Influence of symptomatic pseudoaneurysms on postoperative renal function after partial nephrectomy: results of a matched pair analysis.

PURPOSE: A symptomatic pseudoaneurysm (SPA) is a rare but severe complication after partial nephrectomy (PN). Selective trans-arterial embolization (TAE) is the treatment of choice with high success rates. However, the influence of this intervention on postsurgical renal function has not been studied. METHODS: Between 2005 and 2016 we performed 1047 PNs at our institution. Postsurgical SPA occurred in 40 patients (3.8%). Patients with and without SPA were matched in a 1:2 ratio concerning tumor complexity (RENAL) and pre-operative renal function (CKD stage). Any CKD upstage and a relevant CKD progression (CKD ≥ III) were defined as endpoints. Furthermore, the influence of the amount of contrast agent applied during TAE was assessed. RESULTS: All patients with SPA were treated successfully with TAE. No significant difference could be detected concerning clinical, functional and surgical aspects. Median follow-up time accounted for 12.5 (6.75-27.5) months. Kaplan-Meier analyses detected an increased rate of any CKD upstage (p = 0.066) and relevant CKD progression (p = 0.01) in patients with SPA. Multivariate analysis identified post-operative SPA to be an independent predictor for a relevant CKD progression (HR 4.15, p = 0.01). The amount of contrast agents used did not have an impact on the development of a relevant CKD progression (p = 0.72). CONCLUSION: Patients treated with TAE after PN show an additional risk for an impairment of renal function over time. Hence, those patients should explicitly be informed about possible consequences and closely monitored by nephrologists.

[Ablative therapy of small renal masses]. / Ablative Therapien kleiner Nierentumoren.

Renal cell cancer is nowadays predominantly diagnosed in early stages due to the widespread use of sectional imaging for unrelated symptoms. Small renal masses (<4 cm) feature a largely indolent biology with a very low risk for metastasis or even a benign biology in up to 30% of the cases. Consequently, there is a need for less invasive therapeutic alternatives to nephron-sparing surgery. Meanwhile, there is a broad portfolio of local ablation techniques to treat small renal tumors. These include the extensively studied radiofrequency ablation and cryoablation techniques as well as newer modalities like microwave ablation and irreversible electroporation as more experimental techniques. Tumor ablation can be performed percutaneously under image guidance or laparoscopically. In particular, the percutaneous approach is a less invasive alternative to nephron-sparing surgery with lower risk for complications. Comparative studies and meta-analyses report a higher risk for local recurrence after renal tumor ablation compared to surgery. However, long-term oncological results after treatment of small renal masses are promising and do not seem to differ from partial nephrectomy. The possibility for salvage therapy in case of recurrence also accounts for this finding. Especially old patients with an increased risk of surgical and anesthesiological complications as well as patients with recurrent and multiple hereditary renal cell carcinomas may benefit from tumor ablation. Tumor biopsy prior to intervention is associated with very low morbidity rates and is oncologically safe. It can help to assess the biology of the renal mass and prevent therapy of benign lesions.

Open Partial Nephrectomy for High-Risk Renal Masses Is Associated with Renal Pseudoaneurysms: Assessment of a Severe Procedure-Related Complication.

OBJECTIVES: A symptomatic renal pseudoaneurysm (RPA) is a severe complication after open partial nephrectomy (OPN). The aim of our study was to assess incidence and risk factors for RPA formation. Furthermore, we present our management strategy. PATIENTS AND METHODS: Clinical records of consecutive patients undergoing OPN were assessed for surgical outcome and postoperative complications. Renal masses were risk stratified for tumor complexity according to the PADUA score. Uni- and multivariate analysis for symptomatic RPAs were performed using the t-tests and logistic regression. RESULTS: We identified 233 patients treated with OPN. Symptomatic RPAs were observed in 13 (5.6%) patients, on average 14 (4-42) days after surgery. Uni- and multivariate analysis identified tumor complexity to be an independent predictor for symptomatic RPAs (p = 0.004). There was a significant correlation between RPAs and transfusion and the duration of stay (p < 0.001 and p = 0.021). Symptomatic RPAs were diagnosed with CT scans and successfully treated with arterial embolization. DISCUSSION: Symptomatic RPAs are not uncommon after OPN for high-risk renal masses. A high nephrometry score is a predictor for this severe complication and may enable a risk-stratified followup. RPAs can successfully be located by CT angiography, which enables targeted angiographic treatment.

