A rubber tube in the bladder as a complication of autoerotic stimulation of the urethra.

Self-insertion of foreign bodies in the urethra is most commonly associated with sexual or erotic arousal of adolescents with mental health disorders. Rarely it may practiced by healthy adults for masturbation. Migration of foreign bodies used for the abovementioned purpose from the urethra to adjacent organs is a relatively uncommon urologic problem that may cause serious complications which arose tardive. Presentation includes a variety of acute or chronic symptoms that depend of the underlying complications. The method of extraction depends on the shape, size and nature of the object and should be tailored according to the condition of the patient. In the present article we present a case of a rubber tube inserted to the urethra for erotic arousal purposes which migrated to the bladder during masturbation.

Treatment of urethral strictures with balloon dilation: A forgotten tale.

Urethral stricture is a common condition that can lead to serious complications such as urinary infections and renal insufficiency secondary to urinary retention. Treatment options include catheterization and dilation, urethroplasty and endoscopic internal urethrotomy as well. Although treatment option depends on the type, length and aetiology of stricture, the choice can be influenced to varying degrees by the simplicity of the method, the preferences of the patient the available accoutrements and the patient health condition. Both urethroplasty and endoscopic internal urethrotomy require anaesthesia and thus are not suitable for many elder and unfit for surgical treatment patients. On the other hand, dilations are easy to perform in every day clinical practice however they have been associated with iatrogenic urethral trauma. In contrast, balloon dilation under vision dilates by radial application of forces against the stricture, avoiding the potentially shearing forces associated with sequential rigid dilation. Since it reduces the possibility of an iatrogenic urethral trauma and the subsequent spongiofibrosis may lead into improved therapeutic outcomes. In this report we describe a technique for the treatment of urethral strictures with balloon dilation in elder and unfit for surgical treatment patients.

Transradial Prostatic Artery Embolization as a Salvage Procedure in a Patient With Severe Deformities and Refractory Hematuria of Prostatic Origin.

Benign prostatic hyperplasia is a common condition causing urinary symptoms in older men. It can sometimes lead to hematuria of prostatic origin, due to increased vascularity of the enlarged gland. If this type of hematuria is severe and refractory to conservative measures, it can be life-threatening. Prostatic artery embolization (PAE) serves as a minimally invasive alternative to traditional surgical interventions, particularly in patients with comorbidities and contraindications to surgery. We present a case of a 79-year-old male with refractory hematuria of prostatic origin (RHPO), multiple comorbidities, and significant deformities of the left upper and both lower limbs. The patient was treated with PAE via the right radial artery, a less common approach in interventional radiology. The procedure was successful and led to a complete resolution of hematuria, with no complications. This report highlights the importance of adapting treatment for complex patients and shows that PAE can be safe and effective in such cases.

Percutaneous thrombin injection under contrast-enhanced ultrasound guidance to control active extravasation not associated with pseudoaneurysm.

The technique of percutaneous thrombin injection (PTI) under contrast-enhanced ultrasound (CEUS) guidance for control of acute hemorrhage-active extravasation not associated with pseudoaneurysm is demonstrated in three cases: 1) Massive spontaneous retroperitoneal hematoma in a patient with multiple comorbidities. Contrast-enhanced computed tomography (CT) showed extensive active extravasation, which was only partially controlled by transarterial embolization. CEUS was performed in the angiography suite. Contrary to unenhanced US and colour Doppler US (CDUS), CEUS confirmed persistent extravasation; CEUS-guided PTI was performed immediately thereafter. 2) Large rectus sheath hematoma in a patient on anticoagulant therapy. Contrast-enhanced CT and unenhanced US/CD could not definitely diagnose extravasation. CEUS clearly showed extravasation and was used for guidance of PTI. 3) Chest wall hematoma complicating central venous catheter placement in a patient with coronavirus on anticoagulant therapy. CDUS was inconclusive. CEUS was performed at the bedside, clearly showed active extravasation, and was used for guidance of PTI. In all three cases, post-PTI CEUS confirmed the absence of residual enhancement of the hematomas, and the hemodynamic status of the patients improved. PTI appears to be effective in selected cases of hematomas associated with active extravasation. In this context, CEUS may be the most suitable modality for guidance and for an immediate evaluation of the treatment effect.

