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Müllhaupt G, Hechelhammer L, Graf N, Mordasini L, Schmid HP, Engeler DS, Abt D. Prostatic Artery Embolisation Versus Transurethral Resection of the Prostate for Benign Prostatic Obstruction: 5-year Outcomes of a Randomised, Open-label, Noninferiority Trial. Eur Urol Focus 2024:S2405-4569(24)00045-2. [PMID: 38531756 DOI: 10.1016/j.euf.2024.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Accepted: 03/07/2024] [Indexed: 03/28/2024]
Abstract
BACKGROUND AND OBJECTIVE Prostatic artery embolisation (PAE) and transurethral resection of the prostate (TURP) are two of the surgical options for treatment of lower urinary tract symptoms/benign prostatic obstruction (LUTS/BPO). Our aim was to compare the efficacy and safety of PAE and TURP for LUTS/BPO treatment at long-term follow-up. METHODS We conducted a randomised, open-label, single-centre trial at a Swiss tertiary care centre. The main outcome was the change in International Prostate Symptom Score (IPSS) after PAE versus TURP. Secondary outcomes included patient-reported outcomes, functional measures, and adverse events assessed at baseline and at 3, 6, 12, 24, and 60 mo. Between-group differences in the change from baseline to 5 yr were tested using two-sided Mann-Whitney and t tests. KEY FINDINGS AND LIMITATIONS Of the 103 patients with refractory LUTS/BPO who were randomised between 2014 and 2017, 18/48 who underwent PAE and 38/51 who underwent TURP reached the 60-mo follow-up visit. The mean reduction in IPSS from baseline to 5 yr was -7.78 points after PAE and -11.57 points after TURP (difference 3.79 points, 95% confidence interval [CI] -0.66 to 8.24; p = 0.092). TURP was superior for most patient-reported secondary outcomes except for erectile function. At 5 yr, PAE was less effective than TURP regarding objective parameters, such as the improvement in maximum urinary flow rate (3.59 vs 9.30 ml/s, difference -5.71, 95% CI -10.72 to -0.70; p = 0. 027) and reduction in postvoid residual volume (27.81 vs 219.97 ml; difference 192.15, 95% CI 83.79-300.51; p = 0.001). CONCLUSIONS AND CLINICAL IMPLICATIONS The improvement in LUTS/BPO at 5 yr after PAE was inferior to that achieved with TURP. The limitations of PAE should be considered during patient selection and counselling. PATIENT SUMMARY In this study, we show the long-term results of prostate artery embolisation (PAE) in comparison to transurethral resection of the prostate (TURP) for the treatment of benign prostate enlargement causing urinary symptoms. PAE shows good long-term results in properly selected patients, although the improvements are less pronounced than with TURP. This trial is registered on ClinicalTrials.gov as NCT02054013.
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Affiliation(s)
- Gautier Müllhaupt
- Department of Urology, St. Gallen Cantonal Hospital and School of Medicine, University of St. Gallen, St. Gallen, Switzerland; Department of Urology, Spital Thun, Thun, Switzerland.
| | - Lukas Hechelhammer
- Department of Radiology and Nuclear Medicine, St. Gallen Cantonal Hospital, St. Gallen, Switzerland
| | - Nicole Graf
- Biostatistics Department, Clinical Trials Unit, St. Gallen Cantonal Hospital, St. Gallen, Switzerland
| | - Livio Mordasini
- Department of Urology, St. Gallen Cantonal Hospital and School of Medicine, University of St. Gallen, St. Gallen, Switzerland; Uroviva Practice Sursee, Uroviva Group, Sursee, Switzerland
| | - Hans-Peter Schmid
- Department of Urology, St. Gallen Cantonal Hospital and School of Medicine, University of St. Gallen, St. Gallen, Switzerland
| | - Daniel S Engeler
- Department of Urology, St. Gallen Cantonal Hospital and School of Medicine, University of St. Gallen, St. Gallen, Switzerland
| | - Dominik Abt
- Department of Urology, St. Gallen Cantonal Hospital and School of Medicine, University of St. Gallen, St. Gallen, Switzerland; Department of Urology, Spitalzentrum Biel, Biel, Switzerland
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Jung JH, McCutcheon KA, Borofsky M, Young S, Golzarian J, Kim MH, Narayan VM, Dahm P. Prostatic arterial embolization for the treatment of lower urinary tract symptoms in men with benign prostatic hyperplasia. Cochrane Database Syst Rev 2022; 3:CD012867. [PMID: 35349161 PMCID: PMC8962961 DOI: 10.1002/14651858.cd012867.pub3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
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.
