postoperative cystography is a reliable and cost-effective tool for predicting PPI. A more downward bladder neck and a sharper bladder neck angle have the greatest predictive power for short- and long-term PPI.

Discrimination of gangrenous from uncomplicated acute cholecystitis: accuracy of CT findings.

In acute cholecystitis, the presence of gangrene is associated with higher morbidity and mortality and necessitates open surgical intervention rather than laparoscopic cholecystectomy. As Murphy's sign may be absent, gangrene may not be detected ultrasonographically. This retrospective study evaluated indications of acute gangrenous cholecystitis on computed tomography (CT) in 25 patients, who were proven as having acute cholecysitis surgically and pathologically within 3 days of pre-operative CT. The CT images were reviewed by two board-certified radiologists blind to the initial CT report. Acute gangrenous cholecystitis was significantly correlated with the CT signs of perfusion defect (PD) of the gallbladder wall (P = 0.02), pericholecystic stranding (PS) (P = 0.028), and no-gallstone condition (No-ST) (P = 0.026). The presence of PD was associated with acute gangrenous cholecystitis with a relatively high accuracy (80%), a sensitivity of 70.6%, a specificity of 100%, a positive predictive value (PPV) of 100%, and a negative predictive value (NPV) of 61.5%. The combination CT signs of PD or No-ST improved the accuracy for acute gangrenous cholecystitis to 92%, with a sensitivity, specificity, PPV, and NPV of 88.2%, 100%, 100%, and 80%, respectively. Other CT signs were highly specific for acute gangrenous cholecystitis but of low sensitivity, including mucosal hemorrhage, mucosal sloughing, wall irregularity, pericholecystic abscess, gas formation, and portal venous thrombosis. CT was found to accurately diagnose acute cholecystitis, with the presence of PD, PS, or No-ST significantly correlated with that of gangrenous change. Thus, CT is useful in the preoperative detection of acute gangrenous cholecystitis.

Contrast-enhanced multiphasic computed tomography for identifying life-threatening mesenteric hemorrhage and transmural bowel injuries.

BACKGROUND: Active mesenteric hemorrhage and bowel perforation after blunt abdominal trauma warrant immediate surgical intervention. We investigate whether findings on multiphasic computed tomography (CT) can identify life-threatening mesenteric hemorrhage and bowel injuries. METHODS: Within 1-year period, 106 patients underwent multiphasic CT for evaluation of blunt abdominal injuries. Images obtained at arterial phase, portal phase, and equilibrium phase were retrospectively reviewed with special focus on mesentery and bowel injuries. We compared the recorded findings with surgically proven active mesenteric hemorrhage and transmural bowel injuries. The diagnostic values and positive likelihood ratios of individual CT signs were calculated. RESULTS: Mesenteric contrast extravasation had 73.5 positive likelihood ratio and 75% sensitivity for active mesenteric hemorrhage. Hemorrhage first appeared at arterial phase and portal phase was active and life threatening, different from a contained hemorrhage appeared only at equilibrium phase. For transmural bowel injuries, positive likelihood ratio of full-thickness bowel wall abnormality and extraluminal air was large at 32.5 and 26.9, respectively. However, increased mesenteric fat density and peritoneal fluid had high negative predictive value at 98.9 and 97.8. Mean radiodensity of peritoneal fluid in transmural bowel injuries was significantly lower (30 vs. 44 Hounsfield unit, p = 0.008). CONCLUSIONS: Multiphasic CT is accurate in identifying life-threatening mesenteric hemorrhage and transmural bowel injuries.

IVIM Parameters on MRI Could Predict ISUP Risk Groups of Prostate Cancers on Radical Prostatectomy.

