Troubleshooting Complex Vascular Cases in the Kidney Graft: Multiple Vessels, Aneurysms, and Injuries During Harvesting Procedures.

PURPOSE OF THE REVIEW: To update the most relevant literature regarding complex vascular cases in kidney transplant setting involving the graft, especially during the harvesting procedure and back-table preparation from the subsequent implant. RECENT FINDINGS: Challenging situations affecting the kidney graft such as multiple vessels, renal artery aneurysms, kidney anatomical anomalies, or major injuries do not contraindicate the transplant, but require an exhaustive graft viability assessment and several bench surgery techniques. Graft vessel conditioning in the back-table might include simple anastomosis between them, enlarging with venous patch or reconstruction with donor or synthetic grafts. Compared with conventional transplant, literature reports longer warm ischemia time (40 vs 32 min) and slightly increased rates of delayed graft function (10.3% vs 8.2%) and vascular complications (10.8% vs 8.1%), but similar graft and patient survival. Kidney graft vascular complex cases require exhaustive assessment, meticulous harvesting, good surgical technique in the bench table, and proper surgery in the recipient. Despite its complexity, vascular complex kidney transplant offers comparable outcomes in the long term to conventional population when technically well performed, with slightly increased rates of vascular complications and delayed graft function.

Troubleshooting Complex Vascular Cases in the Kidney Transplant Recipient: Vascular Anomalies, Challenging Vessel Diseases, and Procedural Disasters.

PURPOSE OF REVIEW: To update the most relevant literature regarding complex cases during kidney transplant setting that recipient presents by himself, especially during implantation surgery due to vascular diseases and/or urinary tract anomalies. RECENT FINDINGS: Increasing age of donors and recipients is leading to an increased complexity of kidney transplant implantation surgery. In addition, the high peripheral vascular disease prevalence worldwide increases difficulty of surgery and decreases long-term outcomes as well. Moreover, it also increases transplant morbidity and mortality, both overall and cardiovascular, and finally clearly decreases graft survival. However, dialysis alternative has even worse outcomes in terms of mortality, with a proportional risk of death 2.66 higher compared with transplanted patients. Aorto-iliac prosthesis and 3rd and 4th transplants in occupied iliac fossae do also represent a challenging situation with a clearly increased morbidity and mortality. In some of those particular conditions, orthotopic kidney transplant technique is an alternative with good functional and survival outcomes, but not exempt of complications. Kidney transplant in vascular complex recipients has worse outcomes compared with conventional non-risky population. It remains a challenging surgical and medical procedure with higher morbidity and mortality, and decreased graft survival. However, dialysis mortality is still even greater and a transplant attempt might be justified. Orthotopic kidney transplant technique might play a role in selected patients with aorto-iliac unworkable segments or even in patients with special urinary tract conditions.

Evaluación del sistema PI-RADSv2 en una cohorte de pacientes sometidos a biopsia prostática por fusión / Evaluation of the PI-RADSv2 classification in a cohort of patients who underwent a prostate fusion biopsy