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Affiliation(s)
- Jae Hung Jung
- Department of Urology, Yonsei University Wonju College of Medicine, Wonju, Korea, South
- Center of Evidence-Based Medicine, Institute of Convergence Science, Yonsei University, Seoul, Korea, South
| | | | - Michael Borofsky
- Department of Urology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Shamar Young
- Department of Radiology, Division of Interventional Radiology & Vascular Imaging, University of Minnesota, Minneapolis, Minnesota, USA
| | - Jafar Golzarian
- Department of Radiology, Division of Interventional Radiology & Vascular Imaging, University of Minnesota, Minneapolis, Minnesota, USA
| | - Myung Ha Kim
- Yonsei Wonju Medical Library, Yonsei University Wonju College of Medicine, Wonju, Korea, South
| | - Vikram M Narayan
- Department of Urology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Philipp Dahm
- Department of Urology, University of Minnesota, Minneapolis, Minnesota, USA
- Urology Section, Minneapolis VA Health Care System, Minneapolis, Minnesota, USA
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Gremen E, Frandon J, Lateur G, Finas M, Rodière M, Horteur C, Benassayag M, Thony F, Pailhe R, Ghelfi J. Safety and Efficacy of Embolization with Microspheres in Chronic Refractory Inflammatory Shoulder Pain: A Pilot Monocentric Study on 15 Patients. Biomedicines 2022; 10:biomedicines10040744. [PMID: 35453492 PMCID: PMC9028229 DOI: 10.3390/biomedicines10040744] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 03/15/2022] [Accepted: 03/21/2022] [Indexed: 11/18/2022] Open
Abstract
Purpose: Musculoskeletal (MSK) embolization is emerging in tendinopathy treatment. The objective of this study was to assess the efficacy and safety of MSK embolization with microspheres in the treatment of chronic shoulder pain. Patients and methods: This retrospective monocentric study included patients with chronic shoulder pain resistant to 6 months or more of conventional therapies who were treated with MSK embolization between 2017 and 2021. Embolization was performed using calibrated 100–250 µm microspheres. Clinical success was defined as pain reduction, i.e., a decrease in the visual analogue scale (VAS) pain score of ≥50% at 3 months after MSK embolization as compared to baseline. Adverse events were collected. Results: Fifteen patients (11 women, 4 men) were included, with a median age of 50.3 years (IQR: 46.7–54.5). The median duration of symptoms was 26.6 months (20.6–39.8). The median VAS pain scores were 7.0 (7.0–8.0) at baseline, 6.0 (3.5–7.0) at 1 month, 5.0 (4.5–6.5) and 5.0 (3.0–7.4) at 3 months and 6 months (p = 0.002). Three patients (20%) reported clinical success at 3 months. Three patients experienced minor complications after embolization (paresthesia, n = 2; transient osteo-medullary edema, n = 1) and two patients had moderate complications (transient skin ischemia). Conclusion: MSK embolization with microspheres for treatment of refractory chronic shoulder pain showed moderate results in terms of clinical success and safety.
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Affiliation(s)
- Emeric Gremen
- Faculty of Medecine, Grenoble-Alpes University, 38043 Grenoble, France; (E.G.); (R.P.)
- Radiology Department, Grenoble Alpes University Hospital, 38043 Grenoble, France; (M.F.); (M.R.); (F.T.)
| | - Julien Frandon
- Radiology Department, Nimes University Hospital, University of Montpellier, 30900 Nimes, France;
| | - Gabriel Lateur
- Orthopaedic and Traumatology Surgery Department, Albertville Hospital, 73200 Albertville, France;
| | - Mathieu Finas
- Radiology Department, Grenoble Alpes University Hospital, 38043 Grenoble, France; (M.F.); (M.R.); (F.T.)
| | - Mathieu Rodière
- Radiology Department, Grenoble Alpes University Hospital, 38043 Grenoble, France; (M.F.); (M.R.); (F.T.)
| | - Clément Horteur
- Department of Orthopaedic Surgery, Grenoble Alpes University Hospital, 38043 Grenoble, France;
| | - Michaël Benassayag
- Orthopaedic Surgery Department, Medipôle de Savoie Hospital, 73190 Challes-les-Eaux, France;
| | - Frédéric Thony
- Radiology Department, Grenoble Alpes University Hospital, 38043 Grenoble, France; (M.F.); (M.R.); (F.T.)
| | - Régis Pailhe
- Faculty of Medecine, Grenoble-Alpes University, 38043 Grenoble, France; (E.G.); (R.P.)
- Department of Orthopaedic Surgery, Grenoble Alpes University Hospital, 38043 Grenoble, France;
| | - Julien Ghelfi
- Faculty of Medecine, Grenoble-Alpes University, 38043 Grenoble, France; (E.G.); (R.P.)
- Radiology Department, Grenoble Alpes University Hospital, 38043 Grenoble, France; (M.F.); (M.R.); (F.T.)
- Institute of Advanced Biosciences, INSERM U1209, CNRS UMR 5309, 38043 Grenoble, France
- Correspondence: ; Tel.: +33-4-76-76-89-09
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Franco JV, Jung JH, Imamura M, Borofsky M, Omar MI, Escobar Liquitay CM, Young S, Golzarian J, Veroniki AA, Garegnani L, Dahm P. Minimally invasive treatments for lower urinary tract symptoms in men with benign prostatic hyperplasia: a network meta-analysis. Cochrane Database Syst Rev 2021; 7:CD013656. [PMID: 34693990 PMCID: PMC8543673 DOI: 10.1002/14651858.cd013656.pub2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
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.
