Prostatic artery embolization as a primary treatment for benign prostatic hyperplasia: preliminary results in two patients. Cardiovasc Intervent Radiol. 2010;33:355-361. [PMID: 19908092 PMCID: PMC2841280 DOI: 10.1007/s00270-009-9727-z]

Prostate Artery Embolization (PAE) in the Treatment of Benign Prostatic Hyperplasia: A Case Series and Narrative Review

Background/Objectives: Prostatic artery embolization (PAE) has emerged as a minimally invasive alternative for treating lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH), particularly in high-risk surgical candidates. This study aims to evaluate the efficacy, safety, and clinical outcomes of PAE, combining a retrospective case series with a narrative review of the literature. Methods: A single-center retrospective analysis was conducted on 10 patients aged ≥ 70 years with moderate-to-severe LUTS due to BPH who underwent PAE between January 2021 and January 2024. Inclusion criteria included IPSS > 18, Qmax < 12 mL/s, prostate volume > 45 cc, and resistance to medical therapy. Embolization was performed using 300-500 µm tris-acryl gelatin microspheres via the PErFecTED technique. Follow-up included IPSS, Qmax, prostate volume (PV), PSA levels, and complications. A narrative review of 18 studies (n = 1539 patients) was also conducted to contextualize findings. Results: Technical success was achieved in all patients (100%), and clinical success (IPSS reduction ≥ 50%) in 90%. At 12 months, the following significant improvements were observed: mean IPSS decreased from 24 to 12 (p < 0.0001), Qmax increased from 8.7 to 12.6 mL/s (p < 0.0001), PV reduced from 66.4 to 49.4 cc (p < 0.0001), and PSA from 5.0 to 3.4 ng/mL (p < 0.0001). Outcomes remained stable up to 36 months. Two patients developed transient post-procedural fever; no major complications were recorded. Conclusions: PAE is a safe and effective treatment for LUTS related to BPH, offering durable symptom relief and minimal morbidity, particularly in elderly and comorbid patients. While the evidence supports its role as an alternative to TURP, larger prospective trials are necessary to confirm its long-term efficacy and optimize patient selection.

Early experience of prostate artery embolization: a retrospective single-centre study

OBJECTIVE

The aim of this study was to evaluate the early experiences of prostate artery embolization (PAE) in patients with benign prostatic hyperplasia (BPH).

MATERIAL AND METHODS

This retrospective study included all patients treated for BPH who were referred to the radiology department for PAE in Västmanland between 2018 and 2021. Data were collected on patient demographics, International Prostate Symptom Score (IPSS), prostate-specific antigen level, and peri- and post-procedure outcomes. Clinical success was defined as a decrease in the IPSS by ≤3 points or catheter freedom.

RESULTS

A total of 96 patients (median age 74 years) underwent PAE. Before PAE, 65% of the patients were treated with α-blockers and 83% with 5α-reductase inhibitors. Clinical success was achieved in 60 patients (63%). Among catheterized patients, 33 (53%) achieved catheter freedom. In the non-catheterized group, 27 (79%) experienced clinical success. No significant differences in outcomes were observed based on the presence of a median lobe.

CONCLUSIONS

PAE appears to be a viable treatment option for BPH and may provide substantial symptom relief and catheter freedom for most patients. These findings suggest that PAE may be an effective alternative to more invasive procedures. Further research is needed to refine the patient selection criteria.

Prostatic Artery Embolization for the Treatment of Benign Prostatic Hyperplasia: A Retrospective Single-Center Study

Introduction The purpose of this study is to assess the effectiveness and short-term outcomes of prostatic artery embolization (PAE) in Indian patients suffering from benign prostatic hyperplasia (BPH). Methods This retrospective analysis was performed at a single center and included 25 patients with BPH who received PAE from January 2019 to June 2023. The symptoms of patients had been assessed utilizing the International Prostate Symptom Score (IPSS) and the Quality of Life (QoL) questionnaire. The prostate volume and post-void residual (PVR) volume were assessed using transabdominal ultrasonography prior to and following the embolization. The procedure occurred in the interventional radiology suite with the patient under conscious anesthesia, employing polyvinyl alcohol (PVA) particles. Prostate volume, PVR, IPSS, and QoL scores had been assessed at a follow-up three months later. Results Twenty-five males, with an average age of 76.56 years, underwent PAE. Bilateral embolization was conducted in 23 patients, whereas unilateral embolization was executed in two cases. Following a duration of three months, the average maximum improvement was as defined: IPSS, 10.44 ± 2.91; QoL score, 1.80 ± 0.81; prostatic volume decrease, 49.40 ± 24.13 cc (43% ± 13.95); and PVR volume, 70.08 ± 39.85 mL (52% ± 14.14) (p < 0.001 for all) as evaluated by the paired t-test. Conclusion PAE is a secure and efficacious intervention for BPH, yielding favorable short-term outcomes for lower urinary tract symptoms.

Prostate Artery Embolization as Minimally Invasive Treatment for Benign Prostatic Hyperplasia: An Updated Systematic Review

Background/Objectives: Benign prostatic hyperplasia (BPH) has a significant impact on the quality of life of symptomatic patients. In patients manifesting lower urinary tract symptoms (LUTS), prostatic arterial embolization (PAE) has become a topic of interest in recent years. The purpose of this systematic review is to analyze and review techniques and clinical outcomes of patients who underwent endovascular treatment of BPH, with a special focus on the comparison of surgical and endovascular procedures. Methods: Through the major scientific databases, 1225 articles were selected from the initial research utilizing specific keywords and medical subject headings. Based on the inclusion and exclusion criteria established for selecting relevant studies for our purposes, the systematic analysis of the literature was conducted on a total of seven articles. Results: We collected data on 718 male patients (408 patients underwent PAE and 310 received TURP). The technical success rate varied from 86% to 100% for TAE and was 100% for TURP. During a 12-month follow-up period, both PAE and TURP were comparable on the reduction in IPSS and QoL questionnaire, while TURP showed significant improvements in Qmax and in the reduction in prostate volume. Length and cost of hospitalization were lower for PAE. Complication and adverse events rates were higher in the TURP group rather than in the PAE group (60.6% vs. 35.5%). Conclusions: Prostatic artery embolization represents an emerging minimally invasive procedure for BPH. According to previously released clinical studies, quality-of-life and urological symptom scores of the PAE group were comparable to those of the TURP group. Our research strengthens the evidence supporting the effectiveness and safety of PAE as a therapy for LUTS related to BPH.

Prostate Artery Embolization in the Treatment of Massive Intractable Bleeding from Prostatic Neoplasms: A Case Report and Systematic Review

Lower urinary tract symptoms (LUTS) and hematuria are common symptoms in men with neoplasms, mainly affecting the elderly population. Prostatic arterial embolization (PAE) is a minimally invasive procedure that has shown promising results in managing LUTS and massive intractable prostatic hematuria in patients with benign prostatic hyperplasia (BPH) and prostate cancer (PCa). A few studies, however, have provided valuable insights into the durability and efficacy of PAE focusing on the long-term effectiveness, quality of life, and cancer-specific control of hemostasis and urinary symptoms. As a result of concomitant cardiovascular conditions, these patients often take anticoagulants or antithrombotics, which can worsen their hematuria and clinical status. Transurethral resection of the prostate (TURP) is considered a very high-risk procedure, even without massive bleeding, and requires discontinuation of vitamin K antagonists and antiplatelet therapies. Such patients usually have their surgery postponed, and PAE should be considered a safe alternative treatment. We aimed to report a narrative review from 1976 to June 2023 of the current state of PAE for massive and intractable hematuria, highlighting recent developments in this technique, including prospective cohort studies, and focusing on long-term outcome, safety, and complication management of patients with prostatic neoplasms who develop significant hemorrhagic symptoms. Additionally, we present a case report and a simple algorithm for treating intractable bleeding in a 92-year-old man with PCa and massive hematuria.

Prostatic Artery Origin Variability: Five Steps to Improve Identification during Percutaneous Embolization

Background and Objectives: The purpose of the current paper is to present our study on the variability in the prostatic artery origin, discuss the less frequent origins, and present the challenges of the prostatic artery embolization (PAE) procedure, thus aiding young interventional radiologists. Materials and Methods: We studied the origins of the prostatic artery on digital subtraction angiography (DSA) examinations from PAE procedures on 35 male pelvises (70 hemi-pelvises). Results: Our study has demonstrated that the most frequent origin of the prostatic artery (PA) is the internal pudendal artery (IPA), 37.1%, followed by the anterior gluteal trunk, 27.1%, and the superior vesical artery (SVA), 21.4%. Less frequent origins are the obturator artery (OBT), 11.4%, and the inferior gluteal artery (IGA), 2.8%. Conclusions: Compared to other studies, we notice some differences in the statistical results, but the most frequent origins remain the same. What is more important for young interventional radiologists is to be aware of all the possible origins of the PA in order to be able to offer a proper treatment to their patients. The important aspect that will ensure the success of the procedure without post-procedural complications is represented by the successful embolization of the targeted prostatic parenchyma.