INTRODUCCIÓN: La biopsia prostática por fusión se describe como superior a la biopsia transrectal sistemática para identificar lesiones sospechosas de carcinoma de próstata. OBJETIVOS: Evaluar la clasificación PIRADS propuesto por la Sociedad Europea de Radiología Urogenital para la detección de cáncer de próstata mediante RNM en una cohorte consecutiva de pacientes con RNM y biopsia guiada por fusión. MATERIAL Y MÉTODOS: Estudio observacional transversal. 87 pacientes con sospecha de cáncer de próstata sometidos a biopsia de próstata transperineal y fusión con RNM en nuestro centro. Describimos tumor significativo como Gleason ≥ 7(3 + 4), y carcinoma de alto riesgo como Gleason ≥ 8. Utilizamos la prueba de Chi-cuadrado para analizar la relación entre cáncer de próstata y PIRADS, así como regresión logística y pruebas de tendencia lineal, comparando las proporciones con medidas de intensidad de asociación. Empleamos el sistema HITACHI Real-Time Virtual Sonography y el software STATA/IC v.14.2 para el análisis estadístico. RESULTADOS: 64,37% pacientes presentaron resultado positivo para malignidad. Media de edad 67,89 años (SD 7,42), de PSA total 9,15 ng/ml (SD 7,85), y de volumen prostático 54,05 cc (SD 22,92). Se biopsiaron 124 lesiones sospechosas en RNM (25% PIRADS III, 57,26% PIRADS IV y 17,74% PIRADS V). 5/31 lesiones PIRADS III, 47/71 PIRADS IV y 18/22 PIRADS V fueron positivas para malignidad, con relación lineal estadísticamente significativa entre PIRADS y malignidad (p < 0,001), razón de prevalencias (RP) 4,10 (IC95% 1,81-9,32) para PIRADS IV, y RP 5,07 (CI95% 2,2211,59) para PIRADS V respecto a PIRADS III. 3,23% lesiones PIRADS III, 32,39% PIRADS IV y 63,64% PIRADS V correspondieron a tumores significativos. Encontramos asociación estadísticamente significativa entre PIRADS y tumores significativos (p < 0,001), RP 10,04 (IC95% 1,42-71,09) para PIRADS IV y RP 19,73 (IC95% 2,80139,18) para PIRADS V respecto a PIRADS III. CONCLUSIÓN: Nuestros resultados muestran que la biopsia de próstata ecodirigida y por fusión utilizando RNM es una técnica segura con excelentes resultados para obtener un diagnóstico preciso de cáncer de próstata, y puede mejorar el diagnóstico de malignidad y de tumores significativos reduciendo el sobrediagnóstico

INTRODUCTION: Prostate Fusion biopsy (MRI + prostate ultrasound) is described in literature as superior to classic random transrectal biopsy in order to identify suspicious lesion. OBJECTIVES: To evaluate the Prostate Imaging Reporting and Data System (PI-RADS) proposed by the European Society of Urogenital Radiology (ESUR) for detection of prostate cancer by multiparametric MRI in a consecutive cohort of patients with MRI and transrectal ultrasound prostate fusion-guided biopsy. MATERIAL AND METHODS: 87 patients with suspected Prostatic Cancer on prostate MRI underwent fusion transperineal prostate biopsy in our Department. 37 patients had at least one prior negative classic prostatic transrectal biopsy. Clinically significant tumor was described as Gleason 7(3+4) or higher. The Chi-square test was used to analyze the relationship between prostate cancer and the different PIRADS stages, as well as logistic regression and linear trend tests, comparing the proportions using measures of association intensity. We use the HITACHI Real-Time Virtual Sonography (HI-RVS) system, and the STATA/IC v.14.2 software for statistical analysis. RESULTS: 64.37% patients had tested positive for malignancy. Median age 67.89 years old. Median PSA 9.15 ng/ml, and average prostate volume was 54.05 cc. 124 suspicious lesions were described in prostate MRI (25% PIRADS III, 57% PIRADS IV and 17% PIRADS V). 5/31 lesions PIRADS III, 47/71 PIRADS IV and 18/22 PIRADS V were positive for malignancy, with a statistically significant linear relationship between PIRADS and malignancy (p < 0.001) - HR 4.10 (CI 95% 1.81 to 9.32) for PIRADS IV and HR 5.07 (CI95% 2.22 to 11.59) for PIRADS V vs. PIRADS III. 3.23% lesions PIRADS III, 32.39% PIRADS IV and 63.64% PIRADS V corresponded to significant tumors. A statistically significant association between PIRADS and significant tumors (p < 0.001) - HR 10.04 (CI95% 1.42 to 71.09) for PIRADS IV and HR 19.73 (CI95% 2.80 to 139.18) for PIRADS V vs PIRADS III was observed -. CONCLUSION: Our results show that transperineal targeted prostate biopsy using multiparametric MRI and transrectal ultrasound fusion is a safe procedure with excellent outcomes to obtain an accurate diagnosis of prostate cancer. Fusion biopsy has the potential to improve the diagnosis of malignancy and clinically significant tumors while reducing overdiagnosis

[Evaluation of the PI-RADSv2 classification in a cohort of patients who underwent a prostate fusion biopsy.] / Evaluación del sistema PI-RADSv2 en una cohorte de pacientes sometidos a biopsia prostática por fusión.