Blood volume flow quantification of the brain-supplying circulation in fibromuscular dysplasia using 2D cine phase-contrast MRI.

To determine blood volume flow (BVF) in the brain-supplying arteries in patients with fibromuscular dysplasia (FMD), we used two-dimensional cine phase-contrast MR blood flow quantification to evaluate haemodynamic compromise. Nine patients with angiographically proven FMD (mean age, 46.7+/-10.4 years) of the cervical and intracranial arteries were examined using two-dimensional phase contrast MR to measure blood flow in the carotid arteries and the basilar artery (BA). Quantitative BVF results were compared intra- and inter-individually and also with the results of 15 age-matched normal controls. No patient showed evidence of acute or chronic infarction of the brain. FMD lesions were found in a total of 19 arteries (internal carotid artery: n = 14; vertebral arteries: n = 5). Five patients demonstrated severe stenoses of cervical vessels; four patients showed only mild or up to moderate stenoses. Total brain BVF in all FMD patients reached high-normal values compared with normal controls (747+/-64 ml min(-1) vs 682+/-38 ml min(-1)). In the five patients with severe stenotic lesions, blood flow was reduced in stenotic vessels and higher in the non-haemodynamically relevant stenosed cervical vessels. BVF was normal in the four patients with mild and moderate stenoses. By quantifying blood flow, we demonstrated for the first time changes (which can be severe) in the BVF of the brain-supplying arteries in FMD. Individual differences are associated with the haemodynamic relevance of the FMD lesions. Total BVF in patients with severe FMD was not decreased but maintained or even increased, possibly as an overcompensation.

[Cardiac MR imaging in arrhythmogenic heart diseases]. / Kardiale MRT in der Diagnostik arrhythmogener Herzerkrankungen.

INTRODUCTION: Cardiac arrhythmias are assessed with a combination of history, clinical examination, electrocardiogram, Holter monitor, if necessary supplemented by invasive cardiac electrophysiology. In ischemic heart disease (IHD) coronary angiography is performed in addition. METHODS: Echocardiography is usually the primary imaging modality. MRI is increasingly recognized as an important investigation allowing more accurate cardiac morphological and functional assessment. RESULTS: Approximately one-fifth of deaths in Western countries are due to sudden cardiac death, 80% of which are caused by arrhythmias. Typical causes range from diseases with high prevalence (IHD in men 30%) to myocarditis (prevalence 1-9%) and rare cardiomyopathies (prevalence HCM 0.2%, ARVC 0.02%, Brugada syndrome approx. 0.5%). The characteristic MRI features of arrhythmogenic diseases and the new aspects of characteristic distribution of late enhancement allow etiologic classification and differential diagnosis. CONCLUSION: MRI represents an important tool for detection of the underlying cause and for risk stratification in many diseases associated with arrhythmias.

[Negative endoscopy and MSCT findings in patients with acute lower gastrointestinal hemorrhage. Value of (99m)Tc erythrocyte scintigraphy]. / Negative Endoskopie sowie Mehrzeilendetektor-CT bei Patienten mit akuter unterer Gastrointestinalblutun. Wertigkeit der Szintigraphie mit (99m)Tc-markierten Erythrozyten.

PURPOSE: To evaluate the clinical use of (99m)Tc red blood cell imaging (RBC imaging) in patients presenting with acute lower gastrointestinal (GI) bleeding and negative endoscopy and multislice computed tomography (MSCT) findings. PATIENTS AND METHODS: In 31 consecutive patients with acute lower GI bleeding in whom the endoscopy findings were negative or the procedure was not feasible, dual-phase MSCT of the abdomen was performed [collimation 4x1 mm (arterial phase), 4x2.5 mm (venous phase)]. MSCT was followed by a (99m)Tc red blood cell scan in patients in whom no active bleeding was visible by CT. Images were created within 24 h after administration of the tracer, depending on the clinical symptoms. The results of the imaging modalities were correlated with clinical course and surgical treatment. RESULTS: In 20 of 31 patients MSCT showed no active bleeding and a (99m)Tc red blood cell scan was performed. In 8 of 20 patients RBC imaging was also negative. Of these eight patients five were stable and did not require further diagnostic work-up; in the other three bleeding persisted and these patients required surgical treatment. In 12 of 20 patients active bleeding was demonstrated using a (99m)Tc red blood cell scan. Of 12 patients with positive RBC scintigraphy findings, 8 underwent surgery, where the site of bleeding was confirmed. CONCLUSION: In patients with acute lower GI bleeding with negative or nondiagnostic endoscopy or MSCT findings, (99m)Tc red blood cell imaging is a useful tool in an emergency algorithm, improving the overall bleeding detection rate.