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Affiliation(s)
- Juan Va Franco
- Associate Cochrane Centre, Instituto Universitario Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Jae Hung Jung
- Department of Urology, Yonsei University Wonju College of Medicine, Wonju, Korea, South
- Center of Evidence-Based Medicine, Institute of Convergence Science, Yonsei University, Seoul, Korea, South
| | - Mari Imamura
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Michael Borofsky
- Department of Urology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Muhammad Imran Omar
- Guidelines Office, European Association of Urology, Arnhem, Netherlands
- Academic Urology Unit, University of Aberdeen, Aberdeen, UK
| | | | - Shamar Young
- Department of Radiology, Division of Interventional Radiology & Vascular Imaging, University of Minnesota, Minneapolis, Minnesota, USA
| | - Jafar Golzarian
- Department of Radiology, Division of Interventional Radiology & Vascular Imaging, University of Minnesota, Minneapolis, Minnesota, USA
| | - Areti Angeliki Veroniki
- Department of Primary Education, School of Education, University of Ioannina, Ioannina, Greece
| | - Luis Garegnani
- Associate Cochrane Centre, Instituto Universitario Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Philipp Dahm
- Department of Urology, University of Minnesota, Minneapolis, Minnesota, USA
- Urology Section, Minneapolis VA Health Care System, Minneapolis, Minnesota, USA
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Dahm P, MacDonald R, McKenzie L, Jung JH, Greer N, Wilt T. Newer Minimally Invasive Treatment Modalities to Treat Lower Urinary Tract Symptoms Attributed to Benign Prostatic Hyperplasia. EUR UROL SUPPL 2021; 26:72-82. [PMID: 34337510 PMCID: PMC8317814 DOI: 10.1016/j.euros.2021.02.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/02/2021] [Indexed: 12/14/2022] Open
Abstract
Context Several newer device-based procedures have recently become available for treating men with lower urinary tract symptoms attributed to benign prostatic hyperplasia, but their effectiveness remains uncertain. Objective To assess the longer-term comparative effectiveness (defined as >12 mo of follow-up) of the newer treatment modalities prostatic urethral lift (PUL), transurethral prostate convective radiofrequency water vapor (Rezūm), Aquablation, and prostatic arterial embolization (PAE). Evidence acquisition Ovid Medline, the Cochrane Central Register of Controlled Trials (CENTRAL), and the Agency for Healthcare Research and Quality databases were searched through September 30, 2019; hand searches of references of relevant studies were also performed. Eligible studies were randomized controlled trials (RCTs) published in English language. We excluded observational studies. Evidence synthesis One RCT (n = 91) found that patients undergoing PUL may be less likely to respond (risk ratio [RR] 0.8; 95% confidence interval [CI] 0.7-1.0; low certainty of evidence [CoE]) and have a higher mean International Prostate Symptom Score (IPSS; mean difference 6.1; 95% CI 2.2-10.0; low CoE) than those undergoing transurethral resection of the prostate (TURP). Among patients undergoing PAE, one small RCT (n = 30) reported similar IPSS response rates (RR 0.9; 95% CI 0.7-1.1; low CoE) and one trial (n = 107) found similar mean IPSS (-0.7; 95% CI -1.3 to 2.7; moderate CoE) scores to those among patients undergoing TURP. A single study on Aquablation reported 12 mo of follow-up only, and a single 3-mo trial compared Rezūm with sham treatment. Conclusions The current best evidence underlying these newer therapies is limited to few trials (PUL and PAE), short-term follow-up of 12 mo (Aquablation and Rezūm), or sham comparison only (Rezūm). Patient summary Evidence for four of the newer surgical treatments for men with an enlarged prostate is limited to few small trials with short-term follow-up; only one trial compared a new treatment modality with sham surgery.
