Radiologic anatomy of arteriogenic erectile dysfunction: a systematized approach.

INTRODUCTION: Erectile Dysfunction is a highly prevalent disease and there is growing interest in its endovascular treatment. Due to the complexity of the male pelvic arterial system, thorough anatomical knowledge is paramount. We evaluated the applicability of the Yamaki classification with Computerized Tomography Angiography and Digital Subtraction Angiography in the evaluation of patients with arteriogenic Erectile Dysfunction, illustrating the arterial lesions that can cause Erectile Dysfunction. METHODS: Single-center retrospective analysis of the Computerized Tomography Angiography and Digital Subtraction Angiography imaging findings in 21 male patients with suspected arteriogenic Erectile Dysfunction that underwent selective pelvic arterial embolization. Assessment of erectile function was achieved using the IIEF-5. The branching patterns of the Internal Iliac Artery were classified according to the Yamaki classification. The diagnosis of arteriogenic Erectile Dysfunction was based on the presence of atherosclerotic lesions (stenoses and/or occlusions) of the Internal Iliac Artery or the Internal Pudendal Arteries. RESULTS: The mean patient age was 67.2 years; with a mean IIEF of 10.6 points. Computerized Tomography Angiography and Digital Subtraction Angiography findings allowed classification of all the 42 pelvic sides according to the Yamaki classification. Twenty-four pelvic sides were classified as Group A (57%), 9 as Group B (21.5%) and 9 as Group C (21.5%). The Digital Subtraction Angiography detected 19 abnormal Internal Pudendal Arteries (with atherosclerotic lesions) (45%). The Computerized Tomography Angiography detected 24 abnormal Internal Pudendal Arteries (57%). CONCLUSION: Computerized Tomography Angiography and Digital Subtraction Angiography findings of arteriogenic Erectile Dysfunction include stenotic and occlusive lesions of the Internal Iliac Artery and Internal Pudendal Artery. The Yamaki classification is radiologically reproducible and allows easy recognition of the Internal Pudendal Artery in patients with arteriogenic Erectile Dysfunction.

Introdução: A disfunção erétil é uma doença com elevada prevalência existindo crescente interesse na sua terapêutica endovascular. Devido à complexidade do sistema arterial pélvico masculino, o conhecimento anatómico é fundamental. Avaliou-se a aplicabilidade da classificação de Yamaki na avaliação de doentes com disfunção erétil arteriogénica usando a Angiografia Tomográfica Computorizada e a Angiografia Digital de Subtração.Métodos: Análise retrospetiva dos achados imagiológicos de Angiografia Tomográfica Computorizada e Angiografia Digital de Subtração em 21 doentes do sexo masculino, com suspeita de disfunção erétil arteriogénica, que foram submetidos a embolização pélvica seletiva numa única instituição. A função erétil foi avaliada através do IIEF-5. O padrão de bifurcação da Artéria Ilíaca Interna foi caracterizado de acordo com a classificação de Yamaki. O diagnóstico da disfunção erétil arteriogénica foi feita baseado na presença de lesões ateroscleróticas da Artéria Ilíaca Interna e da Artéria Pudenda Interna.Resultados: A idade média foi de 67,2 anos; a média do IIEF foi 10,6 pontos. A Angiografia Tomográfica Computorizada e a Angiografia Digital de Subtração permitiram a classificação de todos os 42 lados pélvicos de acordo com a classificação de Yamaki. Vinte e quatro lados pélvicos foram classificados como Grupo A (57%), nove como Grupo B (21,5%) e nove como Grupo C (21,5%). A Angiografia Digital de Subtração detectou 19 Artérias Pudendas Internas anormais (lesões ateroscleróticas) (45%). A Angiografia Tomográfica Computorizada detectou 24 Artérias Pudendas Internas anormais (57%).Conclusão: Os achados por Angiografia Tomográfica Computorizada e Angiografia Digital de Subtração incluem estenoses e oclusões da Artéria Ilíaca Interna e da Artéria Pudenda Interna. A classificação de Yamaki tem reprodutibilidade radiológica e permite o reconhecimento da Artéria Pudenda Interna em doentes com disfunção erétil arteriogénica.

Treatment of benign prostatic hyperplasia.

Lower urinary tract symptoms (LUTS) may be a sign of aging rather than a consequence of benign prostatic enlargement (BPE) or benign prostatic obstruction (BPO). Medical or invasive treatments should address the bothersome symptoms and the quality of life of patients. Alpha blockers and 5-alpha reductase inhibitors are most frequently used in benign prostatic hyperplasia (BPH) medical treatments, whereas Transurethral Resection of the Prostate (TURP) remains the "gold standard" for surgical treatments. Several minimal invasive treatments are emerging with promising outcomes.