Angiographic Imaging of Prostatic Artery Origin in a Greek Population and Correlation With Technical and Clinical Aspects of Prostatic Artery Embolization.

Background This study aimed, first, to angiographically investigate and analyze prostatic artery (PA) origin in a Greek male population with benign prostatic hyperplasia (BPH) treated with prostatic artery embolization (PAE) and, second, to correlate prostatic arterial anatomy with technical and clinical aspects of PAE. Methodology This was a retrospective study of BPH patients who underwent PAE in a single tertiary center in Greece from June 2019 to July 2022. For the first part of the study, PA was imaged with computed tomography angiography (CTA) before PAE and with digital subtraction angiography (DSA) during PAE in all patients. A widely accepted system for the classification of PA origin was applied. Type I, a common origin of PA and superior vesical artery (SVA) from the anterior division of internal iliac artery (IIA). Type II, PA originating from the anterior division of IIA, separate from, and inferior to SVA. Type III, the origin of PA from the obturator artery. Type IV, the origin of PA from the internal pudendal artery. Type V, rarer origins of PA. For the second part of the study, a subgroup of patients from the first part (treated with the same PAE protocol and free of vascular pathology that could have interfered with the technical success of PAE) was selected. In this subgroup, differences in PA origin were correlated with technical aspects (feasibility of catheterization of PA, fluoroscopy time (FT), dose area product (DAP)) and clinical outcomes of PAE. Results After the exclusion of four patients, 159 patients were included in the first part of the study. From a total of 355 PAs, 110 (31%) were compatible with type I, 58 (16.3%) type II, 45 (12.7%) type III, 110 (31%) type IV, and 32 (9%) type V. PA origin from an accessory internal pudendal artery was the most common among the rare origins of type V. Regarding the second part of the study (a subgroup of 101 patients selected to facilitate comparisons between the different types of PA origin), type I was associated with significantly more incidences of failed or difficult catheterization of the PA compared to all other types combined (27/64 vs. 18/138, p < 0.001). Types III, IV, and V showed a relatively low degree of technical difficulty. Patients with type I PA origin of at least one pelvic side (subgroup (I), n = 48) had significantly longer FT and DAP compared to the rest (subgroup (O), n = 53). Clinical success rates of PAE were slightly lower for the subgroup (I), although the difference was not statistically significant (75.8% vs. 83.8% at 18 months post-PAE, p = 0.137). No major complications were observed. Conclusions This is the first study of PA origin in Greece. It was demonstrated that types I and IV of PA origin were the most common and had the same prevalence. Type I showed significantly higher technical difficulty compared to the others, but had no significant impact on the clinical outcomes of PAE.

Ewing Sarcoma of the Lung: Imaging of a Rare Tumor.

Primary pulmonary Ewing sarcoma is an extremely rare tumor of neuroectodermal tissue. In this article, we report on the case of a 45-year-old female who presented in the emergency department with shortness of breath and night fever. Radiologic findings suggested a massive pulmonary mass and a metastatic liver lesion. The diagnosis of Ewing sarcoma was established through a percutaneous biopsy of the lung mass and liver lesion. We highlight the importance of considering a broad differential diagnosis for a large pulmonary mass in order to lead to a prompt diagnosis and treatment.

A Retrospective, Single-Center Study of Technical-Procedural Factors Affecting Radiation Dose During Prostatic Artery Embolization.

