Phil Boardman

The role of interventional radiology and imaging in pancreatic islet cell transplantation

Pancreatic islet cell transplantation (PICT) is a novel treatment for patients with insulin-dependent diabetes who have inadequate glycaemic control or hypoglycaemic unawareness, and who suffer from the microvascular/macrovascular complications of diabetes despite aggressive medical management. Islet transplantation primarily aims to improve the quality of life for type 1 diabetic patients by achieving insulin independence, preventing hypoglycaemic episodes, and reversing hypoglycaemic unawareness. The islet cells for transplantation are extracted and purified from the pancreas of brain-stem dead, heart-beating donors. They are infused into the recipients portal vein, where they engraft into the liver to release insulin in order to restore euglycaemia. Initial strategies using surgical access to the portal vein have been superseded by percutaneous access using interventional radiology techniques, which are relatively straightforward to perform. It is important to be vigilant during the procedure in order to prevent major complications, such as haemorrhage, which can be potentially life-threatening. In this article we review the history of islet cell transplantation, present an illustrated review of our experience with islet cell transplantation by describing the role of imaging and interventional radiology, and discuss current research into imaging techniques for monitoring graft function.

Immediate Resolution of a Grade 3 Varicocele Post Prostatic Artery Embolisation (PAE)

To the Editor, Here, we describe the immediate resolution (\24 h) of a grade 3 left-sided male varicocele post-prostatic artery embolisation (PAE). Embolisation of the internal spermatic vein to treat male varicocele is well established and successful [1, 2]. Prostatic artery embolisation (PAE) for benign prostatic hyperplasia (BPH) is gaining momentum as a robust alternative to transurethral resection of the prostate gland (TURP) [3]. The anatomy of the prostatic artery and accompanying venous drainage is highly variable [4]. Following PAE, there is likely a transient increase in size of the prostate before the established reduction in size of the gland over the following months. In addition to the highly variable and poorly understood vasculature of the prostate gland, the venous drainage of the testicle is complex with 3 routes for testicular venous return: (1) anterior/internal pampiniform plexus joins the internal spermatic vein; (2) medium pampiniform plexus which accompanies the vas deferens; and (3) posterior/cremasteric pampiniform plexus that drains into the pudendal veins. A 60-year-old man presented to our institution following 6 years of worsening lower urinary tract symptoms (LUTS). He had suffered from a symptomatic left varicocele for a similar period of time which was confirmed on ultrasound examination (see Fig. 1). The patient refused surgical intervention for his LUTS and had significant morbidity from medical management. Pre-PAE, he had a prostatic volume of 70 cm, a urinary flow rate of 9 ml/sec and an International Prostate Symptom Score (IPSS) of 19. Planning pre-procedure prostate MRI with contrast confirmed the left-sided varicocele, and a planning CT angiogram confirmed bilateral prostatic arteries were branches of the internal pudendal artery. Embolisation was performed bilaterally via a 2.4 Progreat catheter (Terumo, Tokyo, Japan) following administration of 100 micrograms of intra-arterial glyceryl trinitrate (GTN) (Ayrton Saunders Ltd, Runcorn, Cheshire, UK) and confirmation of anatomical position following rotational angiography (cone beam CT). 200-lm PVA particles (Cook Incorporated, Bloomington, IN, USA) were injected until stasis in the vessels were achieved. \24 h following the day case procedure, the patient reported completed resolution of the varicocele. This was confirmed on US examination. The patient was reviewed at 3 months post-PAE and 12 months post-PAE. At 3 months post-procedure, the prostate volume was 50 cm, the urinary flow rate was 16 ml/sec and the IPSS was 10. At 12 months post-procedure, the prostatic volume was 43 cm, the urinary flow rate was 22 ml/sec and the IPSS was 22. Over the 12 months follow-up, the International Index of Erectile Function (IIEF) improved by 1 point. There had also been an improvement in the quality of life indices measured. Successful PAE for BPH usually causes a reduction in size of the prostate gland; however, this takes time. A schematic of the proposed theory for the immediate resolution of the grade 3 varicocele is suggested in Fig. 2. PrePAE, there was greater flow in the prostatic arteries. The subsequent venous drainage became congested, and in this case there was not sufficient capacity in the pudendal venous drainage system of the prostate which caused & Charles R. Tapping Charles.tapping@ouh.nhs.uk

