Role of Coil Embolization during Prostatic Artery Embolization: Incidence, Indications, and Safety Profile ☆

Penile Glans Necrosis Following Prostatic Artery Embolization for Benign Prostatic Hyperplasia: Case Series and Review of Current Literature

PURPOSE

To report a case series of 6 patients with penile glans necrosis (PGN) following prostatic artery embolization (PAE) and review the current literature relating to PAE and PGN, including the emerging role of hyperbaric oxygen therapy (HBOT) for PGN.

MATERIALS AND METHODS

All patients have failed medical BPH therapy and chose to undergo PAE over other minimally invasive BPH surgery. Patient demographics, preoperative and postoperative validated questionnaires such as the International Prostate Symptom Severity (IPSS) and International Index of Erectile Function (IIEF) scores, treatment-related adverse events (TRAE) and subsequent treatment for PGN were reviewed. All patients were follow-up with a minimum of 12 months post-PAE.

RESULTS

Between January 2018 and June 2020, six males with a mean age of 52.3 years (44-66 y) received PAE for BPH therapy. An immediate postoperative PGN was recognised in 4 out of 6 patients with the mean penile glans pain score of 3 and 4 patients reported altered penile glans sensitivity. Comparing the mean (and median) IPSS and IIEF-5 scores were 16.5 (16) and 21.3 (21) pre-PAE, there was improvements in IPSS and IIEF-5 scores at 12.0 (12) and 18.0 (18) at 12 months review. All patients reported normal penile glans sensitivity and only 1 patient reported an on-going penile glans pain (score 2). Four patients received HBOT while 2 patients elected for conservative care. All patients reported worse erectile function scores despite complete resolution of PGN.

CONCLUSIONS

PGN is a rare but serious complication of PAE with ensuing erectile dysfunction. HBOT appears to expedite the recovery process in men with PGN related to PAE with better erection scores compared to conservative measure.

Case report. Necrose van de glans penis na prostaatembolisatie

Prostaatembolisatie is een nieuwe minimaal-invasieve procedure die onder andere wordt ingezet bij benigne prostaathyperplasie. Bij nieuwe technieken komen echter ook nieuwe complicaties kijken. In deze uitgebreide case report bespreken we vier patiënten bij wie necrose van de glans penis optrad na de embolisatie van de prostaat. De oorzaak van deze complicatie is niet bij alle patiënten duidelijk, en meer onderzoek is zeker nodig. Patiënten dienen op de hoogte gesteld te worden van deze complicatie, gezien de soms zeer uitgebreide esthetische veranderingen die embolisatie teweeg kan brengen.

Prostatic Artery Embolization: Technical Pearls

Benign prostatic hyperplasia (BPH) is a condition that primarily affects men between the fourth and seventh decades of life, occurring due to enlargement of the prostate which subsequently causes compression of the prostatic urethra causing chronic obstruction of the urinary outflow tract. BPH can cause significant quality-of-life issues such as urinary hesitancy, intermittency, decreased urinary stream, a sensation of incomplete emptying, dysuria, urinary retention, hematuria, and nocturia. Several medical and surgical treatment modalities are available for the treatment of lower urinary tract symptoms and other BPH-related sequela; however, increasingly prostate artery embolization is being utilized in this patient population. Technical demands for this procedure in this population can be significant. This article describes the optimal techniques, tricks, and advanced imaging techniques that can be used to achieve desired technical outcomes.

Cone Beam CT with Automatic vessel Detection Software versus Conventional 2D Fluoroscopy with Overlay for Prostate Artery Embolization: A Comparison of Prostatic Artery Catheterization Time and Radiation Exposure

Purpose To evaluate the effect of cone-beam computed tomography (CT) with automatic vessel detection software on prostate artery catheterization and fluoroscopy time in prostate artery embolization (PAE).

Methods Fifty patients undergoing PAE for BPH were enrolled in this prospective study. Twenty-five PAEs were performed using automatic vessel detection software with syngo embolization guidance (study) and were compared with 25 PAEs performed using conventional two-dimensional (2D) fluoroscopy with overlay (control). PAE was performed using 300–500 μm trisacryl gelatin spherical particles. The primary outcome parameters were prostatic artery catheterization time and fluoroscopy time.

