Feasibility of dynamic 3-D color Doppler ultrasound for imaging penile vascular change in renal transplant patients with erectile dysfunction responding to sildenafil.

Renal transplant recipients (RTRs) have a high incidence of erectile dysfunction (ED). Differentiation of penile vasculogenic impotence from other causes is important for treatment. Conventional 2-D color Doppler assessment after intracavernosal stimulant injection often fails to produce reliable results because of limited views by the cross-sectional imaging and the painful procedure. In comparison to the findings in three healthy volunteers, we determined cavernosal vascular hemodynamics in eight RTRs with ED before and after oral sildenafil by using live 3-D ultrasound and dynamic 3-D color Doppler. Results showed that, before sildenafil, penile arterial flow signals could only be reliably detected in one patient. After sildenafil, all had reliably detectable flow with grades II to III erection. Our data suggest that 3-D volumetric changes of the penis and its vasculature during erection can be studied by this technique and that this method could be useful for the evaluation of new drugs and therapeutic biofeedback.

Multi-section CT angiography compared with digital subtraction angiography in diagnosing major arterial hemorrhage in inflammatory pancreatic disease.

PURPOSE: Major arterial hemorrhage is an uncommon but serious complication of pancreatitis with high morbidity and mortality. Digital subtraction angiography (DSA) has long been the gold standard for the detection of a visceral artery pseudoaneurysm or for the site of active bleeding in patients with pancreatitis. Multi-section CT angiography is a minimally invasive technique which can provide high-resolution and high-contrast images of the arterial lumen and wall, with a much lower risk of complication and morbidity compared to DSA. The aim of this study was to determine the accuracy of multi-section CT angiography for the diagnosis of arterial complications of inflammatory pancreatitic disease. MATERIALS AND METHODS: A retrospective analysis of all patients undergoing visceral angiography for major bleeding as a complication of pancreatitis between 1998 and 2004 was performed. Twenty-nine studies in 25 patients (20 males, 5 females) with a mean age of 50.9 years (range 11-67 years) were identified where multi-section CT angiography was performed in the 24 h preceding the digital subtraction angiogram. RESULTS: Digital subtraction angiography detected a pseudoaneurysm or contrast extravasation in 19 studies and no bleeding was demonstrated in 9 studies. CT angiography correctly identified the site and type of bleeding in 18 of the 19 positive studies. CT angiography detected extravasation of contrast in one study that was not demonstrated on digital subtraction angiography. The sensitivity and specificity for multi-section CT angiography for the detection of major arterial bleeding on a background of pancreatitis were 0.947 and 0.900, respectively. CONCLUSION: Multi-section CT angiography is a sensitive and accurate technique for the detection of major arterial hemorrhage in inflammatory pancreatic disease and should be considered as the first investigation in the management of these patients.

'Nipped in the Budd': hepatic venous outflow obstruction in evolution.

Hepatic venous thrombosis (Budd-Chiari) in evolution is a rare phenomenon and carries a high morbidity and mortality. We describe the case of a 39-year-old Bangladeshi lady who presented with severe abdominal pain secondary to a perforated duodenal ulcer and during her hospital admission developed an asymptomatic Budd-Chiari syndrome (BCS). Our report highlights the important role of an inflammatory focus, and how this process with an associated reactive thrombocytosis may act as a trigger for the development of BCS in an individual with predisposing risk factors. Our patient had been on the contraceptive pill, and was homozygous for the C677T mutation of 5,10-methylenetetrahydrofolate reductase, which results in hyperhomocysteinaemia. These pro-thrombotic risk factors were compounded by the thrombogenic potential of subsequent laparoscopic surgery, and resulted in an evolving thrombus that progressed into the inferior vena cava causing hepatic infarction. A particular feature of this case was the radiological demonstration of complete regression of the thrombus and the hepatic parenchymal changes, upon resolution of the inflammation and normalization of the platelet count. These changes occurred with oral anticoagulation as the only treatment modality, since our patient declined systemic thrombolysis. The demonstration of complete radiological resolution raises the question of how long one should continue oral anticoagulants and, indeed, whether in some instances a conservative approach may be the best management strategy for evolving BCS.

A novel therapy with testosterone and sildenafil for erectile dysfunction in patients on renal dialysis or after renal transplantation.