INTRODUCTION: Prostate Fusion biopsy (MRI + prostate ultrasound) is described in literature as superior to classic random transrectal biopsy in order to identify suspicious lesion. OBJECTIVES: To evaluate the Prostate Imaging Reporting and Data System (PI-RADS) proposed by the European Society of Urogenital Radiology (ESUR) for detection of prostate cancer by multiparametric MRI in a consecutive cohort of patients with MRI and transrectal ultrasound prostate fusion-guided biopsy. MATERIAL AND METHODS: 87 patients with suspected Prostatic Cancer on prostate MRI underwent fusion transperineal prostate biopsy in our Department. 37 patients had at least one prior negative classic prostatic transrectal biopsy. Clinically significant tumor was described as Gleason 7(3+4) or higher. The Chi-square test was used to analyze the relationship between prostate cancer and the different PIRADS stages, as well as logistic regression and linear trend tests, comparing the proportions using measures of association intensity. We use the HITACHI Real-Time Virtual Sonography (HI-RVS) system, and the STATA/IC v.14.2 software for statistical analysis. RESULTS: 64.37% patients had tested positive for malignancy. Median age 67.89 years old. Median PSA 9.15 ng/ml, and average prostate volume was 54.05 cc. 124 suspicious lesions were described in prostate MRI (25% PIRADS III, 57% PIRADS IV and 17% PIRADS V). 5/31 lesions PIRADS III, 47/71 PIRADS IV and 18/22 PIRADS V were positive for malignancy, with a statistically significant linear relationship between PIRADS and malignancy (p<0.001) - HR 4.10 (CI 95% 1.81 to 9.32) for PIRADS IV and HR 5.07 (CI95% 2.22 to 11.59) for PIRADS V vs. PIRADS III. 3.23% lesions PIRADS III, 32.39% PIRADS IV and 63.64% PIRADS V corresponded to significant tumors. A statistically significant association between PIRADS and significant tumors (p<0.001) - HR 10.04 (CI95% 1.42 to 71.09) for PIRADS IV and HR 19.73 (CI95% 2.80 to 139.18) for PIRADS V vs PIRADS III was observed -. CONCLUSION: Our results show that transperineal targeted prostate biopsy using multiparametric MRI and transrectal ultrasound fusion is a safe procedure with excellent outcomes to obtain an accurate diagnosis of prostate cancer. Fusion biopsy has the potential to improve the diagnosis of malignancy and clinically significant tumors while reducing overdiagnosis.

INTRODUCCIÓN: La biopsia prostática por fusión se describe como superior a la biopsia transrectal sistemática para identificar lesiones sospechosas de carcinoma de próstata.OBJETIVOS: Evaluar la clasificación PIRADS propuesto por la Sociedad Europea de Radiología Urogenital para la detección de cáncer de próstata mediante RNM en una cohorte consecutiva de pacientes con RNM y biopsia guiada por fusión.MATERIAL Y MÉTODOS: Estudio observacional transversal. 87 pacientes con sospecha de cáncer de próstata sometidos a biopsia de próstata transperineal y fusión con RNM en nuestro centro. Describimos tumor significativo como Gleason ≥7(3+4), y carcinoma de alto riesgo como Gleason ≥8. Utilizamos la prueba de Chi-cuadrado para analizar la relación entre cáncer de próstata y PIRADS, así como regresión logística y pruebas de tendencia lineal, comparando las proporciones con medidas de intensidad de asociación. Empleamos el sistema HITACHI Real-Time Virtual Sonography y el software STATA/IC v.14.2 para el análisis estadístico.RESULTADOS: 64,37% pacientes presentaron resultado positivo para malignidad. Media de edad 67,89 años (SD7,42), de PSA total 9,15 ng/ml (SD7,85), y de volumen prostático 54,05 cc (SD22,92). Se biopsiaron 124 lesiones sospechosas en RNM (25% PIRADS III, 57,26% PIRADS IV y 17,74% PIRADS V). 5/31 lesiones PIRADS III, 47/71 PIRADS IV y 18/22 PIRADS V fueron positivas para malignidad, con relación lineal estadísticamente significativa entre PIRADS y malignidad (p<0,001), razón de prevalencias (RP) 4,10 (IC95% 1,81-9,32) para PIRADS IV, y RP 5,07 (CI95% 2,2211,59) para PIRADS V respecto a PIRADS III. 3,23% lesiones PIRADS III, 32,39% PIRADS IV y 63,64% PIRADS V correspondieron a tumores significativos. Encontramos asociación estadísticamente significativa entre PIRADS y tumores significativos (p<0,001), RP 10,04 (IC95% 1,42-71,09) para PIRADS IV y RP 19,73 (IC95% 2,80139,18) para PIRADS V respecto a PIRADS III.CONCLUSIÓN: Nuestros resultados muestran que la biopsia de próstata ecodirigida y por fusión utilizando RNM es una técnica segura con excelentes resultados para obtener un diagnóstico preciso de cáncer de próstata, y puede mejorar el diagnóstico de malignidad y de tumores significativos reduciendo el sobrediagnóstico.

