Factors Predicting a Good Symptomatic Outcome After Prostate Artery Embolisation (PAE)

Prostate volume: does it predict patient outcomes following prostate artery embolisation? A retrospective cohort study

Prostate artery embolisation (PAE) is a minimally invasive procedure commonly performed to treat lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia. International Prostate Symptom Score (IPSS) is a validated patient questionnaire quantifying LUTS and is used for patient selection for PAE, but it is largely subjective. Prostate volume is an easily estimated objective parameter across multiple imaging modalities. No strict threshold of prostate volume is established as a selection criterion for PAE, but it is generally accepted that prostate volume should be over 40 to 50 mL.We looked at a sample of 65 cases performed at a large teaching hospital between 2017 and 2019 with a minimum of four years follow up. Embospheres between 100 to 500 microns were injected into the prostatic arteries bilaterally (if technically feasible). A 'bullet shape' model was used to estimate prostatic volume from initial CT. N = 13 had an estimated volume < 51 mL (range 31-50 mL). IPSS before and at 3 months post-procedure were collected.80% of patients indicated a beneficial response to PAE (IPSS improvement > 5). 23% of patients required further PAE procedure or surgery. No major complications were recorded. The mean change in IPSS under 51 mL compared to over 51 mL cohort was 10.2 versus 11 (standard deviation 7.5 versus 7.3) (p = 0.44, 2 tailed Student's T-test).There was no statistically significant difference in the IPSS improvement or outcome of small volume prostates under 51 mL compared to large volume. Our results suggest that prostate volume should not be used to exclude patients for PAE.

Prostatic Artery Embolization: Lessons From 551 Procedures at a Single-Center

RATIONALE AND OBJECTIVES

This retrospective study evaluates the efficacy and safety of Prostatic Artery Embolization (PAE) for the treatment of benign prostatic hyperplasia (BPH) over five years at a single center, conducted by an experienced interventional radiologist.

MATERIALS AND METHODS

We analyzed 551 PAE interventions from January 2019 to July 2023. Key metrics included patient demographics, procedural details (radiation exposure, particle size), complication rates, pre- and post-interventional prostatic volume (PV), Prostate-specific Antigen (PSA) levels, International Prostate Symptom Score (IPSS), Quality of Life (QoL) scores and International Index of Erectile Function (IIEF) scores. We assessed data normality, performed group and paired sample comparisons, and evaluated correlations.

RESULTS

For 551 men, the average patient age was 68.81 ± 8.61 years undergoing bilateral embolization. The particle size predominantly used was 100-300 µm (n = 441). PAE lead to significant (p < .001) reduction of both PV (-9.67 ± 14.52 mL) and PSA level (-2,65 ± 1.56 ng/mL) between pre- and three months after PAE. Substantial improvement were observed for IPSS (-9 points) and QoL scores (-2 points), with stable IIEF scores. Only minor complications (n = 16) were reported, and no major complications were observed. Between the first PAE in 2019 and the routinely performed PAE in 2023 significant (p < .0001) reductions in fluoroscopy (-25.2%), and procedural times (-26.1%) were observed.

CONCLUSION

In conclusion, PAE is a safe and effective treatment for BPH, offering significant improvements in lower urinary tract symptoms (LUTS) and QoL while maintaining sexual function.

Prostate artery embolization using n-butyl cyanoacrylate glue for symptomatic benign prostatic hyperplasia: A six-month outcome analysis in 103 patients

PURPOSE

The purpose of this study was to assess the feasibility, safety, and 6-month outcomes of prostate artery embolization (PAE) using N-butyl-cyanoacrylate (NBCA) glue as the only embolic agent in patients with benign prostatic hyperplasia (BPH)-related lower urinary tract symptoms.

MATERIALS AND METHODS

Patients with BPH-related lower urinary tract symptoms who were treated by PAE using methacryloxysulfolane-NBCA mixed with ethiodized oil (1:8 ratio) between September 2018 and January 2023 were retrospectively included. Vascular mapping was made using cone-beam computed tomography angiography. PAEs were performed as an outpatient procedure, under local anaesthesia. Outcomes were assessed at six months using the International Prostate Symptoms Score (IPSS) and associated quality-of-life score (IPSS-QoL), prostate-specific antigen (PSA) level, prostate volume, and International Index of Erectile Function form 5 (IIEF5).

RESULTS

A total of 103 men with a mean age of 68.4 ± 6 (standard deviation [SD]) years were included. Technical success rate was 100%. The mean fluoroscopy time was 26.4 ± 12.5 (SD) min and the median radiation dose was 23 980 mGy·cm (Q1, Q3: 16 770, 38 450). Compared to baseline, statistically significant improvements were observed at six months for the IPSS (8.9 ± 6.2 [SD] vs. 20.2 ± 6.5 [SD]; P = 0.01), IPSS-QoL (2.1 ± 1.4 [SD] vs. 5.1 ± 0.9 [SD]; P = 0.01), PSA level (3.6 ± 3.2 [SD] ng/mL vs. 4.8 ± 4.2 [SD] ng/mL; P = 0.0001), and prostate volume (78.6 ± 43.5 [SD] mL vs. 119.1 ± 65.7 [SD] mL; P = 0.01). Minor adverse events developed in 19/103 (18.4%) patients. No major complications occurred. Compared to baseline, the IIEF5 did not change significantly at six months (15.3 ± 6.8 [SD] vs. 15.8 ± 6.8 [SD]; P = 0.078).

CONCLUSION

PAE with NBCA is a feasible and safe method that provides good outcomes at six months in patients with BPH-related lower urinary tract symptoms. This method deserves further evaluation in randomized trials with longer follow-up.

Monopolar Transurethral Enucleoresection of Prostate: Feasibility of Modified Nesbit's Enucleoresection with Apical Release

Background: Transurethral resection of the prostate (TURP) has been the standard surgical treatment for Benign Hyperplasia of the Prostate (BPH) for decades. Our objective was to evaluate the outcome of our new technique: Monopolar Transurethral Enucleoresection of the Prostate (TUERP) with apical release (bring it all to centre). Methods: A prospective study of all cases undergoing TUERP at a tertiary centre from January 2020 to October 2022 was performed. Patient demographics, intraoperative variables and postoperative results along with follow-up data were collected. Data of all the cases who had completed a one-year follow-up post-surgery were included and analysed. Results: A total of 240 patients with complete data including a one-year follow-up were included. Mean prostatic volume was 55.3 ± 11.6 gm, and 28 (11.67%) cases were >100 gm. The mean operative time was 31.7 ± 7.6, and mean haemoglobin drop at 24 h was 0.73 ± 1.21 gm/dL. The overall complication rate was 16.67%, with only two (0.83%) Clavien-Dindo III complications (haematuria and clots needing evacuation) and the other complications being Clavien-Dindo I/II complications. Sustained improvement at 1 year of follow-up was noted: Qmax: 25.2 ± 5.6 mL/s, IPSS: 4.7 ± 2.5 and PVR: 22.5 ± 9.6 mL. Conclusions: Monopolar TUERP with a modified Nesbit's enucleoresection with apical release can be considered a promising technique, which needs further studies to be validated with appropriate comparisons.

