INTERVENTIONAL RADIOLOGY

Pathologies

The prostate is a small gland of the male genital tract, about the size and shape of a chestnut, located below the bladder. It secretes fluids used in the composition of sperm. It surrounds the upper part of the urethra, the urinary tract, where it joins the bladder. This gland tends to increase in size as we approach forty, and continues to grow with age.

In some men, as they age, the prostate gland becomes too large, making it difficult to urinate. This is known as benign prostatic hyperplasia (BPH), or prostatic adenoma. The risk of suffering from this disease increases with age: after 60, 60% of men suffer from it, rising to 90% after 85. This pathology is mainly linked to age-related hormonal changes. The male hormone testosterone is converted into another hormone (DHT), which contributes to prostate enlargement. BPH never degenerates into prostate cancer and does not increase the risk of developing prostate cancer.

Although benign prostatic hyperplasia (BPH), or prostate adenoma, causes no symptoms for two-thirds of men over 50, the risk of developing symptomatic BPH increases with age: after 60, 60% of men suffer from prostate problems, and this figure rises to 90% after 85.

BPH symptoms can vary in severity. Urinating often becomes difficult, with discomfort at the start and end of micturition. The frequency of these increases and the urinary stream becomes weak. Other symptoms include a feeling of incomplete bladder emptying, frequent nocturnal urination (nocturia) and acute urinary retention (inability to urinate). These symptoms can affect the quality of life of the patient, who is also more prone to urinary bladder stones and recurrent urinary tract infections. They are also often linked to erectile dysfunction (problems with erection and ejaculation).

In fact, a bladder that doesn't empty properly increases the risk of urinary tract infection and kidney problems. Urinary retention is sometimes a problem, and very occasionally the urethra becomes completely blocked, which constitutes a medical emergency: this is acute urinary retention (globe). For some patients, urinary problems related to BPH have negative psychological consequences on their sexuality.

Diagnosis of benign prostatic hyperplasia generally involves several stages, including :
- Information gathering (symptoms, medical and surgical history, lifestyle....)
- Symptom assessment with IPSS score
- PSA assay
- Prostate ultrasound or MRI
Additional examinations may be suggested

Uterine fibroids (or myomas) are benign (non-cancerous) tumors that develop in the uterus and are composed of smooth muscle cells and connective tissue. While most fibroids are small (a few millimeters), some grow to several centimeters and can invade the entire uterine cavity. Several of these tumors can develop in the same person.

Uterine fibroids, depending on their location, size and number, can cause a variety of symptoms, including :

- Long, heavy menstrual bleeding
- Bleeding between periods
- Pelvic pain with a sensation of compression in the pelvis
- Pain during intercourse
- A feeling of heaviness in the lower abdomen and/or abdominal swelling
- Frequent urination, difficulty urinating or passing stools, and sometimes infertility.

At present, the exact reasons for the appearance of uterine fibroids are not known. However, their development is influenced by hormonal secretions, particularly estrogen.
Uterine fibroids are generally diagnosed using medical imaging tests such as :

- Pelvic ultrasound,
- MRI
- Computed tomography (CT).

A hemorrhoid is a venous network located in the anal canal. Hemorrhoids are varicose veins in the anus and rectum. In hemorrhoidal disease, the veins are swollen and dilated. This dilation can cause discomfort, pain, itching and rectal bleeding.

There are 2 types of hemorrhoids:

- External hemorrhoids: These are located under the skin of the anus orifice, and are therefore palpable and visible. They are generally very painful, sometimes leading to the formation of blood clots (hemorrhoidal thrombosis).

- Internal hemorrhoids: These are located inside the rectum (at the top of the anal canal) and are generally neither visible nor palpable. Although generally painless, they can cause rectal bleeding or itching.
They are classified in 4 degrees according to their severity.

Grade 1: Hemorrhoids remain inside (no prolapse).

Grade 2: Hemorrhoids protrude and retract on their own (spontaneously reducible prolapse).

Grade 3: Hemorrhoids protrude and have to be pushed back in (prolapse with manual reduction).

Grade 4: Hemorrhoids do not retract even when pushed (non-reducible prolapse)

The common steps in diagnosing hemorrhoids are as follows:

- Collection of medical data (symptoms, medical and surgical history, lifestyle....)

- Rectal examination by a physician +/- colonoscopy to classify hemorrhoids

Varicocele is a varicose dilatation of the testicular veins in men. This abnormal and often painful dilatation is located in the spermatic cord, which is found in the bursa and surrounds each testicle. This pathology affects the left side in 80% of cases.