Non-target embolic events during prostatic embolization with ethylene vinyl alcohol copolymer (EVOH)

BACKGROUND

This study evaluated nontarget embolization (NTE) during prostatic artery embolization (PAE) with ethylene vinyl alcohol copolymer (EVOH).

RESULTS

Ten consecutive patients treated by PAE with EVOH for the presence of disabling benign prostatic hyperplasia (BPH)-related lower urinary tract symptoms (LUTS) between June 22 and January 2023 were included in this prospective study. The inclusion criteria were as follows: LUTS attributed to BPH, LUTS duration ≥ 6 months, failure to respond to standard pharmacotherapy, IPSS > 18 or QoL score > 2, and prostate volume > 40 mL. Embolization was performed under general anaesthesia. According to established techniques, a microcatheter was positioned bilaterally within the feeding arteries, and EVOH was injected slowly under X-ray control. Unenhanced pelvic computed tomography scans were carried out before and after embolization to assess the NTE. The safety of the prostatic embolization procedure with EVOH was assessed by collecting adverse effects over 3 months of evaluation that included the International Prostate Symptom Score (IPSS) and quality of life (QoL) score.-up evaluations, occurring at 3, 6, and 12months, included International Prostate Symptom Score. Bilateral PAE was technically successful in 9 patients, and unilateral injection was performed in one patient. The postoperative scanner showed a distribution of the embolization material in the two lobes of the prostate in all patients. The procedure time varied from 120 to 150 (mean: 132) minutes. Eight out of 10 patients developed pollakiuria within 24 h; none of the patients had postoperative pain. Two patients required catheterization for postoperative urinary retention. Catheters were removed successfully at the end of the first day for one of these patients and on the tenth day for the other. At the 3-month follow-up, patients showed significant improvement in the International Prostate Symptom Score (n = 10; mean = -11,5; P < 0.01) and quality of life score (n = 10; mean = -3,40; P < 0.01). Only one patient presented one asymptomatic muscular NTE.

CONCLUSIONS

PAE with EVOH is safe, effective, and associated with few NTEs and no postoperative pain. Prospective comparative studies with longer follow-ups are warranted.

TRIAL REGISTRATION

IDRCB, 2021-AO29-56-35. Registered 27 May 2022, http://clinicaltrials.gov/study/NCT05395299?cond=embolization&term&rank=1 .

Prostatic Arterial Embolization for Treatment of Lower Urinary Tract Symptoms Associated with Benign Prostatic Enlargement

PURPOSE OF REVIEW

Prostatic artery embolization (PAE) is an emerging minimally invasive technique for lower urinary tract symptom reduction from benign prostatic hypertrophy (BPH). While the technique is becoming increasingly popular with patients and interventional radiologists, most urologists remain skeptical of the PAE's long-term efficacy and comparative success to the gold standard transurethral resection of the prostate.

RECENT FINDINGS

PAE has been found in multiple meta-analyses to perform similarly to the gold standard transurethral resection of the prostate (TURP) with regard to patient-driven measures like IPSS and IPSS-QoL, while also performing favorably in objective measurements including Qmax and PVR out to at least 12 months post intervention. Furthermore, PAE has a demonstrated shorter hospital length of stay and fewer adverse events when compared to TURP. PAE provides patients with an alternative to transurethral options for the management of LUTS in the setting of bladder outlet obstruction. While long-term evidence demonstrating the durability of PAE is still forthcoming, the procedure has been demonstrated to be safe according to multiple meta-analyses. Patients deserve to be counseled on PAE as an alternative to surgery and made aware that while the overall treatment effect may not be as robust or durable, the procedure carries a favorable adverse event profile that is attractive to patients wishing to avoid a trans-urethral approach.

Update on the management of benign prostatic hyperplasia and the role of minimally invasive procedures

Lower urinary tract symptoms due to benign prostatic hyperplasia constitute a substantial burden, affecting the quality of life of those affected by this condition. While watchful waiting and medical management using a wide array of pharmaceuticals can be effective, surgery has been one of the most definite solutions for those highly affected by this condition. Transurethral resection of the prostate (TURP) is the gold standard surgical procedure, but other alternatives using laser (HoLEP and ThuLEP) and robotic water jets (Aquablation) are emerging treatments aimed at reducing postoperative morbidity. Minimally invasive procedures conducted in outpatient settings and under local anesthesia or sedation are increasingly being used, especially in those patients with high surgical risk due to comorbidities. These procedures include prostatic arterial embolization, water vapor thermal therapy (Rezum), prostatic urethral lift (Urolift), temporary implantable nitinol device (TIND/iTIND), and transurethral microwave thermotherapy (TUMT). The evidence supporting these treatments is growing, but some uncertainties remain as to what is the magnitude of their advantages and disadvantages compared to TURP. Innovations in the technologies involved in these new procedures may improve their profile for effectiveness and safety. Moreover, new devices are being investigated for marketing approval. Issues around costs and patients' preferences are also yet to be elucidated, thus their evolving role needs to be weighed against the aforementioned considerations.

Anatomical variants in prostatic artery embolization in treatment of benign prostatic hyperplasia

Background

Benign prostatic hyperplasia (BPH) is the most prevalent benign tumor in aged men, and its prevalence is rising with age reaching 8% in the fourth decade of life and up to 90% in the ninth decade. PAE has long been considered as a safe and effective minimally invasive therapy option for individuals with moderate to severe lower urinary tract symptoms caused by prostatic hypertrophy. Because of the varying degrees of atherosclerosis seen in the elderly, PAE is generally a difficult treatment that necessitates a particular amount of knowledge of anatomy and a specific set of abilities. It is critical to emphasize anatomical information about PA that is required for a successful PAE, as well as radiation exposure factors that can be helpful in such a protracted treatment. This thesis provides a pictorial review of PA anatomy and prevalence of related anatomical variants, besides additional anatomical and radiation dosage concerns, and knows the important effect of the anastomosis on non-target embolization as in our study we included large number of cases (83 patients) to cover all types of variations and different types of anastomosis all were covered.

Results

A total of 83 patients (166 sides) were analyzed. Double arterial supply on the same side was noted in 1 patient (1.2%). In 3 patients (3.6%), only a unilateral PA was identified. PA origin frequencies were computed. Penile, rectal, vesical anastomoses, and anastomosis with the other side were identified with 7 (8.4%), 3 (3.6%), 2 (2.4%), and 8 (9.6%) of PAs, respectively. Mean skin radiation dose was 479 mGy.

Conclusions

When treating BPH with PAE, understanding PA anatomy is critical for achieving the best results. The anatomy of the PA is critical for preventing non-target embolization and is directly related to the correct identification of the anatomical pattern of the prostate arteries, and we should also take into account the presence of contralateral anastomoses; it is possible to achieve both prostate lobes through catheterization of the prostatic artery on only one side.

Prostate Cancer after Percutaneous Arterial Embolization of the Prostate: A Case Report

We report a patient with prostate cancer found 2 years after percutaneous arterial embolization (PAE) of the prostate with a rapid increase in prostate specific antigen (PSA) 3 months later, even though the initial result was low. He did not consult a urologist during or after PAE until acute urinary retention developed. The clinical stage was cT2cN1M1b with Gleason grade 5 + 5 = 10. An increase in PSA a short interval after PAE may suggest the presence of prostate cancer. We suggest that patients undergoing PAE should consult a urologist, and that PSA levels should be checked every 3 months in the first year after PSA.

Influence of Prostate Artery Embolization on Different Qualities of Lower Urinary Tract Symptoms Due to Benign Prostatic Obstruction

BACKGROUND

Prostate artery embolization (PAE) is an increasingly used minimally invasive treatment for lower urinary tract symptoms secondary to benign prostatic obstruction (BPO) OBJECTIVE: To analyze the impact of PAE on voiding and storage symptoms.

DESIGN, SETTING, AND PARTICIPANTS

Between July 2014 and May 2019, 351 consecutive men with BPO who underwent PAE were included in a single-center study.

INTERVENTION

PAE is an interventional radiological procedure embolizing the prostatic arteries with microspheres.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The primary endpoint represented assessment of the International Prostatic Symptom Score (IPSS) at baseline and at 1, 3, 6, 12, and 24 mo after PAE. Secondary endpoints comprised assessment of IPSS quality of life (QoL), International Index of Erectile Function, peak urinary flow rate, postvoid residual volume, prostate volume, and prostate-specific antigen at the same time points. Data were analyzed using standard statistical methods, generalized estimating equations (symptom improvement over time as odds ratios), and McNemar-Bowker test (degree of improvement compared between symptoms).

RESULTS AND LIMITATIONS

Clinical success rates for PAE were 68%, 73%, and 66% at 1, 12, and 24 mo, respectively. The median IPSS improved significantly from 22 to 10 points after 2 yr (p < 0.001). Storage (-50%) and voiding (-58%) symptoms improved similarly (each p < 0.001), with nocturia decreasing least frequently but significantly (p < 0.001). After 1 and 2 yr, 35% (95% confidence interval [CI] 29-41%) and 30% (95% CI 21-40%) of patients reported alleviated storage, and 39% (95% CI 33-45%) and 38% (95% CI 29-49%) reported alleviated voiding symptoms, respectively. QoL improved from 5 to 2 points (p < 0.001). The main limitation is the number of patients lost during follow-up.