Renal Complex Cystic Masses: Usefulness of Contrast-Enhanced Ultrasound (CEUS) in Their Assessment and Its Agreement with Computed Tomography.

INTRODUCTION: Around 10 % of renal cell carcinomas (RCC) are cystic, while some benign cysts have complex appearance in conventional diagnostic tests such as computed tomography (CT) or magnetic resonance imaging (MRI). These renal complex cystic masses (RCCMs) are a challenging entity in urological practice and sometimes have a difficult management, requiring surgical removal. Contrast-enhanced ultrasound (CEUS) is a very sensitive test detecting microvascularization in real time, and it has been used in the diagnostic workup of these kinds of lesions. The aim of our study was to assess the diagnostic power of CEUS in the evaluation of RCCM. MATERIAL AND METHODS: This is a prospective observational study between April 2011 and July 2014. A total of 66 patients with 67 RCCMs were enrolled (Bosniak 2-4). Twenty-four patients underwent surgical removal of the RCCM. All participants underwent CEUS (experimental) and CT (control). All CEUS procedures were performed by a single high-experienced observer (urologist). Benign lesions were defined as those Bosniak 2-2F, and malignant were Bosniak 3-4. Statistical analysis was made measuring consistency (kappa index and Landis-Koch scale) and validity (sensitivity, specificity, positive and negative predictive values) of the study. RESULTS: Median size of RCCM measured by CEUS and CT was 3.8 cm (interquartile range (AIQ) 3.2-4.6) and 3.9 cm (AIQ 3.2-4.5), respectively. Kappa index shows good agreement between both tests (0.71; 95 % CI 0.57-0.85), both overall and stratified by categories according to Bosniak classification. CEUS has a sensitivity 100 %, specificity 81.4 %, positive predictive value 70.4 %, and negative predictive value 100 %. A total of eight RCCMs were discordant, and seven of eight classified as malignant by CEUS and not by CT. Of those seven lesions classified as malignant by CEUS, six (six of seven, 85.7 %) were malignant in the pathological exam. CONCLUSIONS: CEUS is a very useful tool for assessing RCCM, with good results in terms of consistency and validity. It has a good diagnostic power, with a sensitivity of 100 % and a negative predictive value of 100 %. Its main limitations are the experience required, a special software, and being observer-dependent.

[Prostatic biopsy: From organ biopsy to lesion biopsy. The role of MRI and MRI based biopsy systems]. / Biopsia prostática: de la biopsia del órgano a la biopsia de la lesión. Papel de la resonancia magnética y sistemas de biopsia basados en ella.