Varicoceles usually develop as a result of malfunctioning valves in the veins of the scrotum, leading to blood reflux and accumulation in the veins. This incontinence of the spermatic veins prevents them from ensuring sufficient return of venous blood into the general circulation.

Varicocele may be asymptomatic in some men, but others may experience pain or discomfort in the scrotum, particularly after standing or sitting for long periods. It can also lead to testicular atrophy (reduction in testicular size) in certain cases.

Varicocele is generally diagnosed by a clinical examination carried out by a doctor, who may detect a mass or venous dilatation in the scrotum. Imaging tests such as echo-Doppler or scrotal ultrasound may also be used to confirm the diagnosis.

Although varicocele is not always associated with serious symptoms, it can lead to fertility problems in some men. Excessive heat caused by venous dilation can affect sperm production and lead to impaired sperm quality.

TREATMENTS

Prostatic Artery Embolization (PAE) is a treatment option. This is a non-invasive procedure, innovative in its endovascular approach to reach the prostate without surgery, performed by an interventional radiologist for the treatment of benign prostatic hyperplasia.

The interventional radiologist inserts a 1.6 mm-diameter catheter into the artery in the wrist or groin. Secondly, under X-ray control, the catheter is directed into the small arteries supplying the prostate.

After checking that the catheter is correctly positioned in the prostatic artery, microscopic particles are injected. Celles-ci permettent de bloquer l’apport sanguin aux artères de la prostate. The prostate receives less blood, shrinks in size and allows urine to pass through more easily.

Prostate embolization can treat all urinary symptoms related to your prostate.

The main advantage of prostatic artery embolization (PAE) is that the urethra and bladder neck are not affected during the procedure. This means no urinary incontinence or retrograde ejaculation.

One treatment option is uterine artery embolization. This minimally invasive procedure avoids the need for hysterectomy (removal of the uterus) or multiple myomectomies (myoma surgery), which ultimately weaken the uterus.

Uterine embolization involves injecting microbeads into the uterine arteries supplying the fibroids. The aim is to block these arteries and thus cause necrosis of the fibroids. It shrinks the fibroids, so that symptoms disappear.

It is compatible with the desire to become pregnant.

THE 3 STAGES OF INTERVENTION

1 A catheter is inserted through an arterial puncture in the groin or wrist and guided under X-ray control to the uterine arteries.

2 Durable polymer microparticles, the size of grains of sand, are then injected to occlude the blood vessels feeding the fibroids. Our interventional radiologists search for and occlude any arterial connections that might compromise fertility beforehand.

3 Fibroids, no longer irrigated, will significantly reduce in size

Embolization is an option being considered for the treatment of grade 2/3 internal hemorrhoids. This minimally invasive radiological technique is used to alleviate the chronic bleeding associated with these hemorrhoids.

An interventional radiologist inserts a catheter into an artery in the arm, which is then guided to the arteries supplying the hemorrhoids. Under constant X-ray surveillance, small platinum devices known as "coils" and/or "particles" are positioned in these arteries, causing them to close completely within minutes.

Depending on the situation, the radiologist may also administer micro-particles to obstruct vessels even thinner than those blocked by the "coils". Once this step is complete, the radiologist simply removes the catheter from the artery and applies a dressing to the puncture site. It's important to note that no incisions, manipulations or scars are present in the anus, as the entire procedure takes place inside the blood vessels, via the endo-vascular route. This procedure is painless.

One of the treatment options for varicocele is embolization of the spermatic vein. This is a non-invasive procedure, innovative in its endovascular approach to reach the spermatic vein without surgery, performed by an interventional radiologist with a short hospital stay. This minimally invasive technique is highly effective and painless.

THE 3 STAGES OF INTERVENTION

1 The interventional radiologist inserts a 1.6 mm-diameter catheter into the vein in the groin or arm. Secondly, under radiological control, the catheter is directed into the spermatic vein supplying the varicocele(s).

2 After checking that the catheter is correctly positioned, the spermatic vein is occluded with synthetic glue or sclerosing foam. In addition to embolization, coils (fibrous platinum springs that form a plug inside the vein) can be inserted.
3 Once embolization is complete, the radiologist removes the catheter. All that remains is a small 2mm incision in the skin, which will heal in less than 24 hours.

This technique provides non-invasive treatment for the disabling pain and infertility associated with varicocele veins, and enables all dilated veins to be seen and treated in a single procedure.

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