Interventional Urology Research Articles

Uterine Artery Embolization Prior to Laparoscopic Hysterectomy for a Large Fibroid Uterus

Video Objective The objective of this video was to present the use of uterine artery embolization prior to supracervical hysterectomy of a large fibroid uterus Setting A 40 year old woman, gravida 0, with a history of heavy menses, bloating, back pain and pelvic pressure presented to her primary care physician for symptomatic anemia and notable family history of fibroids. The patient reported a history of regular, monthly menses however noted an interval increase in her vaginal bleeding. Her past medical history was notable for anemia for which she was taking iron supplementation. She was found to have numerous large uterine leiomyomas on magnetic resonance imaging, with the largest measuring 12.6 centimeters on the anterior body of the uterus. Physical examination was notable for a 26cm, bulky uterus extending up to the liver edge and xiphoid process. The patient declined uterine artery embolization and Lupron as initial treatment for fibroids. She instead elected for definitive surgical management, and strongly desired a minimally invasive approach. Interventions Uterine artery embolization and ureteral stent placement immediately followed by laparoscopic supracervical hysterectomy, bilateral salpingectomy and cystoscopy with stent removal Conclusion This case is unique in its collaboration between interventional radiology, urology and gynecology to ensure the safest outcome for the patient. Use of uterine artery embolization immediately prior to laparoscopic hysterectomy for large uterine leiomyomas is beneficial in decreasing intraoperative blood loss and thereby improving visualization as well as decreasing morbidity during minimally invasive laparoscopic surgery. Furthermore, placement of ureteral stents intraoperatively allows identification of the ureters when pelvic anatomy is distorted by fibroid location and size. Distortion of pelvic anatomy can limit the use of a uterine manipulator but is not a contraindication to proceeding with minimally invasive technique.

103. Multi-site experiences of radiation dose index monitoring (RDMI) in interventional radiology (IR) and cardiology

Purpose The Council Directive 2013/59/EURATOM considers IR to be a special practice involving high doses and requiring strict monitoring to ensure the best quality assurance programs. This work reports the early experience of managing dose data of angiographic patients in a multicenter study. Methods The project has involved a sample of about 10000 procedures gathered from twelve Italian hospitals centers involved on voluntary basis. The survey concerned the collection of data related to different IR procedures: interventional cardiology, radiology, neuroradiology, vascular surgery, Urology, Endoscopy and Pain Therapy from mobile and fixed units. The analysis includes 24 procedure and for each exam, air-kerma, kerma-area product and fluoroscopy time were collected. In few centres data collection was made with the aid of automatic DACS systems. For others, data were collected and processed manually. Results Duration and complexity of fluoroscopic exposures for each procedure are strongly dependent on the individual clinical circumstances, the observed distribution of patient doses is very wide, even for a specified protocol. The fixed radiological machines, all with Flat Panel, are of four different brands: Philips, Siemens, Toshiba and GE; C-arm are Siemens, Philips and Eurocolumbus. The median values of the parameters were compared with the LDRs proposed at Italian level for some procedures (GISE, INAIL, ISS) or at international level. For other procedures without LDRs, this work is a first attempt to propose LDR values also in the light of the ICRP 135. Conclusions This first data collection serves to take stock of the situation on patient’s dosimetry in several sectors and is the starting point for obtaining any LDRs recalling that, these latter, are dependent on the state of practice and the available technology at a particular point in time. A certain degree of patient dose reduction can be achieved without affecting image quality adversely.

Eye lens radiation exposure of the medical staff performing interventional urology procedures with an over-couch X-ray tube

The purpose of this work was to estimate the eye lens radiation exposure of the medical staff during interventional urology procedures. The measurements were carried out for six medical staff members performing 33 fluoroscopically-guided procedures. All procedures were performed with the X-ray tube positioned over the couch. The dose equivalents (Hp(0.07)) were measured at the eye level using optically stimulated luminescent (OSL) dosimeters and at the chest level with OSL dosimeters placed over the protective apron. The ratio of the dose measured close to the eye lens and on the chest was determined. The annual eye lens dose was estimated based on the workload in the service. For the physician and the instrumentalist nurse, the eye to chest dose ratios were 0.9±0.4 and 2.6±1.6 (k = 2), respectively. The average doses per procedure received by the eye lens were 78±24 μSv and 38±18 μSv, respectively. The eye lens dose per DAP was 8.4±17.5 μSv/(Gy·cm2) for the physician and 4.1±8.7 μSv/(Gy·cm2) for the instrumentalist nurse. The results indicate that the eye lens to chest dose ratio greatly varies according to the staff function and that the dose equivalent measured by the personal dosimeter worn on the chest may underestimate the eye lens dose of some medical staff members.

