Diagnostic reference levels and complexity indices in interventional radiology: a national programme.

OBJECTIVES: To propose national diagnostic reference levels (DRLs) for interventional radiology and to evaluate the impact of the procedural complexity on patient doses. METHODS: Eight interventional radiology units from Spanish hospitals were involved in this project. The participants agreed to undergo common quality control procedures for X-ray systems. Kerma area product (KAP) was collected from a sample of 1,649 procedures. A consensus document established the criteria to evaluate the complexity of seven types of procedures. DRLs were set as the 3rd quartile of KAP values. RESULTS: The KAP (3rd quartile) in Gy cm2 for the procedures included in the survey were: lower extremity arteriography (n = 784) 78; renal arteriography (n = 37) 107; transjugular hepatic biopsies (THB) (n = 30) 45; biliary drainage (BD) (n = 314) 30; uterine fibroid embolization (UFE) (n = 56) 214; colon endoprostheses (CE) (n = 31) 169; hepatic chemoembolization (HC) (n = 269) 303; femoropopliteal revascularization (FR) (n = 62) 119; and iliac stent (n = 66) 170. The complexity involved the increases in the following KAP factors from simple to complex procedures: THB x4; BD x13; UFE x3; CE x3; HC x5; FR x5 and IS x4. CONCLUSIONS: The evaluation of the procedure complexity in patient doses will allow the proper use of DRLs for the optimization of interventional radiology. KEY POINTS: • National DRLs for interventional procedures have been proposed given level of complexity • For clinical audits, the level of complexity should be taken into account. • An evaluation of the complexity levels of the procedure should be made.

Urachal adenocarcinoma with late brain metastases.

OBJECTIVE: To describe a case of urachal adenocarcinoma with late brain metastases in a sixty one year old man who presented abdominal discomfort and hematuria during six months. METHODS: The clinical suspicion was bladder tumor and diagnostic studies were performed (urinary cytology, cystoscopy, abdominal ultrasound and abdominopelvic CT scan). Surgical treatment was performed. RESULTS: Negative urinary cytology. Cystoscopy showed a lesion with infiltration of the bladder dome. Ultrasound and CT scan showed a five centimeter rounded lesion, with intermediate density, internal echoes and calcifications on the anterior supravesical middle line, that infiltrated the bladder. The extension study had not findings. Partial cystectomy and lymphadenectomy were performed. The histopathologic diagnosis was mucin-secreting urachal adenocarcinoma. After five years without disease the patient suffered lung and brain metastases. CONCLUSIONS: Urachal adenocarcinoma is a tumor which must be distinguished of primary bladder adeno-carcinoma. The mucing-secreting adenocarcinoma can be associated with calcifications that can be demostrated on imaging studies. Late metastases without signs of local recurrence (after five years without disease) are an infrequent clinical-pathologic finding.

[Obstructive uropathy secondary to vesico-ureteral endometriosis: clinical, radiologic and pathologic features]. / Uropatía obstructiva secundaria a endometriosis vésico-ureteral: características clinico-radiológicas y anatomopatológicas.

OBJECTIVES: To report the case of a 37 year-old woman suffering from endometriosis of the urinary tract, that presented with lumbar and pelvic pain associated to cyclic recurrent haematuria. METHODS: Following history, physical examination, abdomino-pelvic ultrasound (USS), CT scan and cystoscopy with biopsies, surgical treatment was indicated RESULTS: Imaging (USS-CT ) revealed a protrusion of the left bladder hemi-trigone with a nodular, irregular thickening and ipsilateral grade II-III/IV uretero-hydronefrosis. Cistoscopy confirmed a swollen and oedematous lesion in left hemi-trigone that seemed extrinsic in origin. With the clinical diagnosis of a possible neoplasia of gynaecological origin, the patient underwent surgical treatment consisting in radical hysterectomy with bilateral oophorectomy, partial cystectomy and left ureteroneocystostomy. CONCLUSIONS: The frequency of endometriosis in the urinary tract is relatively low and therefore, endometriosis presenting with ureteral obstruction (uretero-hydronephrosis) has been rarely reported in the literature and should be part of the differential diagnosis in young women, especially if symptoms are cyclic. The treatment is surgery and the final diagnosis by pathology report.

Uropatia obstructiva secundaria a endometriosis vésico-ureteral: características clínico radiológicas y anatomopatológicas / Obstructive uropathy secondary to vesico-ureteral endometriosis: clinical, radiologic and pathologic features

OBJETIVOS: Describir un nuevo caso de afectación del tracto urinario por endometriosis en una mujer de 37 años que consultó por dolor pélvico, lumbar y hematuria de carácter cíclicos.MÉTODO: Tras la realización de historia clínica y exploraciones complementarias como ecografía abdominal, TAC abdominopélvico y cistoscopia con toma de biopsias se indicó tratamiento quirúrgico.RESULTADOS: En las pruebas de imagen realizadas (ECO-TAC) se apreció una impronta y engrosamiento nodular e irregular de la hemibase vesical izquierda, con afectación ureteral y dilatación pielocalicial grado II-III/IV. En la cistoscopia se observó lesión congestiva y edematosa a nivel de hemitrígono izquierdo. Con el diagnóstico clínico de neoformación ginecológica localmente avanzada con afectación uréterovesical se realizó tratamiento quirúrgico consistente en histerectomía, anexectomía bilateral, cistectomía parcial y ureterocistoneostomía izquierda.CONCLUSIONES: La frecuencia de la afectación del tracto urinario por endometriosis es relativamente baja, sin embargo, la afectación ureteral obstructiva (hidronefrosis) es un hecho escasamente referido en la literatura consultada y que debe tenerse en cuenta ante cuadros de este tipo en mujeres jóvenes, principalmente si se acompaña de síntomas cíclicos. El diagnóstico definitivo es histológico y el tratamiento quirúrgico(AU)