Patient selection and counseling before prostatic arterial embolization.

Prostatic arterial embolization (PAE) for relief of lower urinary tract symptoms (LUTS) in patients with prostate enlargement or benign prostatic hyperplasia (PE or BPH) is an experimental procedure with promising preliminary results. Patient evaluation and selection before PAE is paramount to improve technical and clinical results. Our inclusion criteria for PAE include: male patients, age>40 years, prostate volume>30 cm(3) and diagnosis of PE or BPH with moderate to severe LUTS refractory to medical treatment for at least 6 months (International Prostate Symptom Score [IPSS]>18, or quality of life [QoL]>3, or both) or with acute urinary retention refractory to medical therapy. Exclusion criteria include: malignancy (based on pre-embolization digital rectal and transrectal ultrasound [TRUS] examinations and prostate specific antigen [PSA] measurements with positive biopsy), large bladder diverticula, large bladder stones, chronic renal failure, tortuosity and advanced atherosclerosis of a) iliac or b) prostatic arteries on pre-procedural computed tomographic angiography (CTA), active urinary tract infection and unregulated coagulation parameters. Approximately one-third of the patients seen initially on consultation satisfy the criteria to be selected for PAE after undergoing the pre-procedural patient evaluation workflow. In the pre-procedural consultation patients are informed of all possible therapeutic options for LUTS with the investigational nature of the procedure being strongly reinforced. The major advantage of PAE relies on the minimally-invasive nature of the technique with minimal morbidity and rapid recovery,and it being performed as an outpatient procedure. However, the experimental nature and uncertain clinical outcome should also be weighed before opting for PAE. All these considerations should be explained to the patient and discussed during the informed consent before PAE.

Radiological anatomy of prostatic arteries.

One of the most challenging aspects of prostatic arterial embolization for patients with lower urinary tract symptoms and prostate enlargement or benign prostatic hyperplasia is identifying the prostatic arteries (PAs). With preprocedural computed tomography angiography it is possible to plan treatment and exclude patients when arterial anatomy is not suited, or when extensive atherosclerotic changes may affect technical success. There is an excellent correlation between the computed tomography angiography and digital subtraction angiography findings, enabling correct depiction of the male pelvic arterial anatomy (internal iliac branching patterns, relevant variants as accessory pudendal arteries, and PA anatomy). The prostate has a dual vascular arterial supply: a cranial or vesico-PA (named anterior-lateral prostatic pedicle) and a caudal PA (named posterior-lateral prostatic pedicle). These 2 prostatic pedicles may arise from the same artery in patients with only 1 PA (found in 60% of pelvic sides), or may arise independently in patients with 2 independent PAs (found in 40% of pelvic sides). The anterior-lateral prostatic pedicle vascularizes most of the central gland and benign prostatic hyperplasia nodules, frequently arises from the superior vesical artery in patients with 2 independent PAs, and is the preferred artery to embolize. The posterior-lateral prostatic pedicle has an inferior or distal origin, vascularizes most of the peripheral and caudal gland, and may have a close relationship with rectal or anal branches. In up to 60% of cases considerable anastomoses may be seen between the prostatic branches and surrounding arteries that should be taken into account when planning embolization. PAs lack pathognomonic digital subtraction angiography features; thus correct anatomical identification of the male pelvic and PAs is necessary to avoid untargeted ischemia to the bladder, rectum, anus, or corpus cavernosum.

How to perform prostatic arterial embolization.

Prostatic arterial embolization (PAE) is an experimental alternative treatment for benign prostatic hyperplasia, with promising preliminary results. In comparison with surgery, its main advantages are the minimally invasive nature, outpatient setting, rapid recovery, and low morbidity. To avoid complications and to achieve technical success it is important to know the procedural technique in detail. In addition, for good clinical results, it is important to perform a bilateral and complete prostatic embolization. In this article, the different technical steps, including the initial site of puncture and the catheters and guidewires to be used, are described. Identification of the prostatic arteries is crucial. Correlation between computed tomography angiography and digital subtraction angiography helps to solve the difficulty of such identification. The skills for superselective catheterization of the prostatic arteries, the amounts of contrast injected, the preparation and size of the used particles and the end point of the procedure are also described.

Prostatic artery embolization in the treatment of benign prostatic hyperplasia: short and medium follow-up.