A correlation study between prostate necrosis rate calculated by 3D Slicer software and clinical efficacy of prostatic artery embolization, along with an analysis of predictors of clinical success after prostatic artery embolization

PURPOSE

To analyze the correlation between the prostate necrosis rate at 1-month after prostatic artery embolization (PAE) and the clinical efficacy at 1-year after PAE, and to explore potential predictors of clinical success after PAE for the treatment of lower urinary tract symptoms secondary to benign prostatic hyperplasia (BPH).

METHODS

The prostate magnetic resonance imaging data at 1-month after PAE were imported into 3D Slicer software for calculating the prostate necrosis rate and thus analyzing the relationship between the prostate necrosis rate at 1-month after PAE and the efficacy score ratio at 1-year after PAE. The 151 patients with PAE technical success were divided into a clinical success group (n = 126) and a clinical failure group (n = 25). Independent predictors of clinical success after PAE were analyzed by multifactorial logistic regression, and the predictive performance of each factor was evaluated by applying the receiver operating characteristic curve and the area under the curve (AUC).

RESULTS

There was a linear negative correlation between the prostate necrosis rate at 1-month after PAE and the efficacy score ratio at 1-year after surgery (P < 0.001). In the clinical success group, both the initial prostate volume (PV) and the prostate necrosis rate at 1-month after PAE were significantly higher than in the clinical failure group (P < 0.001), and acute urinary retention (AUR) and adenomatous-dominant BPH were also associated with clinical success (P < 0.05). Multifactorial logistic regression analysis revealed that larger initial PV, a higher prostate necrosis rate at 1-month after surgery, and AUR were independent predictors of clinical success after PAE. The AUC values for these three indicators and their combination were 0.720, 0.928, 0.599, and 0.951, respectively, in which the prostate necrosis rate at 1-month after PAE demonstrating a high predictive value.

CONCLUSION

The higher the prostate necrosis rate at 1-month after PAE, the better the clinical efficacy at 1-year after PAE is likely to be, and the prostate necrosis rate at 1-month after PAE is expected to become a predictor of clinical success after PAE.

Clinical, Technical, and MRI Features Associated with Patients' Outcome at 3 Months and 2 Years following Prostate Artery Embolization: Is There an Added Value of Radiomics?

Our aim was to investigate which features were associated with clinical successes at short- and mid-terms following prostate artery embolization (PAE) for symptomatic benign prostate hypertrophy (BPH). All adults treated by PAE for BPH at our referral center between January 2017 and March 2021, with pre-treatment MRI, technical success, and follow-up at 3 months and 2 years were included in this single-center retrospective study. Radiologists reviewed the prostatic protrusion index (PPI), adenomatous dominant BPH (adBPH), and Wasserman classification on pre-treatment MRI. Radiomics analysis was achieved on the transitional zone on pre-treatment T2-weighted imaging (WI) and ADC, and comprised reproducibility assessment, unsupervised classifications, and supervised radiomics scores obtained with cross-validated Elasticnet regressions. Eighty-eight patients were included (median age: 65 years), with 81.8% clinical successes at 3 months and 60.2% at 2 years. No feature was associated with success at 3 months, except the radiomics score trained on T2-WI and ADC (AUROC = 0.694). Regarding success at 2 years, no radiomics approaches provided significant performances; however, Wasserman type-1 and change in international prostate symptom score (IPSS) at 3 months ≤ -35% were associated with success in multivariable analysis (OR = 5.82, p = 0.0296, and OR = 9.04, p = 0.0002). Thus, while radiomics provided limited interest, Wasserman classification and early IPSS changes appeared predictive of mid-term outcomes.

Cardiovascular Comorbidities Do Not Impact Prostate Artery Embolisation (PAE) Outcomes: Retrospective Analysis of the National UK-ROPE Registry

PURPOSE

Prostate artery embolisation (PAE) is a key treatment for the management of symptomatic benign prostatic hyperplasia (BPH). Common cardiovascular risk factors might be associated with suboptimal outcomes and thus influence patient treatment selection. The aim of the study was to evaluate whether cardiovascular comorbidities affect PAE outcomes.

METHODS

Retrospective subset analysis of the UK Registry of Prostate Artery Embolisation (UK-ROPE) database was performed with patients who had a full documented past medical histories including hypertension, diabetes, coronary artery disease (CAD), diabetes and smoking status as well as international prostate symptom score (IPSS) at baseline and at 12 months. Multiple regression was performed to assess for any significant predictors.

RESULTS

Comorbidity data were available for 100/216 patients (mean age 65.8 ± 6.4 years), baseline IPSS 20.9 ± 7.0). Regression analysis revealed that the presence of hypertension (53.7% IPSS reduction vs. absence 51.4%, p = 0.94), diabetes (52.6% vs. absence 52.1%, p = 0.6), CAD (59.2% vs. absence 51.4%, p = 0.95), no comorbidities (49.8% vs. any comorbidity present 55.3%, p = 0.66), smoking status (non-smoker, 52.6%, current smoker, 61.5%, ex-smoker, 49.8%, p > 0.05), age (p = 0.52) and baseline Qmax (p = 0.41) did not significantly impact IPSS reduction at 12 months post-PAE. Baseline prostate volume significantly influenced IPSS reduction (≥ 80 cc prostates, 58.9% vs. < 80 cc prostates 43.2%, p < 0.05).

CONCLUSION

The presence of cardiovascular comorbidities/smoking history does not appear to significantly impact PAE symptom score outcomes at 12 months post procedure. Our findings suggest that if the prostatic artery can be accessed, then clinical success is comparable to those without cardiovascular comorbidities.