CONCLUSIONS

PAE significantly improved voiding and storage symptoms to a similar extent. This study may aid in counseling patients about this minimally invasive BPO treatment.

PATIENT SUMMARY

Prostate artery embolization (PAE) is a minimally invasive treatment option for patients with voiding and storage symptoms from benign prostate enlargement. Our analysis shows that PAE improves relevant lower urinary tract symptoms.

Efficacy and safety of prostate artery embolization for patients with lower urinary tract symptoms and indwelling urinary catheter: A retrospective multicenter study

PURPOSE

The purpose of this multicenter study was to evaluate the clinical success at three months of prostate artery embolization (PAE), assess PAE safety in centers with various experiences and identify factors associated with PAE success.

PATIENTS AND METHODS

This multicenter, retrospective study included patients who underwent PAE for lower urinary tract symptoms (LUTS) including those with indwelling urinary catheter. PAE clinical success was defined as either 25% improvement of the International Prostate Symptom Score (IPSS) or 1-point improvement of quality of life (QoL) score, or catheter removal at three months. Multivariable analyses were performed using a logistic regression adjusted on patient variables, technical parameters and center experience in PAE.

RESULTS

A total of 383 men (mean age, 68.4 ± 9.7 [standard deviation] years; range: 46-94) with LUTS, including 99 (25.8%) patients with indwelling urinary catheter, were included in seven centers from January 2017 to March 2019. Five patients reported major complications (1.3%), three (0.8%) penile ulceration, three (0.8%) acute urinary retention, one (0.3%) prostatic abscess, and 56 (14.6%) minor complications. Follow up data were available for 271 patients (center 1: n = 159; other centers: n = 112). Clinical success was reported in 232 patients (85.6%). In multivariable analyses, presence of cardiovascular comorbidities (diabetes, stroke history, myocardial infarction and lower limb artery disease) was the single independent variable inversely associated with PAE clinical success (odds ratio = 0.396; 95% confidence interval: 0.17-0.91; P = 0.029). There was no center effect.

CONCLUSION

Our results show that PAE is safe and effective in centers with various PAE experiences. Cardiovascular comorbidity is the single independent variable associated with PAE failure.

Prostate Artery Embolization in Patients above Eighty Years Old: Clinical Efficacy and Safety

Purpose Prostate artery embolization (PAE) has been established as an effective treatment option for benign prostate hyperplasia or hematuria of prostatic origin. We aim to confirm the effectiveness and safety of PAE in elderly patients aged ≥ 80 years old.

Materials and Methods Between January 2014 and August 2020, PAE was attempted on 54 elderly patients with lower urinary tract symptoms (LUTS) or prostatic hematuria who were unfit for surgical treatment or opted for PAE. Outcome parameters (International Prostate Symptom Score [IPSS], quality of life [QoL] score, International Index of Erectile Function score (IIEF), maximal urinary flow rate, postvoid residual, and prostate volume) were collected and analyzed at baseline, 6 months, 1, 2, and 3 years.

Results The mean patient age was 85.29 years (range: 80–98). Technical success was achieved in 50 patients (92.6%). Mean IPSS improved from 18 at baseline to 7.7, 8.5, 8.6, and 9.1 at 6 months, 1, 2, and 3 years. Mean QoL improved from 4.9 at baseline to 2.8, 1.7, and 1.5 at 6 months, 1, and 2 years. Mean prostate volume reduced from a baseline of 152.7 to 123.5 mL within 6 months and 120.5 mL after 7 months of PAE. Urinary catheter removal was successful in 13 out of 19 patients with urinary retention. PAE succeeded in stopping bleeding in 16 out of 17 patients with prostate-induced hematuria.

Conclusion PAE is a feasible low-risk treatment for LUTS with or without urinary retention or prostatic hematuria in elderly patients.

Prostatic Artery Embolization for Benign Prostatic Obstruction: Single-Centre Retrospective Study Comparing Microspheres Versus n-Butyl Cyanoacrylate

PURPOSE

To compare the safety and efficacy of n-butyl cyanoacrylate glue (NBCA) versus microspheres for prostatic artery embolization (PAE) in patients with benign prostatic obstruction (BPO).

MATERIALS AND METHODS

This institutional review board-approved, single-centre, retrospective study included consecutive patients undergoing PAE from September 2017 to July 2020. Age, medical history, previous treatment, pre- and post-PAE prostatic volumes and International Prostate Symptom Scores (IPSSs) were systematically analysed. Procedural duration, dosimetry, immediate and delayed complications were recorded. Patients at the beginning of the study were treated with microspheres and patients at the end of the study with NBCA. The main outcome measures were the absolute and relative changes in IPSS at 3 months. Statistical analyses comprised unpaired t-tests, Wilcoxon tests, Chi-2 tests, uni- and multivariate linear regressions.

RESULTS

Sixty-two patients were included (median age: 65.9 years). Thirty-two patients were treated with microspheres and 30 with NBCA. There were no significant baseline differences between the two groups except for the baseline PSA (P = 0.0251). Average procedural and fluoroscopy times, and radiation exposure were significantly lower in the NBCA group versus the microspheres group (80.7 ± 22.5 versus 112 ± 42.1 min [P = 0.0011], 24.2 ± 9.6 min versus 42.1 ± 20.2 min [P = 0.0001], 12,004.6 ± 6702 uGy.m² versus 25,614.9 ± 15,749.2 uGy.m² [P = 0.0001], respectively). Immediate complications were all minor, and there were no significant differences between the two groups (4/32 [12.5%] with microspheres versus 7/30 [23.3%] with NBCA, P = 0.4335), nor for delayed complications (P = 1). No association was found between the PAE techniques and the absolute change in IPSS at 3 months (-10.2 ± 7.9 with microspheres versus -9.5 ± 7.6 with NBCA, P = 0.7157).

CONCLUSION

PAE using NBCA was safe and effective for symptomatic BPO, with faster procedures, lower radiation exposure and similar safety and efficacy compared to microspheres. Operator learning curve could have biased the procedural times and radiation exposure between groups favouring NBCA.

Guiding the prostatic artery embolization procedure with computational uid dynamics

Benign prostatic hyperplasia (BPH) is a common disease associated with lower urinary tract symptoms and the most frequent benign tumor in men. To reduce BPH therapy complications, prostatic artery embolization (PAE) was developed to replace the surgical options. PAE is a minimally invasive technique in which emboli are injected into the prostate arteries (PA), obstructing the blood flow in the hypervascular nodules. In this work, a personalized PAE treatment strategy was proposed using patient-specific computational fluid dynamics (CFD). First, the hemodynamics environment in the iliac arterial tree considering a large network of bifurcations was studied. The results showed complex blood flow patterns in the iliac arterial network. Subsequently, the transport of embolic particulates during PAE for the standard horizontal and a hypothetical vertical patient positioning was simulated using Lagrangian particle tracking. Emboli with different sizes were released at various locations across the iliac arterial tree. The emboli entering the PA were mapped back to their initial location to create emboli release maps (ERMs). The obtained ERMs during the standard patient positioning for smaller emboli at certain release locations showed distinct regions in which if the emboli were released within these regions, all of them would reach the PA without non-target embolization. During the hypothetical vertical patient positioning, the larger emboli formed a larger coherent region in the ERMs. Our patient-specific model can be used to find the best spatial location for emboli injection and perform the embolization procedure with minimal off-target delivery.

Prostatic Artery Embolization for Treatment of Lower Urinary Tract Symptoms: A Markov Model-Based Cost-Effectiveness Analysis

PURPOSE

The aim of this study was to investigate whether prostatic artery embolization (PAE) can be considered a long-term cost-effective treatment option in patients with lower urinary tract symptoms secondary to benign prostatic hyperplasia in comparison to transurethral resection of the prostate (TURP).

METHODS

The in-hospital costs of PAE and TURP in the United States were obtained from a recent cost analysis. Clinical outcomes including nature and rate of adverse events for TURP and PAE along with rates of retreatment because of complications or clinical failure were obtained from peer-reviewed literature. A decision tree-based Markov model was created, analyzing long-term cost-effectiveness for TURP and PAE from a US health care sector perspective. Cost-effectiveness over a time frame of 5 years was estimated while assuming a willingness to pay of $50,000 per quality-adjusted life-year (QALY). The primary outcome was incremental cost-effectiveness ratio.

RESULTS

PAE resulted in overall cost of $6,464.92 and an expected outcome of 4.566 QALYs. In comparison, TURP cost $9,221.09 and resulted in expected outcome of 4.577 QALYs per treatment. The incremental cost-effectiveness ratio for TURP was $247,732.65 per QALY. On the basis of the willingness-to-pay threshold, PAE is cost effective compared with TURP.