[Primary diagnostics of acute diverticulitis of the sigmoid]. / Primärdiagnostik der akuten Sigmadivertikulitis. Sonografie versus Computertomografie, eine prospektive Studie.

AIM: The initial diagnostics of acute diverticulitis of the sigmoid should render the correct diagnosis as well as assisting in the decision on the options of conservative or surgical treatment by ruling out or demonstrating complications. At present, sonography or computed tomography (CT) are the two competing diagnostic options. This study was designed to demonstrate that sonography could be used as the method of choice. METHOD: 63 patients with clinical suspicion of acute diverticulitis of the sigmoid were examined initially by sonography or CT in a prospective study. RESULTS: Sonography and CT showed a 97 % sensitivity and specificity for reaching the accurate and clinically plausible diagnosis. As to the demonstration of complications of the disease, sensitivity and specificity were comparably high for both diagnostic methods. CONCLUSIONS: Sonography can compete with the more complex CT examination and therefore represents the recommended primary diagnostic procedure.

[Emergency diagnostic imaging in mesenteric ischemia]. / Bildgebung im Rahmen der Notfalldiagnostik bei mesenterialer Ischämie.

Diagnostic imaging in patients with suspected acute mesenteric ischemia is started with abdominal ultrasound including duplex sonography of the mesenteric vessels. Despite low sensitivity even in experienced hands, ultrasound is used because operative treatment can be initiated without further imaging if a positive diagnosis is made. Plain abdominal X-rays are usually unspecific in acute mesenteric ischemia and are mainly used to rule out differential diagnoses. Spiral CT (ideally using a multislice technique) can accurately demonstrate morphology of the arterial and venous mesenteric vessels, changes in the bowel wall, and additional mesenteric or peritoneal findings. Therefore, CT has the potential for diagnosis of mesenteric ischemia on a pathological basis. Furthermore, CT is successfully used to confirm or exclude most other causes of acute abdominal conditions. Magnetic resonance imaging (MRI) may be as accurate as CT for the diagnosis of acute mesenteric ischemia and its differential diagnoses. However, MRI is not widely available and therefore not used as an emergency imaging modality so far. Catheter angiography remains the diagnostic gold standard for mesenteric vasculature when spiral CT is not available.

Multi-slice spiral CT in routine diagnosis of suspected acute left-sided colonic diverticulitis: a prospective study of 120 patients.

This prospective study evaluated the use of multi-slice CT (MSCT) for detection of clinically suspected left-sided colonic diverticulitis with regard to diagnosis, complications and alternative diagnoses. One hundred twenty patients with clinically suspected acute left-colonic diverticulitis underwent MSCT of the lower abdomen with IV contrast after rectal application of iodic contrast. The MSCT results were compared with histopathological and intraoperative findings or other radiological or endoscopic methods and clinical outcome. Acute diverticulitis was proven in 67 of the 120 (55.8%) patients, which was detected by MSCT with an accuracy of 98% (sensitivity 97%, specificity 98%). Contained perforation or abscess formation were detected with an accuracy of 96% (sensitivity 100%, specificity 91%) and 98% (sensitivity 100%, specificity 97%), respectively. In 31 of 120 (25.8%) patients diagnoses other than diverticulitis caused abdominal pain, which was correctly diagnosed by MSCT in 71%. The MSCT as well as other concurrently performed diagnostic methods showed normal findings and no causes for the patients symptoms in 22 of the 120 (18.4%) patients. Multi-slice CT is reliable in detecting diverticulitis, including extracolic complications, and often reveals other diagnoses; therefore, MSCT is recommended as standard diagnostic procedure in suspected acute diverticulitis.