BACKGROUND: We undertook a prospective pilot study in a small cohort of patients with renal replacement therapy to determine the cause of erectile dysfunction (ED) and evaluate the role of testosterone replacement therapy and sildenafil. METHODS: We investigated 12 patients (eight post-transplant and four on haemodialysis) who presented with ED for hypogonadism and cavernosal insufficiency. We assessed sexual performance before and after treatment by a questionnaire method based on the modified International Index of Erectile Function (IIEF) and National Institutes of Health (NIH) rating. Patients received 250 mg intramuscular monthly injections of testosterone cypionate and 50-100 mg sildenafil orally once or twice weekly for 12 months. Therapeutic response was considered good if the patient could maintain an erection adequate for successful sexual intercourse (NIH criteria) and had a marked improvement in the overall sexual performance (IIEF scoring). RESULTS: Before treatment all patients had severe ED with a poor IIEF score while 11 also had diminished libido. Eleven patients had diminished testicular volume and six had elevated follicle-stimulating hormone levels suggestive of germ cell damage. All patients had a good response to the therapeutic trial of testosterone and sildenafil. CONCLUSIONS: Therapy with testosterone and sildenafil may be indicated for those with both cavernosal arterial insufficiency and reproductive hormone abnormalities. Further longer-term data are needed to determine the safety and efficacy of this novel regimen.

Radiofrequency ablation of lung metastases: factors influencing success.

This paper analyses the factors associated with successful radiofrequency ablation (RFA) of lung metastases. The study group comprised 37 patients [19 female, mean age 61 (34-83)] with 72 metastases who had follow-up CT scans available for analysis and for those with no recurrence >6 months follow-up. Internally cooled electrodes were used in 64 and expandable electrodes in 8. The tumour size and location, electrode type, number of ablations, duration of ablation, year of treatment and tumour contact with vessels larger than 3 mm were recorded. The mean tumour diameter was 1.8 cm (0.4-6.6 cm). Mean follow-up in those without recurrence was 13.1 months (6-48). Recurrence was common in larger tumours, occurring in 7/7 (100%) tumours >3.5 cm compared with 18/65 (28%) < or = 3.5 cm (P < 0.01). Recurrence occurred in 14/24 (58%) tumours in direct contact with large vessels compared with 11/48 (23%) of the remainder (P = 0.04). On multivariate analysis, size was the dominant feature (P = 0.013); vessel contact and peripheral location did not reach significance (P = 0.056 and 0.054 respectively). Peripheral tumours less than 3.5 cm with no large vessel contact are the optimal tumours for RFA.

Five-year survival following radiofrequency ablation of small, solitary, hepatic colorectal metastases.

PURPOSE: Radiofrequency (RF) ablation is an increasingly accepted treatment for nonsurgical candidates with a limited number of colorectal hepatic metastases. RF ablation is most effective in tumors smaller than 4.0 cm. This report describes 5-year survival in patients with single tumors with a maximum diameter of 4 cm. MATERIALS AND METHODS: Forty of 291 patients (14%; 24 men, 16 women; mean age, 67 years; age range, 34-86 y) with no or treated extrahepatic disease were identified who were not candidates for resection and who had a minimum follow-up of 6 months. Sixteen had undergone hepatic resection and two had undergone lung resection and lung ablation. Thirty-two (80%) received chemotherapy. Thirty-five were treated under general anesthesia and five under conscious sedation. Our standard ablation protocol used internally water-cooled electrodes introduced percutaneously with ultrasonography and computed tomography guidance and monitoring. Follow-up data were obtained from primary care physicians or oncologists. RESULTS: Mean tumor diameter was 2.3 cm (range, 0.8-4.0 cm). There were two successfully treated systemic complications: a chest infection and an exacerbation of asthma. There were no local complications. Mean follow-up was 38 months (range, 6-132 months). The median survival duration and 1-, 3-, and 5-year survival rates were 59 months and 97%, 84%, 40%, respectively, after ablation; and 63 months, 100%, 88%, and 54%, respectively, from the diagnosis of liver metastases. History of liver resection did not impact survival. CONCLUSIONS: RF ablation of solitary liver metastases 4 cm or smaller can be performed with minimal morbidity and results in excellent long-term survival, approaching that of surgical resection, even in patients who are not surgical candidates.

Endovascular management of major arterial hemorrhage as a complication of inflammatory pancreatic disease.