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Affiliation(s)
- Philipp Dahm
- Minneapolis VA Health Care System, Minneapolis, MN, USA
| | | | | | - Jae Hung Jung
- Wonju College of Medicine, Yonsei University, Wonju, South Korea
| | - Nancy Greer
- Minneapolis VA Health Care System, Minneapolis, MN, USA
| | - Timothy Wilt
- Minneapolis VA Health Care System, Minneapolis, MN, USA
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Abt D, Müllhaupt G, Hechelhammer L, Markart S, Güsewell S, Schmid HP, Mordasini L, Engeler DS. Prostatic Artery Embolisation Versus Transurethral Resection of the Prostate for Benign Prostatic Hyperplasia: 2-yr Outcomes of a Randomised, Open-label, Single-centre Trial. Eur Urol 2021; 80:34-42. [PMID: 33612376 DOI: 10.1016/j.eururo.2021.02.008] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 02/02/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Prostatic artery embolisation (PAE) for the treatment of lower urinary tract symptoms secondary to benign prostatic obstruction (LUTS/BPO) still remains under investigation. OBJECTIVE To compare the efficacy and safety of PAE and transurethral resection of the prostate (TURP) in the treatment of LUTS/BPO at 2 yr of follow-up. DESIGN, SETTING, AND PARTICIPANTS A randomised, open-label trial was conducted. There were 103 participants aged ≥40 yr with refractory LUTS/BPO. INTERVENTION PAE versus TURP. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS International Prostate Symptoms Score (IPSS) and other questionnaires, functional measures, prostate volume, and adverse events were evaluated. Changes from baseline to 2 yr were tested for differences between the two interventions with standard two-sided tests. RESULTS AND LIMITATIONS The mean reduction in IPSS after 2 yr was 9.21 points after PAE and 12.09 points after TURP (difference of 2.88 [95% confidence interval 0.04-5.72]; p = 0.047). Superiority of TURP was also found for most other patient-reported outcomes except for erectile function. PAE was less effective than TURP regarding the improvement of maximum urinary flow rate (3.9 vs 10.23 ml/s, difference of -6.33 [-10.12 to -2.54]; p < 0.001), reduction of postvoid residual urine (62.1 vs 204.0 ml; 141.91 [43.31-240.51]; p = 0.005), and reduction of prostate volume (10.66 vs 30.20 ml; 19.54 [7.70-31.38]; p = 0.005). Adverse events were less frequent after PAE than after TURP (total occurrence n = 43 vs 78, p = 0.005), but the distribution among severity classes was similar. Ten patients (21%) who initially underwent PAE required TURP within 2 yr due to unsatisfying clinical outcomes, which prevented further assessment of their outcomes and, therefore, represents a limitation of the study. CONCLUSIONS Inferior improvements in LUTS/BPO and a relevant re-treatment rate are found 2 yr after PAE compared with TURP. PAE is associated with fewer complications than TURP. The disadvantages of PAE regarding functional outcomes should be considered for patient selection and counselling. PATIENT SUMMARY Prostatic artery embolisation is safe and effective. However, compared with transurethral resection of the prostate, its disadvantages regarding subjective and objective outcomes should be considered for individual treatment choices.
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Affiliation(s)
- Dominik Abt
- Department of Urology, School of Medicine, University of St. Gallen, St. Gallen, Switzerland.
| | - Gautier Müllhaupt
- Department of Urology, School of Medicine, University of St. Gallen, St. Gallen, Switzerland
| | - Lukas Hechelhammer
- Department of Radiology and Nuclear Medicine, School of Medicine, University of St. Gallen, St. Gallen, Switzerland
| | - Stefan Markart
- Department of Radiology and Nuclear Medicine, School of Medicine, University of St. Gallen, St. Gallen, Switzerland
| | - Sabine Güsewell
- Biostatistics, Clinical Trials Unit, School of Medicine, University of St. Gallen, St. Gallen, Switzerland
| | - Hans-Peter Schmid
- Department of Urology, School of Medicine, University of St. Gallen, St. Gallen, Switzerland
| | - Livio Mordasini
- Department of Urology, School of Medicine, University of St. Gallen, St. Gallen, Switzerland
| | - Daniel S Engeler
- Department of Urology, School of Medicine, University of St. Gallen, St. Gallen, Switzerland
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Uflacker A, Haskal ZJ, Patrie J, Smith A, Tramel R, Irish N, Ashley B, Johnson DT, Yamada R. Improving Cone-Beam CT Angiography for Prostatic Artery Embolization: Is a Low-Dose Protocol Equivalent to the Standard? J Vasc Interv Radiol 2021; 32:562-568. [PMID: 33558125 DOI: 10.1016/j.jvir.2020.12.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 11/17/2020] [Accepted: 12/06/2020] [Indexed: 11/29/2022] Open
Abstract
PURPOSE To compare the utility of low-dose versus standard cone-beam computed tomography (CT) angiography protocols in identifying nontarget embolization (NTE) during prostatic artery embolization (PAE). MATERIALS AND METHODS A prospective, single-center, Phase-1 study (NCT02592473) was conducted for lower urinary tract symptoms in benign prostatic hyperplasia. Prostate volume, international prostate symptom score (IPSS), quality of life score (QoL), International Index of Erectile Function (IIEF), peak flow rate, UCLA Prostate Cancer Index (UCLA-PCI), and postvoid residual were recorded at baseline and 1, 3, 6, 12, and 24-months after PAE. Six-second (standard protocol, n = 29) or 5-second (low-dose protocol n = 45) rotations were made. Images were selected and matched in pairs by areas of NTE and compared by readers using a binomial generalized estimating equation model. Procedural outcomes were analyzed using a linear mixed model. RESULTS Seventy-four cone-beam CT angiographies were performed in 21 patients. IPSS and QoL scores significantly improved (P <.05). There was no change in UCLA-PCI or IIEF scores. Dose area product of the low- and standard-dose protocol were 37,340.82 mGy·cm2 ± 104.66 and 62,645.66 mGy·cm2 ± 12,711.48, respectively, representing a dose reduction of 40.4%. A total of 120 comparisons showed no preference between the 2 protocols (P =.24). Observers identified 76 and 69 instances of NTE in the standard- and low-dose protocols, respectively (P =.125). CONCLUSIONS Low-dose cone-beam CT angiography achieved equivalent clinical utility in identifying NTE during PAE, with the advantage of a lower radiation dose.