Introduction This study aims to evaluate the effect of technical-procedural factors on radiation dose during prostatic artery embolization (PAE). Methods This was a single-center, retrospective study of 59 patients with benign prostatic hyperplasia (BPH) who underwent prostatic artery embolization from March 2020 to September 2021. Computed tomography angiography (CTA) was performed for vascular planning prior to PAE in all patients. The effect of the following techniques on the dose area product (DAP) of PAE was evaluated: application of low-dose protocol (LDP) for digital subtraction angiography (DSA), reduction of oblique projections by performing PAE of at least one pelvic side utilizing anteroposterior projections only (AP-PAE), utilization of "roadmap" technique instead of DSA for the delineation of pelvic arterial anatomy (RDMP-PAE), and cone-beam CT (CBCT). The impact of the patient's body mass index (BMI) on DAP was also calculated. The effective dose (ED) of PAE and pre-PAE CTA was calculated from DAP and from dose length products, respectively, using appropriate conversion factors. Results For the entire study population (n = 59), the mean DAP of PAE was 16,424.7 ± 8,019 µGy‧m2. On simple regression analysis, LDP, AP-PAE, and RDMP-PAE significantly contributed to DAP reduction during PAE (30% (p = 0.004), 26.7% (p = 0.013), and 31.2% (p = 0.004), respectively). On multiple regression, LDP and AP-PAE maintained their significant effect (p = 0.002 and p = 0.006, respectively). CBCT was associated with a not statistically significant increase in DAP (10.1%) (p = 0.555). The ED of CTA represented 21.2% ± 10.6% of the ED of PAE. Conclusion Of the four studied factors, LDP, AP-PAE, and RDMP-PAE proved to be relatively simple and widely available techniques that could limit radiation exposure of both the operators and the patients during PAE. The contribution of planning CTA to the overall radiation exposure of patients undergoing PAE appears to be not negligible.

Complications of Totally Implantable Central Venous Catheters (Ports) Inserted via the Internal Jugular Vein Under Ultrasound and Fluoroscopy Guidance in Adult Oncology Patients: A Single-Center Experience.

Introduction In this retrospective study, the safety and complication rates of port implantations via the internal jugular vein under ultrasound and fluoroscopy guidance in adult oncology patients were analyzed. Material and methods Eight hundred seven ports implanted in 799 adult oncology patients at a tertiary Oncology-Anticancer Hospital during a 36-month period from January 1, 2017 to December 31, 2019 were retrospectively reviewed. Data acquisition was obtained until December 31, 2020. All procedures were performed by two specialized interventional radiologists under ultrasound and fluoroscopy guidance. The vein access was via the internal jugular vein. Catheter days (the total number of days of maintenance of the port by all of the patients until removal, death, or December 31, 2020), technical success rates, and complication rates were evaluated based on the interventional radiological reports and patient medical records. Multivariate analysis regarding patients such as age, sex, body mass index (BMI), marital status, educational level, cancer type, side of insertion, diameter of internal jugular vein, diabetes, anticoagulants/antiplatelets, purpose of implantation, and catheter material as to the risk of complications was conducted. Results A total of 369,329 catheter maintenance days were observed (457.7±345.0). The technical success rate was 99.9%, and a total of 85 (10.5%) complications occurred, of which 24 (28.2%) occurred early (<30 days) and the remaining 61 (71.8%) were late (>30 days) complications. Specifically, 28 (3.5%) were catheter-related thrombosis (CRT), 27 (3.4%) related to infection, 17 (2.1%) were mechanical complications (16 fibrin sheath formation and one catheter occlusion), six (0.7%) related to catheter migration, four (0.5%) related to incision healing problems, and the remaining three (0.4%) related to ischemic skin necrosis. Forty-seven (5.8%) ports were removed due to complications. On multivariate analysis, cancer type was found as a risk factor for the development of a complication. Additionally, there was an indication that hematologic malignancy is related to infection. Conclusion Placement of ports via the internal jugular vein under ultrasound and fluoroscopy guidance is a safe procedure, with low rates of early and late complications.

