Successful embolisation of pelvic fistulating vessels to the prostate arising after TURP - a rare cause of postoperative bleeding.

Transurethral resection of the prostate (TURP) is considered the gold-standard operation to treat lower urinary tract symptoms due to benign prostatic enlargement in men. Postoperative bleeding is a recognised complication and managing it is a core skill required by attending urologists. We report a rare case of postoperative bleeding caused by fistulating vessels to the prostate which developed after TURP. These fistulas arose from the right internal iliac vessels and communicated with pre-existing pelvic varices affecting the right paraprostaticand seminal vesicle tissues. The fistulating vessels were successfully embolised with liquid embolic agent. Surgeons should be aware that persisting haemorrhage can occur post-TURP from the rare presence of fistulating vessels communicating with pelvic varices. Early computed tomography angiographic assessment is warranted in cases where bleeding is prolonged and refractory to standard management in view of timely referral for percutaneous embolisation.

The use of foam sclerotherapy to treat low-flow vascular malformations of the head and neck.

Liquid sclerotherapy, laser and surgery have been used in the treatment of head and neck vascular anomalies with variable success for many years. A multidisciplinary team consisting of plastic surgery, maxillofacial surgery and interventional radiology currently treats such lesions by converting liquid sclerosant into foam. Foam sclerotherapy is currently used successfully to treat varicosities of the lower limbs and in this study, we present four cases in which 3% sodium tetradecyl sulfate has been used to treat low-flow vascular malformations in the head and neck.

Prostate MRI: who, when, and how? Report from a UK consensus meeting.

The current pathway for men suspected of having prostate cancer [transrectal biopsy, followed in some cases by magnetic resonance imaging (MRI) for staging] results in over-diagnosis of insignificant tumours, and systematically misses disease in the anterior prostate. Multiparametric MRI has the potential to change this pathway, and if performed before biopsy, might enable the exclusion of significant disease in some men without biopsy, targeted biopsy in others, and improvements in the performance of active surveillance. For the potential benefits to be realized, the setting of standards is vital. This article summarizes the outcome of a meeting of UK radiologists, at which a consensus was achieved on (1) the indications for MRI, (2) the conduct of the scan, (3) a method and template for reporting, and (4) minimum standards for radiologists.

Inferior vena cava filters: what radiologists need to know.

Inferior vena cava (IVC) filters are a controversial mechanical adjunct in the prevention of pulmonary embolism, the most serious result of venous thromboembolism. Despite modern IVC filters being in clinical use for more than 45 years, there is still uncertainty amongst many radiologists about the indications for IVC filter placement and their removal, particularly the more recent prophylactic use in patients without confirmed deep vein thrombosis (DVT) or pulmonary embolism (PE). Recently published guidelines on filter use from the National Institute of Health and Clinical Excellence (NICE) and other professional bodies are discussed. The vast majority of IVC filters in the UK are inserted by interventional radiologists, so radiologists may be the first point of contact for information requested by other clinicians. The increasing use of filters means that radiologists will encounter filters increasingly often during abdominal cross-sectional imaging. Awareness of common filter-related complications, such as tilting, thrombosis, and caval perforation, is useful to reassure or alert other clinicians. The potential role of filters in upper extremity DVT and requirement for concomitant anticoagulation is discussed.

Imaging and management of vascular malformations.

Vascular malformations are a diffuse collection of abnormalities that are usually present at birth but may present any time during childhood or as an adult. Historically terminology has been complicated and used interchangeably causing confusion to patients and clinicians alike; however, a structured internationally agreed classification system exists. It is not uncommon for patients with vascular malformations to be referred to various specialties without obtaining a correct diagnosis and appropriate treatment. Vascular malformations can occur anywhere within the body and all patients will require imaging at some stage; therefore, it is important for all radiologists to be aware of the correct terminology and imaging characteristics. This review discusses classification and illustrates salient imaging findings and the modern approach to treatment of vascular malformations.

A description of CT features of Clostridium difficile infection of the small bowel in four patients and a review of literature.

Clostridium difficile associated disease is an increasingly common cause of morbidity and mortality. Pseudomembranous colitis following hospital-administered antibiotic treatment is the most common symptomatic manifestation. Small bowel enteritis caused by C. difficile, however, is rarely described. Here, we present a series of four patients with hospital-acquired small bowel enteritis caused by C. difficile, discuss its CT and histopathological features, and review the current literature.