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Affiliation(s)
- Andre Uflacker
- Division of Vascular and Interventional Radiology, Department of Radiology, Medical University of South Carolina, Charleston, South Carolina.
| | - Ziv J Haskal
- Division of Vascular and Interventional Radiology, Department of Radiology and Medical Imaging, University of Virginia, Charlottesville, Virginia
| | - James Patrie
- Department of Public Health Sciences, University of Virginia, Charlottesville, Virginia
| | - Alex Smith
- Division of Vascular and Interventional Radiology, Department of Radiology, Medical University of South Carolina, Charleston, South Carolina
| | - Richard Tramel
- Division of Vascular and Interventional Radiology, Department of Radiology, Medical University of South Carolina, Charleston, South Carolina
| | - Nolan Irish
- Division of Vascular and Interventional Radiology, Department of Radiology, Medical University of South Carolina, Charleston, South Carolina
| | - Bryan Ashley
- Division of Vascular and Interventional Radiology, Department of Radiology, Medical University of South Carolina, Charleston, South Carolina
| | - David T Johnson
- Division of Vascular and Interventional Radiology, Department of Radiology, Medical University of South Carolina, Charleston, South Carolina
| | - Ricardo Yamada
- Division of Vascular and Interventional Radiology, Department of Radiology, Medical University of South Carolina, Charleston, South Carolina
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8
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Jung JH, McCutcheon KA, Borofsky M, Young S, Golzarian J, Reddy B, Shin TY, Kim MH, Narayan V, Dahm P. Prostatic arterial embolization for the treatment of lower urinary tract symptoms in men with benign prostatic hyperplasia. Cochrane Database Syst Rev 2020; 12:CD012867. [PMID: 33368143 PMCID: PMC8728637 DOI: 10.1002/14651858.cd012867.pub2] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
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.
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Affiliation(s)
- Jae Hung Jung
- Department of Urology, Yonsei University Wonju College of Medicine, Wonju, Korea, South
- Center of Evidence Based Medicine, Institute of Convergence Science, Yonsei University, Seoul, Korea, South
| | | | - Michael Borofsky
- Department of Urology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Shamar Young
- Department of Radiology, Division of Interventional Radiology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Jafar Golzarian
- Division of Interventional Radiology and Vascular Imaging, University of Minnesota, Minneapolis, Minnesota, USA
| | - Balaji Reddy
- Department of Urology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Tae Young Shin
- Department of Urology, Ewha Womans University, Seoul, Korea, South
| | - Myung Ha Kim
- Yonsei Wonju Medical Library, Yonsei University Wonju College of Medicine, Wonju, Korea, South
| | - Vikram Narayan
- Department of Urology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Philipp Dahm
- Department of Urology, University of Minnesota, Minneapolis, Minnesota, USA
- Urology Section, Minneapolis VA Health Care System, Minneapolis, Minnesota, USA
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Kovács A, Bücker A, Grimm MO, Habermann CR, Katoh M, Massmann A, Mahnken AH, Meyer BC, Moche M, Reimer P, Teichgräber U, Wacker FK. Position Paper of the German Society for Interventional Radiology (DeGIR) on Prostatic Artery Embolization. ROFO-FORTSCHR RONTG 2020; 192:835-846. [PMID: 32615637 DOI: 10.1055/a-1183-5438] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
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.
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Affiliation(s)
- Attila Kovács
- MediClin Robert Janker Clinic, Clinic of Diagnostic and Interventional Radiology and Neuroradiology, Bonn, Germany
| | - Arno Bücker
- Saarland University Medical Center, Clinic of Diagnostic and Interventional Radiology, Homburg/Saar, Germany
| | | | - Christian R Habermann
- Kath. Marienhospital Hamburg, Department of Diagnostic and Interventional Radiology, Hamburg, Germany
| | - Marcus Katoh
- Helios-Hospital Krefeld, Diagnostic and Interventional Radiology, Krefeld, Germany
| | - Alexander Massmann
- Saarland University Medical Center, Clinic of Diagnostic and Interventional Radiology, Homburg/Saar, Germany
| | - Andreas H Mahnken
- Marburg University Hospital, Clinic of Diagnostic and Interventional Radiology, Marburg, Germany
| | - Bernhard C Meyer
- Hannover Medical School, Department of Diagnostic and Interventional Radiology, Hannover, Germany
| | - Michael Moche
- Helios-Park-Klinikum Leipzig, Department of Interventional Radiology, Leipzig, Germany
| | - Peter Reimer
- Städtisches Klinikum Karlsruhe, Academic teaching hospital of the University of Freiburg, Institute of Diagnostic and Interventional Radiology, Karlsruhe, Germany
| | - Ulf Teichgräber
- Jena University Hospital, Department of Radiology, Jena, Germany
| | - Frank K Wacker
- Hannover Medical School, Department of Diagnostic and Interventional Radiology, Hannover, Germany
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10
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Hechelhammer L, Müllhaupt G, Mordasini L, Markart S, Güsewell S, Betschart P, Schmid HP, Engeler DS, Abt D. Predictability and Inducibility of Detachment of Prostatic Central Gland Tissue after Prostatic Artery Embolization: Post Hoc Analysis of a Randomized Controlled Trial. J Vasc Interv Radiol 2019; 30:217-224. [DOI: 10.1016/j.jvir.2018.09.029] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 09/19/2018] [Accepted: 09/21/2018] [Indexed: 01/14/2023] Open
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11
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Abt D, Müllhaupt G, Mordasini L, Güsewell S, Markart S, Zumstein V, Kessler TM, Schmid HP, Engeler DS, Hechelhammer L. Outcome prediction of prostatic artery embolization: post hoc analysis of a randomized, open-label, non-inferiority trial. BJU Int 2018; 124:134-144. [PMID: 30499637 DOI: 10.1111/bju.14632] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
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 (Qmax ), 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 Qmax (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 Qmax (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.