PURPOSE: To elucidate the usefulness of intravoxel incoherent motion (IVIM)/apparent diffusion coefficient (ADC) parameters in preoperative risk stratification using International Society of Urological Pathology (ISUP) grades. MATERIALS AND METHODS: Forty-five prostate cancer (PCa) patients undergoing radical prostatectomy (RP) after prostate multiparametric magnetic resonance imaging (mpMRI) were included. The ISUP grades were categorized into low-risk (I-II) and high-risk (III-V) groups, and the concordance between the preoperative and postoperative grades was analyzed. The largest region of interest (ROI) of the dominant tumor on each IVIM/ADC image was delineated to obtain its histogram values (i.e., minimum, mean, and kurtosis) of diffusivity (D), pseudodiffusivity (D*), perfusion fraction (PF), and ADC. Multivariable logistic regression analysis of the IVIM/ADC parameters without and with preoperative ISUP grades were performed to identify predictors for the postoperative high-risk group. RESULTS: Thirty-two (71.1%) of 45 patients had concordant preoperative and postoperative ISUP grades. Dmean, D*kurtosis, PFkurtosis, ADCmin, and ADCmean were significantly associated with the postoperative ISUP risk group (all p < 0.05). Dmean and D*kurtosis (model I, both p < 0.05) could predict the postoperative ISUP high-risk group with an area under the curve (AUC) of 0.842 and a 95% confidence interval (CI) of 0.726-0.958. The addition of D*kurtosis to the preoperative ISUP grade (model II) may enhance prediction performance, with an AUC of 0.907 (95% CI 0.822-0.992). CONCLUSIONS: The postoperative ISUP risk group could be predicted by Dmean and D*kurtosis from mpMRI, especially D*kurtosis. Obtaining the biexponential IVIM parameters is important for better risk stratification for PCa.

Multidetector computerized tomography urography is more accurate than excretory urography for diagnosing transitional cell carcinoma of the upper urinary tract in adults with hematuria.

PURPOSE: It is debatable whether traditionally used excretory urography or the recently introduced multidetector computerized tomography urography is more accurate for diagnosing upper urinary tract transitional cell carcinoma. We compared accuracy measures of both methods for diagnosing upper urinary tract transitional cell carcinoma in adult patients with hematuria. MATERIALS AND METHODS: We retrospectively analyzed consecutive adult patients with hematuria undergoing excretory urography and multidetector computerized tomography urography before any surgery, intervention or treatment from April 2004 to December 2006 in our hospital. The presence of upper urinary tract transitional cell carcinoma on excretory urography and multidetector computerized tomography urography was reviewed independently by 2 uroradiologists who were blinded to clinical information and other imaging results. Final diagnosis of upper urinary tract transitional cell carcinoma was confirmed by histological results. Measures of the diagnostic accuracy of excretory urography and multidetector computerized tomography urography for upper urinary tract transitional cell carcinoma were calculated and compared with reference to the final diagnosis. RESULTS: Of 34 men and 26 women with hematuria (mean age 60.73 +/- 12.95 years) 19 (31.7%) had a final diagnosis of 24 upper urinary tract transitional cell carcinomas. The sensitivity, specificity and accuracy of excretory urography were 0.750, 0.860 and 0.849, respectively. In contrast, the sensitivity, specificity and accuracy of multidetector computerized tomography urography were 0.958, 1.000 and 0.996, respectively. Overall the area under the receiver operating characteristic curve for multidetector computerized tomography urography was significantly larger than that for excretory urography (0.978 vs 0.815, p = 0.005). CONCLUSIONS: Multidetector computerized tomography urography is more sensitive, specific and accurate than excretory urography in the diagnosis of upper urinary tract transitional cell carcinoma in adult patients with hematuria. Therefore, multidetector computerized tomography urography rather than excretory urography should be the first choice noninvasive imaging modality for diagnosing upper urinary tract transitional cell carcinoma.

Diagnostic accuracy of transitional cell carcinoma on multidetector computerized tomography urography in patients with gross hematuria.