Results Bilateral PAE was achieved in 24/25 cases in both groups. The median right and left prostatic artery catheterization times were similar between the two groups, (p = 0.473 and p = 0.659, respectively). The median fluoroscopy time (28.0 and 42.0 minutes, p = 0.046) and total procedure time (70.0 and 118.0 minutes, p < 0.001) were shorter in the study group. The median total dose area product (DAP) was not significantly different. However, the median CBCT DAP (11406 vs. 6248, p < 0.001) was higher in the study group, while median fluoroscopy DAP (7371 vs. 8426, p < .049) was higher in the control group. Median digital subtraction angiography (DSA), CBCT, and fluoroscopy DAP accounted for 27%, 45%, and 29% of the total DAP in the study group and 32%, 29%, and 39% in the control group (p < 0.001), respectively. All complications were Clavien–Dindo Grade 1.

Conclusion Although CBCT with automatic vessel detection software had no significant effect on time-to-prostatic artery catheterization and total radiation exposure, it reduced the fluoroscopy time and procedure time.

Nononcologic Embolization

The scope of conditions managed by embolization, which was initially used for the treatment of hemorrhage and vascular malformations, is constantly expanding. Apart from oncologic indications, embolization is used to treat a wide range of benign pathology, including uterine fibroids and benign prostatic hyperplasia. While various particulate embolic agents are successfully used for benign embolization, there is growing evidence that unique properties of these may result in different outcomes. This article reviews available evidence comparing various particles used for uterine fibroid embolization and prostate artery embolization. In addition, we provide an overview of periprocedural pharmacology and protocols facilitating same-day discharge for these interventions.

Prostatic artery occlusion versus prostatic artery embolisation for the management of benign prostatic hyperplasia: early results in a canine model

OBJECTIVE

To compare the technical efficacy and safety between prostatic artery occlusion (PAO) with ethylene vinyl alcohol copolymer (EVOH) and prostatic artery embolizsation (PAE) with microspheres in a canine model.

METHODS

17 adult male beagles underwent PAO (n = 7) with Onyx-18 or PAE (n = 10) with microspheres (300-500 µm). To evaluate the primary outcomes (technical efficacy and safety), MRI evaluations were performed immediately before and 1 week, 2 weeks, and 1 month after procedures to document prostate volume (PV); and all dogs were inspected for procedure-related complications during 1 month follow-up. The secondary outcomes included the prostate ischaemia size detected by MRI and recanalisation of prostatic artery by follow-up angiography. Differences between groups were statistically analysed.

RESULTS

Both procedures were bilaterally successful in all animals. Compared with PAE, the mean fluoroscopy time (23.80 vs 36.24 min, p = 0.014) and radiation dose (68.19 vs 125.26 mGy, p = 0.003) were significantly less in PAO procedure. The mean percentage of PV change significantly decreased in both groups at 2 weeks (30.71% vs  37.89%) and 1 month (56.41% %vs 55.56%) after PAO and PAE respectively), without significant differences between groups at either time point. No major complications were observed except one animal after PAO with transient haematuria and acute urinary retention. The mean prostate ischaemia induced by PAO was significant greater compared with PAE at 1 week (43.44% vs 18.91%, p=0.001). PAO with EVOH is technically feasible and with comparable efficacy and safety with PAE. There are possible benefits to PAO over PAE.

ADVANCES IN KNOWLEDGE

A new technical modification of the PAE consisting of the use of liquid embolic agent to occlude the prostatic artery trunk and its branches has been developed in pre-clinical study, showing to be an effective and safe procedure which can induce a significant prostate shrinkage for the management of symptomatic benign prostatic hyperplasia in patients. In addition, the findings have showed a similar therapeutic effect comparable with the conventional PAE using microspheres.