Prostatic stents: a narrative review of current evidence

Benign prostatic hyperplasia (BPH) is a common chronic urologic condition affecting approximately 50% of men above the age of 60. As per European Association of Urology Guidelines, BPH can be treated according to a stepwise approach starting from a conservative management, a pharmacologic approach, and finally surgery. Both medical and surgical therapies have side effects, impacting on ejaculation and sexual function and patients with multiple comorbidities might not be considered surgically suitable candidates. Prostatic stents offer a minimally invasive procedures in an out-patient setting, possibly under local anaesthesia. Utilized since the 1980s, the past stents encompassed permanent (epithelializing) or temporary (non-epithelializing) devices, like the Uro-Lume (American Medical Systems, Minnetonka, MN, USA) and the Memokath, or Memotherm (Engineers & Doctors A/S, Denmark), and the biodegradable stents made of self-reinforced poly-L-lactide or braided poly lactic-co-glycolic acid. Previous stents however showed a quite high rate of complications among which pain, incontinence, infections, stent migration or blockage, and incomplete degradation that might lead to premature removal of stent. The stents currently available on the market instead are the temporary device Allium Triangular Prostatic Urethral Stent (Allium Urological Solutions, Caesarea, Israel) and the temporary stent SPANNER (AbbeyMoor Medical, Inc., Parkers Prairie, MN, USA), which might be used in case of bladder outflow obstruction, post-operatively, or for acute urinary retention. Studies showed encouraging results, in terms of effectiveness and safety improving patients' quality of life and International Prostate Symptom Score, but longer-term studies are needed to identify the most suitable patients who might benefit from their use. Newer stents and nitinol devices are currently investigated, and we are waiting for the results of the ongoing clinical trials.

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.

Treatment Algorithm for Management of Benign Prostatic Obstruction: An Overview of Current Techniques

The management of benign prostatic obstruction (BPO) should involve a treatment algorithm that takes into account prostate size, and patient's symptoms and preference with the aim of helping with urinary symptoms and enhance quality of life. The diagnostic assessment for men with lower urinary tract symptoms (LUTS) should be comprehensive to help choose the best management strategy. Strategies from lifestyle modifications to medical treatment with alpha blockers and/or 5-alpha-reductase inhibitors to surgical procedures can all be used in the management algorithm. Surgical management ranges from transurethral resection of prostate (TURP) to minimally invasive surgical therapies (MIST) including laser therapies such as Holmium laser enucleation (HoLEP) and photoselective vaporisation (PVP), aquablation, Rezūm system, prostate artery embolisation (PAE), prostatic urethral lift (PUL), temporary implantable nitinol device (iTind) and Optilume BPH catheter system. BPO is a common urological condition that has a significant impact on quality of life and economic burden globally and is likely to become increasingly prevalent with an ageing population. Selecting the most appropriate treatment modality will depend on the individual patient preferences, availability of resources, cost, anatomical factors and the goals of treatment.

Minimally Invasive Urological Procedures and Related Technological Developments-Series 2

The world of minimally invasive urology has experienced enormous growth in recent decades with technological innovations related to new techniques and equipment, better training, and the clinical adoption of translational research [...].

Influence of benign prostatic hyperplasia patterns detected with MRI on the clinical outcome after prostatic artery embolization

BACKGROUND

To investigate the influence of benign prostatic hyperplasia (BPH) patterns detected with MRI on clinical outcomes after prostatic artery embolization (PAE).

MATERIALS & METHODS

This retrospective study included 71 consecutive patients with lower urinary tract symptoms (LUTS), who underwent magnetic resonance imaging (MRI) of the prostate followed by PAE at a single centre. MRI scans were evaluated and BPH patterns were determined according to Wasserman type and a modified BPH classification. Additionally, scans were evaluated regarding the presence of adenomatous-dominant benign prostatic hyperplasia (AdBPH). LUTS were assessed using the International Prostate Symptom Score (IPSS) and urinary flow rate (Qmax). Follow-up examination included MRI and clinical outcome.

RESULTS

For clinical outcome at follow-up, IPSS showed median reduction of 54% (IQR 41-75%) and Qmax improved by 4.1 ml/s. We noted significant reduction in volume, intraprostatic protrusion, and prostatic urethral angle in our collective (p < 0.01). Median volume reduction was 25% (IQR 15%-34%). Bilateral embolization was a significant predictor for volume reduction at follow-up. Multiple linear regression analysis showed significant effect of high initial volume on reduction in IPSS after treatment (p < 0.01). Presence of AdBPH was significantly associated with both, volume loss and clinical improvement in terms of IPSS reduction (p < 0.01). Neither BPH pattern based on the Wassermann type nor modified BPH classification were significantly related with postinterventional IPSS and volume loss.

CONCLUSIONS

Men benefit from PAE regardless the macroscopic BPH MRI pattern. Preinterventional prostate volume and presence of AdBPH on MRI should be considered for outcome prognosis after PAE.

Role of Phytotherapy in the Management of BPH: A Summary of the Literature

Benign prostatic hyperplasia (BPH) describes the non-malignant enlargement of the prostate. It is both common and growing in incidence. Treatment is multimodal, involving conservative, medical, and surgical interventions. This review aims to examine the evidence base for phytotherapies, specifically analyzing their role in treating lower urinary tract symptoms (LUTS) attributable to BPH. A literature search was completed, specifically looking for randomized control trials (RCTs) and systematic reviews involving phytotherapy treating BPH. Specific emphasis was placed on exploring substance origin, the proposed mechanism of action, evidence of efficacy, and the side-effect profile. Several phytotherapeutic agents were evaluated. These included serenoa repens, cucurbita pepo, and pygeum Africanum, among others. For most of the reviewed substances, only modest effectiveness was reported. Generally, though, all treatments were tolerated well with minimal side effects. None of the treatments discussed in this paper form part of the recommended treatment algorithm in either European or American guidelines. We, therefore, conclude that phytotherapies, in the treatment of LUTS attributable to BPH, do provide a convenient option for patients, with minimal side effects. At present, however, the evidence for the usage of phytotherapy in BPH is inconclusive, with some agents having more backing than others. This remains an expansive field of urology whereby there is still more research to be done.

Long-Term Efficacy and Recurrence Prediction of Prostatic Artery Embolization for Lower Urinary Tract Symptoms Secondary to Benign Prostatic Hyperplasia

PURPOSE

To explore the efficacy of prostatic artery embolization (PAE) for lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH) during long-term follow-up and analyze predictors related to LUTS recurrence.

METHODS

This was a single-center retrospective study involving 125 BPH patients with LUTS who underwent PAE from February 2014 to February 2020. The median follow-up was 36 months. Clinical success was defined as reductions in the International Prostate Symptom Score (IPSS) and quality of life (QoL) score and no need for any other treatment for LUTS; otherwise, it was regarded as a clinical failure. Recurrence was defined as a clinical failure that occurred after an initial success. Cumulative clinical success rates, recurrence rates and re-intervention rates were evaluated. Friedman test was performed to compare differences in IPSS, QoL and prostatic volume (PV) among baseline and follow-up times. Predictors for LUTS recurrence were analyzed with the univariate and multivariate Cox regression model.