PURPOSE: We analyzed the diagnostic value of multidetector computerized tomography urography for transitional cell carcinoma in patients with gross hematuria. MATERIALS AND METHODS: All consecutive adult patients with gross hematuria who underwent multidetector computerized tomography urography in a 23-month period were prospectively enrolled. Transitional cell carcinoma and its location on multidetector computerized tomography urography were recorded at a prospective reading with knowledge of the pertinent history and at a retrospective reading while blinded to all information. Histological evidence of transitional cell carcinoma served as the gold standard for final diagnosis. Patients who were lost to followup, refused biopsy/surgery for clinically suspicious neoplasms or had negative diagnostic evaluation but a followup of less than 1 year were excluded from study. We analyzed the diagnostic value of multidetector computerized tomography urography for transitional cell carcinoma by location with reference to final diagnosis. RESULTS: A total of 139 patients were eligible for study, of whom 24 were excluded from analysis. There was no difference in demographic features between included and excluded patients. Of the 115 included patients 60 had a final diagnosis of a total of 77 transitional cell carcinomas in the renal pelvis, ureter or bladder. Overall sensitivity, specificity and accuracy of multidetector computerized tomography urography for diagnosing transitional cell carcinoma were 0.857, 0.980 and 0.963 at the retrospective reading, and 0.961, 0.988 and 0.984 at the prospective reading, respectively. Multidetector computerized tomography urography had the highest accuracy for diagnosing renal transitional cell carcinoma and the lowest sensitivity for detecting ureteral transitional cell carcinoma. CONCLUSIONS: Multidetector computerized tomography urography is an accurate, noninvasive imaging modality for diagnosing transitional cell carcinoma in patients with gross hematuria. However, careful assessment of the ureter for multidetector computerized tomography urography is required for detecting ureteral transitional cell carcinoma.

Evaluation of renal function of angiomyolipoma patients after selective transcatheter arterial embolization.

BACKGROUND: Angiomyolipoma patients may have renal insufficiency before selective transcatheter arterial embolization (TAE) or may undergo subsequent surgery after TAE. Therefore, this retrospective study examined our experience with TAE or TAE and subsequent surgery on renal function of angiomyolipoma patients with and without preexisting renal insufficiency. METHODS: 25 patients who had undergone TAE for renal angiomyolipoma over a 7-year period were reviewed. The 25 patients were grouped according to whether or not they had undergone further surgery. Preexisting renal insufficiency was compared between the 2 groups. The TAE and surgery group was further subdivided into 2 subgroups according to total nephrectomy or not. The TAE-alone group was further subdivided into 2 subgroups by presence of preexisting renal insufficiency or not. In each group and subgroup, pre-TAE and post-TAE renal function, including serum creatinine and creatinine clearance were compared. RESULTS: TAE rather than TAE and surgery was more likely chosen in the presence of preexisting renal insufficiency (6/13 versus 1/12, P=0.035). In TAE-alone patients, no statistical differences were noted between serum creatinine and creatinine clearance before and after TAE. Conversely, TAE and surgery patients who had undergone total nephrectomy rather than nephron-sparing surgery differed significantly in preand post-TAE serum creatinine (0.77 versus 1.07, P=0.014) and creatinine clearance (98.1 versus 70.7, P=0.032). CONCLUSIONS: This study demonstrated that TAE alone for treating renal angiomyolipomas was able to preserve renal function, despite the presence of mild preexisting renal insufficiency. Conversely, surgery after TAE, particularly total nephrectomy, should be avoided whenever possible.

Intrapulmonary lymph nodes: computed tomography findings with histopathologic correlations.

We retrospectively assessed the computed tomography (CT) features of 31 intrapulmonary lymph nodes (IPLNs) with histopathologic correlations. CT scans revealed that the IPLNs are located in the subpleural region, frequently below the level of the carina, and angular in shape. Most of the IPLNs are solid in texture but occasionally present with a ground-glass appearance. For pleura-attached and pleura-separated IPLNs, one or more and 3 or more linear opacities extending from the nodules can be identified, respectively. Histologically, the IPLNs are located either at the junction of the pleura and lung lobules or at the junction of adjacent lung lobules.