OBJECTIVES: To report the case of a 37 year-old woman suffering from endometriosis of the urinary tract, that presented with lumbar and pelvic pain associated to cyclic recurrent haematuria.METHODS: Following history, physical examination, abdomino-pelvic ultrasound (USS), CT scan and cystoscopy with biopsies, surgical treatment was indicatedRESULTS: Imaging (USS-CT) revealed a protrusion of the left bladder hemi-trigone with a nodular, irregular thickening and ipsilateral grade II-III/IV uretero-hydronefrosis. Cistoscopy confirmed a swollen and oedematous lesion in left hemi-trigone that seemed extrinsic in origin. With the clinical diagnosis of a possible neoplasia of gynaecological origin, the patient underwent surgical treatment consisting in radical hysterectomy with bilateral oophorectomy, partial cystectomy and left ureteroneocystostomy.CONCLUSIONS: The frequency of endometriosis in the urinary tract is relatively low and therefore, endometriosis presenting with ureteral obstruction (uretero-hydronephrosis) has been rarely reported in the literature and should be part of the differential diagnosis in young women, especially if symptoms are cyclic. The treatment is surgery and the final diagnosis by pathology report(AU)

Patient dose in radiologically guided interventional vascular procedures: conventional versus digital systems.

PURPOSE: To calculate the difference in the patient radiation dose in radiologically guided interventional vascular procedures between conventional and digital systems and to estimate the effective dose and the energy imparted with the digital system. MATERIALS AND METHODS: A total of 318 procedures (in 318 patients) in 15 different examination groups were analyzed. The dose-area product was determined by using a transmission chamber fitted to an x-ray-tube light-beam diaphragm; the effective dose was determined by using software. RESULTS: Urinary and biliary tract procedures showed small differences in the average dose-area product between conventional and digital systems. The dose-area products in the vascular procedures were higher with the digital than with the conventional system. The average effective dose and energy imparted were 0.88 mSv and 129 mJ, respectively, in the subcutaneous placement of a reservoir for analgesic administration and as much as 25.7 mSv and 829 mJ, respectively, in spermatic vein embolization. CONCLUSION: The dose-area product was higher with the digital system than with the conventional system in 13 of the 15 groups. To reduce the patient dose in vascular interventional radiology procedures, the training of personnel and the frequent use of conventional fluoroscopy and low-dose imaging are required.

Transjugular intrahepatic portosystemic shunt for the management of hepatic hydrothorax in the absence of ascites.

Hepatic hydrothorax in the absence of clinical ascites (HHAA) is a somewhat rare complication in decompensated cirrhosis. Patients with HHAA have a congenital defect in the tendinous portion of the diaphragm allowing rapid leakage of ascites into pleural cavity because of the cyclical negative intrathoracic pressure. Although several therapeutic approaches, including peritoneovenous shunt and chemical or surgical pleurodesis, have been attempted in these patients the results are largely unsatisfactory. A poor-risk surgical cirrhotic woman who was also considered not suitable for liver transplantation underwent transjugular intrahepatic portosystemic shunt (TIPS) for palliation of HHAA. After TIPS procedure hydrothorax completely resolved. TIPS can offer an attractive alternative to standard therapy in cirrhotic patients with HHAA.

Common bile duct stones after laparoscopic cholecystectomy and its treatment. The role of ultrasound and intravenous and intraoperative cholangiography.

In the present work we recount our experience in handling common bile duct stones (CBDS) in our first 100 cases of laparoscopic cholecystectomy. In the first 50 cases our diagnostic procedures involved the use of ultrasound exploration and intravenous cholangiotomography 48 h before laparoscopic surgery. We found three cases of residual CBDS. One of the cases was treated by means of ERCP. The other two cases were resolved by carrying out a transparietohepatic cholangiography after the ERCP procedure failed. After this experience, we changed our strategy, introducing the intraoperative cholangiography in the cases with an unclear diagnosis. With this new approach, no residual CBDS occurred in the following 50 cases. These findings demonstrate the following: (1) In our hands, intravenous cholangiography is not more effective than ultrasound exploration in resolving dubious cases. (2) These dubious cases are more effectively diagnosed by means of selective intraoperative cholangiography. (3) When CBDS is treated by transparietohepatic cholangiography it proves to be less uncomfortable for the patient than ERCP and, as we found, even more efficient in removing the stones, although our experience is based on only two cases.

[Rupture of aneurysm of anomalous hepatic artery (right unfolding)]. / Ruptura de un aneurisma de arteria hepática anómala (desdoblamiento derecho).

Un uncommon case of aneurysm located in an aberrant hepatic artery is described. It was the cause of massive hemoperitoneum. It was treated by ligation and excision without post-operative complications. In spite of the complex vascular malformation, there was no hepatic insufficiency. We have not been able to find a similar case in the literature.

Direct percutaneous ureteral approach for the treatment of ureteral stenosis or obstruction.

Two cases are presented in which conventional approaches did not permit dilation of and stent placement in obstructed ureters. In patients with iatrogenic ureteral laceration or rigid ureteral kinking, direct percutaneous translumbar puncture may provide a safe alternative. The authors' technique is described.