Utility of MR Angiography in the Identification of Prostatic Artery Origin Prior to Prostatic Artery Embolization

Pre-therapeutical assessment of lower urinary tract symptoms in adult men: Systematic review and clinical practice guidelines

INTRODUCTION

The aim was to propose initial and pre-therapeutical assessment of lower urinary tract symptoms in adult men through a systematic review and clinical practice guidelines.

METHODS

These guidelines were based on a systematic review performed between January 2011 and November 2021 in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria. The protocol was registered in the International Prospective Register of Systematic Reviews database (CRD42022336418). The recommendations and the methodology of elaboration were prospectively validated by the French Health Authority (Haute Autorité de santé [HAS]).

RESULTS

In total, 1662 publications were screened for eligibility and 311 met the inclusion criteria, 167 studies were retained among them 17 guidelines from French, European or International institutions. Perform on initial evaluation: identification of cardiovascular risk factors, metabolic syndrome, current medication, urinary and sexual symptoms (by structured interview or validated self-questionnaires), physical examination (lumbar fossa, pelvis, prostate, genitalia), urinalysis (dipstick or microscopy), abdominal ultrasound of the urinary tract (kidneys, bladder, prostate), post-void residual urine measurement (by ultrasound or automated measurement; under physiological conditions). Micturition flowmetry is recommended (except for general practitioners). Update and complete initial assessment before medication, interventional or surgical treatment if too old or incomplete. Perform a preoperative assessment (bleeding risk, infectious risk, geriatric risk). Urodynamic assessment, endorectal ultrasound and cystoscopy should not be systematically performed (only if additional information is needed). Perform urodynamics and urethrocystoscopy in case of failed interventional or surgical treatment. Following the initial workup, it is recommended to refer the patient to a urologist in case of: macroscopic hematuria, recurrent urinary tract infection or persistent perineal and/or suprapubic pain, persistent microscopic hematuria or leukocyturia in absence of urinary tract infection, predominant storage-phase symptoms, abnormal examination of the genitals or suspected prostate cancer, urinary retention, urinary tract stones, ureterohydronephrosis or morphological abnormalities of the prostate or the urinary tract.

CONCLUSION

These guidelines aimed to define the recommended investigation for LUTS in adult men at diagnosis, before medical treatment and before surgical and interventional treatments, in order to better personalize management and avoid unnecessary and/or invasive examinations.

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.

Prostatic artery embolization via inferior epigastric collateral in chronic total occlusion of the anterior division of the left internal iliac artery

Prostatic artery embolization (PAE) is one of the new treatment therapies for lower urinary tract symptoms in male patients with benign prostatic hyperplasia. PAE is considered a minimally invasive option besides other famous traditional therapies such as transurethral resection of the prostate (TURP) and open surgery. Additionally, PAE has a specific advantage in managing the elderly group and underlying health conditions like anticoagulation. In this article, we presented the case of an 83-year-old male patient who has chronic urinary retention due to benign prostatic hyperplasia, left coronary artery stent placement, and long-term anticoagulation. The preinterventional computed tomography angiography showed chronic total occlusion of the anterior division of the left internal iliac artery. Bilateral PAE was performed successfully, and his urinary symptoms were significantly improved. Computed tomography allows for the accurate detection of prostatic anatomy and facilitates planning prostatic artery embolization.

Value of magnetic resonance angiography before prostatic artery embolization for intervention planning

Knowledge about anatomical details seems to facilitate the procedure and planning of prostatic artery embolization (PAE) in patients with symptomatic benign prostatic hyperplasia (BPS). The aim of our study was the pre-interventional visualization of the prostatic artery (PA) with MRA and the correlation of iliac elongation and bifurcation angles with technical success of PAE and technical parameters. MRA data of patients with PAE were analysed retrospectively regarding PA visibility, PA type, vessel elongation, and defined angles were correlated with intervention time, fluoroscopy time, dose area product (DAP), cumulative air kerma (CAK), contrast media (CM) dose and technical success of embolization. T-test, ANOVA, Pearson correlation, and Kruskal-Wallis test was applied for statistical analysis. Between April 2018 and March 2021, a total of 78 patients were included. MRA identified the PA origin in 126 of 147 cases (accuracy 86%). Vessel elongation affected time for catheterization of right PA (p = 0.02), fluoroscopy time (p = 0.05), and CM dose (p = 0.02) significantly. Moderate correlation was observed for iliac bifurcation angles with DAP (r = 0.30 left; r = 0.34 right; p = 0.01) and CAK (r = 0.32 left; r = 0.36 right; p = 0.01) on both sides. Comparing the first half and second half of patients, median intervention time (125 vs. 105 min.) and number of iliac CBCT could be reduced (p < 0.001). We conclude that MRA could depict exact pelvic artery configuration, identify PA origin, and might obviate iliac CBCT. Vessel elongation of pelvic arteries increased intervention time and contrast media dose while the PA origin had no significant influence on intervention time and/or technical success.