Mesenteric vascular occlusion: comparison of ancillary CT findings between arterial and venous occlusions and independent CT findings suggesting life-threatening events.

OBJECTIVE: To compare the ancillary CT findings between superior mesenteric artery thromboembolism (SMAT) and superior mesenteric vein thrombosis (SMVT), and to determine the independent CT findings of life-threatening mesenteric occlusion. MATERIALS AND METHODS: Our study was approved by the institution review board. We included 43 patients (21 SMAT and 22 SMVT between 1999 and 2008) of their median age of 60.0 years, and retrospectively analyzed their CT scans. Medical records were reviewed for demographics, management, surgical pathology diagnosis, and outcome. We compared CT findings between SMAT and SMVT groups. Multivariate analysis was conducted to determine the independent CT findings of life-threatening mesenteric occlusion. RESULTS: Of 43 patients, 24 had life-threatening mesenteric occlusion. Death related to mesenteric occlusion was 32.6%. A thick bowel wall (p < 0.001), mesenteric edema (p < 0.001), and ascites (p = 0.009) were more frequently associated with SMVT, whereas diminished bowel enhancement (p = 0.003) and paralytic ileus (p = 0.039) were more frequent in SMAT. Diminished bowel enhancement (OR = 20; p = 0.007) and paralytic ileus (OR = 16; p = 0.033) were independent findings suggesting life-threatening mesenteric occlusion. CONCLUSION: The ancillary CT findings occur with different frequencies in SMAT and SMVT. However, the independent findings indicating life-threatening mesenteric occlusion are diminished bowel wall enhancement and paralytic ileus.

Value of CT in the discrimination of fatal from non-fatal stercoral colitis.

OBJECTIVE: Clinical presentation and physical signs may be unreliable in the diagnosis of stercoral colitis (SC). This study evaluates the value of computed tomography (CT) in distinguishing fatal from non-fatal SC. MATERIALS AND METHODS: Ten patients diagnosed as SC were obtained from inter-specialist conferences. Additional 13 patients with suspected SC were identified via the Radiology Information System (RIS). These patients were divided into two groups; fatal and non-fatal SCs. Their CT images are reviewed by two board-certified radiologists blinded to the clinical data and radiographic reports. RESULTS: SC occurred in older patients and displayed no gender predisposition. There was significant correlation between fatal SC and CT findings of dense mucosa (p = 0.017), perfusion defects (p = 0.026), ascites (p = 0.023), or abnormal gas (p = 0.033). The sensitivity, specificity, and accuracy of dense mucosa were 71%, 86%, and 81%, respectively. These figures were 75%, 79%, and 77% for perfusion defects; 75%, 80%, and 78% for ascites; and 50%, 93%, and 78% for abnormal gas, respectively. Each CT sign of mucosal sloughing and pericolonic abscess displayed high specificity of 100% and 93% for diagnosing fatal SC, respectively. However, this did not reach statistical significance in diagnosing fatal SC. CONCLUSION: CT appears to be valuable in discriminating fatal from non-fatal SC.

Necrotic stercoral colitis: importance of computed tomography findings.

AIM: To study the computed tomography (CT) signs in facilitating early diagnosis of necrotic stercoral colitis (NSC). METHODS: Ten patients with surgically and pathologically confirmed NSC were recruited from the Clinico-Pathologic-Radiologic conference at Chang Gung Memorial Hospital, Taoyuan, Taiwan. Their CT images and medical records were reviewed retrospectively to correlate CT findings with clinical presentation. RESULTS: All these ten elderly patients with a mean age of 77.1 years presented with acute abdomen at our Emergency Room. Nine of them were with systemic medical disease and 8 with chronic constipation. Seven were with leukocytosis, two with low-grade fever, two with peritoneal sign, and three with hypotensive shock. Only one patient was with radiographic detected abnormal gas. Except the crux of fecal impaction, the frequency of the CT signs of NSC were, proximal colon dilatation (20%), colon wall thickening (60%), dense mucosa (62.5%), mucosal sloughing (10%), perfusion defect (70%), pericolonic stranding (80%), abnormal gas (50%) with pneumo-mesocolon (40%) in them, pericolonic abscess (20%). The most sensitive signs in decreasing order were pericolonic stranding, perfusion defect, dense mucosal, detecting about 80%, 70%, and 62.5% of the cases, respectively. CONCLUSION: Awareness of NSC and familiarity with the CT diagnostic signs enable the differential diagnosis between NSC and benign stool impaction.