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Affiliation(s)
- Dominik Abt
- Department of Urology, St Gallen Cantonal Hospital, St Gallen, Switzerland
| | - Gautier Müllhaupt
- Department of Urology, St Gallen Cantonal Hospital, St Gallen, Switzerland
| | - Livio Mordasini
- Department of Urology, St Gallen Cantonal Hospital, St Gallen, Switzerland
| | - Sabine Güsewell
- Clinical Trials Unit, St Gallen Cantonal Hospital, St Gallen, Switzerland
| | - Stefan Markart
- Department of Radiology and Nuclear Medicine, St Gallen Cantonal Hospital, St Gallen, Switzerland
| | - Valentin Zumstein
- Department of Urology, St Gallen Cantonal Hospital, St Gallen, Switzerland
| | - Thomas M Kessler
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Hans-Peter Schmid
- Department of Urology, St Gallen Cantonal Hospital, St Gallen, Switzerland
| | - Daniel S Engeler
- Department of Urology, St Gallen Cantonal Hospital, St Gallen, Switzerland
| | - Lukas Hechelhammer
- Department of Radiology and Nuclear Medicine, St Gallen Cantonal Hospital, St Gallen, Switzerland
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12
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Abt D, Hechelhammer L, Müllhaupt G, Markart S, Güsewell S, Kessler TM, Schmid HP, Engeler DS, Mordasini L. Comparison of prostatic artery embolisation (PAE) versus transurethral resection of the prostate (TURP) for benign prostatic hyperplasia: randomised, open label, non-inferiority trial. BMJ 2018; 361:k2338. [PMID: 29921613 PMCID: PMC6006990 DOI: 10.1136/bmj.k2338] [Citation(s) in RCA: 169] [Impact Index Per Article: 28.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/06/2018] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To compare prostatic artery embolisation (PAE) with transurethral resection of the prostate (TURP) in the treatment of lower urinary tract symptoms secondary to benign prostatic hyperplasia in terms of patient reported and functional outcomes. DESIGN Randomised, open label, non-inferiority trial. SETTING Urology and radiology departments of a Swiss tertiary care centre. PARTICIPANTS 103 patients aged ≥40 years with refractory lower urinary tract symptoms secondary to benign prostatic hyperplasia were randomised between 11 February 2014 and 24 May 2017; 48 and 51 patients reached the primary endpoint 12 weeks after PAE and TURP, respectively. INTERVENTIONS PAE performed with 250-400 μm microspheres under local anaesthesia versus monopolar TURP performed under spinal or general anaesthesia. MAIN OUTCOMES AND MEASURES Primary outcome was change in international prostate symptoms score (IPSS) from baseline to 12 weeks after surgery; a difference of less than 3 points between treatments was defined as non-inferiority for PAE and tested with a one sided t test. Secondary outcomes included further questionnaires, functional measures, magnetic resonance imaging findings, and adverse events; changes from baseline to 12 weeks were compared between treatments with two sided tests for superiority. RESULTS Mean reduction in IPSS from baseline to 12 weeks was -9.23 points after PAE and -10.77 points after TURP. Although the difference was less than 3 points (1.54 points in favour of TURP (95% confidence interval -1.45 to 4.52)), non-inferiority of PAE could not be shown (P=0.17). None of the patient reported secondary outcomes differed significantly between treatments when tested for superiority; IPSS also did not differ significantly (P=0.31). At 12 weeks, PAE was less effective than TURP regarding changes in maximum rate of urinary flow (5.19 v 15.34 mL/s; difference 10.15 (95% confidence interval -14.67 to -5.63); P<0.001), postvoid residual urine (-86.36 v -199.98 mL; 113.62 (39.25 to 187.98); P=0.003), prostate volume (-12.17 v -30.27 mL; 18.11 (10.11 to 26.10); P<0.001), and desobstructive effectiveness according to pressure flow studies (56% v 93% shift towards less obstructive category; P=0.003). Fewer adverse events occurred after PAE than after TURP (36 v 70 events; P=0.003). CONCLUSIONS The improvement in lower urinary tract symptoms secondary to benign prostatic hyperplasia seen 12 weeks after PAE is close to that after TURP. PAE is associated with fewer complications than TURP but has disadvantages regarding functional outcomes, which should be considered when selecting patients. Further comparative study findings, including longer follow-up, should be evaluated before PAE can be considered as a routine treatment. TRIAL REGISTRATION Clinicaltrials.gov NCT02054013.
