Prostate mpMRI in the UK: the state of the nation.

The diagnosis of prostate cancer has changed. Improved magnetic resonance imaging (MRI) technology with diffusion-weighted imaging has led to the use of multiparametric MRI (mpMRI) before biopsy in patients suspected of having prostate cancer. This has the advantage that patients with a negative mpMRI may not need biopsy, therefore avoiding the risk of complications. Those in whom mpMRI is positive can have targeted biopsies with a higher probability of diagnosing clinically significant cancer. Prostate Cancer UK (PCUK) and the British Society of Urogenital Radiology submitted a Freedom of Information (FOI) request in 2016 to UK health areas in order to assess the use of mpMRI before biopsy as part of the initial diagnosis pathway. Another request was submitted by PCUK in 2018 to assess the progress made in the UK between these two dates. Both requests had the secondary aim of identifying barriers to the implementation of mpMRI. The FOI requests showed an increase in the use of mpMRI before biopsy with 59% of areas reporting improvement between the two requests. There has been a reduction in the percentage of areas not providing any form of pre-biopsy MRI from 25% in 2016 to 13% in 2018. There remains, however, geographical variation in implementation across the UK nations. Imaging practice also shows variation with some areas performing scans without dynamic contrast enhancement (DCE) and using the findings to guide referral decisions for biopsy. Eligibility criteria for pre-biopsy MRI also vary leading to some restrictive practices. Reported barriers to implementation included scanner capacity and staffing levels. Recent guidelines and recommendations by the National Institute for Health and Care Excellence (NICE) and NHS England for men aged 50-69 years with a prostate-specific antigen (PSA) level between >3 and <30 ng/ml to receive mpMRI before biopsy put further pressure on already understaffed and under-resourced radiology departments.

Ultrasound-guided endocavitary drainage of pelvic abscesses: technique, results and complications.

AIM: To evaluate the experience in our institution with ultrasound-guided transrectal and transvaginal (endocavitary) drainage of pelvic abscesses. MATERIALS AND METHODS: Eighteen patients (four male, 14 female; mean age 55 years, range 30-78 years) presenting with pelvic abscesses were referred to our institution for therapeutic drainage over a 4 year period. Patients received broad-spectrum antibiotics prior to drainage, which was performed by either the transvaginal or transrectal route under ultrasound guidance. Patients were given sedo-analgesia in the form of midazolam and fentanyl and local anaesthesia was also employed. Eight French catheters were inserted into the abscess cavities, and patients were subsequently monitored on a daily basis by a member of the interventional radiology team until such time as it was deemed appropriate to remove the catheter. RESULTS: Eighteen catheters were placed in 17 patients, and transvaginal aspiration alone was performed in one patient. Drainage was successful in 16 of 17 patients, but a transgluteal approach was ultimately required in the remaining patient to enable passage of a larger catheter into an infected haematoma. The mean duration of drainage was 5 days, mean time to defervesce 2 days. Spontaneous catheter dislodgement occurred in four patients associated with straining, but this did not have any adverse effect in three of the four patients. CONCLUSION: Endocavitary drainage is an effective method of treatment for pelvic abscesses. Spontaneous catheter dislodgement does not affect patient outcome.

Percutaneous radiologic gastrostomy with and without T-fastener gastropexy: a randomized comparison study.

PURPOSE: T-fastener gastropexy is used by many interventional radiologists during percutaneous radiologic gastrostomy (PRG) placement. Whether gastropexy is a prerequisite to safe gastrostomy placement is uncertain. We evaluated the use of T-fastener gastropexy versus no gastropexy for PRG in a prospective, randomized study. METHODS: Of 90 consecutive patients referred for PRG, 48 were randomly selected to receive T-fastener gastropexy (M:F, 35:13; mean age 62 years, range 20-90 years) and 42 to receive no gastropexy (M:F, 31:11; mean age 63 years, range 40-90 years). Technical difficulties and fluoroscopy times were recorded for both groups and all patients were followed up for postprocedural complications. T-fasteners were removed between 3 and 7 days after gastrostomy insertion. RESULTS: A major complication was encountered in four patients from the non-gastropexy group (10%). In these cases the guidewire and dilator "flipped" out of the stomach into the peritoneal cavity. This resulted in misplacement of the gastrostomy tube in the peritoneal cavity in two of the patients. This was discovered at the end of the procedure when a test injection of contrast medium was performed. In three of these patients the procedure was rescued and completed radiologically. One patient underwent endoscopic gastrostomy placement. Five of 48 patients (10%) who received a gastropexy had pain associated with the T-fastener sites. Six patients (13%) had skin excoriation at the T-fastener sites. No skin complications were seen in the non-gastropexy group. No statistical difference in fluoroscopy time was observed between the two groups. CONCLUSION: Our experience of PRG without T-fastener gastropexy involved a 10% incidence of serious technical complications. We suggest that T-fastener gastropexy should be performed routinely for all PRG procedures. T-fastener gastropexy has an associated minor complication of pain and skin excoriation at the gastrostomy site which resolves on removing the T-fasteners.

Anesthesia practice and clinical trends in interventional radiology: a European survey.

