Woven EndoBridge Device Migration and Microsnare Retrieval Strategy: Single Institutional Case Reports with Technical Video Demonstration / 신경중재치료의학

The Woven EndoBridge (WEB) (MicroVention/Terumo) device is a treatment option for wideneck bifurcation aneurysms. An uncommon adverse effect is WEB device migration. While certain bailout strategies for WEB recovery have been described, there is still a paucity of information on optimal strategies to maximize both short and long-term post-operative outcomes. We add 2 cases at our institution to the existing literature of WEBectomy in the setting of complicated intracranial aneurysm treatment. We discuss the long-term imaging outcomes with additional fluoroscopy video demonstrating our technique. Our findings reflect a clear benefit for the use of the Amplatz GooseneckTM microsnare (Medtronic) device as a means of WEB recovery, coupled with potential stent-assisted WEB embolization to remove the aneurysm from the parent circulation, while minimizing recurrence and thromboembolic complications.

Does prostate size impact upon perioperative outcomes associated with photoselective vaporization of the prostate using the 180W lithium triborate laser?

Photoselective vaporization of the prostate [PVP] has been widely adopted as a surgical treatment for lower urinary tract symptoms due to benign prostatic hyperplasia [BPH]. Recently, a high-powered 180 W lithium triborate [LBO] laser has become commercially available and there is relatively little information on the impact of this very high-powered laser on perioperative outcomes. Even more so is the impact of the laser on outcomes according to prostate size. The objective of this study was to evaluate perioperative outcomes after PVP with the 180W laser, relative to prostate size. A prospectively maintained institutional ethics approved database was retrospectively reviewed. Subjects were analyzed according to transrectal ultrasound and categorized into groups namely 0-39 mL, 40-79 mL, 80-120 mL and >120 mL. Perioperative measures included energy utilized, length of operation, duration catheterization, post operative length of stay [POLOS], Clavien-Dindo adverse events and number discharged home within 24 hours catheter free. With increasing prostate size, there was a statistically significant increase in energy utilization and operation time [P < 0.01 between groups]. Duration of catheterization, POLOS, incidence of Grade 3 and above Clavien-Dindo adverse events and discharge home catheter free within 24 hours was not statistically significant across groups. Prostate volume impacts upon energy utilized with PVP surgery. Prostate volume does not influence duration of catheterization or POLOS. Clavien-Dindo Grade 3 or greater adverse events were low and do not appear to be influenced by prostate size. The ability to be discharged home catheter free within 24 hours likewise does not appear to be influenced by prostate size

Dichotomous Estimation of Prostate Volume: A Diagnostic Study of the Accuracy of the Digital Rectal Examination

PURPOSE: To assess the diagnostic reliability of a dichotomous digital rectal examination (DRE) tool in assessing prostate volume (PV) compared to gold-standard transrectal ultrasound (TRUS) volume measurement. MATERIALS AND METHODS: Male patients presenting to a single tertiary referral centre urology practice requiring TRUS were prospectively recruited between January 2010 and August 2011. Size was estimated by DRE immediately prior to TRUS measurement. DRE measurements were classed into four groups: 100 mL. The primary outcomes were sensitivity, specificity, and the positive and negative likelihood ratios for a 30 mL cut-off. RESULTS: Three hundred and three patients were recruited to the study. The median age of the study group was 64.9 years. On TRUS analysis, 244 patients had a PV larger than 30 mL and 139 of them, larger than 50 mL. The median PV was 47 mL with a median International Prostate Symptom Score of 10 and prostatic specific antigen (PSA) of 5.7. When analysed for the ability to identify a gland larger than 30 mL, DRE had a high sensitivity and low negative likelihood ratio. The median PSA level (ng/L) for prostates measured by DRE with a 30 mL cut-off was significantly different with higher median PSA values for volumes larger than 30 mL. CONCLUSIONS: DRE is a reliable tool for dichotomous assessment of prostatic volumes above 30 mL and 50 mL. These results illustrate the value of re-examining the role of categorical DRE estimations in benign prostatic hyperplasia patients.

Results of low threshold to biopsy following high-intensity focused ultrasound for localized prostate cancer

There are different treatment options for localized prostate cancer. The success of high-intensity focused ultrasound [HIFU] is based largely on biochemical prostate specific antigen [PSA] results. To evaluate the impact of using a low PSA threshold to perform prostate biopsies after HIFU in order to more accurately gauge treatment success. Eleven patients underwent HIFU at Sydney Adventist Hospital in Sydney, 10 as primary and 1 as salvage therapy [post external beam radiation therapy [EBRT]]. The median age was 67 years [49-77 years]. This was a prospective case series. Between 2006 and 2008, the Sonoblate device was used. Prostate biopsies were 12-core biopsies performed under local anesthesia, if PSA was >/= 0.5 ng/mL or after two consecutive rises in PSA. The statistical analysis involved prospective data collection of results to calculate median and ranges. The median PSA at diagnosis was 6.7 ng/mL [5.7-10.8 ng/mL]. The median follow-up was 16 months [7-26 months]. Nine men [82%] had post-HIFU biopsy. The median time to post-HIFU biopsy was 11.6 months [5-20 months], and all nine men had biopsy-proven residual disease. A low threshold to re-biopsy post-HIFU reveals a high local failure rate of 82%. Oncological efficacy is questioned, and using high threshold to biopsy may therefore be overestimating the effectiveness of HIFU as a primary treatment for localized prostate cancer

Photoselective vaporization of the prostate in men taking clopidogrel

To evaluate the peri-operative morbidity of men taking clopidogrel who underwent photoselective vaporisation of the prostate [PVP]. A prospective database was collected. Between March 2005 and July 2010, 480 men underwent PVP. Of these, 18 men underwent PVP treatment while on clopidogrel. The surgery was carried out with either an 80W KTP laser or a 120W lithium triborate laser. In the peri-operative period there were no complications related to PVP. There were no urinary tract infections, nor did any patient require bladder re-catheterisation. No cardiovascular events were reported within 3 months of the procedure. At 3 months post operatively, the International Prostate Symptom Score +/- standard deviation had improved from was 17.5 +/- 10.6 to 9.2 +/- 6.1 P<0.05. While the Quality of Life +/- standard deviation improved from 4.7 +/- 1.2 to 2.2 +/- 1.5 P<0.01. The maximum flow rate [Qmax], and post void residual volume [PVR] improved from 6.2 +/- 3.0 mL/s to 19.7 +/- 9.1 mL/s [P<0.01], and 140 +/- 102 mL to 59 +/- 77 mL [P<0.05], respectively. PVP is a safe and efficacious in the treatment of high risk patients with bladder outlet obstruction. Further, the ability to continue therapeutic anticoagulation and anti-platelet agents, is a significant advantage over Holmium enucleation of the prostate and conventional transurethral resection of the prostate. Larger studies with greater numbers of patients are required prior to PVP becoming the gold standard for high-risk patients with bladder outlet obstruction