CONCLUSIONS

On the basis of our model, PAE in comparison with TURP can be regarded as a cost-effective treatment option for patients with lower urinary tract symptoms within the US health care system.

Robotic-assisted simple prostatectomy after prostatic arterial embolization for large benign prostate hyperplasia: Initial experience

Background and objective

We aimed to evaluate the safety and efficacy of robot-assisted simple prostatectomy (RASP) after prostatic arterial embolization (PAE) in large benign prostatic hyperplasia (BPH).

Material and methods

This retrospective study included 11 cases of PAE and subsequent RASP, performed on 11 patients with BPH from March 2018 to September 2020. Clinical information on the patients was collected before surgery and 3 months after surgery. For the quantification of lower urinary tract symptoms (LUTS), International Prostate Symptom Scores (IPSSs), prostate-specific antigen (PSA) levels, urinary peak flow rate (Qmax), voided volume (Vvol), and postvoid residual volume (PVR) were measured.

Results

PAE and the subsequent RASP were successfully performed in all 11 patients. The mean total prostate volume was 129.7 ± 65.1 mL, and the transitional zone volume was 71.7 ± 5.9 mL. The mean resected prostate volume was 60.8 ± 26.1 mL. The mean hemoglobin level of the patients prior to PAE was 14.2 ± 2.3 g/dL, and one day after RASP, the hemoglobin level was 12.4 ± 1.9 g/dL. The outcome indicated that there was a considerable decline in IPSS and PVR after RASP was performed compared to before PAE (21.6 ± 9.4 vs. 10.6 ± 8.0 and 159.4 ± 145.8 mL vs. 43.9 ± 45.9 mL). Qmax and Vvol significantly improved after RASP was performed (7.6 ± 5.2 mL/s vs. 26.1 ± 12.6 mL/s; 114.2 ± 92.5 mL vs. 192.4 ± 91.8 mL, respectively).

Conclusion

This research demonstrated that RASP could be performed safely and effectively after PAE in patients with large BPH.

Prostatic arterial embolization for the treatment of lower urinary tract symptoms in men with benign prostatic hyperplasia

BACKGROUND

A variety of minimally invasive surgical approaches are available as an alternative to transurethral resection of the prostate (TURP) for management of lower urinary tract symptoms (LUTS) in men with benign prostatic hyperplasia (BPH). Prostatic arterial embolization (PAE) is a relatively new, minimally invasive treatment approach.

OBJECTIVES

To assess the effects of PAE compared to other procedures for treatment of LUTS in men with BPH.

SEARCH METHODS

We performed a comprehensive search the Cochrane Library, MEDLINE, Embase, three other databases, trials registries, other sources of grey literature, and conference proceedings with no restrictions on language of publication or publication status, up to 8 November 2021.

SELECTION CRITERIA

We included parallel-group randomized controlled trials (RCTs), as well as non-randomized studies (NRS, limited to prospective cohort studies with concurrent comparison groups) enrolling men over the age of 40 years with LUTS attributed to BPH undergoing PAE versus TURP or other surgical interventions.  DATA COLLECTION AND ANALYSIS: Two review authors independently classified studies for inclusion or exclusion and abstracted data from the included studies. We performed statistical analyses by using a random-effects model and interpreted them according to the Cochrane Handbook for Systematic Reviews of Interventions. We used GRADE guidance to rate the certainty of evidence of RCTs and NRSs.  MAIN RESULTS: We found data to inform two comparisons: PAE versus TURP (six RCTs and two NRSs), and PAE versus sham (one RCT). Mean age was 66 years, International Prostate Symptom Score (IPSS) was 22.8, and prostate volume of participants was 72.8 mL. This abstract focuses on the comparison of PAE versus TURP as the primary topic of interest. Prostatic arterial embolization versus transurethral resection of the prostate We included six RCTs and two NRSs with short-term (up to 12 months) follow-up, and two RCTs and one NRS with long-term follow-up (13 to 24 months).  Short-term follow-up: based on RCT evidence, there may be little to no difference in urologic symptom score improvement measured by the International Prostatic Symptom Score (IPSS) on a scale from 0 to 35, with higher scores indicating worse symptoms (mean difference [MD] 1.72, 95% confidence interval [CI] -0.37 to 3.81; 6 RCTs, 360 participants; I² = 78%; low-certainty evidence). There may be little to no difference in quality of life as measured by the IPSS-quality of life question on a scale from 0 to 6, with higher scores indicating worse quality of life between PAE and TURP, respectively (MD 0.28, 95% CI -0.28 to 0.84; 5 RCTs, 300 participants; I² = 63%; low-certainty evidence). While we are very uncertain about the effects of PAE on major adverse events (risk ratio [RR] 0.75, 95% CI 0.19 to 2.97; 4 RCTs, 250 participants; I² = 24%; very low-certainty evidence), PAE likely increases retreatments (RR 3.20, 95% CI 1.41 to 7.27; 4 RCTs, 303 participants; I² = 0%; moderate-certainty evidence). PAE may make little to no difference in erectile function measured by the International Index of Erectile Function-5 on a scale from 1 to 25, with higher scores indicating better function (MD -0.50 points, 95% CI -5.88 to 4.88; 2 RCTs, 120 participants; I² = 68%; low-certainty evidence). Based on NRS evidence, PAE may reduce the occurrence of ejaculatory disorders (RR 0.51, 95% CI 0.35 to 0.73; 1 NRS, 260 participants; low-certainty evidence). Long-term follow-up: based on RCT evidence, PAE may result in little to no difference in urologic symptom scores (MD 2.58 points, 95% CI -1.54 to 6.71; 2 RCTs, 176 participants; I² = 73%; low-certainty evidence) and quality of life (MD 0.50 points, 95% CI -0.03 to 1.04; 2 RCTs, 176 participants; I² = 29%; low-certainty evidence). We are very uncertain about major adverse events (RR 0.91, 95% CI 0.20 to 4.05; 2 RCTs, 206 participants; I² = 72%; very low-certainty evidence). PAE likely increases retreatments (RR 3.80, 95% CI 1.32 to 10.93; 1 RCT, 81 participants; moderate-certainty evidence). While PAE may result in little to no difference in erectile function (MD 3.09 points, 95% CI -0.76 to 6.94; 1 RCT, 81 participants; low-certainty evidence), PAE may reduce the occurrence of ejaculatory disorders (RR 0.67, 95% CI 0.45 to 0.98; 1 RCT, 50 participants; low-certainty evidence).

AUTHORS' CONCLUSIONS

Compared to TURP, PAE may provide similar improvement in urologic symptom scores and quality of life. While we are very uncertain about major adverse events, PAE likely increases retreatment rates. While erectile function may be similar, PAE may reduce ejaculatory disorders. Certainty of evidence for the outcomes of this review was low or very low except for retreatment (moderate-certainty evidence), signaling that our confidence in the reported effect size is limited or very limited, and that this topic should be better informed by future research.

Protection of nontarget structures in prostatic artery embolization

Objective

To describe the efficacy and safety of protective embolization during prostatic artery embolization, as well as to discuss its clinical relevance.

Materials and Methods

This was a retrospective, observational, single-center study including 39 patients who underwent prostatic artery embolization to treat lower urinary tract symptoms related to benign prostatic hyperplasia between June 2008 and March 2018. Follow-up evaluations, performed at 3 and 12 months after the procedure, included determination of the International Prostate Symptom Score, a quality of life score, and prostate-specific antigen levels, as well as ultrasound, magnetic resonance imaging, and uroflowmetry.

Results

Protective embolization was performed in 45 arteries: in the middle rectal artery in 19 (42.2%); in the accessory internal pudendal artery in 11 (24.4%); in an internal pudendal artery anastomosis in 10 (22.2%); in the superior vesical artery in four (8.9%); and in the obturator artery in one (2.2%). There was one case of nontarget embolization leading to a penile ulcer, which was attributed to reflux of microspheres to an unprotected artery. There were no complications related to the protected branches. All of the patients showed significant improvement in all of the outcomes studied (p < 0.05), and none reported worsening of sexual function during follow-up.

Conclusion

Protective embolization can reduce nontarget embolization during prostatic artery embolization without affecting the results of the procedure. In addition, no adverse events other than those expected or previously reported were observed. Therefore, protective embolization of pudendal region is safe.

Outcomes of Prostate Artery Embolisation in Patients with Severe Symptoms of Benign Prostate Hyperplasia

Background

Benign prostatic hyperplasia (BPH) is associated with severe lower urinary tract symptoms (LUTS). The severity of LUTS is assessed by the International Prostate Symptoms Score (IPSS). Prostate artery embolisation (PAE) is a newly available method for combating LUTS. This study aims to assess the outcomes of PAE in reducing LUTS and prostate volume in patients with BPH.

Methods

Patients diagnosed with BPH with severe LUTS who had undergone PAE were included. Their IPSS score was ≥ 20 despite medical therapy. PAE was performed via the unilateral femoral artery using various types of embolic material. Bilateral or unilateral embolisation of the prostate artery was considered a technical success. The severity of LUTS pre- and post-PAE were assessed using IPSS while prostate volume pre- and post-PAE were assessed by ultrasound and magnetic resonance imaging (MRI).