RESULTS

Technical success (bilateral PAE) rate was 92.8% (116/125). Significant differences in IPSS, QoL and PV were observed between baseline and follow-up time points (P < 0.001). The cumulative clinical success rates at 2, 3, 4 and 5 years were 82.4%, 65.5%, 52.4% and 37.4%. The cumulative recurrence rates and re-intervention rates at 1, 2 and 5 years were 6.8%, 12.7%, 60.4% and 5.9%, 10.2%, 50.8%, respectively. Unilateral PAE was an significant predictor of recurrence (P < 0.05).

CONCLUSIONS

PAE is an effective treatment option for LUTS. Unilateral PAE is a significant independent predictor of LUTS recurrence.

Initial Experience Using Digital Variance Angiography in Context of Prostatic Artery Embolization in Comparison with Digital Subtraction Angiography

RATIONALE AND OBJECTIVES

In previous clinical studies digital variance angiography (DVA) provided higher contrast-to-noise ratio (CNR) and better image quality in lower extremity angiography than digital subtraction angiography (DSA). Our aim was to investigate whether DVA has similar quality reserve in prostatic artery embolization (PAE). The secondary aim was to explore the potential advantages of the color-coded DVA (ccDVA) technology in PAE.

MATERIAL AND METHODS

This retrospective study evaluated 108 angiographic acquisitions from 30 patients (mean ± SD age 68.0 ± 8.9, range 41-87) undergoing PAE between May and October 2020. DSA and DVA images were generated from the same unsubtracted acquisition, and their CNR was calculated. Visual evaluation of DVA and DSA image quality was performed by four experienced interventional radiologists in a randomized, blinded manner. The diagnostic value of DSA and ccDVA images was also evaluated using clinically relevant criteria (visibility of small [< 2.5 mm] and large arteries [> 2.5 mm], feeding arteries and tissue blush) in a paired comparison. Data were analysed by the Wilcoxon signed rank test or the binomial test, the interrater agreement was determined by the Kendall W or Fleiss Kappa analysis.

RESULTS

DVA provided 4.11 times higher median CNR than DSA (IQR: 1.72). The visual score of DVA images (4.40 ± 0.05) was significantly higher than that of DSA (3.39 ± 0.07, p < 0.001). The Kendall W analysis showed moderate but significant agreement (W_DVA = 0.38, W_DSA = 0.53). The preference of ccDVA images was significantly higher in all criteria (63-89%) with an interrater agreement of 58-79%. The Fleiss Kappa range was 0.02-0.18, significant in all criteria except large vessels.

CONCLUSION

Our data show that DVA provides higher CNR and better image quality in PAE. This quality reserve might be used for dose management (reduction of radiation dose and contrast agent volume), and ccDVA technology has also a high potential to assist PAE interventions in the future.

MR angiography-planned prostatic artery embolization for benign prostatic hyperplasia: single-center retrospective study in 56 patients

PURPOSE

We aimed to evaluate the advantages of magnetic resonance angiography (MRA)-planned prostatic artery embolization (PAE) for benign prostatic hyperplasia (BPH).

METHODS

In this retrospective study, MRAs of 56 patients (mean age, 67.23±7.73 years; age range, 47-82 years) who underwent PAE between 2017 and 2018 were evaluated. For inclusion, full information about procedure time and radiation values must have been available. To identify prostatic artery (PA) origin, three-dimensional MRA reconstruction with maximum intensity projection was conducted in every patient. In total, 33 patients completed clinical and imaging follow-up and were included in clinical evaluation.

RESULTS

There were 131 PAs with a second PA in 19 pelvic sides. PA origin was correctly identified via MRA in 108 of 131 PAs (82.44%). In patients in which MRA allowed a PA analysis, a significant reduction of the fluoroscopy time (-27.0%, p = 0.028) and of the dose area product (-38.0%, p = 0.003) was detected versus those with no PA analysis prior to PAE. Intervention time was reduced by 13.2%, (p = 0.25). Mean fluoroscopy time was 30.1 min, mean dose area product 27,749 µGy•m2, and mean entrance dose 1553 mGy. Technical success was achieved in all 56 patients (100.0%); all patients were embolized on both pelvic sides. The evaluated data documented a significant reduction in IPSS (p < 0.001; mean 9.67 points).

CONCLUSION

MRA prior to PAE allowed the identification of PA in 82.44% of the cases. MRA-planned PAE is an effective treatment for patients with BPH.

Prostate Artery Embolization-Review of Indications, Patient Selection, Techniques and Results

Lower urinary tract symptoms (LUTS) due to benign prostatic hypertrophy (BPH) are a very common problem in men ranging from mild urinary symptoms to recurrent urinary tract infections or renal failure. Numerous treatment options are available ranging from conservative medical therapies to more invasive surgical options. Prostate artery embolization (PAE) has emerged as a novel treatment option for this common problem with clinical efficacy comparable to the current surgical gold standard, transurethral resection of the prostate (TURP). PAE offers fewer complications and side effects without a need for general anesthesia or hospitalization. This review discusses the indications for prostate artery embolization in addition to LUTS, patient evaluation in patients with LUTS, PAE technique and clinical results, with an emphasis on efficacy and safety.

New Ultra-minimally Invasive Surgical Treatment for Benign Prostatic Hyperplasia: A Systematic Review and Analysis of Comparative Outcomes

Context

Benign prostatic hyperplasia (BPH) associated with lower urinary tract symptoms (LUTS) is diagnosed in up to 80% of men during their lifetime. Several novel ultra-minimally invasive surgical treatments (uMISTs) for BPH/benign prostatic obstruction (BPO) have become available over the past 5 yr.

Objective

To evaluate the perioperative and functional outcomes of recently introduced uMISTs for BPH/BPO, including Urolift, Rezūm, temporary implantable nitinol device, prostatic artery embolization (PAE), and intraprostatic injection.

Evidence acquisition

A systematic literature search was conducted in December 2020 using Medline (via PubMed), Embase (via Ovid), Scopus, and Web of Science (registered on PROSPERO as CRD42021225014). The search strategy used PICO criteria and article selection was conducted in accordance with the PRISMA guidelines. The risk of bias and the quality of the articles included were assessed. A dedicated data extraction form was used to collect the data of interest. Pooled and cumulative analyses were performed to compare perioperative and functional outcomes between study groups. A random-effects model using the DerSimonian and Laird method was used to evaluate heterogeneity. Stata version 15.0 software was used for all statistical analyses.