Treatment of haematospermia with prostatic artery embolisation (PAE)

At one-year and six-year post-transrectal ultrasound (TRUS) prostate biopsy two patients (aged 62 and 65) suffered from persistent haematospermia. There had been no haematospermia prior to TRUS biopsy. Both patients also suffered from lower urinary tract symptoms (LUTS) due to benign prostatic hypertrophy (BPH). Both patients were successfully treated for their BPH with prostatic artery embolisation (PAE). Three months post-procedure the patients reported that their haematospermia had ceased. At 12-month follow-up they had improvements in urodynamics (Qmax), a reduced post-void bladder residual volume of urine, an improvement in International Prostate Symptom Score (IPSS), and improvement in quality of life endpoints (EQ-5D-5L). The prostate volumes had reduced by 42% and 50% (Figures 1 and 2) at 12-month follow-up magnetic resonance imaging (MRI) scan.

Neck or groin access for varicocele embolisation: Is it important?

Varicocele embolisation is an excellent treatment option for symptomatic scrotal varicosities. The purpose of this study was to assess the current practice of the endovascular treatment of left‐sided varicoceles at our institution, to compare the findings to international standards and to identify which access site reduces screening time and radiation dose.

Retrograde transileal conduit stent placement for obstructed uropathy--success of primary and exchange stent placement.

PURPOSE To assess the safety, success, and complications associated with retrograde ureteric stent insertion via the ileal conduit. MATERIALS AND METHODS The study population comprised 35 consecutive patients (17 men and 18 women; mean age, 55 y; age range, 40-75 y) requiring primary (20 stents) and exchange (70 stents) retrograde ureteric stent insertion via the ileal conduit over a 3-year period. Patient demographic data, procedural and technical data, and clinical follow-up data were collected. RESULTS Technical success was 90% (18 of 20) for primary stent placement and 100% (70 of 70) for stent exchange. There were two immediate complications (< 24 h) of sepsis and ureteric injury and one early complication (> 25 h but < 30 d) of sepsis requiring observation and medical management. Difficult procedures (defined as a fluoroscopy screening time > 31 min) and technical failures were found to be associated with encrusted stents visualized on prior computed tomography (P = .012), increased length of ileal conduit (> 20 cm) (P = .023), and ileal conduit kink (< 90 degrees) (P = .032). Only the occurrence of encrusted stents visualized on prior computed tomography (P = .022) was associated with complications. CONCLUSIONS Retrograde placement of ureteric stents via the ileal conduit is safe and effective. Retrograde stent placement should be considered the treatment option of choice for a first-time occurrence of obstructive uropathy at the ureteroileal anastomosis.

Retrograde exchange of heavily encrusted ureteric stents via the ileal conduit: A technical report

We describe two cases of retrograde ureteric stent exchange of heavily encrusted ureteric stents (JJ) via tortuous ileal conduits. The blocked ureteric stents were snared from inside the conduit so they could be accessed and a wire inserted. The lumens of the stents were unblocked with a wire but the stents could not be withdrawn due to heavy encrustation of the ureteric stent in the renal pelvis. A stiff wire was inserted to provide support and a 9 French peel away sheath was used to remove the encrustations allowing the stents to be withdrawn and exchanged. This is a safe and successful technique allowing ureteric stents to be removed when heavily encrusted.

Transplant renal artery stenosis: Narrow and prone to closure

Renal transplant dysfunction: over-reliance on subjective investigations can contribute to diagnostic uncertainty.