Results

Ninety percent of patients had technical success and one required transurethral resection of the prostate (TURP). The mean IPSS reduction at the final follow-up was 12.9 (P < 0.028). The mean reduction of prostate volume at the last follow-up by ultrasound was 114.99 mL (P < 0.028) and by MRI was 29.17 mL (P < 0.028).

Conclusion

PAE is safe and effective in reducing severe LUTS and prostate gland volume in BPH patients.

Minimally Invasive Treatments for Benign Prostatic Hyperplasia: Systematic Review and Network Meta-Analysis

PURPOSE

To review and indirectly compare the outcomes of minimally invasive therapies for the treatment of lower urinary tract symptoms secondary to benign prostatic hyperplasia.

MATERIALS AND METHODS

A literature search via Medline and Cochrane Central databases was completed for randomized control studies published between January 2000 to April 2020 for the following therapies: Rezum, Urolift, Aquablation, and prostate artery embolization (PAE). Data on the following variables were included: international Prostate Symptom Score (IPSS), maximum urinary flow rate (Qmax), quality of life (QoL), and post-void residual (PVR). Standard mean differences between treatments were compared through a meta-analysis using transurethral resection of the prostate (TURP) to assess differences in treatment effect.

RESULTS

No significant difference in outcomes between therapies were noted for IPSS at the 3-, 6-, and 12-month follow-ups. Although outcomes for rezum were only available out to 3 months, there were no consistently significant differences in outcomes when comparing Aquablation vs PAE vs Rezum. TURP PVR was significantly better than Urolift at 3-, 6-, and 12 months. No significant differences in minor or major AEs were noted.

CONCLUSION

Although significant differences in outcomes were limited, aquablation and PAE were the most durable at 12 months. PAE has been well studied on multiple randomized control trials with minimal adverse events while aquablation has limited high quality data and has been associated with bleeding-related complications.

Retrospective observation of the efficacy and safety of prostatic artery embolization combined with transurethral resection of the prostate and simple transurethral resection of the prostate in the treatment of large (> 100 mL) benign prostatic hyperplasia

PURPOSE

To retrospectively compare the efficacy and safety of prostatic artery embolization (PAE) combined with transurethral resection of the prostate (TURP) and simple TURP in treating large (> 100 mL) benign prostatic hyperplasia (BPH).

METHODS

We retrospectively analyzed the clinical data of 13 and 17 patients with large BPH who underwent TURP and PAE + TURP, respectively, from January 2016 to January 2020. The changes in various indices before and after surgery were compared between the two groups.

RESULTS

In the PAE + TURP group, the operation time (OT), intraoperative blood loss (BL), postoperative bladder flushing time (PBFT), and postoperative catheter retention time (PCRT) were lower, and the speed of the excised lesion (SEL) was higher than that in the TURP group (P < 0.05). Following-up for 12 months, the prostatic volume (PV), maximum urinary flow rate (Qmax), postvoid residual volume (PVR), International Prostate Symptom Score (IPSS), quality of life (QoL) score, total prostate-specific antigen (T-PSA), and free prostate-specific antigen (F-PSA) in each group improved as compared to before the surgery (P < 0.05), and the above improved indicators, IPSS ratio, and obstructive symptoms in the PAE + TURP group were higher than those in the TURP group (P < 0.05). The incidence of postoperative complications in the PAE + TURP group was lower than that in the TURP group. We obtained the pathological picture of a prostate biopsy after PAE for the first time.

CONCLUSION

Compared to TURP alone, PAE + TURP should be promoted, because of its greater efficacy and safety in treating large BPH and fewer post-surgical complications.

Prostatic Artery Embolization: Indications, Preparation, Techniques, Imaging Evaluation, Reporting, and Complications

Benign prostatic hyperplasia (BPH) is a noncancerous growth of the transitional zone of the prostate, which surrounds the prostatic urethra. Consequently, it can cause lower urinary tract symptoms (LUTS) and bladder outlet obstruction symptoms that may substantially reduce a patient's quality of life. Several treatments are available for BPH, including medications such as α-blockers and 5α-reductase inhibitors and surgical options including transurethral resection of the prostate and prostatectomy. Recently, prostatic artery embolization (PAE) has emerged as a minimally invasive treatment option for selected men with BPH and moderate to severe LUTS. Adequate pre- and postprocedural evaluations with clinical examinations and questionnaires, laboratory tests, and urodynamic and imaging examinations (particularly US, MRI, and CT) are of key importance to achieve successful treatment. Considering that the use of PAE has been increasing in tertiary hospital facilities, radiologists and interventional radiologists should be aware of the main technical concepts of PAE and the key features to address in imaging reports in pre- and postprocedural settings. An invited commentary by Lopera is available online. Online supplemental material is available for this article. ^©RSNA, 2021.

Minimally invasive treatments for lower urinary tract symptoms in men with benign prostatic hyperplasia: a network meta-analysis

BACKGROUND

A variety of minimally invasive treatments are available as an alternative to transurethral resection of the prostate (TURP) for management of lower urinary tract symptoms (LUTS) in men with benign prostatic hyperplasia (BPH). However, it is unclear which treatments provide better results.

OBJECTIVES

Our primary objective was to assess the comparative effectiveness of minimally invasive treatments for lower urinary tract symptoms in men with BPH through a network meta-analysis. Our secondary objective was to obtain an estimate of relative ranking of these minimally invasive treatments, according to their effects.

SEARCH METHODS

We performed a comprehensive search of multiple databases (CENTRAL, MEDLINE, Embase, Scopus, Web of Science and LILACS), trials registries, other sources of grey literature, and conference proceedings, up to 24 February 2021. We had no restrictions on language of publication or publication status.

SELECTION CRITERIA

We included parallel-group randomized controlled trials assessing the effects of the following minimally invasive treatments, compared to TURP or sham treatment, on men with moderate to severe LUTS due to BPH: convective radiofrequency water vapor therapy (CRFWVT); prostatic arterial embolization (PAE); prostatic urethral lift (PUL); temporary implantable nitinol device (TIND); and transurethral microwave thermotherapy (TUMT).

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the literature, extracted data, and assessed risk of bias. We performed statistical analyses using a random-effects model for pair-wise comparisons and a frequentist network meta-analysis for combined estimates. We interpreted them according to Cochrane methods. We planned subgroup analyses by age, prostate volume, and severity of baseline symptoms. We used risk ratios (RRs) with 95% confidence intervals (CIs) to express dichotomous data and mean differences (MDs) with 95% CIs to express continuous data. We used the GRADE approach to rate the certainty of evidence.

MAIN RESULTS

We included 27 trials involving 3017 men, mostly over age 50, with severe LUTS due to BPH. The overall certainty of evidence was low to very low due to concerns regarding bias, imprecision, inconsistency (heterogeneity), and incoherence. Based on the network meta-analysis, results for our main outcomes were as follows. Urologic symptoms (19 studies, 1847 participants): PUL and PAE may result in little to no difference in urologic symptoms scores (MD of International Prostate Symptoms Score [IPSS]) compared to TURP (3 to 12 months; MD range 0 to 35; higher scores indicate worse symptoms; PUL: 1.47, 95% CI -4.00 to 6.93; PAE: 1.55, 95% CI -1.23 to 4.33; low-certainty evidence). CRFWVT, TUMT, and TIND may result in worse urologic symptoms scores compared to TURP at short-term follow-up, but the CIs include little to no difference (CRFWVT: 3.6, 95% CI -4.25 to 11.46; TUMT: 3.98, 95% CI 0.85 to 7.10; TIND: 7.5, 95% CI -0.68 to 15.69; low-certainty evidence). Quality of life (QoL) (13 studies, 1459 participants): All interventions may result in little to no difference in the QoL scores, compared to TURP (3 to 12 months; MD of IPSS-QoL score; MD range 0 to 6; higher scores indicate worse symptoms; PUL: 0.06, 95% CI -1.17 to 1.30; PAE: 0.09, 95% CI -0.57 to 0.75; CRFWVT: 0.37, 95% CI -1.45 to 2.20; TUMT: 0.65, 95% CI -0.48 to 1.78; TIND: 0.87, 95% CI -1.04 to 2.79; low-certainty evidence). Major adverse events (15 studies, 1573 participants): TUMT probably results in a large reduction of major adverse events compared to TURP (RR 0.20, 95% CI 0.09 to 0.43; moderate-certainty evidence). PUL, CRFWVT, TIND and PAE may also result in a large reduction in major adverse events, but CIs include substantial benefits and harms at three months to 36 months; PUL: RR 0.30, 95% CI 0.04 to 2.22; CRFWVT: RR 0.37, 95% CI 0.01 to 18.62; TIND: RR 0.52, 95% CI 0.01 to 24.46; PAE: RR 0.65, 95% CI 0.25 to 1.68; low-certainty evidence). Retreatment (10 studies, 799 participants): We are uncertain about the effects of PAE and PUL on retreatment compared to TURP (12 to 60 months; PUL: RR 2.39, 95% CI 0.51 to 11.1; PAE: RR 4.39, 95% CI 1.25 to 15.44; very low-certainty evidence). TUMT may result in higher retreatment rates (RR 9.71, 95% CI 2.35 to 40.13; low-certainty evidence). Erectile function (six studies, 640 participants): We are very uncertain of the effects of minimally invasive treatments on erectile function (MD of International Index of Erectile Function [IIEF-5]; range 5 to 25; higher scores indicates better function; CRFWVT: 6.49, 95% CI -8.13 to 21.12; TIND: 5.19, 95% CI -9.36 to 19.74; PUL: 3.00, 95% CI -5.45 to 11.44; PAE: -0.03, 95% CI -6.38, 6.32; very low-certainty evidence). Ejaculatory dysfunction (eight studies, 461 participants): We are uncertain of the effects of PUL, PAE and TUMT on ejaculatory dysfunction compared to TURP (3 to 12 months; PUL: RR 0.05, 95 % CI 0.00 to 1.06; PAE: RR 0.35, 95% CI 0.13 to 0.92; TUMT: RR 0.34, 95% CI 0.17 to 0.68; low-certainty evidence). TURP is the reference treatment with the highest likelihood of being the most efficacious for urinary symptoms, QoL and retreatment, but the least favorable in terms of major adverse events, erectile function and ejaculatory function. Among minimally invasive procedures, PUL and PAE have the highest likelihood of being the most efficacious for urinary symptoms and QoL, TUMT for major adverse events, PUL for retreatment, CRFWVT and TIND for erectile function and PUL for ejaculatory function.