Evidence synthesis

The initial electronic search identified 3978 papers, of which 48 ultimately met the inclusion criteria and were included in the analysis. Pooled analysis revealed a uMIST benefit in terms of International Prostate Symptom Score (IPSS; −9.81 points, 95% confidence interval [CI] −11.37 to −8.25 at 1 mo; −13.13 points, 95% CI −14.98 to −11.64 at 12 mo), maximum flow rate (from +3.66 ml/s, 95% CI 2.8–4.5 to +4.14 ml/s, 95% CI 0.72–7.56 at 12 mo), and postvoid residual volume (−10.10 ml, 95% CI −27.90 to 7.71 at 12 mo). No negative impact was observed on scores for the International Index of Erectile Function-5, Male Sexual Health Questionnaire-Ejaculatory Dysfunction bother and function scales (overall postintervention change in pooled median score of 1.88, 95% CI 1.34–2.42 at the start of follow-up; and 1.04, 95% CI 0.28–1.8 after 1 yr), or the IPSS-Quality of Life questionnaire.

Conclusions

Novel uMISTs can yield fast and effective relief of LUTS without affecting patient quality of life. Only Rezūm, UroLift, and PAE had a minimal impact on patients’ sexual function with respect to baseline, especially regarding preservation of ejaculation.

Patient summary

We reviewed outcomes for recently introduced ultra-minimally invasive surgical treatments for patients with lower urinary tract symptoms caused by benign prostate enlargement or obstruction. The evidence suggests that these novel techniques are beneficial in terms of controlling symptoms while preserving sexual function.

Take Home  Message

Novel ultra-minimally invasive treatments can yield fast and effective relief of lower urinary tract symptoms without affecting a patient’s quality of life.

Prostate Artery Embolization Using N-Butyl Cyanoacrylate Glue for Urinary Tract Symptoms Due to Benign Prostatic Hyperplasia: A Valid Alternative to Microparticles?

Our goal was to evaluate the feasibility, safety, and short-term outcomes of prostate artery embolization (PAE) with N-butyl cyanoacrylate (NBCA) glue as the only embolic agent in patients with benign prostatic hyperplasia (BPH)-related lower urinary tract symptoms (LUTSs). A two-center retrospective study of 50 patients (mean age, 67.6 ± 7.4 years; range, 54-85 years) treated with NBCA between 2017 and 2020 was conducted. PAE was performed using a mixture of Glubran 2 glue and Lipiodol in a 1:8 ratio, under local anesthesia, on an outpatient basis, after cone-beam computed tomography vascular mapping. Mean total injected NBCA/Lipiodol volume was 0.9 ± 0.3 mL, total injection time was 21.9 ± 7.8 s, and total radiation dose was 18,458 ± 16,397 mGy·cm. Statistically significant improvements over time occurred for the International Prostate Symptoms Score (9.9 ± 6.8 versus 20.5 ± 6.7, p = 0.0001), quality-of-life score (2.2 ± 1.5 versus 4.9 ± 1.0, p = 0.0001), prostate-specific antigen level (4.6 ± 3.0 versus 6.4 ± 3.7, p = 0.0001), and prostate volume (77.3 ± 30.5 versus 98.3 ± 40.2, p = 0.0001) at a median of 3 months versus baseline. Minor adverse events developed in 11/50 (22%) patients, but no major complications occurred. The International Index of Erectile Function did not change significantly. PAE with NBCA is feasible, safe, fast, and effective for patients with BPH-related LUTSs. Prospective comparative studies with longer follow-ups are warranted.

Using prostate contrast retention (PCR) as the procedural endpoint in prostatic artery embolization for benign prostatic hyperplasia

OBJECTIVES

The failure rate following prostate artery embolization (PAE) is around 20%, which may in part result from inadequate embolization. Prostate contrast retention (PCR) adequacy on immediate post-embolization cone-beam CT may provide better assessment of embolization completeness than arterial contrast stasis seen on fluoroscopy alone. The aim of this study was to evaluate outcomes of PAE using PCR adequacy as the procedural endpoint.

METHODS

A retrospective cohort study of all PAE cases using this technique at a single large volume center was conducted. Following initial embolization of the main prostatic arteries, if PCR was inadequate, additional embolization was performed. Technical success (adequate PCR) was defined as > 75% global prostate gland contrast staining. Clinical success was determined in accordance to CIRSE standards of practice.

RESULTS

One hundred sixty-five patients (mean age 68 ± 8.4 years) underwent PAE from June 2017 to March 2019. Technical and clinical success rates were 98.8% and 96.4% respectively. Clinical success rate was significantly higher in patients with adequate PCR. International Prostate Symptom Scores (IPSS) and Quality of Life (QoL) scores significantly improved at 1-, 3-, 6-, and 12-month follow-up when compared to baseline. Prostate volume (PV) and post-voiding residual bladder volume were significantly reduced at 3, 6, and 12 months in comparison to baseline. Mild (Clavien-Dindo grade I/II) and moderate (grade III) complication rates were 12.1% and 3.6% respectively.

CONCLUSIONS

By using PCR adequacy as a guide to determine the procedure endpoint for PAE, it may be possible to achieve more complete embolization and thus higher clinical success rates.

KEY POINTS

• By using PCR adequacy as a guide to determine the procedure endpoint for PAE, it may be possible to achieve more complete embolization and thus higher clinical success rates.

Prostatic Artery Embolization (PAE) and Transurethral Resection of the Prostate (TURP) have a Differential Impact on Lower Urinary Tract Symptoms (LUTS): Retrospective Analysis of the Multicentre UK-ROPE (UK Register of Prostate Embolization) Study

PURPOSE

To compare the relative IPSS (International Prostate Symptom Score) improvement in storage and voiding symptoms between prostatic artery embolization (PAE) and transurethral resection of the prostate (TURP).

METHOD

Retrospective analysis of the UK-ROPE (UK Register of Prostate Embolization) multicentre database was conducted with inclusion of all patients with full IPSS questionnaire score data. The voiding and storage subscore improvement was compared between interventions. Student's t-test (paired and unpaired) and ANOVA (Analysis of variance) were used to identify significant differences between the groups.

RESULTS

146 patients (121 PAE, 25 TURP) were included in the analysis. Storage symptoms were more frequently the most severe symptom ('storage' in 75 patients vs 'voiding' in 17 patients). Between groups, no significant difference was seen in raw storage subscore improvement (TURP 4.9 vs PAE 4.2; p = 0.34) or voiding subscore improvement (TURP 8.4 vs PAE 6.7; p = 0.1). ANOVA demonstrated a greater proportionate reduction (relative to total IPSS) towards voiding symptoms in the TURP group (27.3% TURP vs 9.9% PAE, p = 0.001).