Diagnosis and treatment of enterovesical fistulas

A fistula is an atypical connection between two epithelial surface. We studied retrospectively four male pa­tients with enterovesical fistulas treated in our departments between March 2016 - March 2017. These in­cluded colovesical, rectovesical and ileovesical fistulas. Patients presented with urinary symptoms (pneu­maturia, faecaluria and recurrent urinary tract infections). One patient had received radiotherapy after rec­tal resection for rectal carcinoma. For another of the cases the fistula was being due to periprostatic abscess. The third patient was diagnosed with bladder carcinoma with rectal invasion. The fourth patient was with direct invasion of sigmoid cancer to the bladder. The most common investigations included abdominal ul­trasound, CT scan, cystoscopy and colonoscopy. Enteral stoma was performed in all cases as a part of sur­gical treatment. All patients underwent open procedure, as a main rule enteral stoma was performed to cease the contami­nation, and primary repair of the bladder was performed. No recurrences were recorded, but there were sev­eral complications, including Clavien-Dindo gr. V. Most of the complications were treated by interventional urology. In conlusion, enteral division and primary repair of the bladder are safe approaches for treatment of enterovesical fistulas. As a rule ceasing of contamination should always be performed. Cystoscopy can manage most of the complications occurring in the early postoperative period. Scr Sci Med 2017; 49(3): 53-56

Staff doses in fluoroscopically guided invasive diagnostic and interventional urology procedures

Introduction The number of fluoroscopically guided invasive diagnostic and interventional urology procedures is increasing during the last few years. This leads to higher staff doses in comparison with other radiology procedures. Purpose The aim of this study is to evaluate staff doses in fluoroscopically guided invasive diagnostic and interventional urology procedures. All the data were collected in Emergency Hospital “N. I. Pirogov” on an old fluorography unit with X-ray tube over the table. Materials and methods Staff doses for intravenous pyelogram (IVP), percutaneous nephrostomy (PN) and ureteral “double-J” stenting were estimated with the system RaySafe i2 . It contains four dosimeters, with a wireless connection to a real time display. The dosimeters were worn on the unprotected upper part of the body and measured the personal dose equivalent H p (10). In order to evaluate the dose of the eye lense in personal dose equivalent H p (3) two methods were used: thermoluminescent dosimetry and Monte Carlo simulations. Results The highest staff dose for PN and “double-J” is received by the urologist (116.7 μSv and 42.6 μSv, respectively), while for the IVP the radiographer has the highest exposure (20.7 μSv). First results for the dose of the eye lense show values of 1.63 mSv for left eye and 5.67 mSv for right eye. Each member of the medical staff was on a different position in respect to the X-ray tube and the patient which is the main reason for the differences in the staff doses. Conclusion The variations in the mean staff doses are mostly due to the interventions themselves, their complexity and the individual treatment of every patient. RaySafe i2 is very useful and educational system. It can be a helpful tool for decreasing radiation exposure to medical staff. Acknowledgement The authors would like to thank RaySafe for the kindly submitted for temporary use i2 system.

Staff lens doses in interventional urology. A comparison with interventional radiology, cardiology and vascular surgery values

The purpose of this work is to evaluate radiation doses to the lens of urologists during interventional procedures and to compare them with values measured during interventional radiology, cardiology and vascular surgery. The measurements were carried out in a surgical theatre using a mobile C-arm system and electronic occupational dosimeters (worn over the lead apron). Patient and staff dose measurements were collected in a sample of 34 urology interventions (nephrolithotomies). The same dosimetry system was used in other medical specialties for comparison purposes. Median and 3rd quartile values for urology procedures were: patient doses 30 and 40 Gy cm2; personal dose equivalent Hp(10) over the apron (μSv/procedure): 393 and 848 (for urologists); 21 and 39 (for nurses). Median values of over apron dose per procedure for urologists resulted 18.7 times higher than those measured for radiologists and cardiologists working with proper protection (using ceiling suspended screens) in catheterisation laboratories, and 4.2 times higher than the values measured for vascular surgeons at the same hospital. Comparison with passive dosimeters worn near the eyes suggests that dosimeters worn over the apron could be a reasonable conservative estimate for ocular doses for interventional urology. Authors recommend that at least the main surgeon uses protective eyewear during interventional urology procedures.

Economically affordable anatomical kidney phantom with calyxes for puncture and drainage training in interventional urology and radiology.