PURPOSE: Major arterial hemorrhage is an important complication of inflammatory pancreatic disease, with an overall mortality of 37%. The present study was undertaken to evaluate the experience of a tertiary referral center for pancreaticobiliary disease in the management of major arterial complications of pancreatitis with selective visceral angiography and transcatheter arterial embolization (TAE). MATERIALS AND METHODS: A 6-year retrospective analysis of all patients undergoing visceral angiography for major bleeding as a complication of pancreatitis identified 35 patients (26 male, 9 female) with a mean age of 51.2 years (range, 11-73 y). Patient demographics, history, clinical presentation, angiographic findings, angiographic treatment, and follow-up outcomes were retrospectively noted. Technical success was defined as the devascularization of a focal lesion or reduction or cessation of blood flow to a target vascular bed or organ, and clinical success was defined as the resolution of the symptoms and signs that prompted the initial embolization. RESULTS: Angiography identified the site of bleeding in 54.3% of patients (n=19) and angiographic intervention was performed in 77.1% of patients (n=27). Technical success was achieved in 81.5% of those 27 patients (n=22), with overall clinical success in 80.0% (n=28). Multiple angiograms were required in 12 patients, with four demonstrating bleeding from new sites. The mortality rate was 20% (7 of 35). CONCLUSIONS: In major arterial hemorrhage resulting from pancreatic inflammatory disease, visceral angiography can identify the site of bleeding and hemostasis can be achieved. Repeat angiography is often required with bleeding from new sites. The mortality rate is comparable to that associated with surgery and reflects multisystem involvement in acute severe pancreatitis.

Autoimmune pancreatitis: clinical and radiological features and objective response to steroid therapy in a UK series.

OBJECTIVE: Most cases of autoimmune pancreatitis (AIP) have been reported from Japan. We present data on a UK series, including clinical and radiological features at presentation, and longitudinal response to immunosuppression. METHODS: Over an 18-month period, all patients diagnosed in our center with AIP were studied. Endoscopic biliary stenting was performed as required, and patients were treated with prednisolone, with response assessed longitudinally. In cases of disease relapse following steroid reduction, azathioprine was instituted. RESULTS: Eleven patients met diagnostic criteria for AIP. Diffuse pancreatic enlargement was seen in eight patients (73%), and pancreatic duct strictures in all. Seven patients required biliary stents. Extrapancreatic involvement occurred in all, including intrahepatic stricturing and renal disease. Eight weeks after starting steroids, the median serum bilirubin level had fallen from 38 mumol/L to 11 mumol/L (P= 0.001), and ALT from 97 IU/L to 39 IU/L (P= 0.002). Stents were removed in all cases, with no recurrence of jaundice. Improvements in mass lesions and pancreaticobiliary stricturing occurred in all patients. During a median 18-month follow-up, six patients relapsed, four of whom responded to azathioprine. Two patients discontinued steroids and remained well. CONCLUSIONS: Extrapancreatic disease was an important feature of AIP in this UK series. Initial response to immunosuppressive therapy was excellent, but disease relapse was common. Optimal long-term management remains to be established.

Real-time three-dimensional ultrasound visualization of erection and artificial coitus.

To investigate the feasibility of imaging penile erection and coitus in real time and in three dimensions, a 'Live' three-dimensional (3-D) ultrasound system was used to acquire the volume of interest at 25 Hz from five healthy men. Water baths and gel-made artificial vaginas were devised to facilitate the 3-D scans without the probe being in direct contact with the penis. For the first volunteer scanned with the water bath alone, the penis failed to erect within 30 min. For the other four volunteers, the 'vagina' successfully initiated and maintained the erection and allowed artificial intercourse. Results have shown that the 'Live' 3-D ultrasound and minimally compressive imaging techniques together can offer an objective means for visualizing erection and coitus in spatial totality and temporal reality. They can be further developed to reveal more reliable details about the dynamic morphology, improving scientific understanding of sexual activities and clinical management of related problems.

Measurement of aortic compliance in abdominal aortic aneurysms before and after open and endoluminal repair: preliminary results.

PURPOSE: To assess aortic wall compliance as a portent of rupture risk in patients with abdominal aortic aneurysms. METHODS: In this pilot study, 38 patients (32 men; median age 78 years, range 63-95) underwent an ultrasound scan: 20 pre-repair and 24 post-repair (18 endovascular [EVR] and 6 open). Six patients from the pre-repair group were included in a post repair study after EVR. Cine loop images were analyzed offsite using wall tracking software, which measured aortic diameter changes during cardiac cycles. Brachial blood pressure was measured, and elastic modulus (Ep) and stiffness (beta) were calculated. Preop Ep and beta were determined at the neck, inflection points (IP), and mid sac levels. Postop Ep and beta were calculated in mid sac only for technical reasons. RESULTS: Preoperative Ep and beta were significantly higher at IP compared with neck (median Ep 24.22 versus 12.95 N/cm(2), p<0.003; median beta 16.27 versus 8.65, p<0.003). At the mid sac, Ep and beta were also significantly higher compared with neck: Ep 26.41 versus 12.95 N/cm(2), p=0.001; beta 17.94 versus 8.65, p=0.001. The values for IP and mid sac were Ep 24.22 versus 26.41 N/cm(2), p=0.64; beta 16.27 versus 17.94, p=0.64. In the postop cases (n=24), Ep and beta in successful endovascular repair (n=12) were significantly higher than in open repair, respectively: median Ep 34.31 versus 12.33 N/cm(2), p<0.001; median beta 23.18 versus 8.24, p<0.001. Patients with endoleaks or endotension (n=6) had significantly elevated Ep and beta compared with those without endoleaks (n=12): median Ep 79.79 versus 34.31 N/ cm(2), p=0.002; median beta 51.52 versus 23.18, p<0.002. Six patients scanned before and after EVR showed a decrease of Ep and beta in 3, no change in 1, and an increase in 2. An increase greater than 2 fold was noted in a patient with a gross type II endoleak. CONCLUSIONS: This pilot study shows that estimates of aortic wall compliance agree well with known values for wall stress distribution. EVR leaves patients with greater wall stiffness than those undergoing open repair, a situation accentuated by endoleaks. Wall compliance and stiffness measurement promises to be useful for the evaluation of success of endovascular repair.