OBJECTIVES: Ultrasound guided prostatic biopsy is still the reference method for the diagnosis of prostate cancer. Nevertheless, multiparametric magnetic resonance imaging (mpMRI) has become the best imaging method to identify clinically significant tumors. Form this new situation derives the search of the best method to enable the biopsy of the lesions identified by mpMRI and are not visible on ultrasound. The objective of this work is to review the current role of MRI and the various modalities of MRI based biopsies. METHODS: Non-structured literature review about the current status of prostatic mpMRI and the various methods of biopsy of the lesions identified with it: in bore, cognitive and different commercial fusion software biopsy methods available for directed biopsies. RESULTS: Although results in the literature are very heterogeneous, all three bore biopsy, cognitive biopsy in experienced hands and the various fusion/biopsy software platforms enable a precise biopsy of mpMRI/identified lesions, increasing the yield of each sample obtained. Fusion systems do not imply a clear advantage in global detection over systematic biopsy, except in the subgroup of patients with previous negative biopsy. Nevertheless, they do demonstrate a higher detection rate for clinically significant tumors that increases in patients with a first negative biopsy. Its role in the new therapeutic approaches for prostate cancer is yet to be defined, but it will be growing and essential in a near future. CONCLUSIONS: Multiparametric MRI is already an essential test in diagnostic algorithms for prostate cancer and the systems that enable to biopsy the lesion identified are day by day a more integrated tool in the urological daily practice, and urological procedures that will enable a more precise diagnosis leading to a personalized treatment for each patient.

Biopsia prostática: de la biopsia del órgano a la biopsia de la lesión. Papel de la resonancia magnética y sistemas de biopsia basados en ella / Prostatic biopsy: From organ biopsy to lesion biopsy. The role of MRI and MRI based biopsy systems

OBJETIVO: La biopsia prostática ecodirigida continúa siendo el método de referencia para el diagnóstico del cáncer de próstata. Sin embargo la Resonancia Magnética multiparamétrica (RMmp) se ha situado como el mejor método de imagen en la identificación de los tumores clínicamente significativos. De esta nueva situación deriva la búsqueda del mejor método para poder biopsiar las lesiones que la RMmp identifica y que no resultan visibles en ecografía. El objetivo de este trabajo es revisar el papel actual de la RM y las distintas modalidades de biopsia basadas en ella. MÉTODO: Revisión no estructurada de la literatura sobre el estado actual de la RMmp prostática y los diversos métodos de biopsiar las lesiones identificadas por ella: biopsia "in bore", biopsia cognitiva y los diversos software de fusión comerciales disponibles para la biopsia dirigida. RESULTADOS: Aunque los resultados en la literatura son muy heterogéneos, tanto la biopsia "in bore", la biopsia cognitiva en manos experimentadas, y los distintos software de "biopsia/fusión" permiten biopsiar de forma certera las lesiones identificadas en la RMmp, aumentando el rendimiento de cada muestra obtenida. Los sistemas de fusión no suponen una clara ventaja frente a la Biopsia Sistemática en la detección global de cáncer salvo en el subgrupo de pacientes con biopsia previa negativa. Sin embargo sí demuestran una mayor tasa de detección de tumores clínicamente significativos que se acentúa en pacientes con primera biopsia negativa. Su papel en los nuevos enfoques terapéuticos del cáncer de próstata, vigilancia activa y tratamientos focales, está todavía por definir pero será creciente y fundamental en un futuro próximo. CONCLUSIONES: La Resonancia Magnética multiparamétrica es ya una prueba imprescindible en los algoritmos diagnósticos del cáncer de próstata y los sistemas que permiten biopsiar las lesiones identificadas cada vez una herramienta más integrada en la rutina y procedimientos urológicos que nos permitirá un diagnóstico más exacto encaminado a un tratamiento personalizado de cada paciente

OBJECTIVES: Ultrasound guided prostatic biopsy is still the reference method for the diagnosis of prostate cancer. Nevertheless, multiparametric magnetic resonance imaging (mpMRI) has become the best imaging method to identify clinically significant tumors. Form this new situation derives the search of the best method to enable the biopsy of the lesions identified by mpMRI and are not visible on ultrasound. The objective of this work is to review the current role of MRI and the various modalities of MRI based biopsies. METHODS: Non-structured literature review about the current status of prostatic mpMRI and the various methods of biopsy of the lesions identified with it: in bore, cognitive and different commercial fusion software biopsy methods available for directed biopsies. RESULTS: Although results in the literature are very heterogeneous, all three bore biopsy, cognitive biopsy in experienced hands and the various fusion/biopsy software platforms enable a precise biopsy of mpMRI identified lesions, increasing the yield of each sample obtained. Fusion systems do not imply a clear advantage in global detection over systematic biopsy, except in the subgroup of patients with previous negative biopsy. Nevertheless, they do demonstrate a higher detection rate for clinically significant tumors that increases in patients with a first negative biopsy. Its role in the new therapeutic approaches for prostate cancer is yet to be defined, but it will be growing and essential in a near future. CONCLUSIONS: Multiparametric MRI is already an essential test in diagnostic algorithms for prostate cancer and the systems that enable to biopsy the lesion identified are day by day a more integrated tool in the urological daily practice, and urological procedures that will enable a more precise diagnosis leading to a personalized treatment for each patient