BackgroundTrends in interventional radiology and urology training are orientated towards reducing costs and increasing efficiency. In order to comply with the trends, we propose training on inexpensive patient-specific kidney phantoms.PurposeTo develop a new kidney phantom for puncture and drainage training in interventional urology and radiology, and to evaluate their anatomical correctness and suitability for training compared to the traditional way of training on home-made phantoms.Material and MethodsA case study for validation of kidney phantoms was conducted with nine radiology students divided into two groups: one trained on standard home-made training phantom (n = 4) and the other on our kidney phantoms (n = 5). Another test phantom was used to evaluate the effectiveness of the training of the two groups. The tests were video recorded and analyzed. Duration of the procedure was used as the primary indicator of procedure’s quality. Comparison tests were also conducted with professional radiologists. Anatomical correctness of the kidney phantom was evaluated by comparing the post mortem kidney scans with reconstructed models from CT scans. Subjective feedback was also collected from the participants. Wider use of kidney phantoms was analyzed.ResultsThe average volumetric difference between post mortem kidney scans and reconstructed CT kidney models was 4.70 ± 3.25%. All five students practicing on the kidney phantom improved their performance and the results were almost equal to the results of the professional radiologist while in the other group two students out of four trained on standard home-made training phantoms failed to improve their performance. However, the small number of test subjects prevents us from drawing general conclusions about the efficiency of the new practice. The kidney phantoms were found usable also for nephrostomy catheter placement training under fluoroscopy.ConclusionThe feedback from radiologists showed that the anatomically correct features of the phantom is an added value for the training and has a potential to increase the quality of minimally invasive procedures in general.

‘An interventional urology list’ – a novel concept for UK urological services

Almost all patients in the UK with obstructed and/or infected kidneys are referred to interventional radiology for percutaneous nephrostomy and/or placement of an anterograde JJ stent. Although this 'tradition' is going strong in the UK, urologists throughout the world have evolved their practice to encompass such interventional procedures in their remit. We have set up a local anaesthetic list 'interventional urology list' in our ESWL suite. We present our 4-year experience and discuss the benefits that this interventional list brings to our patients, our trainees, our interventional radiology colleagues and to the hospital trust. From May 2005 to May 2009, we have been running this list, twice-weekly, performing procedures such as nephrostomies, anterograde stents, nephrostograms and stent exchanges all under local anaesthetic. A total of 580 procedures have been carried out on this list over this period. Our success rate for nephrostomy insertion is 96% with three failures, as a result of patient discomfort. No major complications and three minor complications were reported. We had four failed anterograde stenting procedures (out of 80). All other procedures including nephrostograms, stent exchanges/removals/insertions, as well as renal cyst aspiration and sclerotisation were successfully carried out. Our results of percutaneous nephrostomy and antegrade stenting are favourable when compared with published data on nephrostomies. This novel set up has resulted in several improvements to the service we offer patients and also provided significant improvement in training for our residents. We encourage other departments to try and develop this type of 'interventional urology list'.

Imaging in Percutaneous Nephrolithotomy

Image guidance is a critical factor for the performance of urologic interventions. Percutaneous minimally invasive procedures have been developed and are being used with constantly increasing frequency. Procedures such as percutaneous nephrolithotomy (PCNL) are not performed without any image guidance. Recent developments in medical imaging, such as three-dimensional radiographic fluoroscopy, CT, and magnetic resonance (MR) fluoroscopy, four-dimensional ultrasonography, and image fusion techniques, propose a new generation of image-guidance tools that promise to improve patient care. These developments have been used or have the potential to be used in PCNL and other urologic interventional procedures. Moreover, advanced needles and needle guidance systems provide a new perspective for the nephrolithotomy suite of the future. The current review presents existing imaging technology in PCNL and interventional urology as well as advanced imaging techniques that are being or are expected to be evaluated in PCNL practice.

Biomaterials for Injectable Therapeutic Implants

Injectable biomaterials that have the ability to form semi-solid implants in situ are of keen interest for therapeutic applications. The materials may be used to fill in pathological vascular spaces or be designed to possess functional properties such as being radiopaque for an improved visibility during image-guided minimally invasive interventions, or induce a localized biological activity. Among the variety of solidification principles that may be used to produce implants in situ, the precipitation of water-insoluble polymers driven by solubility changes shows some particular features that may be valuable for specific therapeutic applications. This paper reviews some of the applications of these implant-forming biomaterials in interventional radiology, urology, and oncology.

Percutaneous and Interventional Urology and Radiology

Percutaneous and Interventional Urology and Radiology

Book Reviews

Book reviewed in this article:Percutaneous and Interventional Urology and Radiology. Clinical Practice in Urology. Edited by E. K. Lang.Care of the Disabled Urinary Tract: Prevention of Renal Deterioration. By Ellen Newman, Mary Price and Jean Magney.Diabetic Renal‐Retinal Syndrome. Volume 3—Therapy. Edited by E. A. Friedman and F. A. L'Esperance, Jr.Principles and Management of Testicular Cancer. Edited by N. Javadpour.