Tiago Bilhim

Prostatic Arterial Embolization to Treat Benign Prostatic Hyperplasia

PURPOSEnTo evaluate whether prostatic arterial embolization (PAE) might be a feasible procedure to treat lower urinary tract symptoms associated with benign prostatic hyperplasia (BPH).nnnMATERIALS AND METHODSnFifteen patients (age range, 62-82 years; mean age, 74.1 y) with symptomatic BPH after failure of medical treatment were selected for PAE with nonspherical 200-μm polyvinyl alcohol particles. The procedure was performed by a single femoral approach. Technical success was considered when selective prostatic arterial catheterization and embolization was achieved on at least one pelvic side.nnnRESULTSnPAE was technically successful in 14 of the 15 patients (93.3%). There was a mean follow-up of 7.9 months (range, 3-12 months). International Prostate Symptom Score decreased a mean of 6.5 points (P = .005), quality of life improved 1.14 points (P = .065), International Index of Erectile Function increased 1.7 points (P = .063), and peak urinary flow increased 3.85 mL/sec (P = .015). There was a mean prostate-specific antigen reduction of 2.27 ng/mL (P = .072) and a mean prostate volume decrease of 26.5 mL (P = .0001) by ultrasound and 28.9 mL (P = .008) by magnetic resonance imaging. There was one major complication (a 1.5-cm(2) ischemic area of the bladder wall) and four clinical failures (28.6%).nnnCONCLUSIONSnIn this small group of patients, PAE was a feasible procedure, with preliminary results and short-term follow-up suggesting good symptom control without sexual dysfunction in suitable candidates, associated with a reduction in prostate volume.

Pregnancy after uterine fibroid embolization

OBJECTIVEnTo evaluate the outcome of pregnancy after uterine fibroid embolization (UFE).nnnDESIGNnRetrospective study.nnnSETTINGnPrivate hospital affiliated with a university.nnnPATIENT(S)nIn a single center, UFE was performed in 74 patients who wanted to become pregnant.nnnINTERVENTION(S)nPolyvinyl alcohol particles (PVA) or embozene microspheres were used to embolize the uterine arteries. Enhanced pelvic magnetic resonance was performed before UFE and 6 months after UFE in all patients.nnnMAIN OUTCOME MEASURE(S)nThe number of pregnancies and their development.nnnRESULT(S)nOf the 74 women who wanted to become pregnant, 44 of them became pregnant (59.5%). There are five (11.3%) ongoing pregnancies and 39 (88.7%) finished pregnancies, with 33 successful live births (84.6%), four spontaneous abortions (10.3%), one induced abortion, and one stillbirth. There were 22 cesarean deliveries (66.6%), two preterm deliveries at 36 weeks (6.1%), and five low birth weights.nnnCONCLUSION(S)nPregnancy after UFE appears to be safe.

Pelvic Pain after Uterine Artery Embolization: A Prospective Randomized Study of Polyvinyl Alcohol Particles Mixed with Ketoprofen versus Bland Polyvinyl Alcohol Particles

PURPOSEnTo evaluate whether pelvic pain following uterine artery embolization (UAE) can be decreased by using ketoprofen mixed with polyvinyl alcohol (PVA).nnnMATERIALS AND METHODSnA randomized prospective study was performed in 80 patients (age range, 25-52 years; mean age, 41 years) undergoing UAE with PVA between March and August 2006. Forty patients received PVA particles mixed with ketoprofen, and 40 received bland PVA particles. Fifty-three patients who were asymptomatic 8 hours after embolization were discharged. Pain scores were compared during the first 8 hours after the procedure, at discharge, and the following day. The results were evaluated after 6 months.nnnRESULTSnEight hours after UAE, 13 of the 40 patients in the group without ketoprofen (32%) reported severe or very severe pain, whereas none of the patients in the group receiving ketoprofen reported severe or very severe pain, as determined with a numeric pain score scale (P = .0015). Nineteen of the 40 patients without ketoprofen (48%) were treated as inpatients, but only 10 in the ketoprofen group (25%) were treated as inpatients. The differences in the clinical outcome, as well in the uterus and fibroid sizes at discharge and at 6 months, were not statistically significant (P > .05).nnnCONCLUSIONSnThe use of PVA particles mixed with ketoprofen resulted in a statistically significant reduction in pelvic pain during the first 8 hours after UAE as compared to the use of PVA alone. However, no significant differences in pain scores were seen after 8 hours. These findings may lead to a reduction in inpatient management for UAE; however, further study of this approach is warranted.