A fatal complication following hybrid total arch replacement with supra-aortic artery translocation and endovascular stenting.

This case highlights the successful management of acute Type B dissection complicated by visceral malperfusion. Even though the procedure of hybrid supra-aortic translocation and endovascular stenting corrected the malperfusion, it is important for vigilant CT scan surveillance for the post operative complications which can occur with this procedure.

CT colonography: interpretative performance in a non-academic environment.

AIM: To investigate interpretative accuracy and reporting time for radiologists performing computed tomography (CT) colonography in day-to-day non-academic clinical practice. MATERIALS AND METHODS: Thirteen radiologists from seven centres, who were reporting CT colonography in non-academic daily clinical practice, interpreted a dataset of 15 colonoscopically validated cases in a controlled environment. Ten cases had either a cancer or polyp >10mm; one case had a medium polyp and four were normal. Correct case categorization and interpretation times were compared using analysis of variance to aggregated results obtained from both experienced observers and observers recently trained using 50 cases, working in an academic environment. The effect of experience was determined using Spearman's rank correlation. RESULTS: Individual accuracy was highly variable, range 53% (95% CI 27-79%) to 93% (95% CI 68-100%). Mean accuracy overall was significantly inferior to experienced radiologists (mean 75 versus 88%, p=0.04) but not significantly different from recently trained radiologists (p=0.48). Interpretation time was not significantly different to experienced readers (mean 12.4 min versus 11.7, p=0.74), but shorter than recently trained radiologists (p=0.05). There was a significant, positive, linear correlation between prior experience and accuracy (p<0.001) with no plateau. CONCLUSION: Accuracy for sub-specialist radiologists working in a non-academic environment is, on average, equivalent to radiologists trained using 50 cases. However, there is wide variability in individual performance, which generally falls short of the average performance suggested by meta-analysis of published data. Experience improves accuracy, but alone is insufficient to determine competence.

Frequency and impact of extracolonic findings detected at computed tomographic colonography in a symptomatic population.

BACKGROUND: Extracolonic findings are frequently recognized alongside colonic pathology at computed tomographic colonography (CTC). This study assessed the clinical impact of extracolonic findings in a symptomatic population at high risk of colorectal cancer. METHODS: CTC was performed in a consecutive cohort of patients assessed in a fast-track colorectal cancer clinic as being at high risk of colorectal cancer. A review of CTC findings and case notes was undertaken. Patients with extracolonic findings were followed up for at least 12 months. RESULTS: Thirty-one (13.8 per cent) of 225 patients investigated by CTC had colorectal cancer. Extracolonic findings were identified in 81 (53.3 per cent) of 152 patients with normal or non-neoplastic bowel findings, compared with 27 (37 per cent) of 73 patients with colorectal neoplasia (P = 0.025). Twenty-four patients (10.7 per cent) with extracolonic findings underwent further investigation or treatment. The median duration of investigation was 19.5 weeks. Seventy-five clinical events were recorded, including 14 surgical procedures. CONCLUSION: A prospective cost-benefit analysis of diagnostic CTC should be performed before it is established as a first-line investigation for colonic symptoms.

Intra-osseous pseudoaneurysm following curettage of an aneurysmal bone cyst.

BACKGROUND: Pseudoaneurysms secondary to bone tumours are rare and most of the reported cases are related to osteochondromas, either due to direct pressure or following surgery. Aneurysmal bone cysts are relatively common bony lesions usually treated by curettage. DISCUSSION: We describe an unusual case of pseudoaneurysm of the anterior tibial artery complicating curettage of an aneurysmal bone cyst which presented as a rapidly enlarging mass clinically thought to be rapid recurrence of the tumour. This was successfully treated by embolisation.

Extramedullary haematopoiesis in the kidney: a case report and review of literature.

We report a 47-year-old man with myelofibrosis who presented with bilateral nephromegaly secondary to extramedullary haematopoiesis. We discuss diagnosis and treatment of this rare case and review the literature.

The use of self-expandable metal stents in the palliation of malignant bowel obstruction.