AUTHORS' CONCLUSIONS

Minimally invasive treatments may result in similar or worse effects concerning urinary symptoms and QoL compared to TURP at short-term follow-up. They may result in fewer major adverse events, especially in the case of PUL and PAE; resulting in better rankings for symptoms scores. PUL may result in fewer retreatments compared to other interventions, especially TUMT, which had the highest retreatment rates at long-term follow-up. We are very uncertain about the effects of these interventions on erectile function. There was limited long-term data, especially for CRFWVT and TIND. Future high-quality studies with more extended follow-up, comparing different, active treatment modalities, and adequately reporting critical outcomes relevant to patients, including those related to sexual function, could provide more information on the relative effectiveness of these interventions.

Prostatic Artery Embolization: An Alternative Treatment for Benign Prostatic Hyperplasia

Purpose Prostatic artery embolization (PAE) has emerged as a minimally invasive alternative for patients with prostates >80 mL and has demonstrated lower morbidity rates. We sought to evaluate PAE at a single tertiary medical center. Methods A retrospective review of all patients who underwent PAE was completed. Demographic, clinicopathologic, procedure, and outcome data were collected to include international prostatic symptom score (IPSS) and quality of life (QoL) assessments. Results The pre-PAE mean prostate-specific antigen (PSA) was 8.4 ng/mL, mean prostate volume was 146.9 mL (9% >200 mL), and mean postvoid residual (PVR) was 208.2 mL (21.9% 200–300 mL). IPSS mean was 19.8 and QoL was “mostly dissatisfied.” Following PAE, mean PSA was reduced by 3.2 ng/mL (38.1%, p = 0.3014), the mean prostate volume reduction was 59.2 mL (40.3%, n = 19, p < 0.0001), and the average PVR reduction was 150.3 mL (72.2%, n = 27, p = 0.0002). Average IPSS score was also lower (11.9; 60.1%, n = 25, p < 0.0001) and QoL was reduced to “mostly satisfied” (p < 0.0001). Technical success was 100% with 24% minor morbidities. Conclusion PAE is a successful treatment for patients with BPH resulting in large prostates that are not good candidates for simple prostatectomy, providing optimal care with less operative and postoperative complications.

Prostatic Artery Embolization for Benign Prostatic Hyperplasia Treatment: A Russian Multicenter Study in More Than 1,000 Treated Patients

Benign prostatic hyperplasia (BPH) is one of the most common diseases of the genitourinary system. The prevalence of BPH increases in men with advancing age. While transurethral resection of the prostate gland entails complications such as retrograde ejaculation, urinary incontinence, hematuria, urethral strictures, bladder neck sclerosis, and other adverse events, it is necessary to apply minimally invasive surgical methods such as superselective embolization of the prostatic arteries (PAE), particularly Proximal Embolization First Then Distal Embolization (PErFecTED). The data from 1,015 BPH patients who underwent endovascular surgery demonstrate the benefits of PErFecTED treatment during 24 months after surgery. Both Quality of Life score and International Prostate Symptom Score were around three times better in the PErFecTED group and remained stable during the entire observation period. However, the technique needs to be improved due to the high risk of postembolization syndrome.

Perioperative Blood Loss after Preoperative Prostatic Artery Embolization in Patients Undergoing Simple Prostatectomy: A Propensity Score‒Matched Study

PURPOSE

To assess perioperative blood loss following prostatic artery embolization (PAE) before surgery in patients undergoing simple prostatectomy.

METHODS

A retrospective chart review was used to identify 63 patients (mean age, 65.3 ± 8.0 years) with prostatic hypertrophy and severe lower urinary tract symptoms who underwent prostatectomy from September 2014 to December 2019, 18 (28.5%) of whom underwent PAE before surgery. Demographic data, pertinent laboratory results, procedural or operative information, hospital course details, and pathology reports were obtained. A 2:1 propensity score‒matching analysis was performed to compare intraoperative blood loss in patients who underwent prostatectomy alone with intraoperative blood loss in those who first underwent bilateral PAE before surgery.

RESULTS

Sixteen (89%) of the 18 patients underwent bilateral PAE before surgery. Thirty-two patients who underwent prostatectomy without embolization before surgery were selected for the 2:1 propensity score‒matched analysis based on age, race, surgery type, prostate gland size, and comorbidities. The mean estimated blood loss (EBL) for prostatectomy alone was 545 ± 380 mL (mean ± standard deviation). There was a statistically significant reduction in the EBL for patients who underwent bilateral PAE (303 ± 227 mL, P < .01). The operative time was also significantly decreased for patients who underwent PAE before surgery (P < .05). For patients who underwent PAE, there were no complications related to the procedure.

CONCLUSIONS

Bilateral PAE before surgery appears to be safe and may be effective in reducing perioperative bleeding and operative time.

Patients' perspective on prostatic artery embolization: A qualitative study

Objectives

The aim was to describe the patients' experience of undergoing prostatic artery embolization.

Methods

A retrospective qualitative interview study was undertaken with 15 patients of mean age 73 years who had undergone prostatic artery embolization with a median duration of 210 min at two medium sized hospitals in Sweden. The reasons for conducting prostatic artery embolization were clean intermittent catheterization (n = 4), lower urinary tract symptoms (n = 10) or haematuria (n = 1). Data were collected through individual, semi-structured telephone interviews 1-12 months after treatment and analysed using qualitative content analysis.

Results

Four categories with sub-categories were formulated to describe the results: a diverse experience; ability to control the situation; resumption of everyday activities and range of opinions regarding efficacy of outcomes. Overall, the patients described the procedure as painless, easy and interesting and reported that while the procedure can be stressful, a calm atmosphere contributed to achieving a good experience. Limitations on access to reliable information before, during and after the procedure were highlighted as a major issue. Practical ideas for improving patient comfort during the procedure were suggested. Improved communications between treatment staff and patients were also highlighted. Most patients could resume everyday activities, some felt tired and bruising caused unnecessary worry for a few. Regarding functional outcome, some patients described substantial improvement in urine flow while others were satisfied with regaining undisturbed night sleep. Those with less effect were considering transurethral resection of the prostate as a future option. Self-enrolment to the treatment and long median operation time may have influenced the results.

Conclusions

From the patients' perspective, prostatic artery embolization is a well-tolerated method for treating benign prostate hyperplacia.

Superselective prostatic artery embolization in the treatment of large benign prostatic hyperplasia

PURPOSE

To evaluate the use of prostatic artery embolization (PAE) as a treatment option for patients with symptomatic benign prostatic hyperplasia (BPH) with prostate volumes of 80 cc and more.

MATERIALS AND METHODS

The study included 75 patients with high anesthesia-related risks for conventional surgery (TURP). All patients were surveyed for symptom burden, using IPSS and quality of life score. The prostate volume was determined by transrectal ultrasonography (TRUS). At baseline, prostate-specific antigen (PSA) level was obtained in all patients. Urodynamics was evaluated using uroflowmetry. Clinical outcomes were assessed at follow-up 1, 3, 6, 12, and 24 months after PAE.