A randomized trial of intravaginal nonoxynol 9 versus oral metronidazole in the treatment of vaginal trichomoniasis.

OBJECTIVE: This study was undertaken to investigate the efficacy of nonoxynol 9 suppositories in the treatment of vaginal trichomoniasis. STUDY DESIGN: In this prospective comparison trial 46 women with documented motile trichomonads found on a wet preparation were randomly assigned to one of two treatment arms: (1) a single oral dose of 2 g metronidazole and (2) a single 150-mg nonoxynol 9 suppository placed intravaginally for 3 consecutive nights. Cure was determined by a repeated wet preparation examination. After its first year, the study was terminated because of the poor efficacy of the nonoxynol 9 suppositories. RESULTS: Results were available for 33 patients. Three of 17 patients treated with nonoxynol 9 had negative wet preparation results at retest (17.6% cure rate). All 16 patients treated with metronidazole had negative wet preparation results (100% cure rate). All women with nonoxynol 9 failures who were evaluated after treatment with 2 g metronidazole had negative wet preparation results. CONCLUSION: Intravaginal nonoxynol 9 at the tested dose and by the tested method of delivery was not an effective cure for vaginal trichomoniasis.

Evaluation of breath-hold contrast-enhanced 3D magnetic resonance angiography technique for imaging visceral abdominal arteries and veins.

RATIONALE AND OBJECTIVES: To evaluate the diagnostic value of breath-hold contrast-enhanced 3D magnetic resonance angiography (MRA) for assessment of the visceral abdominal arteries and veins in patients with suspected abdominal neoplasms. METHODS: Twenty-one patients underwent MR imaging on a 1.5 T unit using a body phased-array coil. MRA was performed with a 3D-FLASH sequence (TR 3.8 ms, TE 1.3 ms, flip angle 25 degrees, acquisition time 20 seconds), 8 to 12 seconds after an intravenous bolus injection of Gd-DTPA. The acquisition delay between the arterial and the portal venous phase was 12 seconds. The image quality and the degree of vascular involvement were evaluated using coronal source images and maximum intensity projection reconstructions. Diagnosis was confirmed by surgery/histology. RESULTS: Image quality was optimal in more than 85% of the patients (19/21 arterial phase and 17/21 portal venous phase). MRA correctly predicted vascular status in 20 of 21 patients (95%), with complete concordance between MRA results and surgical findings. In one patient with chronic pancreatitis, MRA demonstrated a false-positive finding that could not be confirmed surgically. CONCLUSIONS. Breath-hold contrast-enhanced 3D-MRA is a valuable technique for assessing visceral abdominal arteries and veins.

MR imaging of pancreatic lesions. Comparison of manganese-DPDP and gadolinium chelate.

RATIONALE AND OBJECTIVES: To compare manganese-DPDP-enhanced and gadolinium-DTPA-enhanced MR imaging in patients suspected of having pancreatic cancer. METHODS: Fifteen patients who underwent MR imaging for suspected pancreatic cancer and received gadolinium-DTPA took part in a clinical phase III trial in which the efficacy of manganese-DPDP for detection of pancreatic cancer was evaluated. T1-weighted gradient-echo (GRE) images with and without fat suppression were used. Signal-to-noise ratio and contrast-to-noise ratio were calculated before and after the administration of each contrast agent. Image quality was assessed using a four-step score; delineation of the normal pancreas was assessed by two readers in consensus. RESULTS: In terms of pancreatic signal-to-noise ratio, only gadolinium-DTPA-enhanced fat-suppressed and non-fat-suppressed GRE imaging showed a significant (P < 0.001) increase (72% and 61%, respectively). In the patients with a focal pancreatic lesion (n = 14), a significant increase in contrast-to-noise ratio was found only in manganese-DPDP-enhanced GRE imaging without (106%) and with (82%) fat saturation. Qualitative image analysis demonstrated a significant improvement of manganese-DPDP-enhanced fat-suppressed MR images in delineating the pancreatic parenchyma (P < 0.01) as well as pancreatic tumors (P < 0.01). CONCLUSIONS: T1-weighted manganese-DPDP-enhanced GRE imaging with fat saturation should be regarded as the most suitable combination for detecting a pancreatic lesion.