Contrast-enhanced magnetic resonance angiography in the identification of prostatic arterial anatomy in patients with benign prostatic hyperplasia: prospective comparison with digital subtraction angiography

AIM

To evaluate the utility of contrast-enhanced magnetic resonance angiography (CE-MRA) for identifying prostatic artery (PA) anatomy in patients with benign prostatic hyperplasia (BPH) before PA embolisation (PAE), using digital subtraction angiography (DSA) as the reference standard.

MATERIALS AND METHODS

A total of 176 patients underwent pelvic CE-MRA at 3 T. DSA was performed within the following 7 days. Two interventional radiologists compared the CE-MRA findings with DSA findings to assess the anatomy of the PAs. The rates of correct identification of the origins and collaterals of the PAs by CE-MRA were calculated. The utility for predicting the optimal X-ray tube angle obliquity for visualising the origins of the PAs by CE-MRA was evaluated. An exact McNemar's test was used to compare the detection rates of the PAs and the collaterals with DSA versus CE-MRA. A two-sided p-value of <0.05 was considered statistically significant.

RESULTS

Of the 376 PAs identified by DSA, CE-MRA correctly identified the origins of 369 vessels (98.1%), with a 1.9% false-negative rate and no false-positive results. Of the 57 total collaterals identified by DSA, CE-MRA identified 50 vessels correctly (87.7%), with a 12.3% false-negative rate and no false-positive results. No significant differences were observed between CE-MRA and DSA in the identification of the PA origins (p=0.824) and the collaterals (p=0.327). The optimal degree for an oblique projection to visualise the origins of the PAs could be predicted accurately (100%) by pre-procedural CE-MRA.

CONCLUSION

CE-MRA before PAE can reliably predict the PA anatomy and facilitate procedural planning.

Potential of pre-interventional magnetic resonance angiography for optimization of workflow and clinical outcome of prostatic arterial embolization

PURPOSE

Impact of pre-interventional magnetic resonance angiography (MRA) on prostatic artery embolization (PAE) regarding workflow, radiation dose, and clinical outcome.

METHOD

Retrospective evaluation of 259 patients (mean age 68 ± 9, range 41-92) with benign prostatic hypertrophy (BPH) undergoing PAE between January 2017 and December 2020. MRA was performed in 137 cases. In 122 patients, no pre-interventional MRA was performed. Origin of the PA, volumetry of the prostatic gland and ADC values were evaluated. International Prostate Symptom Score (IPSS), Quality of Life (QoL) and International Index of Erectile Function (IIEF) were evaluated before and after PAE.

RESULTS

Origin of the PA was identified in all cases. Significant differences regarding volume reduction (-20 ± 13 ml with MRA vs -17 ± 9 ml without MRA) and ADC value reduction were found (-78 ± 111 10-6 mm2/s with MRA vs -45 ± 99 10-6 mm2/s without MRA). PAE workflow was modified in 16 patients due to MRA findings. Radiation dose (5518.54 ± 6677.97 µGym2 with MRA vs 23963.50 ± 19792.25 µGym2 without MRA) and fluoroscopy times (19.35 ± 9.01 min. with MRA vs 27.45 ± 12.54 min. without MRA) significantly differed. IPSS reduction improved (-11 ± 8 points with MRA vs -7 ± 9 points without MRA, p < 0.001), while QOL (-2 ± 1 points with MRA and -2 ± 2 points without MRA) and IIEF (+2 ± 10 points with MRA and +1 ± 11 points without MRA) showed no significant differences (p > 0.05).

CONCLUSIONS

Pre-interventional MRA facilitates improved workflow and patient safety of PAE while reducing radiation dose and intervention time.

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.

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.

Advanced image guidance for prostatic artery embolization - a multicenter technical note

BACKGROUND

Prostatic artery embolization (PAE) is associated with patients' quality of life improvements and limited side effects compared to surgery. However, this procedure remains technically challenging due to complex vasculature, anatomical variations and small arteries, inducing long procedure times and high radiation exposure levels both to patients and medical staff. Moreover, the risk of non-target embolization can lead to relevant complications. In this context, advanced imaging can constitute a solid ally to address these challenges and deliver good clinical outcomes at acceptable radiation levels.

MAIN TEXT

This technical note aims to share the consolidated experience of four institutions detailing their optimized workflow using advanced image guidance, discussing variants, and sharing their best practices to reach a consensus standardized imaging workflow for PAE procedure, as well as pre and post-operative imaging.

CONCLUSIONS

This technical note puts forth a consensus optimized imaging workflow and best practices, with the hope of helping drive adoption of the procedure, deliver good clinical outcomes, and minimize radiation dose levels and contrast media injections while making PAE procedures shorter and safer.

Efficacy and safety of prostatic artery embolization for benign prostatic hyperplasia: a systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

To investigate the efficacy and safety of prostatic artery embolization (PAE) vs. transurethral resection of the prostate (TURP) in patients affected by benign prostatic hyperplasia (BPH). We also reviewed mean changes from baseline in PAE at selected follow-up points.