Short-term evaluation of liver tumors after transarterial chemoembolization: limitations and feasibility of contrast-enhanced ultrasonography.

PURPOSE: To evaluate the limitations and the feasibility of contrast-enhanced ultrasonography (CEUS) for the assessment of tumor response shortly after transarterial chemoembolization (TACE). MATERIALS AND METHODS: Fifty seven patients (41 patients with hepatomas, 16 patients with metastases) were studied with CEUS before, 1 day after, and 30 days after TACE. A CEUS-efficiency score (CEUS-ES) was calculated, which evaluated: (a) the completeness of visualization of the target tumor(s) (2: good, 1: adequate, 0: poor) and (b) the quality of delineation of post-TACE necroses (2: good, 1: adequate, 0: poor). A CEUS study was considered as "diagnostic," if each of the aforementioned parameters was associated with grade 1 or 2. RESULTS: CEUS studies were "diagnostic" in 36/57 patients (63.1%). Patients with hepatomas were more likely to undergo "diagnostic" CEUS than patients with metastases (70.7% vs. 43.7%, P = 0.0728). Lesions' multiplicity, deep location, hypoenhancement on pretreatment CEUS, and diffuse growth had a statistically significant (P < 0.05) negative impact on CEUS-ES. Hyperechogenicity on pre-treatment, unenhanced US had a non-statistically significant (P = 0.176) negative impact. Differences between "diagnostic" CEUS studies and CT/MR regarding detection of residual tumor were insignificant (P = 0.8178). CONCLUSION: The percentage of lesions which are unsuitable for post-TACE evaluation with CEUS is not negligible. For the rest, the respective role of CEUS is promising.

One, No One and One Hundred Thousand: Patterns of chronic prostatic inflammation and infection.

Chronic prostatic inflammation may be classified into three types that share similar symptoms and are distinguished on the basis of microbiological findings. In the present study, consecutive cases of chronic prostatic inflammation and infection were retrospectively reviewed in order to explore the clinical course and long-term outcomes. The cohort consisted of patients with symptoms of prostatitis who visited the Urology Clinic of the Tzaneion Hospital (Piraeus, Greece) between March 2009 and March 2019. The patients were subjected to the Meares and Stamey '4-glass' test and patients with febrile prostatitis were evaluated with a single mid-stream 'clean' urine sample culture. Bacterial identification was performed using the Vitek 2 Compact system and the sensitivity test with the disc and the Vitek 2 system. A total of 656 patients with prostatitis-like symptoms with 1,783 visits for investigation and follow-up were reviewed and patients were divided into two major groups. Group 1 consisted of 549 cases with a single set of chronic prostatitis (CP)-like symptoms assessed in up to three visits. National Institutes of Health (NIH) category II CP (NIH-II) was most frequently diagnosed in those patients (37,6%). At the follow-up, 125 patients were identified as having a type of CP different from that determined initially. Group 2 (107 cases) had recurring episodes of prostatitis-like symptoms assessed or confirmed over the course of 4-18 visits. Most patients (54.2%) were initially diagnosed with NIH-II followed by disease-free periods and recurrence/reinfection or by shifts to NHI-IIIB. In conclusion, CP remains a poorly understood n medical condition characterized by a variety of clinical manifestations and by transitions between different CP classes during its course.

Prostatic artery embolization performed in anteroposterior projections versus steep oblique projections: single centre retrospective comparative analysis.