Safety Profile of Ambulatory Prostatic Artery Embolization after a Significant Learning Curve: Update on Adverse Events

Background: to report the safety of outpatient prostatic artery embolization (PAE) after a significant learning curve. Methods: a retrospective bi-institutional study was conducted between June 2018 and April 2022 on 311 consecutive patients, with a mean age of 69 years ± 9.8 (47–102), treated by outpatient PAE. Indications included lower urinary tract symptoms, acute urinary retention, and hematuria. When needed, 3D-imaging and/or coil protection of extra-prostatic supplies were performed to avoid non-target embolization. Adverse events were monitored at 1-, 6-, and 12-month follow-ups. Results: bilateral PAE was achieved in 305/311 (98.1%). Mean dose area product/fluoroscopy times were 16,408.3 ± 12,078.9 (2959–81,608) μGy.m²/36.3 ± 1.7 (11–97) minutes. Coil protection was performed on 67/311 (21.5%) patients in 78 vesical, penile, or rectal supplies. Embolization-related adverse events varied between 0 and 2.6%, access-site adverse events between 0 and 18%, and were all minor. There was no major event. Conclusion: outpatient PAE performed after achieving a significant learning curve may lead to a decreased and low rate of adverse events. Experience in arterial anatomy and coil protection may play a role in safety, but the necessity of the latter in some patterns may need confirmation by additional studies in randomized designs.

Feasibility of Outpatient Transradial Prostatic Artery Embolization and Safety of a Shortened Deflation Protocol for Hemostasis

Background: to evaluate the safety and feasibility of a shorter time to hemostasis applied to outpatient transradial (TR) Prostatic Artery Embolization (PAE). Methods: a retrospective bi-institutional study was conducted between July 2018 and April 2022 on 300 patients treated by outpatient TR PAE. Indications included lower urinary tract symptoms, acute urinary retention, and hematuria. Mean patient height was 176 ± 6.3 (158–192) cm. The primary endpoint was safety of a 45 min deflation protocol for hemostasis. The secondary endpoint was the feasibility of PAE using TR access. Results: technical success was 98.7% (296/300). There was one failure due to patient height. Mean DAP/fluoroscopy times were 16,225 ± 12,126.3 (2959–81,608) μGy·m²/35 ± 14.7 (11–97) min, and mean time to discharge was 80 ± 6 (75–90) min. All access site and embolization-related adverse events were minor. Mild hematoma occurred in 10% (30/300), radial artery occlusion (RAO) in 10/300 (3.3%) cases, and history of smoking was a predictor for RAO. There was no major event. Conclusion: the safety of TR PAE using a 45 min time to hemostasis was confirmed, and TR PAE is feasible in most cases. Radial artery occlusion was still observed and may be favored by smoking.

Effect of Prostate Artery Embolization on Erectile Function - A Single Center Experience of 167 Patients

BACKGROUND

Prostate artery embolization (PAE) is an emerging therapy for lower urinary tract symptoms (LUTS) associated with benign prostatic hyperplasia (BPH).

AIM

This retrospective study was conducted to assess the effect of prostate artery embolization (PAE) on erectile function in a cohort of patients with LUTS attributable to BPH at 3-months after the procedure.

METHODS

A retrospective review was performed on 167 patients who underwent PAE. Data collected included Sexual Health Inventory in Men (SHIM) scores at 3, 6, and 12 months post-PAE, in conjunction with the International Prostate Symptom Scores (IPSS), Quality of Life (QoL) scores, and prostate volumes. Primary outcome was erectile function as assessed by SHIM scores at 3 months after PAE. An analysis was performed to identify patients with a ±5-point SHIM change to group them according to this minimum clinically significant difference in erectile function. Adverse events were recorded using the Clavien-Dindo (CD) classification.

OUTCOMES

At 3 months following PAE, median IPSS decreased by 16.0 [IQR, 9.0-22.0] points, median QOL decreased by 4.0 [IQR, 2.0-5.0] points, and median prostate volume decreased by 33 g [IQR, 14-55].

RESULTS

Median SHIM score was 17.0 [IQR, 12.0-22.0] at baseline, 18.0 [IQR, 14.0-23.0] at 3 months [P = .031], 19.0 [IQR, 14.5-21.5] at 6 months [P = .106] and 20 [IQR, 16.0-24.0] at 12 months [P = .010] following PAE. In patients with no erectile dysfunction (ED) at baseline, 21% (n = 9) reported some degree of decline in erectile function post-PAE. However, 38% (n = 40) of patients who presented with mild-to-moderate ED reported improvement in their erectile function 3 months following PAE. Overall, the changes in baseline SHIM score were relatively small; 82% (n = 137) of patients did not have more than 5 points of change in their SHIM scores at 3 months following PAE.

CLINICAL IMPLICATIONS

Our findings suggest PAE has no adverse impact on erectile function for most patients.