CONCLUSION

Although both TURP and PAE improve voiding symptoms more than storage, a significantly larger proportion of total symptom reduction is due to voiding in the TURP cohort, with PAE providing a more balanced improvement between voiding and storage.

Reasons to consider prostatic artery embolization

PURPOSE

Prostatic artery embolization (PAE) has emerged as a truly minimally invasive treatment option for patients with lower urinary tract symptoms presumed secondary to benign prostatic obstruction (LUTS/BPO) over the last few years and is now supported by evidence-based international guidelines. Here, we provide an overview on the profile of PAE based on the most relevant and recent literature.

METHODS

A comprehensive review of literature on PAE was conducted on PubMed-Medline. The most relevant literature was summarized narratively.

RESULTS

While there is still a lack of long-term data, efficacy and safety data have been published for the short to mid-term. As with any minimally invasive technique, relief of bladder outlet obstruction is less pronounced after PAE compared to more invasive resective techniques. This is likely to be associated with higher re-intervention rates during the longer term. However, due to its beneficial safety profile, PAE represents an interesting option for many patients and could fill a niche between pharmacotherapy and formal surgical intervention. Given its unique treatment approach, i.e. endovascular instead of transurethral, PAE has a clearly different profile compared to other minimally invasive treatments. Performance with local anesthesia with possible continuation of anticoagulant drugs and no upper prostate size limit are the most important advantages of PAE.

CONCLUSION

PAE represents a valuable supplement in the treatment armamentarium of LUTS/BPH if patients are selected appropriately.

[Surgical and interventional management of benign prostatic obstruction: Guidelines from the Committee for Male Voiding Disorders of the French Urology Association]

OBJECTIVE

The aim of the Male Lower Urinary Tract Symptoms Committee (CTMH) of the French Urology Association was to propose an update of the guidelines for surgical and interventional management of benign prostatic obstruction (BPO).

METHODS

All available data published on PubMed® between 2018 and 2020 were systematically searched and reviewed. All papers assessing surgical and interventional management of adult patients with benign prostatic obstruction (BPO) were included for analysis. After studies critical analysis, conclusions with level of evidence and French guidelines were elaborated in order to answer the predefined clinical questions.

RESULTS/GUIDELINES

Offer a trans-uretral incision of the prostate to treat patients with moderate to severe lower urinary tract symptoms (LUTS) with a prostate volume<30cm³, without a middle lobe. TUIP increases the chances of preserving ejaculation. Propose mono- or bipolar trans-urethral resection of the prostate (TURP) to treat patients with moderate to severe LUTS with a prostate volume between 30 and 80cm³. Vaporization by Greenlight™ or by bipolar energy can be offered as an alternative to TURP. Offer a Greenlight™ laser vaporization to patients at risk of bleeding. Offer endoscopic prostate enucleation to surgically treat patients with moderate to severe LUTS as an alternative to TURP and open prostatectomy (OP). Minimally invasive prostatectomy is an alternative to OP in centers without access to adequate endoscopic procedures. Embolization of the prostatic arteries may be offered in the event of a contraindication or refusal of surgery for prostates with a volume>80cm³. Prostatic uretral lift is an alternative in patients interested in preserving their ejaculatory function and with a prostate volume<70cm³ without a middle lobe. Aquablation and Rezum™ are under evaluation and should be offered in research protocols.

CONCLUSION

Major changes in surgical management of BPO have occurred and aim at reducing morbidity and improving quality of life of patients.

The STREAM Trial (Prostatic Artery Embolization for the Treatment of Benign Prostatic Hyperplasia) 24-Month Clinical and Radiological Outcomes

PURPOSE

To establish factors predictive of success prior to Prostate Artery Embolization (PAE) with MRI imaging.

MATERIALS AND METHODS

A prospective cohort study of 50 patients with Benign Prostatic Hyperplasia (BPH) were treated with PAE in a single institution. Patients had moderate to severe symptoms of BPH refractory to medical management for at least 6 months. Patients were imaged with multiparametric MRI imaging pre-PAE and at 3 months, 12 months and 24 months post-PAE. Clinical success was measured with IPSS, IIEF and EQ-5D-5L quality of life questionnaires.

RESULTS

The technical success was 48/50 (96%).The mean age of the group was 67 (range 54-83). The mean IPSS score pre-PAE was 21 and at 24 months was 8 (p < 0.001). There was no deterioration in erectile function. The mean volume of the prostate post-PAE was reduced at 3 and 12 months post-PAE but not significantly different at 24 months. This did not correlate with the IPSS score. Patients with median lobe enlargement has similar symptomatic improvement as those without median lobe enlargement. Internally within the prostate patients with adenomatous-dominant BPH initially did better than patients with stromal enlargement; however, at 24 months patients with stromal enlargement of the prostate improved greatest. Initial volume of the prostate was not a good predictor of clinical success.

CONCLUSION

PAE is a safe and effective treatment strategy for treating men with BPH. Patients with Adenomatous BPH clinically do better until 12 months but not at 24 months. Initial prostate volume does not affect outcome, and patients with median lobe enlargement do as well as those without.

Prostatic Artery Embolization: Equipment, Procedure Steps, and Overcoming Technical Challenges

In the last decade, prostatic artery embolization (PAE) established itself as a safe and effective treatment option for lower urinary tract symptoms (LUTS) attributed to benign prostate hyperplasia (BPH), with reproducible results across multiple centers and endorsement by important international societies. However, PAE is also known to be a technically demanding procedure. Accompanying the prevalence of benign prostate hyperplasia, the procedure is usually performed in older patients, in whom atherosclerosis and comorbidities are common features. Also, prostatic vascular anatomy is described to be complex and variable, and pelvic structures are deeply interconnected by anastomosis. Thus, PAE demands a deep familiarization with materials and devices, intraprocedure imaging techniques, microcatetherization skills and with the pelvic vascular anatomy. Especially in the beginning of the learning curve, the procedure can be time-consuming and related to high radiation exposure for both medical team and the patient. In this article, the main points of technical concern during PAE are described and discussed, such as the equipment needed, the effect of different embolic materials, patient's preparation for the procedure, arterial access sites, identifying and catheterizing the prostatic arteries, the embolization techniques, among others. Finally, the most frequent technical challenges are presented, and the possible strategies to overcome them are exemplified and discussed.