BACKGROUND: To present and evaluate an approach for reduction of utilization of steep oblique angiographic projections during prostatic artery embolization (PAE). METHODS: Single-center, retrospective study of patients who underwent bilateral PAE (from October 2018 to November 2019) and in whom it was possible to embolize PA of at least one pelvic side utilizing anteroposterior projections only (AP-PAE group), with the following techniques: Identification of the origin of PA on anteroposterior angiographic views. Utilization of anatomic landmarks from the planning computed tomographic angiography. Distal advancement of the angiographic catheter or microcatheter in the anterior division of internal iliac artery. Gentle probing with microguidewire at the expected site of origin of the PA. The AP-PAE approach was initially applied to all PAE patients during the study period and when this approach failed, additional steep oblique projections were acquired; patients who underwent bilateral PAE, with both anteroposterior and oblique projections for both pelvic sides, formed the standard PAE (S-PAE) group. The AP-PAE group was compared with S-PAE group in terms of baseline clinical and anatomic features, technical/procedural aspects and outcomes. RESULTS: Forty-six patients (92 pelvic sides) were studied. AP-PAE was feasible in 12/46 patients (26.0%): unilateral AP-PAE in 9/46 patients (19.5%); bilateral AP-PAE in 3/46 patients (6.5%). AP-PAE group had larger prostates (p = 0.047) and larger PAs (p < 0.001). Body mass index (BMI) and other baseline features were comparable between the two groups (mean BMI, AP-PAE group: 27.9 ± 3.6, S-PAE group: 27.0 ± 3.5, p = 0.451). Mean fluoroscopy time and dose area product were lower in AP-PAE group (46.3 vs 57.9 min, p = 0.084 and 22,924.9 vs 35,800.4 µGy.m2, p = 0.018, respectively). Three months post PAE, comparable clinical success rates (11/12 vs 31/34, p = 0.959) and mean International Prostate Symptom Score reduction (60.2% vs 58.1%, p = 0.740) were observed for AP-PAE and for S-PAE group, respectively. No major complications were encountered. CONCLUSION: AP-PAE is associated with significant reduction in radiation exposure and appears to be feasible, safe and effective, but it can be applied in a relatively small percentage of patients.

Findings and limitations of focused ultrasound as a possible screening test in stable adult patients with blunt abdominal trauma: a Greek study.

Our objective is to underline the place of FAST (focus assessment by sonography for trauma) ultrasonography (US) in the investigation of blunt abdominal trauma. We retrospectively examined the ultrasound findings in 1,999 haemodynamically stable adult patients. These people were admitted to the emergency room (ER) for possible blunt abdominal trauma. All were stable at admission and a FAST ultrasound examination was made. Initial findings were compared with the clinical course after at least 24 h of observation time and CT results. Among the 1,999 US examinations, abnormalities were found in 109 (5.5%) cases. Among them, 102 had free peritoneal fluid, and in 58 examinations, ruptures, lacerations or haematomas were demonstrated. Despite its limitations, such as in cases involving uncooperative patients, excessive bowel gas, obesity and empty bladder, the FAST technique seems to be an accurate method to evaluate the possibility of abdominal blunt trauma in stable patients. Because of the high negative predictive value of the FAST technique in stable patients with blunt abdominal trauma, we recommend that a stable patient with negative ultrasound results at admission remain under close observation for at least 12 or preferably 24 h before being discharged.

Sonographic evaluation of prostatic artery embolization: Far beyond size measurements.

Prostatic artery embolization (PAE) has gained acceptance as a minimally invasive, safe and effective treatment of symptomatic benign prostatic hyperplasia. Radiologic imaging is an indispensable part of post-interventional evaluation of PAE and serves both clinical and investigational purposes. In this context, ultrasonography (US) has a central and multifaceted role. Gray-scale US is routinely utilized for measurement of significant outcome parameters (prostatic volume, intra-vesical prostatic protrusion and post-void residual volume) before and after PAE. Improvement of these parameters may become more obvious one-month post-PAE, or later. Contrast-enhanced US (CEUS) with intravenous administration of a second-generation echo-enhancer can demonstrate prostatic infarcts (as enhancement defects) immediately post-PAE and monitor their resolution over time. The volume of prostatic infarcts can also be measured and compared to prostatic volume. Prostatic infarction is a definite sign of the local efficacy of PAE and a predictor of prostate shrinkage and (at least in some patients) of clinical success. CEUS can also be performed intraoperatively in the angio-suite, for on-site evaluation of the ischemic effect; a variation of this technique, with intraarterial (instead of intravenous) administration of diluted echo enhancer, can also be applied intraoperatively, to map the embolized territory and to prevent non-target embolization. Initial experience with US-elastographic techniques (shear-wave and strain elastography) has shown that they can detect and quantify the improvement of tissue elasticity post-PAE, thus providing new insights into the therapeutic mechanisms of this treatment. With utilization of high-end equipment, experience and standardized imaging protocols, US could be the primary modality for imaging evaluation of PAE.