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Affiliation(s)
- Dominik Abt
- Department of Urology, St Gallen Cantonal Hospital, 9007 St Gallen, Switzerland
| | - Lukas Hechelhammer
- Department of Radiology and Nuclear Medicine, St Gallen Cantonal Hospital, St Gallen, Switzerland
| | - Gautier Müllhaupt
- Department of Urology, St Gallen Cantonal Hospital, 9007 St Gallen, Switzerland
| | - Stefan Markart
- Department of Radiology and Nuclear Medicine, St Gallen Cantonal Hospital, St Gallen, Switzerland
| | - Sabine Güsewell
- Clinical Trials Unit, St Gallen Cantonal Hospital, St Gallen, Switzerland
| | - Thomas M Kessler
- Neuro-Urology, Spinal Cord Injury Center and Research, University of Zürich, Balgrist University Hospital, Zürich, Switzerland
| | - Hans-Peter Schmid
- Department of Urology, St Gallen Cantonal Hospital, 9007 St Gallen, Switzerland
| | - Daniel S Engeler
- Department of Urology, St Gallen Cantonal Hospital, 9007 St Gallen, Switzerland
| | - Livio Mordasini
- Department of Urology, St Gallen Cantonal Hospital, 9007 St Gallen, Switzerland
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13
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Maclean D, Maher B, Modi S, Harris M, Dyer J, Somani B, Hacking N, Bryant T. Prostate artery embolization: a new, minimally invasive treatment for lower urinary tract symptoms secondary to prostate enlargement. Ther Adv Urol 2017; 9:209-216. [PMID: 29662545 DOI: 10.1177/1756287217717889] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Accepted: 06/07/2017] [Indexed: 01/12/2023] Open
Abstract
Prostate artery embolization (PAE) is emerging as a safe and efficacious treatment which approaches benign prostatic obstruction (BPO) from a unique perspective. This brings with it distinct advantages and solutions, which we discuss along with cost, evidence, complications and disadvantages.
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Affiliation(s)
- Drew Maclean
- University Hospital Southampton, Tremona Road, Southampton SO16 6YD, UK
| | - Ben Maher
- Department of Interventional Radiology, University Hospital Southampton, Southampton, UK
| | - Sachin Modi
- Department of Interventional Radiology, University Hospital Southampton, Southampton, UK
| | - Mark Harris
- Department of Urology, University Hospital Southampton, Southampton, UK
| | - Jonathan Dyer
- Department of Urology, University Hospital Southampton, Southampton, UK
| | - Bhaskar Somani
- Department of Urology, University Hospital Southampton, Southampton, UK
| | - Nigel Hacking
- Department of Interventional Radiology, University Hospital Southampton, Southampton, UK
| | - Timothy Bryant
- Department of Interventional Radiology, University Hospital Southampton, Southampton, UK
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14
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Zumstein V, Betschart P, Müllhaupt G, Jochum W, Schmid HP, Abt D. Recurrent Dystrophic Calcification of the Prostatic Resection Cavity After Transurethral Resection of the Prostate: Clinical Presentation and Endoscopic Management. J Endourol Case Rep 2017; 3:81-83. [PMID: 28736747 PMCID: PMC5515091 DOI: 10.1089/cren.2017.0058] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Background: Dystrophic calcification (DC) can occur as a reaction to tissue damage and necrosis. So far, this has never been described as a complication after conventional transurethral resection of the prostate (TURP). Case Presentation: We report on a 59-year-old man who underwent uncomplicated monopolar TURP for lower urinary tract symptoms caused by benign prostatic hyperplasia. The patient showed an excellent course up to 5 weeks after the initial operation. Afterward he suffered from a rapid onset of irritative and obstructive voiding symptoms and pain. Complete DC of the prostatic resection cavity was found by cystoscopy and recurred quickly twice after Re-TURP despite anti-inflammatory treatment and normal urinary and metabolic findings. Complete recovery was only achieved by gently scraping off the calcifications avoiding further trauma to the residual prostatic tissue. Conclusion: In rare cases, delayed occurrence of irritative and obstructive voiding symptoms after TURP can be caused by DC of the prostatic resection cavity and might be misinterpreted as post-TURP infection. The pathomechanism of DC and the presented case suggest minimizing tissue trauma by cautious removal of calcifications rather than performing extensive Re-TURP.