RESULTS

The prostate volume decreased significantly at months 1 and 3 post-treatment; the prostate continued shrinking until month 12, and the size was then stabilized. At month 24, prostate volume decreased by 40.82%, from 134.0 ± 8.3 mL at baseline to 79.3 ± 6.6 mL. Postvoid residual (PVR) urine volume was significantly decreased from 55.9 ± 5.3 mL to 22.0 ± 1.8 mL 1 month after PAE (p < 0.001). Qmax increased from 9.2 ± 0.3 mL/s to 15.7 ± 0.4 mL/s. IPSS score following PAE decreased from 28.2 ± 0.7 to 9.7 ± 0.8 (p < 0.001). QoL improvement was observed from 4.8 ± 0.2 at baseline to 1.8 ± 0.2 at month 24 (p < 0.001). Decreased activity and density of adenomatous tissue resulted in decreased total PSA levels: from 5.9 ± 1.1 ng/mL to 2.6 ± 0.2 ng/mL (p < 0.001). TURP became feasible in 35 patients due to reduction of prostate volumes below 80 mL after PAE.

CONCLUSIONS

PAE was effective in relieving LUTS and reducing prostate size, and may be considered as a preoperative approach for patients with large prostate.

A state-of-art review on the preservation of sexual function among various minimally invasive surgical treatments for benign prostatic hyperplasia: Impact on erectile and ejaculatory domains

There is a strong association between benign prostatic hyperplasia (BPH)/lower urinary tract symptoms (LUTS) and sexual dysfunction. While transurethral resection of the prostate (TURP) is considered the standard BPH treatment, it is however associated with a high rate of erectile and ejaculatory dysfunctions. Over the past decade, new and novel minimally invasive BPH therapies have been shown to improve various parameters of voiding domains while minimizing adverse sexual effects. These minimally invasive BPH therapies can be largely be divided into those with cavitating technology (Rezum, Histotripsy, Aquablation), intra-prostatic injections (Botulinum neurotoxin Type A, Fexapotide Triflutate, prostate specific antigen-activated protoxin PRX-302), and mechanical devices which include intraprostatic stents (Urospinal 2™, Memotherm™, Memokath™, and Allium triangular prostatic stent™) and intraprostatic devices (iTIND™, Urolift™), as well as prostatic artery embolization. Published literature on these technologies showed reasonable preservation of erectile function with limited data reported on ejaculatory domain. Further validation of the performance of these novel minimally invasive treatment options for LUTS due to BPH in well-designed and multi-centre studies are desired, to evaluate their role (or lack of such a role) in clinical practice and whether these BPH therapies can provide equivalent standard or better than TURP.

Safety and efficacy of prostatic artery embolization for large benign prostatic hyperplasia in elderly patients

OBJECTIVE

To assess the safety and efficacy of prostatic arterial embolization (PAE) for elderly patients with lower urinary tract symptoms secondary to large benign prostatic hyperplasia.

METHODS

Twenty-eight patients (>80 years of age) with prostate volume >80 mL were enrolled from October 2016 to October 2019. PAE was performed using microspheres and functional results were evaluated at 1, 3, 6, and 12 months postoperatively. The following data were recorded: International Prostate Symptom Score (IPSS), quality of life (QoL), maximum urine flow rate (Qmax), post-void residual urine volume, prostate volume and total prostate-specific antigen level.

RESULTS

Selective prostatic arterial catheterization and embolization were achieved in 27 of 28 patients. Follow-up data were available for those 27 patients until 12 months postoperatively. Significant improvements were found at all postoperative time points in terms of the mean IPSS, mean QoL score, mean Qmax, mean post-void residual urine volume, mean total prostate-specific antigen level, and mean prostate volume. The overall complication rate was 46.4%.

CONCLUSIONS

PAE is an efficacious and safe treatment for elderly patients with large prostate volume; it may offer an effective approach for patients who are not candidates for open or endoscopic surgical procedures because of comorbidities.

Prostatic arterial embolization for the treatment of lower urinary tract symptoms in men with benign prostatic hyperplasia

BACKGROUND

A variety of minimally invasive surgical approaches are available as an alternative to transurethral resection of the prostate (TURP) for management of lower urinary tract symptoms (LUTS) in men with benign prostatic hyperplasia (BPH). Prostatic arterial embolization (PAE) is a relatively new, minimally invasive treatment approach.

OBJECTIVES

To assess the effects of PAE compared to other procedures for treatment of LUTS in men with BPH.

SEARCH METHODS

We performed a comprehensive search using multiple databases (The Cochrane Library, MEDLINE, Embase, LILACS, Scopus, Web of Science, and Google Scholar), trials registries, other sources of grey literature, and conference proceedings with no restrictions on language of publication or publication status, up until 25 September 2020.

SELECTION CRITERIA

We included parallel-group randomized controlled trials (RCTs), as well as non-randomized studies (NRS, limited to prospective cohort studies with concurrent comparison groups) enrolling men over the age of 40 with LUTS attributed to BPH undergoing PAE versus TURP or other surgical interventions.  DATA COLLECTION AND ANALYSIS: Two review authors independently classified studies for inclusion or exclusion and abstracted data from the included studies. We performed statistical analyses by using a random-effects model and interpreted them according to the Cochrane Handbook for Systematic Reviews of Interventions. We used GRADE guidance to rate the certainty of evidence of RCTs and NRSs.  MAIN RESULTS: We found data to inform two comparisons: PAE versus TURP (six RCTs and two NRSs), and PAE versus sham (one RCT). Mean age, IPSS, and prostate volume of participants were 66 years, 22.8, and 72.8 mL, respectively. This abstract focuses on the comparison of PAE versus TURP as the primary topic of interest. PAE versus TURP We included six RCTs and two NRSs with short-term (up to 12 months) follow-up and one RCT with long-term follow-up (13 to 24 months).  Short-term follow-up: based on RCT evidence, there may be little to no difference in urologic symptom score improvement (mean difference [MD] 1.55, 95% confidence interval [CI] -0.40 to 3.50; 369 participants; 6 RCTs; I² = 75%; low-certainty evidence) measured by the International Prostatic Symptom Score (IPSS) on a scale from 0 to 35, with higher scores indicating worse symptoms. There may be little to no difference in quality of life (MD 0.16, 95% CI -0.37 to 0.68; 309 participants; 5 RCTs; I² = 56%; low-certainty evidence) as measured by the IPSS quality of life question on a scale from 0 to 6, with higher scores indicating worse quality of life between PAE and TURP, respectively. While we are very uncertain about the effects of PAE on major adverse events (risk ratio [RR] 0.71, 95% CI 0.16 to 3.10; 250 participants; 4 RCTs; I² = 26%; very low-certainty evidence), PAE may increase re-treatments (RR 3.64, 95% CI 1.02 to 12.98; 204 participants; 3 RCTs; I² = 0%; low-certainty evidence). Based on 18 re-treatments per 1000 men in the TURP group, this corresponds to 47 more (0 more to 214 more) per 1000 men undergoing PAE.   We are very uncertain about the effects on erectile function (MD -0.03, 95% CI -6.35 to 6.29; 129 participants; 2 RCTs; I² = 78%; very low-certainty evidence) measured by the International Index of Erectile Function at 5 on a scale from 1 to 25, with higher scores indicating better function. NRS evidence when available yielded similar results. Based on evidence from NRS, PAE may reduce the occurrence of ejaculatory disorders (RR 0.51, 95% CI 0.35 to 0.73; 260 participants; 1 NRS; low-certainty evidence). Longer-term follow-up: based on RCT evidence, we are very uncertain about the effects of PAE on urologic symptom scores (MD 0.30, 95% CI -3.17 to 3.77; 95 participants; very low-certainty evidence) compared to TURP. Quality of life may be similar (MD 0.20, 95% CI -0.49 to 0.89; 95 participants; low-certainty evidence). We are also very uncertain about major adverse events (RR 1.96, 95% CI 0.63 to 6.13; 107 participants; very low-certainty evidence). We did not find evidence on erectile function and ejaculatory disorders. Based on evidence from NRS, PAE may increase re-treatment rates (RR 1.51, 95% CI 0.43 to 5.29; 305 participants; low-certainty evidence); based on 56 re-treatments per 1000 men in the TURP group. this corresponds to 143 more (25 more to 430 more) per 1000 men in the PAE group.  AUTHORS' CONCLUSIONS: Compared to TURP up to 12 months (short-term follow-up), PAE may provide similar improvement in urologic symptom scores and quality of life. While we are very uncertain about major adverse events, PAE may increase re-treatment rates. We are uncertain about erectile function, but PAE may reduce ejaculatory disorders. Longer term (follow-up of 13 to 24 months), we are very uncertain as to how both procedures compare with regard to urologic symptom scores, but quality of life appears to be similar. We are very uncertain about major adverse events but PAE may increase re-treatments. We did not find longer term evidence on erectile function and ejaculatory disorders. Certainty of evidence for the main outcomes of this review was low or very low, signalling that our confidence in the reported effect size is limited or very limited, and that this topic should be better informed by future research.

The application of prostate artery embolization in the management of intractable prostate bleeding

Introduction

Prostate cancer is one of the most common malignancies affecting European men. Sequelae of the advanced malignancy require invasive procedures which may not be eligible especially for old, debilitated patients. The aim of this manuscript is to review the outcomes of prostate artery embolization in the management of refractory bleeding.