Contrast-enhanced ultrasound (CEUS): an excellent tool in the follow-up of small renal masses treated with cryoablation.

Strict imaging follow-up is mandatory after cryoablation of small renal masses (SRMs). Although it uses ionizing radiation and nephrotoxic iodinated contrast, computed tomography (CT) is still the gold standard test. Contrast-enhanced ultrasound (CEUS) is a novel technique that informs in real time about renal perfusion avoiding radiation and nephrotoxicity. The objective of this study is to compare outcomes between CEUS and CT in the follow-up of SRMs treated with cryoablation, as well as to assess degree of agreement between them. This is a prospective observational study (May 2012 to December 2013) comparing CEUS and CT in 16 patients with SRMs cryoablated. The on-going protocol of the study includes a CT and CEUS 3 months after treatment and then every 6 months during 5 years. Local relapse was defined as the presence of contrast enhancement in the mass. All the CEUS were performed by a single experienced observer (E.S.). Degree of agreement was measured with kappa index. CEUS detected contrast enhancement in three patients (3/16, 18.8%) and CT in two patients (2/16, 12.5%). Degree of agreement between CEUS and CT, according to Landis-Koch classification, was 0.76 (CI 0.33-1.19; p = 0.0165), which is excellent and higher than expected by random. Sensitivity of the test is 93.75% (15/16). Median time of follow-up after cryoablation is 22 months (15.5-36.5). CEUS has an excellent agreement with CT and a high sensitivity in the follow-up of SRMs treated with cryosurgery, demonstrating its usefulness. Due to these encouraging results, it could become a reference test in the near future for monitoring SRMs after ablative treatment.

Retrobulbar ocular blood flow changes after orbital decompression in Graves' ophthalmopathy measured by color Doppler imaging.

PURPOSE: To evaluate if decompression surgery produces changes in retrobulbar blood flow parameters in Graves' ophthalmopathy (GO). METHODS: Retrobulbar blood vessels of 26 eyes (14 patients) that underwent orbital bone decompression between June 2009 and May 2010 were measured prospectively using color Doppler ultrasound before and after surgery. The disease was inactive in all patients enrolled according to the European Group on Graves' Orbitopathy. Patients were classified with mild, moderate-to-severe, or sight-threatening disease. All patients underwent a full ophthalmic examination including intraocular pressure and Hertel measurement. An age-matched control group included 20 eyes of 20 healthy volunteers. RESULTS: The resistance indexes (RIs) in the central retinal artery (CRA) and ophthalmic artery (OA) were significantly higher in patients with GO preoperatively than in the control group (P < 0.001, P = 0.001 respectively). After decompression surgery, a significant decrease in RIs occurred in the CRA (5%) and OA (6%) (P = 0.002, P < 0.001 respectively). Proptosis was decreased a median of 6 mm (range, 4-7). Three-wall decompression surgery resulted in a significantly greater reduction in exophthalmos (median 7 mm) compared with two-wall surgery (median 5 mm) and one-wall surgery (2.5 mm). Although no significant correlation was found, the RIs decreased more with major reductions in exophthalmos. CONCLUSIONS: In inactive moderate-to-severe GO, the RIs of the CRA and OA are higher than in normal subjects. The authors hypothesized that increased RIs of inactive GO may be due to orbital extrinsic compression of vascular structures because decompression surgery leads to decreases in the RIs of both the CRA and OA.