Transarterial Chemoembolization of HCC with Radiopaque Microspheres: Evaluation with Computed Tomography and the Complementary Role of Contrast-Enhanced Ultrasonography.

PURPOSE: To assess the diagnostic performance of computed tomography (CT), and of the combination of CT with contrast-enhanced ultrasonography (CT + CEUS), for the early evaluation of local response of hepatocellular carcinoma (HCC) treated with transarterial chemoembolization (TACE) with radiopaque drug-eluting microspheres (RO-DEMs). MATERIALS AND METHODS: 30 HCC patients (55 target tumors) were treated with TACE with RO-DEMs (diameter: 70-150 µm) preloaded with 75 mg doxorubicin/2 ml of microspheres. Unenhanced and contrast-enhanced CT, followed by CEUS, were performed 1-3 days post-RO-DEMs-TACE. Contrast-enhanced magnetic resonance (MR) performed 1 month later served as the reference standard. Local tumor response was evaluated with modified Response Evaluation Criteria in Solid Tumors (mRECIST). RESULTS: MR diagnosed 9 tumors with complete response and 46 with residual disease. Compared to MR, CT had 9 false negative and 1 false positive diagnosis for residual tumor. Potential causes for these misdiagnoses were the hyperdensities and associated artifacts (caused by the accumulation of RO-DEMs in the target tumors) and the small size of residual tumor. CT + CEUS had 3 false negative and no false positive diagnosis for residual tumor. The sensitivity, specificity and diagnostic accuracy of CT for detection of residual tumor were, respectively: 80.4%, 88.9% and 81.8%, and for CT + CEUS: 93.5%, 100% and 94.5%, respectively. Agreement (kappa coefficient) in application of mRECIST between MR and CT was lower than between MR and CT + CEUS (0.508 vs. 0.757). CONCLUSION: CT evaluation of TACE with RO-DEMs is associated with limitations which can be partially overcome by combining CT with CEUS.

Atlas Fracture with Concomitant Vertebral Artery Hypoplasia, a Rare but Potentially Hazardous Combination: A Case Report.

The fractures of the first cervical spine vertebrae (atlas) represent 7% of all the overall cervical spine fractures. Hypoplasia of the vertebral artery is also rare (10% of the general population), but even rarer is the combination of those both conditions. This combination should always be identified and treated because sometimes it can be extremely dangerous for the patient. We present a case of a 24-year-old patient who suffered an atlas fracture with concomitant vertebral artery hypoplasia (VAH). We also present the diagnostic algorithm and the treatment management that we have followed. In case of cervical spine trauma the neurovascular symptoms should not be underestimated. Any neurological symptom (sensory, motor, reflex deficits) should be evaluated in detail. In some cases, with uncommon neurological symptoms such as, in our case, unilateral headache, dizziness and vertigo (or generally, involuntary eye movements and salivation, impaired speech and hearing, diplopia, blur vision, incoordination, imbalance, limb weakness) head injury or vertebral artery (VA) injuries have to be suspected. Further evaluation with brain computed tomography (CT) scan and computed tomography angiography (CTA) should be provided. In case of cervical spine trauma over a pre-existing VAH the complications rate is even higher and the early diagnosis and treatment are crucial.