[The value of magnetic resonance tomography (MRT), magnetic resonance cholangiopancreatography (MRCP) and endoscopic retrograde cholangiopancreatography (ERCP) in the diagnosis of pancreatic tumors]. / Wertigkeit von Magnetresonanztomographie (MRT), Magnetresonanz-Cholangiopankreatikographie (MRCP) und endoskopischer retrograder Cholangiopankreatikographie (ERCP) bei der Diagnose von Pankreastumoren.

PURPOSE: To prospectively evaluate the role of MRI including MR cholangiopancreatography (MRCP) compared to endoscopic retrograde cholangiopancreatography (ERCP) in the diagnosis of pancreatic cancer. MATERIAL AND METHODS: ERCP and MRI including MRCP were performed in 52 patients with suspected pancreatic cancer. MRCP was obtained using a single-shot RARE technique. The results of axial images and MRCP were compared to concurrently performed ERCP examinations. The standards of reference were the surgical and pathological findings, respectively. Image quality of MRCP was assessed using a three-step-score (1 = good, 2 = fair, 3 = nondiagnostic). RESULTS: In 88% of the cases the MRCP was of good quality. Only in 4% was MRCP non-diagnostic. The combination of MRI and MRCP showed an overall accuracy of 88%, whereas the overall accuracies of MRCP alone and ERCP were 80%, and 85%, respectively. The positive predictive values of MRI/MRCP, MRCP alone, and ERCP were 91%, 85%, and 88%, respectively. CONCLUSION: For the detection of pancreatic cancer MRI including MRCP is comparable to ERCP and can be regarded as the method of choice in patients with suspected pancreatic cancer. ERCP is the procedure of choice in patients with contraindications to MRI and in patients in whom additional therapeutic procedures are performed.

Station and cervical dilation at epidural placement in predicting cesarean risk.

OBJECTIVE: To compare station and cervical dilation at the time of epidural placement for predicting cesarean delivery risk. METHODS: This prospective cohort study included 275 women in labor with live, singleton fetuses at term in vertex presentations. We excluded women with preeclampsia or previous cesarean deliveries. A multiple logistic regression model evaluated demographic and labor-related variables' associations with cesarean risk. RESULTS: Fifty-nine of the 275 patients receiving epidural analgesia (21.5%) were delivered by cesarean, whereas 216 (78.5%) delivered vaginally. Variables that proved to be statistically significant in increasing the likelihood of cesarean were station at time of epidural placement (odds ratio [OR] 5.3; 95% confidence interval [CI] 2.6, 11.0; P < .001) and nulliparity (OR 3.8, 95% CI 1.8, 8.0; P < .001). Cervical dilation at the time of epidural placement was not a statistically significant predictor (OR 1.2, 95% CI 0.9, 1.6; P = .26). Cesareans were performed in 43 of 129 women (33.3%) who received epidurals with the vertex at a -1 station or higher, whereas only 16 of 146 women (11.0%) had cesareans if placement of the epidural was done after the vertex had reached at least a zero station. CONCLUSION: Station at the time of epidural placement was more accurate predicting cesarean risk than cervical dilation. Placement of the epidural after the fetal vertex has become engaged in the pelvis (at least a zero station) resulted in a substantially lower cesarean risk.

Interpreting the fetal heart rate tracing. Effect of knowledge of neonatal outcome.

OBJECTIVE: To determine if knowledge of neonatal outcome influences obstetricians' retrospective interpretation of fetal heart rate monitor tracings and opinion on the appropriateness of obstetric care. STUDY DESIGN: Ten obstetric case histories that involved a critical judgment by the managing obstetrician were selected for this study. Each case contained a point in the patient's labor at which the physician made a judgment regarding route and timing of delivery. We assembled prenatal history, labor course, delivery, fetal heart rate tracing and neonatal outcome into a concise format. For each case, we created a sham case with identical information and monitor tracing, differing only in having an opposite neonatal outcome. Reviewers were recruited to participate and were unaware of the true intent of the study. Reviewers evaluated tracings for: variability, late decelerations and evidence of hypoxia, and judged whether the decision regarding delivery versus continued labor had been appropriate. Reviewers evaluated the case pairs with one month's time between the true and sham outcome cases. RESULTS: Thirty-six obstetricians reviewed 2 case pairs each for a total of 72 case pairs. When the alleged neonatal outcome was poor, there was a significant tendency to respond that evidence of hypoxia was present (P = .007) or that the obstetrician had made an incorrect decision (P < .001). CONCLUSION: Obstetricians are biased by knowledge of poor neonatal outcome when retrospectively interpreting fetal heart rate tracings and judging appropriateness of obstetric care.