To evaluate the short and mid-term results of prostatic artery embolization in patients with benign prostatic embolization. Retrospective study between March 2009 and June 2011 with 103 patients (mean age 66.8 years, 50-85) that met our inclusion criteria with symptomatic benign prostatic hyperplasia. The clinical outcome was evaluated by the International Prostate Symptom Score (IPSS), quality of life (QoL), International Index of Erectile Function, prostate volume (PV), prostate-specific antigen (PSA), peak urinary flow (Q(max)), and post-void residual volume (PVR) measurements at 3 and 6 months, 1 year, 18 months, and 2 years after PAE and comparison with baseline values was made. Technical and clinical successes, as well as poor clinical outcome definitions, were previously defined. In this review, we evaluate the short and mid-term clinical outcomes and morbidity of patients treated only with non-spherical polyvinyl alcohol. Six months after the procedure, the PV decreased about 23%, IPSS changed to a mean value of 11.95 (almost 50% reduction), the QoL improved slightly more than 2 points, the Q(max) changed to a mean value of 12.63 mL/s, the PVR underwent a change of almost half of the baseline value, and the PSA decreased about 2.3 ng/mL. In the mid-term follow-up and comparing to the baseline values, we still assisted to a reduction in PV, IPSS, QoL, PVR, and PSA, and an increase in Q(max). Prostatic Artery Embolization is a safe procedure with low morbidity that shows good short- and mid-term clinical outcome in our institution.

Prostatic arterial embolization: post-procedural follow-up.

Prostatic arterial embolization (PAE) gained special attention in the past years as a potential minimally invasive technique for benign prostatic hyperplasia. Treatment decisions are based on morbidity and quality-of-life issues and the patient has a central role in decision-making. Medical therapy is a first-line treatment option and surgery is usually performed to improve symptoms and decrease the progression of disease in patients who develop complications or who have inadequately controlled symptoms on medical treatment. The use of validated questionnaires to assess disease severity and sexual function, uroflowmetry studies, prostate-specific antigen and prostate volume measurements are essential when evaluating patients before PAE and to evaluate response to treatment. PAE may be performed safely with minimal morbidity and without associated mortality. The minimally invasive nature of the technique inducing a significant improvement in symptom severity associated with prostate volume reduction and a slight improvement in the sexual function are major advantages. However, as with other surgical therapies for benign prostatic hyperplasia, up to 15% of patients fail to show improvement significantly after PAE, and there is a modest improvement of the peak urinary flow.

[Anatomy and variants of the cerebral venous system--fact or defect?]. / Anatomia e variantes do sistema venoso cerebral--defeito ou feitio?

UNLABELLED: The anatomy of the cerebral venous system (CVS) is based on a known variable three-dimensional structure. For a correct recognition and characterization of its elements, a detailed knowledge of its anatomy and potential variants is essential. However, this structural changes, commonly named as variants, may appear in asymptomatic situations as well as associated to certain pathological syndromes with diagnostic and therapeutic consequences. PURPOSE: The authors present a brief summary of the CVS anatomy, highlight the potential structural changes and discuss their ethiology as constitutional or pathological. METHOD AND RESULTS: Based on clinical cases, the most frequent anatomical modifications will be presented and their ethiology discussed,whether constitutional or pathological. CONCLUSION: The CVS is characterized by its various presentations. These changes are classically named as anatomic variants. However,they may appear associated to certain pathological situations. Only a profound recognition of the normal CVS anatomy allows a correct definition of the ethiology of the structural change as constitutional or pathologic.

[The development of the cerebral venous system--from the embryo to the adult definitive structure]. / O desenvolvimento do sistema venoso cerebral--do embrião à estrutura definitiva no adulto.

INTRODUCTION: The human development consists of a continuous process where an uninterrupted pattern of extremely complex repetitive cycles of growth, modulation and modification take place. Despite this extreme complexity, the normal development is ordered by an impressive regularity, namely, in chronological, anatomical, topographic and physiological trends. In some organic systems, this development will not be totally ended by the time of birth. In this situation, further changes will have to take place until the adult definitive pattern is achieved. The cerebral venous system (CVS) is such a paradigm. PURPOSE: The authors pretend to present a synopsis of the specific organogenesis of the cerebral venous system in order to allow a correct interpretation of the vascular structures, recognise the anatomical variations and better comprehend the topographic correlations between neighbouring structures. METHOD AND RESULTS: Following a structured and synthetic order, the main guiding lines of the principal evolutional steps will be presented from the first embryological stages until the final and definitive adult pattern. CONCLUSION: The detailed study of the continuous development stages of the CVS constitutes a fundamental tool for the whole recognition of the anatomical structures, their correct interpretation and detection of possible variants as well as a better comprehension of topographic relationship between neighbouring structures. In other words and following KL Moore, Embryology illuminates anatomy.