Palliation of malignant gastrointestinal obstruction is a major aspect of oncology. We assessed the efficacy of stents in the palliation of gastric outlet, duodenal and colonic obstruction. We undertook a retrospective study of 35 consecutive patients who were referred for stent insertion with palliative intent from June, 1999 to March, 2003. Thirty-two stents were successfully placed in 30 patients. Technical success rate was 86% (30/35 patients). Of the patients who had successful insertion, 83% had complete relief of symptoms. In 1 patient the stent failed to expand. There was no procedure related mortality. Median survival was 1.6 months (range, 0-14.8). The conclusion was that self-expandable metal stents provide an effective method of palliation in malignant gastrointestinal obstruction, with high clinical and technical success rates and low complication rates.

Managing Budd-Chiari syndrome: a retrospective review of percutaneous hepatic vein angioplasty and surgical shunting.

BACKGROUND: The role of percutaneous hepatic vein angioplasty in the management of Budd-Chiari syndrome has not been well defined. Over a 10 year period at our unit, we have often used this technique in cases of short length hepatic vein stenosis or occlusion, reserving surgical mesocaval shunting for cases of diffuse hepatic vein occlusion or failed angioplasty. AIMS: To review the outcome of angioplasty and surgical shunting to define their respective roles. PATIENTS: All patients treated by angioplasty or surgical shunting for non-malignant hepatic vein obstruction over a ten year period from 1987 to 1996. METHODS: A case note review of pretreatment features and clinical outcome. RESULTS: Angioplasty was attempted in 21 patients with patent hepatic vein branches and was successful in 18; in three patients treatment was unsuccessful and these patients had surgical shunts. Fifteen patients were treated by surgical shunting only. Mortality according to definitive treatment was 3/18 following angioplasty and 8/18 following surgery; in most cases this reflected high risk status prior to treatment. Venous or shunt reocclusion rates were similar for both groups and were associated with subtherapeutic warfarin in half of these cases. Most surviving patients in both groups are asymptomatic although one surgical patient has chronic hepatic encephalopathy. CONCLUSION: With appropriate case selection, many patients with Budd-Chiari syndrome caused by short length hepatic vein stenosis or occlusion may be managed successfully by angioplasty alone. Medium term outcome is good following this procedure provided that anticoagulation is maintained. Further follow up is required to assess for definitive benefits but we suggest that this should be included as a valid initial approach in the algorithm for management of Budd-Chiari syndrome.

Multiplanar reformatting and three-dimensional reconstruction: for pre-operative assessment of the thoracic aorta by computed tomography.

INTRODUCTION: Conventional CT demonstrates pathology of the thoracic aorta. This study aimed to evaluate the additional contributions to surgical planning of multiplanar reformatting, maximum intensity projections and three-dimensional (3-D) reconstruction. DESIGN: Retrospective. SUBJECT AND METHODOLOGY: Fifty-three patients with newly diagnosed pathology of the thoracic aorta were scanned over a 15-month period; 25 scans were spiral acquisitions. Scans were acquired during and following rapid injection of 100 ml of intravenous iopromide. The reconstructed data was displayed as axial images, oblique or other multiplanar reformats and shaded surface display 3-D reconstructions. Two radiologists and two surgeons reviewed the images. The axial images were assessed initially, subsequently the reformats and 3-D reconstructed views were examined looking particularly for additional information that might add to the surgical management. RESULTS: Pathologies encountered were aortic dissection (21 patients, including two with Marfan's syndrome), saccular aneurysms (eight), fusiform aneurysms (16), aortic root and ascending aortic dilatation (seven) and coarctation (one). The relationship of aneurysms and dissections to major vessels are better shown with 3-D reconstruction or oblique reformats. Morphology of saccular aneurysms, particularly the neck, is well shown with 3-D reconstruction. Coarctation was best demonstrated by oblique reformats. There was little additional information from 3-D reconstruction or reformats in assessment of type A dissection. Improved spatial orientation by visualization in varying projections was helpful for surgical planning in certain cases of type B dissection, fusiform aneurysms and aortic root and ascending aortic root dilatation. Spiral acquisitions have the advantage of speed and hence a greater anatomical coverage for a single breath-hold. CONCLUSION: Oblique reformats and 3-D reconstruction, although using identical data as the axial images, in specific cases were felt to aid surgical assessment of aneurysms and dissections, thus assisting pre-operative planning.