Prostatic calcifications are associated with a more severe symptom burden in men with type II chronic bacterial prostatitis.

INTRODUCTION/AIM: Although prostatic calculi/calcifications are encountered frequently in the urological practice, little is known about the incidence of such lesions, their mechanism of formation, their relationship to other prostate conditions and their clinical significance. The purpose of this study is to describe the characteristics and to investigate the clinical significance of prostatic calcifications (PCs) in patients with chronic bacterial prostatitis (CBP). MATERIALS AND METHODS: This study was conducted between 01/02/2013 and 20/02/2018. The patient population for this study included subjects with or without PCs and a confirmed diagnosis of NIH category II Chronic Bacterial Prostatitis (CBP). Demographics and clinical history of each assessed patient were reviewed. Eligible patients underwent prostatic ultrasound with post-void residual measurement, and the Meares-Stamey "4-glass" test. Symptom severity was measured using the National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) and the International Prostatic Symptoms Score (IPSS). Antimicrobials were administered to confirmed cases of CBP according to the results of susceptibility tests. After four weeks off-therapy, the NIH-CPSI and IPSS tests were repeated. Variables were compared between patients with and without prostatic calcifications. RESULTS: Ninety-five CBP patients were included in the study. According to the presence of PCs detected by ultrasound examination, patients were divided into two groups: 41 had PCs (group 1) and 54 didn't (group 2). No significant between-group baseline differences were found regarding age, marital status, prostate volume, the proportion of common CBP pathogens. Concerning highrisk sexual behavior, a significantly higher number of men with PCs practiced anal penetration. Moreover, a significantly higher number of men with PCs had a history of chronic prostatitis relapsing episodes. Microbiological eradication and the complete resolution of clinical symptoms occurred in similar proportions between the two groups. However, intergroup analysis resulted in significantly higher scores of the NIH-CPSI test in group 1, both at the pre-therapy and at the post-therapy time points. Conversely, no IPSS score differences between groups 1 and 2 were found at both pre- and post-therapy time points. CONCLUSIONS: Prostatic calcifications do not seem to influence the microbiological outcome of antibacterial treatment. However, the CBP symptoms appear to be more severe in carriers of prostatic calcifications, either before or after antibacterial therapy.

The value of contrast-enhanced ultrasonography in detection of prostatic infarction after prostatic artery embolization for the treatment of symptomatic benign prostatic hyperplasia.

PURPOSE: We aimed to assess the clinical and predictive role of contrast-enhanced ultrasonography (CEUS) as the primary method for imaging evaluation of prostatic artery embolization (PAE) for the treatment of symptomatic benign prostatic hyperplasia (BPH). METHODS: Thirty-one patients with symptomatic BPH, treated with PAE from October 2016 until February 2018, were enrolled in this prospective, single-center study. Microspheres (100-700 µm) were utilized for PAE. International prostate symptom score (IPSS), quality of life (QoL), maximum urinary flow (Qmax), prostatic volume (PV) and post void residual volume (PVR) were measured at baseline and at 1, 3, and 6 months post PAE. Unenhanced transabdominal US was utilized for PV and PVR measurements; prostatic enhancement was studied with transabdominal CEUS at baseline, during the procedure, 1 day and 1, 3, and 6 months post PAE. Technical success was defined as embolization of the PA of at least one pelvic side. Clinical success was based on the improvement of IPSS and QoL, with no need for any additional treatment. Follow-up time ranged from 6 to 18 months (mean, 9.7±4.3 months). Clinical success rates were calculated and changes in prostatic enhancement were correlated with the outcome parameters. RESULTS: Technical success rate was 90.3%. Clinical success rates at 3, 6, and 12 months post PAE were 85.7%, 85.7%, and 79.1% respectively. Improvement of outcome parameters (baseline vs. 6-month values) was statistically significant, with 12.4 points mean reduction of IPSS (50.4%, P = 0.003), 2.0 points mean reduction of QoL (45.4%, P < 0.001), 30.3 mL mean reduction of PV (30.2%, P < 0.001), 72.6 mL mean reduction of PVR (51.8%, P = 0.005) and 8.6 mL/s mean increase in Qmax (103%, P = 0.002). The most significant complications were bladder ischemia (n=1), and ischemic rectal ulcer (n=1), both attributable to nontarget embolization, with complete recovery. CEUS 1 day post PAE demonstrated prostatic infarcts in 26/28 (92.8%) patients. The percentage of prostatic infarction (pPI, defined as prostatic infarcted volume 1 day post PAE divided by baseline PV) was 1%-71%. There was a very strong positive correlation between pPI and prostate shrinkage (r=0.81, P < 0.001), but a weak correlation between pPI and the improvement of the other outcome parameters (r= 0.01-0.36; P = 0.093-0.965). However, in the subgroup of patients with indwelling bladder catheter (9/28 patients), successful removal of the catheter was achieved only in patients with pPI>10%. CONCLUSION: CEUS appears to be a practical method for the study of the local ischemic effect of PAE, with potential predictive value.