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Affiliation(s)
- Valentin Zumstein
- Department of Urology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Patrick Betschart
- Department of Urology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Gautier Müllhaupt
- Department of Urology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Wolfram Jochum
- Institute of Pathology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Hans-Peter Schmid
- Department of Urology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Dominik Abt
- Department of Urology, Kantonsspital St. Gallen, St. Gallen, Switzerland
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15
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Wang MQ, Wang Y, Yan JY, Yuan K, Zhang GD, Duan F, Li K. Prostatic artery embolization for the treatment of symptomatic benign prostatic hyperplasia in men ≥75 years: a prospective single-center study. World J Urol 2016; 34:1275-83. [PMID: 26818021 DOI: 10.1007/s00345-016-1771-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Accepted: 01/16/2016] [Indexed: 10/22/2022] Open
Abstract
PURPOSE To compare the safety and efficacy of PAE for the treatment of benign prostatic hyperplasia (BPH) in men ≥75 years, who we defined as elderly, to those <75 years. METHODS A total of 157 patients diagnosed with lower urinary tract symptoms (LUTS) due to BPH underwent PAE. Group A (n = 52) included patients ≥75 years, and group B (n = 105) included patients <75 years. Follow-up was performed using the International Prostate Symptoms Score (IPSS), quality of life (QoL), peak urinary flow rate (Q max), post-void residual volume (PVR), the International Index of Erectile Function short form (IIEF-5), prostatic-specific antigen (PSA), and prostate volume (PV), at 1, 3, 6, and every 6 months thereafter. RESULTS More coexistent systemic diseases were identified in group A than in group B (P < 0.05). Technical success rate of PAE was 90.4 % in group A and 95.2 % in group B (P = 0.06). A total of 147 patients had completed the follow-up with a mean of 20 months. Compared with the baseline, there were significant improvements in IPSS, QoL, Q max, PV, PVR, and PSA in both groups after PAE. There were no significant differences in the changes of IPSS, Q max, PVR, PSA, and IIEF-5 between groups after PAE. No major complications were noted. CONCLUSION PAE could be used as an effective, safe, and well tolerable method in the treatment of elderly symptomatic BPH patients, similarly to younger patients, and it may play an important role in patients in whom medical therapy has failed, who are at high surgical and anesthetic risk or who refuse the standard surgical therapy.
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Lebdai S, Delongchamps NB, Sapoval M, Robert G, Amouyal G, Thiounn N, Karsenty G, Ruffion A, de La Taille A, Descazeaud A, Mathieu R. Early results and complications of prostatic arterial embolization for benign prostatic hyperplasia. World J Urol 2015; 34:625-32. [PMID: 26276151 DOI: 10.1007/s00345-015-1665-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Accepted: 08/03/2015] [Indexed: 11/30/2022] Open
Abstract
PURPOSE To review current knowledge on clinical outcomes and peri-operative complications of prostatic arterial embolization (PAE) in patients treated for lower urinary tract symptoms (LUTS) related to benign prostatic obstruction (BPO). METHODS A systematic review of the literature published from January 2008 to January 2015 was performed on PubMed/MEDLINE. RESULTS Fifty-seven articles were identified, and four were selected for inclusion in this review. Only one randomized clinical trial compared transurethral resection of the prostate (TURP) to PAE. At 3 months after the procedure, mean IPSS reduction from baseline ranged from 7.2 to 15.6 points. Mean urine peak-flow improvement ranged from +3.21 ml/s to +9.5 ml/s. When compared to TURP, PAE was associated with a significantly lower IPSS reduction 1 and 3 months after the procedure. A trend toward similar symptoms improvement was however reported without statistical significance from 6 to 24 months. Major complications were rare with one bladder partial necrosis due to non-selective embolization. Mild adverse events occurred in 10 % of the patients and included transient hyperthermia, hematuria, rectal bleeding, painful urination or acute urinary retention. Further comparative studies are mandatory to assess post-operative rates of complications, especially acute urinary retention, after PAE and standard procedures. CONCLUSION Early reports suggest that PAE may be a promising procedure for the treatment of patients with LUTS due to BPO. However, the low level of evidence and short follow-up of published reports preclude any firm conclusion on its mid-term efficiency. Further clinical trials are warranted before any use in clinical practice.
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Affiliation(s)
- Souhil Lebdai
- Service d'Urologie, Centre Hospitalier Universitaire d'Angers, 4, rue Larrey, 49933, Angers Cedex 9, France.
| | | | - Marc Sapoval
- Interventional Radiology Department, Hôpital Européen Georges Pompidou, Paris, France
| | - Grégoire Robert
- Urology Department, University Hospital of Bordeaux, Bordeaux, France
| | - Gregory Amouyal
- Interventional Radiology Department, Hôpital Européen Georges Pompidou, Paris, France
| | - Nicolas Thiounn
- Urology Department, Hôpital Européen Georges Pompidou, Paris, France
| | - Gilles Karsenty
- Urology Department, University Hospital of Marseilles, Marseilles, France
| | - Alain Ruffion
- Urology Department, University Hospital of Lyon, Lyon, France
| | | | | | - Romain Mathieu
- Urology Department, University Hospital of Rennes, 35000, Rennes, France
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