Predictors of technical outcome for prostatic artery embolisation using pre-procedural CT angiography

OBJECTIVES

Predicting patients that will pose procedural technical challenges in prostate artery embolisation (PAE) remains difficult, with prolonged procedural times impacting on both patient dose and resource planning. Understanding the factors that influence these parameters as well as the likelihood of technical success is therefore important in effective patient selection and procedural planning.

METHODS

Data were collected retrospectively for 75 consecutive patients who underwent PAE. Multiple patient predictor variables available from planning computed tomography angiography (CTA) were identified and measured objectively. The vessel angles navigated during the procedure, prostate volume, prostate artery (PA) diameter, PA origin, aortic atheroma, iliac tortuosity and baseline demographics were correlated with outcome variables (fluoroscopy time, air kerma (AK), dose area product (DAP), the number of cone beam CTs (CBCTs)) performed and whether bilateral embolisation was possible (technical success). Data were analysed using linear regression, ANOVA, t tests and chi-squared tests.

RESULTS

Aortic atheroma severity significantly increased fluoroscopy time (p = 0.004), whilst air kerma (AK) was significantly greater in patients with smaller prostatic arteries (p = 0.009) and smaller pre-procedural prostate volumes (p = 0.038). Increased vascular tortuosity and prostatic artery origin were not shown to significantly affect fluoroscopy time or DAP. Smaller prostate artery size (p = 0.007) also increases the likelihood of either unilateral embolisation or technical failure.

CONCLUSIONS

Pre-operative prediction of technical outcome measures in PAE remains challenging. However, vascular calcification, prostatic artery diameter and prostate volume are likely to be important factors when considering the risk/benefits of PAE.

KEY POINTS

• Increased severity of atheroma and the presence of small prostate arteries increase fluoroscopy time and AK respectively during prostate artery embolisation. • Lower pre-procedural prostate volume increases the AK during procedures. • Smaller prostate artery size increases the likelihood of either unilateral embolisation or technical failure.

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.

Can Computed Tomography Perfusion Predict Treatment Response After Prostate Artery Embolization: A Feasibility Study

Prostate artery embolization (PAE) is an emerging therapy for benign prostatic hyperplasia (BPH). Optimal patient selection is an important step when introducing new treatments and several characteristics associated with a good clinical outcome has previously been proposed. However, no prognostic tool is yet available for PAE. Computed tomography perfusion is an imaging technique that provides hemodynamic parameters making it possible to estimate the prostatic blood flow (PBF). This study investigated the relationship between PBF and the response to PAE. A post hoc analysis including prostate-specific antigen (PSA) measurements before and 24-h after embolization from two prospective studies on sixteen patients undergoing PAE with BPH or prostate cancer were performed. The primary outcome was the correlation between baseline PBF and the change in PSA as a surrogate measure of treatment response. Prostate volume strongly correlated with treatment response and the response was greater with incremental amounts of injected embolic material. PBF was not associated with elevation in PSA and added no information that could guide patient selection.

The First 48 Consecutive Patients with 3-Year Symptom Score Follow-Up Post-Prostate Artery Embolization (PAE) at a Single-Centre University Hospital

INTRODUCTION

Few studies on prostate artery embolization (PAE) follow patients up after 12 months. We aimed to evaluate the symptomatic efficacy of PAE in our patient cohort at 3 years.

METHOD

A total of 48 consecutive patients undergoing PAE from June 2012 to August 2014 were included in this retrospective study. All patients underwent formal urodynamics to confirm bladder outflow obstruction prior to PAE. International Prostate Symptom Score (IPSS) was performed at baseline, 3 months, 12 months and 3 years post-PAE.

RESULTS

Mean patient age was 65.6 ± 7.4, prostate volume 99.1 ± 56.6 cm³, IPSS 23.5 ± 6.0, quality-of-life score 4.6 ± 0.9, Qmax 8.4 ± 2.8 ml/s, post-void residual volume 185.8 ± 55.6 ml. Technical success (bilateral embolization) was achieved in 43 out of 48 cases (89.6%). 11/39 bilateral PAE patients completing follow-up (2 died, 2 lost to follow-up) underwent surgery, indicating a 71.8% clinical success rate at 3 years. No significant change was demonstrated in IPSS or QOL between 1 and 3 years for patients free from surgical intervention (IPSS 8.3 vs 10.0, p = 0.09 and QOL 1.3 vs 1.5, p = 0.23). 3/11 patients undergoing surgery had a prominent 'ball-valve' median lobe, and 1/11 patients had a high bladder neck elevation contributing to symptoms.

CONCLUSION

Clinical success post-PAE remains high with few patients opting for surgery or experiencing a worsening of symptoms after 12 months.

Prostatic Artery Embolization-Anatomic Predictors of Technical Outcomes

PURPOSE

To determine if cone-beam CT and digital subtraction angiography analysis of pelvic arterial anatomy has predictive value for radiation exposure and technical success of prostatic artery embolization (PAE).

MATERIALS AND METHODS

This prospective, nonrandomized, single-center study included 104 consecutive patients with lower urinary tract symptoms secondary to benign prostatic hyperplasia. Cone-beam CT was performed in 160/208 (76.9%) hemipelves to determine prostatic artery (PA) origin. Classification of pelvic arterial tortuosity was possible in 73/104 (70.2%) patients. Learning curves of 2 interventionalists who performed 86.5% of PAEs were analyzed.

RESULTS

Tortuosity of pelvic arteries was classified as mild in 25 (34.2%) patients median age 64 years, moderate in 40 (54.8%) patients median age 69 years, and severe in 8 (11.0%) patients median age 70 years (mild vs moderate, P = .002; mild vs severe, P = .019); median fluoroscopy times were 24, 36, and 46 minutes (P = .008, P = .023); median contrast volumes were 105, 122.5, and 142 mL (P = .029, P = .064); and bilateral PAE rates were 84.0%, 77.5%, and 62.5% (P = .437), respectively. PA origin from superior vesical artery was most frequent (27.5%) and showed higher dose area product (median 402.4 vs 218 Gy ∙ cm², P = .033) and fluoroscopy time (median 42.5 vs 27 min, P = .01) compared with PA origin from obturator artery, which was least frequent. Interventionalist experience revealed significant impact on procedure times (median 159 vs 130 min, P = .006).

CONCLUSIONS

Tortuosity of pelvic arteries was more frequent in older patients and predicted worse technical outcomes of PAE. PA origin from obturator artery was associated with lower dose area product and fluoroscopy time, especially compared with PA origin from superior vesical artery. Interventionalist experience showed significant influence on technical outcome.