PURPOSE: To determine current European practice in interventional radiology regarding nursing care, anesthesia, and clinical care trends. METHODS: A survey was sent to 977 European interventional radiologists to assess the use of sedoanalgesia, nursing care, monitoring equipment, pre- and postprocedural care, and clinical trends in interventional radiology. Patterns of sedoanalgesia were recorded for both vascular and visceral interventional procedures. Responders rated their preferred level of sedoanalgesia for each procedure as follows: (a) awake/alert, (b) drowsy/arousable, (c) asleep/arousable, (d) deep sedation, and (e) general anesthesia. Sedoanalgesic drugs and patient care trends were also recorded. A comparison was performed with data derived from a similar survey of interventional practice in the United States. RESULTS: Two hundred and forty-three of 977 radiologists responded (25%). The total number of procedures analyzed was 210,194. The majority (56%) of diagnostic and therapeutic vascular procedures were performed at the awake/alert level of sedation, 32% were performed at the drowsy/arousable level, and 12% at deeper levels of sedation. The majority of visceral interventional procedures were performed at the drowsy/arousable level of sedation (41%), 29% were performed at deeper levels of sedation, and 30% at the awake/alert level. In general, more sedoanalgesia is used in the United States. Eighty-three percent of respondents reported the use of a full-time radiology nurse, 67% used routine blood pressure/pulse oximetry monitoring, and 46% reported the presence of a dedicated recovery area. Forty-nine percent reported daily patient rounds, 30% had inpatient hospital beds, and 51% had day case beds. CONCLUSION: This survey shows clear differences in the use of sedation for vascular and visceral interventional procedures. Many, often complex, procedures are performed at the awake/alert level of sedation in Europe, whereas deeper levels of sedation are used in the United States. Trends toward making interventional radiology a clinical specialty are evident, with 51% of respondents having day case beds, and 30% having inpatient beds.

Percutaneous gastrostomy in patients who fail or are unsuitable for endoscopic gastrostomy.

PURPOSE: Percutaneous endoscopic gastrostomy (PEG) is not possible or fails in some patients. We aimed to categorize the reasons for PEG failure, to study the success of percutaneous radiologic gastrostomy (PRG) in these patients, and to highlight the associated technical difficulties and complications. METHODS: Forty-two patients (28 men, 14 women; mean age 60 years, range 18-93 years) in whom PEG failed or was not possible, underwent PRG. PEG failure or unsuitability was due to upper gastrointestinal tract obstruction or other pathology precluding PEG in 15 of the 42 patients, suboptimal transillumination in 22 of 42 patients, and advanced cardiorespiratory decompensation precluding endoscopy in five of 42 patients. T-fastener gastropexy was used in all patients and 14-18 Fr catheters were inserted. RESULTS: PRG was successful in 41 of 42 patients (98%). CT guidance was required in four patients with altered upper gastrointestinal anatomy. PRG failed in one patient despite CT guidance. In the 16 patients with high subcostal stomachs who failed PEG because of inadequate transillumination, intercostal tube placement was required in three and cephalad angulation under the costal margin in six patients. Major complications included inadvertent placement of the tube in the peritoneal cavity. There was one case of hemorrhage at the gastrostomy site requiring transfusion and one case of superficial gastrostomy site infection requiring tube removal. Minor complications included superficial wound infection in six patients, successfully treated with routine wound toilette. CONCLUSION: We conclude that PRG is a safe, well-tolerated and successful method of gastrostomy and gastrojejunostomy insertion in the technically difficult group of patients who have undergone an unsuccessful PEG. In many such cases optimal clinical evaluation will suggest primary referral for PRG as the preferred option.

Percutaneous ablation of peripheral pseudoaneurysms using thrombin: a simple and effective solution.

PURPOSE: To assess the effectiveness of tissue adhesive and thrombin solution in the percutaneous ablation of peripheral artery pseudoaneurysms. METHODS: Twenty-five pseudoaneurysms were treated over a 33-month period; all had failed ultrasound-guided compression. Tissue adhesive or thrombin solution was injected percutaneously, with needle tip position and changes within the aneurysm confirmed with color Doppler ultrasound. In 19 cases we utilized a protective balloon inflated across the aneurysm neck prior to the injection of tissue adhesive and in six cases used thrombin injection alone. Seven patients were anticoagulated. Patients were followed up after the procedure. RESULTS: All 25 aneurysms were treated successfully; two patients required a return visit and there were no immediate complications or peripheral emboli detected. One patient developed a contralateral pseudoaneurysm. CONCLUSIONS: The percutaneous injection of pseudoaneurysms is a safe, atraumatic, and effective treatment for femoral artery pseudoaneurysms in the peripheral circulation. There are significant advantages over ultrasound-guided compression or surgical repair.

The management of peripheral arterial aneurysms using percutaneous injection of fibrin adhesive.

Most peripheral arterial aneurysms are pseudoaneurysms and are iatrogenic or related to trauma. They can be treated by several techniques that can be performed by the radiologist, negating the need for surgery. Ultrasound guided compression repair is usually the treatment of choice, but is not always successful. The number of available treatment options reflects the varying site and nature of pseudoaneurysms and perhaps the lack of a consistently reliable method. We have successfully treated 13 patients with peripheral aneurysms (11 femoral, 1 popliteal and 1 posterior tibial aneurysm) using a commercial fibrin tissue adhesive. The method involves percutaneous injection of the adhesive components using ultrasound and screening control, following successful occlusion of the aneurysm neck by angioplasty balloon.