Material and methods

A PubMed database search was done for all English language articles on prostate artery embolization in prostate cancer, published between 2003 and 2019. For current review, information related to number, age of the patients, aetiology of the hematuria, bilateral or unilateral procedure, type of embolic material, technical and clinical success, complications, recurrent hematuria, hematocrit and hemoglobin levels were analyzed.

Results

A total of 10 original full-text comparative and non-comparative (case series) studies were reviewed. Minor complications described in the literature ranged from 10–50%. After prostate artery embolization, the recurrence of the haematuria occurred in 10–57% of the patients. Moreover, prostate artery embolization successfully treated lower urinary tract symptoms and urinary retention in prostate cancer patients.

Conclusions

The procedure appears safe, burdened with low risk of complications and accomplishes technical and clinical success. It is a promising option for patients with hemorrhage, but due to the scarcity of data further investigations are needed.

Benign Prostatic Hyperplasia: A Brief Overview of Pathogenesis, Diagnosis, and Current State of Therapy

As prostatic artery embolization is assuming an increasingly important role in the management of benign prostatic hyperplasia, it is important for the practicing interventional radiologist to have a deep understanding of all aspects of the disease process and the available treatment options. This paper provides a comprehensive overview of the pathophysiology, diagnosis and management options for benign prostatic hyperplasia with an emphasis on the surgical and medical treatments.

Sonographic evaluation of prostatic artery embolization: Far beyond size measurements

Prostatic artery embolization (PAE) has gained acceptance as a minimally invasive, safe and effective treatment of symptomatic benign prostatic hyperplasia. Radiologic imaging is an indispensable part of post-interventional evaluation of PAE and serves both clinical and investigational purposes. In this context, ultrasonography (US) has a central and multifaceted role. Gray-scale US is routinely utilized for measurement of significant outcome parameters (prostatic volume, intra-vesical prostatic protrusion and post-void residual volume) before and after PAE. Improvement of these parameters may become more obvious one-month post-PAE, or later. Contrast-enhanced US (CEUS) with intravenous administration of a second-generation echo-enhancer can demonstrate prostatic infarcts (as enhancement defects) immediately post-PAE and monitor their resolution over time. The volume of prostatic infarcts can also be measured and compared to prostatic volume. Prostatic infarction is a definite sign of the local efficacy of PAE and a predictor of prostate shrinkage and (at least in some patients) of clinical success. CEUS can also be performed intraoperatively in the angio-suite, for on-site evaluation of the ischemic effect; a variation of this technique, with intraarterial (instead of intravenous) administration of diluted echo enhancer, can also be applied intraoperatively, to map the embolized territory and to prevent non-target embolization. Initial experience with US-elastographic techniques (shear-wave and strain elastography) has shown that they can detect and quantify the improvement of tissue elasticity post-PAE, thus providing new insights into the therapeutic mechanisms of this treatment. With utilization of high-end equipment, experience and standardized imaging protocols, US could be the primary modality for imaging evaluation of PAE.

Semi-automatic prostatic artery detection using cone-beam CT during prostatic arterial embolization

BACKGROUND

Due to the broad variability of the prostatic artery (PA), its origin, small calibers, and tortuous courses, prostatic arterial embolization (PAE) is challenging, time-consuming, and results in high radiation doses.

PURPOSE

To evaluate the accuracy of PA detection using cone-beam computed tomography (CBCT) performed from the aortic bifurcation in combination with a semi-automatic detection software in comparison to oblique view digital subtraction angiography (DSA) with internal iliac artery (IIA) injection.

MATERIAL AND METHODS

Twenty-two consecutive patients were included in this retrospective, IRB-approved study between July and December 2017. CBCT from the aorta and 30° oblique-view DSA from both IIAs were obtained for PA detection. Results of suggested PAs from the semi-automatic vessel detection software after CBCT and IIA DSA were compared. Moreover, dose area product (DAP) was recorded. Statistical analysis included Spearman's correlation, Mann-Whitney U test, and the Wilcoxon test considering P<0.05 as significant.

RESULTS

PA type was classified significantly better with CBCT compared to DSA (P=0.047). In IIA DSA, PAs could not be identified in 18% on the left and in 17% on the right side. CBCT detected all PAs, although truncation occurred in 59% because of the limited field of view. Mean DAP of the whole procedure was 257,161.32±127,909.36 mGy*cm². Mean DAPs were for a single DSA 14,502.51±9,437.67 mGy*cm² and for one CBCT 15,589.23±2,722.49 mGy*cm². A mean of 14.82 DSAs and only one CBCT were performed. CBCT accounted for 6% and DSA for 84% of the entire DAP of the procedure.

CONCLUSION

CBCT with semi-automatic feeding vessel detection software detects PAs more accurately than IIA DSA and may reduce radiation dose.

Clinical predictive factors in prostatic artery embolization for symptomatic benign prostatic hyperplasia: a comprehensive review

Prostatic artery embolization (PAE) has been established as a routine treatment for symptomatic benign prostatic hyperplasia (BPH) all over the world. With increasing clinical experience in the last decade, investigators have sufficient data to assess predictive factors with the purpose to guide patient selection and counseling for PAE or to individualize therapeutic plans after PAE. This paper is a comprehensive review to introduce the concept of clinical predictors and give a systemic classification of various predictive factors in PAE. The authors review each individual factor and its predictive capability and discuss the possible reasons for the inconsistent or conflicting findings in the literature. Based on current evidence, the baseline prostate volume, in particular the transition zone volume and transition zone index; 24 h post-PAE prostate-specific antigen (PSA) level; and prostate infarction and prostate volume reduction at 1–3 months have potential in prediction of treatment outcomes. Patients with Adenomatous-dominant BPH or with indwelling bladder catheter before PAE may have more benefits from PAE. Baseline intravesical prostatic protrusion (IPP), C-reactive protein (CRP) level at 48 h and early detection of prostate infarct at 1 day and 1 week after PAE need further investigating.

Indications, techniques, and role of new minimally invasive benign prostate hyperplasia surgical options

Novel emerging techniques for the surgical treatment of benign prostate hyperplasia (BPH) related to lower urinary tract symptoms are being investigated very seriously to help search for a better method, and the studies are getting their place in the literature. In this review article, UroLift^® system, (i)TIND^®, Aquablation^®, Rezūm® system, and prostatic artery embolization have been discussed according to the literature and both European and American urological guidelines. All related randomized controlled trials are discussed under the appropriate headings. Indications, technique, and the role of these minimally invasive surgical options for BPH are assessed. These methods, which are still being studied, are promising for the future. As the studies get completed, the indications will become clearer, and these techniques will find their respective places as the personalized treatment options.

Position Paper of the German Society for Interventional Radiology (DeGIR) on Prostatic Artery Embolization

BACKGROUND

 In recent years prostate artery embolization (PAE) evolved into a clinically established minimally invasive endovascular treatment option for lower urinary tract symptoms caused by benign prostate syndrome (BPS).

METHODS

 In this interdisciplinary position paper, initiated by the steering group for research of the German Society for Interventional Radiology (IR), the method of PAE is presented and discussed in the context of current evidence.

RESULTS

 PAE is a safe IR procedure for the treatment of BPS. In terms of symptom relief, measured with the IPSS (International Prostate Symptom Score), the PAE has comparable effect, similar to the historic gold standard, transurethral resection (TUR) of the prostate. With regard to reducing subvesical obstruction PAE is inferior to TUR, but does not limit subsequent surgery. Based on current evidence, PAE is recommended by the British National Institute for Health and Care Excellence as an alternative therapy. The feasibility under local anaesthesia and the preservation of sexual function are important arguments for patients in favour of interventional therapy. Patient selection and therapy concepts require close interdisciplinary collaboration between urologists and radiologists.

CONCLUSION

 Effectiveness and safety of PAE for the treatment of BPS are proven. Further randomized trials should focus on long term outcome and help to identify most suitable indications for PAE.

KEY POINTS

  · PAE, an endovascular procedure, is a patient-friendly, minimally invasive, alternative therapy option of the BPS. · PAE can reduce the symptoms of the lower urinary tract (LUTS), comparable to transurethral resection (TUR). The deobstructive and volume-reducing potential of the PAE is inferior to that of the TUR. · The main advantages of PAE are use of local anesthesia (no general anesthesia required), short patient recovery and maintenance of sexual function, including antegrade ejaculation.. · Based on current evidence PAE should be considered after conservative drug therapy and before TUR.. · The role of PAE in the context of other minimally invasive procedures (MIST) requires further evaluation with an open minded approach towards PAE.. · PAE is carried out by interventional radiologists, usually on a referral basis from urologists, and requires close interdisciplinary cooperation..

CITATION FORMAT

· Kovacs A, Bücker A, Grimm M et al. Position Paper of the German Society for Interventional Radiology (DeGIR) on Prostatic Artery Embolization. Fortschr Röntgenstr 2020; 192: 835 - 846.