Management of Uterine Artery Embolization for Fibroids as an Outpatient Procedure

PURPOSEnTo evaluate whether it is safe to perform uterine artery embolization (UAE) as an outpatient procedure.nnnMATERIALS AND METHODSnThis retrospective study was approved by the institutional review board and included 234 patients (age range, 24-58 years; mean age, 40.5 years) who underwent UAE as an outpatient procedure with polyvinyl alcohol particles between January 2007 and March 2008. Patients were given acid-suppressing drugs, nonsteroidal anti-inflammatory drugs, anti-histaminic drugs, and laxatives twice on the day before UAE and once on the morning of UAE. Pain score, rated from 0 to 10, was evaluated by using a numeric pain scale during UAE, after the procedure, at discharge, at the night of discharge, and on the following morning. The outcome of UAE was evaluated at 6 months by means of pelvic magnetic resonance imaging and clinical observation.nnnRESULTSnThe mean pain score was 0.9 during embolization, 2.5 4-8 hours after embolization, 0.9 at discharge, 1.1 the first night after discharge, and 0.7 the next morning. All patients were discharged from the hospital 4-8 hours after the procedure, with no overnight hospital admissions. At 6 months, 146 of 158 patients (92.4%) reported an improvement in menorrhagia, 39 of 44 (88.6%) reported an improvement in bulk symptoms, and 20 of 25 (80%) reported an improvement in pain. The volumes of the uterus and the dominant fibroid decreased 33.7% and 39.3%, respectively.nnnCONCLUSIONSnWith acid-suppressing, anti-inflammatory, and anti-histaminic drugs started on the day before UAE, the procedure can be performed safely as an outpatient procedure.

A rare variant of the ulnar artery with important clinical implications: a case report

BackgroundVariations in the major arteries of the upper limb are estimated to be present in up to one fifth of people, and may have significant clinical implications.Case presentationDuring routine cadaveric dissection of a 69-year-old fresh female cadaver, a superficial brachioulnar artery with an aberrant path was found bilaterally. The superficial brachioulnar artery originated at midarm level from the brachial artery, pierced the brachial fascia immediately proximal to the elbow, crossed superficial to the muscles that originated from the medial epicondyle, and ran over the pronator teres muscle in a doubling of the antebrachial fascia. It then dipped into the forearm fascia, in the gap between the flexor carpi radialis and the palmaris longus. Subsequently, it ran deep to the palmaris longus muscle belly, and superficially to the flexor digitorum superficialis muscle, reaching the gap between the latter and the flexor carpi ulnaris muscle, where it assumed is usual position lateral to the ulnar nerve.ConclusionAs far as the authors could determine, this variant of the superficial brachioulnar artery has only been described twice before in the literature. The existence of such a variant is of particular clinical significance, as these arteries are more susceptible to trauma, and can be easily confused with superficial veins during medical and surgical procedures, potentially leading to iatrogenic distal limb ischemia.

Uterine Artery Embolization under Electroacupuncture for Uterine Leiomyomas

PURPOSEnTo evaluate whether electroacupuncture is a safe and effective alternative to pharmacologic sedation/analgesia in uterine artery embolization (UAE) for leiomyomas.nnnMATERIALS AND METHODSnA nonrandomized prospective study was undertaken in 70 consecutive patients (mean age, 39.5 years) undergoing UAE with polyvinyl alcohol (PVA) particles between August 2006 and January 2007. Thirty-three patients chose to undergo UAE under electroacupuncture anesthesia (EAA; group A) and 37 were treated under local pharmacologic anesthesia (group B). Pain scores (rated from 0 to 10) in both groups were compared during and after the procedure. The outcome of UAE was evaluated at 6 months.nnnRESULTSnMean pain scores during embolization were 0.36 in group A and 0.84 in group B; scores after embolization and before discharge were 3.00 in group A and 4.49 in group B; and scores at discharge were 0.97 in group A and 2.11 in group B. These differences were statistically significant after embolization and at hospital discharge (P= .02 and P= .0001, respectively). All patients except one in each group were discharged from the hospital 4-8 hours after UAE; the two who remained longer had severe pain. There were no significant differences in clinical outcomes, nor in uterine and leiomyoma volumes, at discharge and at 6 months (P > 0.99 and P= .72, respectively).nnnCONCLUSIONSnThere was a statistically significant postembolization pain reduction in patients treated under EAA versus local pharmacologic anesthesia and no differences in UAE outcomes between groups at 6 months.

Paresthesia and hypesthesia in the dorsum of the foot as the presenting complaints of a ganglion cyst of the foot

Although ganglion cysts of the foot represent a substantial amount of lumps in this region, they rarely cause peripheral nerve symptoms. We describe the clinical case of a 43‐year‐old female with complaints in the previous three months of hypesthesia and paresthesia in the anterior portion of the medial half of the dorsum of her left foot that extended into the first interdigital cleft. She associated the start of her neurological symptoms to the appearance of a lump in the dorsum of the foot. A presumptive diagnosis of compression of the medial branch of the deep fibular nerve and of the medial dorsal cutaneous nerve in the dorsum of the foot by a ganglion cyst was made. Ultrasonography confirmed the cystic nature of the lesion and surgery allowed complete excision of a mass arising from the joint between the medial and intermediate cuneiform bones that was compressing the deep fibular nerve and the medial dorsal cutaneous nerve. Pathological examination confirmed that the lesion was a cystic ganglion. As far as the authors know, the simultaneous compression of the medial branch of the deep fibular nerve and of the medial dorsal cutaneous nerve in the dorsum of the foot by a ganglion cyst has not been described before. Clin. Anat. 23:606–610, 2010.