Embolization of renal angiomyolipomas: short-term and long-term outcomes, complications, and tumor shrinkage.

This study retrospectively evaluated outcomes, complications, and tumor shrinkage in renal angiomyolipomas after transcatheter arterial embolization (TAE). All renal angiomyolipoma patients who underwent TAE between August 2000 and December 2008 and had short-term (6 months) follow-up images were evaluated. Complications and tumor relapse after TAE were reviewed. The sizes of embolized tumors were measured to calculate size reductions and reduction rates after TAE. Differences in tumor size, size reduction, and reduction rate between different time points (pre-TAE, short-term follow-up, and long-term follow-up) and groups (completely and incompletely embolized) were determined. Eleven renal angiomyolipoma patients who had undergone TAE were included. Seven (63.6%) patients had postembolization syndrome and one had abscess formation following TAE. Two patients had a tumor relapse (18.2%). The mean tumor size was 8.57+/-2.66 cm on pre-TAE images. The mean size reduction was 3.1 cm (33.3%) and 3.8 cm (43.0%) at short-term and long-term follow-up. Tumor sizes differed significantly between pre-TAE and short-term (p=0.004) or long-term images (p=0.022) but not between short-term and long-term images (p=0.059). Results stratified by the completeness of embolization indicate that only the short-term size reduction rate differed significantly (p=0.025), while the long-term reduction rate and short- and long-term follow-up tumor size and size reduction were comparable between the two groups. In conclusion, selective TAE is effective for tumor shrinkage in most renal angiomyolipomas, with acceptable complication and relapse rates. Tumor shrinkage occurring within 6 months after TAE may reflect the long-term effect of TAE.

Decreased renal parenchymal density on unenhanced helical computed tomography for diagnosis of ureteral stone disease in emergent patients with acute flank pain.

BACKGROUND: The purpose of this study was to determine the usefulness and optimal cutoff point of decreased renal parenchymal density (DRD) for diagnosis of ureteral stone disease (USD) in emergent patients with acute flank pain. METHODS: A total of 85 emergency patients with acute flank pain who underwent unenhanced helical computed tomography (UHCT) were prospectively included in this study as the study group. An additional 30 patients with no USD undergoing UHCT were retrospectively included as the control group. The mean parenchymal density difference between both kidneys of the control group was compared to that of the study group. Within the study group, the DRD of patients with USD and with no USD was compared. The sensitivities and specificities of DRD for diagnosis of USD in a range of possible optimal cutoff points were analyzed. RESULTS: There was a statistically significant difference in DRD between the study and control groups (p < 0.0001). In the study group, the DRD of patients with USD was significantly higher than that of patients with no USD [mean +/- SD = 4.04 +/- 3.4 Hounsfield units (HU) versus 0.08 +/- 2.7 HU, p = 0.0001]. DRD using cutoff points of > or = 8 HU, > or = 5 HU and > or = 2.06 HU had a sensitivity of 12.5%, 40.3% and 76.4%, and a specificity of 100%, 92.3% and 76.9%, respectively. CONCLUSIONS: DRD may be helpful in the diagnosis of USD in emergent patients with acute flank pain. When a DRD of > or = 2.06 HU is selected as a cutoff point, its sensitivity and specificity are both acceptable and higher than 75%.