Computed Tomography for 4-Dimensional Angiography and Perfusion Imaging of the Prostate for Embolization Planning of Benign Prostatic Hyperplasia

OBJECTIVES

The aim of this study was to evaluate the feasibility of a computed tomography (CT) protocol enabling the visualization of the prostatic artery (PA) before prostatic artery embolization (PAE) in benign prostatic hyperplasia, which provides quantitative perfusion information of the prostate gland.

MATERIALS AND METHODS

In this institutional review board-approved study, 22 consecutive patients (mean age, 67 ± 7 years) who were planned to undergo PAE underwent a dynamic CT scan of the pelvis (scan range, 22.4 cm; cycle time, 1.5 seconds; scan time, 44 seconds; 25 scan cycles; 70 kVp; 100 mAs) after the administration of 70 mL of iodinated contrast media (flow rate, 6 mL/s; 10 seconds' delay). Image postprocessing consisted of a spatiotemporal, frequency-depending multiband filtering technique with noise reduction, motion correction, resulting in (1) time-resolved, temporal maximum intensity projection (MIP) images from fusion of multiple arterial time points; (2) 4-dimensional (4D) CT angiography images after bone and calcium plaque removal; and (3) parametric perfusion maps of the prostate. Intraprocedural cone-beam CT was performed with a microcatheter in the PA. In both modalities, the contrast-to-noise ratio of the right internal iliac artery or the PA was calculated, respectively. Visibility of the PA was scored using a Likert scale (score 1 = not seen, to score 4 = intraprostatic PA branches seen). Quantitative perfusion analysis of the dynamic pelvic CT included calculation of the blood flow, blood volume, mean transit time, and flow extraction product.

RESULTS

The average volume CT dose index and dose length product of CT was 35.7 ± 6.8 mGy and 737.4 ± 146.3 mGy·cm, respectively. Contrast-to-noise ratio of the pelvic vessels on temporal MIP images and cone-beam CT were 45 ± 19 and 69 ± 27, respectively (P < 0.01). The mean visibility score of the PA was 3.6 ± 0.6 for 4D-CT angiography and 3.97 ± 0.2 for cone-beam CT (P < 0.001). The PA was visualized in 100% of 4D-CT angiography examinations, with one PA being visible only proximally. Prostate CT perfusion analysis showed blood flow, blood volume, mean transit time, and flow extraction product values of 27.9 ± 12.5 mL/100 mL/min, 2.0 ± 0.8 mL/100 mL, 4.5 ± 0.5 second, and 12.6 ± 5.4 mL/100 mL/min, respectively, for the whole prostate gland. About half the patients showed a pronounced difference between the lobes.

CONCLUSIONS

We introduced a CT protocol for PAE planning providing excellent visualization of the PA on temporal MIP images and 4D-CT angiography at a reasonable dose and low contrast volume. In addition, quantitative perfusion information is available, which might be useful for outcome prediction after embolization.

Technical and Imaging Outcomes from the UK Registry of Prostate Artery Embolization (UK-ROPE) Study: Focusing on Predictors of Clinical Success

INTRODUCTION

The UK Registry of Prostate Artery Embolization (UK-ROPE) was a prospective, multicentre study comparing PAE against surgical therapies for symptomatic benign prostatic hyperplasia (BPH). A wealth of data was collected supplementary to the main study outcomes which provide a snapshot of UK PAE practice. We aimed to interpret these data in the hope of providing insight into factors which affect clinical outcome and radiation dose.

METHODS

216 patients (mean age 66, mean IPSS 21.3) undergoing PAE at 20 British centres from July 2014 to January 2016 were prospectively followed up to 12 months with retrospective analysis of the data. Technical outcome was evaluated based on procedural and fluoroscopy times, skin dose and dose area product (DAP). Clinical outcome was evaluated through collection of Qmax, IPSS reduction and prostate volume reduction. Multiple analysis of variance (MANOVA) was used to assess the significance of various patients and procedural factors on clinical outcome and patient dose.

RESULTS

Significant predictors of technical outcome which affected patient skin dose included severity of CTA-detected atheroma (p < 0.001), the practitioner (p < 0.001) and use of protective coil embolization (p = 0.019). Predictors of clinical outcome included initial prostate size (dichotomized into groups > 80 ml and = <80 ml, d = 1, p = 0.0138), embolic agent (spherical particles < 300 nm performed best, p = 0.01) and number of arteries embolized (IPSS reduction of 32.9% in unilateral PAE versus 54.4% for bilateral PAE, p = 0.026).

CONCLUSION

We have identified several important factors which are associated with improved clinical outcome and increased patient dose which we hope will facilitate optimal patient selection and encourage improved embolization technique.

Outcome prediction of prostatic artery embolization: post hoc analysis of a randomized, open-label, non-inferiority trial

OBJECTIVES

To identify predictors for different treatment outcomes after prostatic artery embolization (PAE) in the treatment of lower urinary tract symptoms secondary to benign prostatic hyperplasia.

PATIENTS AND METHODS

A post hoc analysis of data derived from the 48 patients undergoing PAE in a randomized, open-label, non-inferiority trial was performed. Relative changes in the International Prostate Symptoms Score (IPSS), absolute changes in maximum urinary flow rate (Q_max ), and relative changes in magnetic resonance imaging-assessed prostate volume from baseline to 12 weeks were defined as the outcomes measures of interest. Their association with various baseline characteristics and measures, technical details of PAE, and early postoperative measures were analysed using Spearman rank correlations and Wilcoxon rank-sum tests. The most promising predictors were further evaluated in receiver-operating characteristic (ROC) curve analyses.

RESULTS

Higher total prostate and central gland (i.e. central plus transitional zone) volumes were associated with more pronounced improvements in the IPSS (Spearman rank correlation [rs]: -0.35 and -0.34; P = 0.01 and P = 0.02, respectively) and the Q_max (rs: 0.31 and 0.39; P = 0.05 and P = 0.01, respectively). ROC curve analyses suggested that volumes of 39 and 38 mL for total prostate and central gland volume, respectively, would be the optimal thresholds with which to predict PAE success as measured by the IPSS. Other anatomical characteristics of the prostate, such as the central gland index, also showed an even more distinct correlation to the improvement in Q_max (rs: 0.46, P = 0.003). The relative changes in prostate volume were clearly dependent on the technical performance of PAE. Occurrence of postoperative pain and blood levels of prostate-specific antigen and C-reactive protein emerged as potential early-stage outcome predictors after PAE.

CONCLUSION

Baseline and peri-operative findings might help to guide patient selection and outcome prediction for PAE. Patients with larger prostates have a higher chance of success with PAE. Larger-scale clinical trials including a longer follow-up are warranted to further elucidate the most suitable patients for PAE.