Prospective study comparing multislice CT colonography with colonoscopy in the detection of colorectal cancer and polyps.

PURPOSE: Multislice CT colonography is an alternative to colonoscopy. The purpose of this study was to compare multislice CT colonography with colonoscopy in the detection of colorectal polyps and cancers. METHODS: Between June 2000 and December 2001, 45 males and 35 females (median age, 68 (29-83) years) with symptoms of colorectal disease were studied prospectively. All patients underwent multislice CT colonography and colonoscopy, and the findings were compared. RESULTS: Colonoscopy was incomplete in 18 (22 percent) patients because of obstructing lesions or technical difficulty, and multislice CT colonography was unsuccessful in 4 (5 percent) because of fecal residue. Colonoscopy was normal in 26 patients and detected 29 colorectal cancers and 33 polyps in 35 patients, diverticulosis in 16 patients, and colitis in 3 patients. Multislice CT colonography identified 28 of 29 colorectal cancers with one false negative and one false positive (sensitivity, 97 percent; specificity, 98 percent; positive predictive value, 96 percent; negative predictive value, 98 percent). Multislice CT colonography identified all 12 polyps measuring >or=10 mm in diameter (sensitivity, 100 percent), 5 of 6 measuring 6 to 9 mm in diameter (sensitivity, 83 percent), 8 of 15 polyps or=6 mm is similar to colonoscopy. Multislice CT colonography allows clinical staging of colorectal cancers, outlines the whole length of the colon in obstructing carcinoma when colonoscopy fails, and can identify extracolonic causes of abdominal symptoms.

Bile duct disruption following radiofrequency ablation: successful repair using a covered stent.

Persistent biliary leaks, whether iatrogenic or secondary to malignancy, often present a difficult management problem. Recent reports have suggested a role for covered metallic stents in this context. We describe the successful use of a covered stent to seal a persistent biliary leak following radiofrequency ablation of colorectal liver metastases.

Photodynamic therapy for prostate cancer recurrence after radiotherapy: a phase I study.

PURPOSE: Photodynamic therapy, using a photosensitizing drug activated by red light, can destroy localized areas of cancer with safe healing and without the cumulative toxicity associated with ionizing radiation. We used photodynamic therapy in a phase I-II study to treat patients with locally recurrent prostate cancer after radiotherapy. MATERIALS AND METHODS: Patients with an increasing prostate specific antigen (PSA) and biopsy proven local recurrence after radiotherapy were offered photodynamic therapy. Three days after intravenous administration of the photosensitizer meso-tetrahydroxyphenyl chlorin, light was applied using optical fibers inserted percutaneously through perineal needles positioned in the prostate with imaging guidance. Patients were followed with PSA measurements, prostate biopsies, computerized tomography or magnetic resonance imaging and questionnaires on urinary and sexual function. RESULTS: Photodynamic therapy was given to 14 men using high light doses in 13. Treatment was well tolerated. PSA decreased in 9 patients (to undetectable levels in 2) and 5 had no viable tumor on posttreatment biopsies. After photodynamic therapy, contrast enhanced computerized tomography or magnetic resonance imaging showed necrosis involving up to 91% of the prostate cross section. In 4 men stress incontinence developed (troublesome in 2 and mild in 2) which is slowly improving. Sexual potency was impaired in 4 of the 7 men able to have intercourse before photodynamic therapy, which did not improve. There were no rectal complications directly related to photodynamic therapy, but in 1 patient a urethrorectal fistula developed following an ill-advised rectal biopsy 1 month after therapy. CONCLUSIONS: Photodynamic therapy is a new option that could be suitable for organ confined prostate cancer recurrence after radiotherapy. With more precise light dosimetry, it may be possible to destroy essentially all glandular tissue within the prostate with few complications. These results suggest that photodynamic therapy merits further investigation.