METHODS

PubMed, Web of Science, and Embase were searched up to May 1, 2020. Randomized controlled trials on PAE were collected according to specific inclusion and exclusion criteria. Meta-analyses were performed using RevMan 5.3, STATA 14, and GraphPad Prism 8. Pooled patient-reported scores and functional outcomes were calculated by using a fixed or random-effect model.

RESULTS

Eleven articles met our selection criteria and ten independent patient series were included in the final analysis. Pooled estimates suggested no significant difference between TURP and PAE for patient-reported outcomes including International Prostate Symptom Score (2.32 (- 0.44 to 5.09)) and quality of life (0.18 (- 0.41 to 0.77)) at 12 months. PAE was less effective regarding improvements in most functional outcomes such as maximum flow rate, prostate volume, and prostate-specific antigen. Moreover, PAE may be associated with relatively fewer complications, lower cost, and shorter hospitalization. After the PAE procedure, the overall weighted mean differences for all outcomes except sexual health scores were significantly improved from baseline during follow-up to 24 months.

CONCLUSION

PAE is non-inferior to TURP with regard to improving patient-reported outcomes, though most functional parameters undergo more changes after TURP than after PAE. Moreover, PAE can significantly continue to relieve symptoms for 24 months without causing serious complications.

KEY POINTS

• PAE is as effective as TURP in improving subjective symptom scores, with fewer complications and shorter hospitalization times. • PAE is inferior to TURP in the improvement of most functional outcomes. • Improvements due to PAE are durable during follow-up to 24 months.

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.

Prostatic Artery Embolization for Benign Prostatic Hyperplasia: Patient Evaluation, Anatomy, and Technique for Successful Treatment

Symptomatic benign prostatic hyperplasia is a common condition in the aging population that results in bothersome lower urinary tract symptoms and decreased quality of life. Patients often are treated with medication and offered surgery for persistent symptoms. Transurethral resection of the prostate is considered the traditional standard of care, but several minimally invasive surgical treatments also are offered. Prostatic artery embolization (PAE) is emerging as an effective treatment option with few reported adverse effects, minimal blood loss, and infrequent overnight hospitalization. The procedure is offered to patients with moderate to severe lower urinary tract symptoms and depressed urinary flow due to bladder outlet obstruction. Proper patient selection and meticulous embolization are critical to optimize results. To perform PAE safely and avoid nontarget embolization, interventional radiologists must have a detailed understanding of the pelvic arterial anatomy. Although the prostatic arteries often arise from the internal pudendal arteries, several anatomic variants and pelvic anastomoses are encountered. Prospective cohort studies, small randomized controlled trials, and meta-analyses have shown improved symptoms after treatment, with serious adverse effects occurring rarely. This article reviews the basic principles of PAE that must be understood to develop a thriving PAE practice. These principles include patient evaluation, review of surgical therapies, details of pelvic arterial anatomy, basic principles of embolization, and an overview of published results. Online supplemental material is available for this article. ^©RSNA, 2019.

Effectiveness of Contrast-enhanced MR Angiography for Visualization of the Prostatic Artery prior to Prostatic Arterial Embolization

Background A major technical challenge of prostatic arterial embolization (PAE) is the identification and catheterization of the prostatic arteries (PAs). Recently, MR angiography has been shown to help visualize PAs, but the clinical utility of MR angiography for this purpose is not known. Purpose To determine the efficacy of contrast material-enhanced MR angiography in identifying the PA and to evaluate its role in PAE for benign prostatic hyperplasia (BPH). Materials and Methods In this prospective study, 100 consecutive men who were scheduled to undergo PAE for BPH from January 2015 to May 2017 were assigned by using a randomized block design to either group A (n = 50; mean age, 71.7 years ± 11.9 [standard deviation]) without MR angiography or group B (n = 50; mean age, 72.3 years ± 12.2) with MR angiography prior to PAE. MR angiography findings of the PA anatomy were compared with those of digital subtraction angiography (DSA). The Student t test and Wilcoxon rank-sum test were used to compare the differences between the parameters indicating the performance of PAE. Results The mean age of the 100 men in the study was 72.0 years ± 11.8 (range, 51-88 years). Compared with DSA as the reference standard, MR angiography identified PAs with a sensitivity of 91.5% (97 of 106) and a positive predictive value of 100% (97 of 97). With the knowledge of tube obliquity and anatomy, group B had lower procedure times than group A (82.3 minutes ± 5.4 vs 123.9 minutes ± 12.4, P < .001) and shorter fluoroscopy times (13.8 minutes ± 2.7 vs 28.5 minutes ± 8.0, P < .001). Additionally, radiation dose was reduced for group A versus group B, from a median of 920 to 339 mGy (P = .004). Conclusion Contrast-enhanced MR angiography can accurately show anatomy for the prostate arteries, leading to shorter prostatic artery embolization times and lower radiation dose than when preprocedural prostate MR angiography is not performed. Published under a CC BY 4.0 license. Online supplemental material is available for this article. See also the editorial by Prince in this issue.