Favorable Outcome of Conservative Management of Extensive Bladder Ischemia Complicating Prostatic Artery Embolization.

This is a report of a case of bladder ischemia which complicated bilateral prostatic artery embolization in an 80-year-old man with benign prostate hyperplasia and indwelling bladder catheter. Reflux of 100 µm microspheres into superior vesical arteries was the most likely cause. An unenhanced computed tomography (CT) scan performed immediately post-embolization showed retention of contrast in the left anterolateral bladder wall. Five days later, CT showed gas collections and dehiscence of the bladder wall at the same site, involving an area of 47 × 42 mm. Treatment included prolonged (6 weeks) bladder catheterization and antibiotics. Partial resolution of the CT findings and 43% reduction in the prostatic volume were noted after that period; no leakage was detected on ascending cystogram, and the patient was capable of spontaneous micturition.

Early post-interventional sonographic evaluation of prostatic artery embolization. A promising role for contrast-enhanced ultrasonography (CEUS).

AIMS: To assess the feasibility, findings and potential value of early post-interventional, contrast-enhanced ultrasonographic (CEUS) study of prostate artery embolization (PAE). MATERIAL AND METHODS: Fourteen patients treated with PAE for symptomatic benign prostatic hyperplasia were prospectively included in the study. Sonographic evaluation of the prostate included: 1) baseline transabdominal and transrectal CEUS (ta-CEUS and tr-CEUS, respectively) 1-3 days prior to PAE; 2) early post PAE CEUS, with ta-CEUS immediately post PAE and tr-CEUS 3 days post PAE; and 3) follow-up with ta-CEUS and tr-CEUS 3 months post PAE. A brief unenhanced US study preceded each CEUS. Post-therapeutic changes in size, echogenicity and enhancement of the prostate were recorded and were correlated with clinical outcomes. RESULTS: PAE resulted in clinical success in 11/14 patients (78.5%). All sonographic studies were technically adequate, with the exception of ta-CEUS immediately post PAE in 2/14 (14.2%) patients. CEUS studies immediately post PAE and 3 days post PAE showed non-enhancing, welldefined infarctions of the prostate in 10/14 patients (71.4%). There was a strong correlation between ta-CEUS immediately post PAE and tr-CEUS 3 days post PAE regarding the measurements of prostatic infarctions (r =0.98, p< 0.01). The presence of infarctions on early post PAE CEUS was associated with clinical success (p=0.01) and their extent correlated with the degree of prostate shrinkage on 3-month follow-up (r=0.84, p<0.05). The 3 cases of failed PAE showed no infarctions and no prostate shrinkage. CONCLUSIONS: Early post-interventional CEUS of PAE is feasible and may have clinical and prognostic value.