[Value of dual-phase-helical CT in the preoperative diagnosis of pancreatic cancer--a prospective study]. / Wertigkeit der Doppelspiral-CT bei der präoperativen Diagnostik des Pankreaskarzinoms--eine prospektive Studie.

PURPOSE: A prospective study was performed to evaluate the accuracy of dual phase helical CT in suspected pancreatic cancer. METHODS: Within one year 136 patients underwent helical CT with arterial and portal venous scans after bolus tracking and NaCl bolus injection. Evidence of pancreatic cancer and assessment of resectability were recorded using a standardised protocol. Suspected benign disease was verified by follow-up examination and clinical data, suspected malignant disease was correlated with biopsy or surgery. RESULTS: For the detection of tumor the overall concordance was 92%, the sensitivity 98% and the specificity 70% (6 false positive, 1 false negative). Resectability was correctly assessed in 90% with a sensitivity of 92% and a specificity of 88% (4 false positive, 4 false negative). Vascular invasion was detected correctly in 91% (veins)-94% (arteries), lymph node invasion in 67% and liver metastasis in 94%. CONCLUSION: Dual phase helical CT is a very reliable tool in the assessment of resectability in pancreatic cancer.

Pancreatic cancer: value of dual-phase helical CT in assessing resectability.

PURPOSE: To evaluate the use of dual-phase helical computed tomography (CT) (with or without CT angiography) to assess resectability in patients suspected to have pancreatic cancer. MATERIALS AND METHODS: Tumor resectability was prospectively evaluated in 89 patients who later underwent surgery for suspected pancreatic cancer. Helical CT scans were obtained in the vascular phase and a phase of maximal hepatic enhancement. CT angiograms were produced with multiprojection volume reconstruction and maximum-intensity projection. CT results were correlated with surgical and histopathologic results. RESULTS: Helical CT allowed detection of pancreatic cancer in 74 of 76 cases (97%). There were six false-positive results (positive predictive value, 92%). For prediction of irresectability, helical CT had an accuracy of 91%, negative predictive value of 79%, and sensitivity of 91%. Helical CT allowed detection of liver metastases in 21 of 28 cases (75%), nodal involvement in 13 of 24 cases (54%), and vascular invasion in 35 of 40 cases (88%). CT angiography demonstrated 30 of the 35 cases of vascular invasion detected with helical CT (86%). CONCLUSION: Use of dual-phase helical CT improves prediction of resectability in patients with pancreatic cancer. CT angiography cannot show all of the findings seen on helical scans.

[Clinical use of a new analytical method for the determination of bone density by means of quantitative computer tomography]. / Klinischer Einsatz eines neu entwickelten Auswerteprogramms zur Bestimmung der Knochendichte mittels der quantitativen Computertomographie.

AIM: Evaluation of the clinical suitability of a new analytical method for the determination of bone mineral density (BMD) by means of SEQCT as well as a comparison with the established method. METHODS: In order to verify the stability of both systems, phantom measurements were performed on a lumbal spine torso as well as on 78 patients. 44 patients were examined by means of the established method and 34 according to the new method. Parallel measurements were possible in 15 patients. RESULTS: The phantom measurements proved a high stability of both methods. Regarding the absolute BMD the new method resulted in higher BMD values. This result was confirmed by parallel measurements in 15 patients. The new method demonstrated increased suitability due to less time consuming preparations. Dose reduced scan parameters could not be achieved in all patients, so that the time saving effect could not be considered. In these cases manual settings were required. CONCLUSION: A substitution of the established method for BMD measurement by means of SEQCT with the new method seems to be possible. However, the results will have to be corrected by the percentage of deviation from the default value of the quality phantom.