STRENGTHS & LIMITATIONS

The study was performed at a single center with 1 operator's experience, and is retrospective with no control group.

CONCLUSION

Findings suggest that prostate artery embolization has no adverse effect on erectile function in the majority of patients with LUTS attributable to BPH at 3 months after the procedure. Bhatia S, Acharya V, Jalaeian H, et al., Effect of Prostate Artery Embolization on Erectile Function - A Single Center Experience of 167 Patients. J Sex Med 2022;19:594-602.

Prostatic Artery Embolization for Benign Prostatic Hyperplasia—A Primer for Interventional Radiologists

Male patients over 50 years with lower urinary tract symptoms (LUTS) and benign prostatic hyperplasia (BPH) are potential candidates for prostatic artery embolization (PAE). PAE is not a perfect fit for all BPH patients. Careful pre- and postpostprocedural evaluation/consultation with correct selection of patients should be tailored on an individual basis. Evaluated parameters include the following: LUTS severity quantification with validated questionnaires as the international prostate symptom score (IPSS) and quality of life (QoL), erectile and ejaculatory evaluation with validated questionnaires, blood tests including full blood count, coagulation profile, renal function and total/free prostate-specific antigen (PSA), prostate volume measured by multiparametric magnetic resonance (mpMR) of the prostate and/or transrectal ultrasound, uroflowmetry measuring the peak urinary flowrate (Qmax), and postvoid residual urine (PVR). Correct arterial anatomy identification with either computed tomography (CT) angiography, MR angiography, or intraprocedural cone-beam CT (CBCT) are suggested for a confident procedure and avoiding potential complications. The minimally invasive nature of PAE with a faster recovery, preserving the sexual function, and comparable results to standard prostatic surgery make the procedure an attractive choice for many male patients suffering with this condition. Patients should be informed about the potential for higher retreatment rates and shorter duration of treatment effect when compared with standard prostatic surgery. In this comprehensive review, we provide an updated toolbox for all interventional radiologists interested in the PAE practice for patients with BPH. We explain how to evaluate patients during consultation before and after PAE, describe the preprocedural imaging required, explain the technique, and narrate how to optimize outcomes. Finally, we review the level of evidence of PAE for BPH.

Protection of nontarget structures in prostatic artery embolization

Objective

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

Materials and Methods

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

Results

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

Conclusion

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

Prostatic Artery Embolization for Lower Urinary Tract Symptoms via Transradial Versus Transfemoral Artery Access: Single-Center Technical Outcomes

Objective

To evaluate the safety and feasibility of prostatic artery embolization (PAE) via transradial access (TRA) compared with transfemoral access (TFA).

Materials and Methods

This retrospective study included 53 consecutive men with lower urinary tract symptoms (LUTS) who underwent PAE between September 2018 and September 2021. Thirty-one patients (mean age ± standard deviation: 70.6 ± 8.4 years) were treated with TFA, including 14 patients treated before adopting TRA. Since December 2019, TRA has also been attempted with the procedure’s selection criteria of patent carpal circulation and a height ≤ 172 cm, with 22 patients treated via TRA (69.1 ± 9.6 years). Parameters of technical success (defined as successful bilateral embolization), clinical success (defined as LUTS improvement), procedural time, radiation dose, and adverse events were compared between the two groups using the Fisher’s exact test, independent sample t test, Wilcoxon signed-rank test, or Mann-Whitney test.

Results

All patients received at least one-side PAE. Technical success of PAE was achieved in most patients (TRA, 21/22; TFA, 30/31; p > 0.999). No technical problem-related conversion from TRA to TFA occurred. The clinical success rate was 85% (11/13) in patients with TRA, and 89% (16/18) in patients with TFA for follow-up > 2 weeks post-PAE (median, 3 months) (p > 0.999). The median procedure time was similar in both groups (TRA, 81 minutes vs. TFA, 94 minutes; p = 0.570). No significant dose differences were found between the TRA and TFA groups in the dose-area product (median Gycm², 95 [range, 44–255] for TRA and 84 [34–255] for TFA; p = 0.678) or cumulative air kerma (median mGy, 609 [236–1584] for TRA and 634 [217–1594] for TFA; p = 0.551). No major adverse events occurred in either of the groups.

Conclusion

PAE via TRA is a safe and feasible method comparable to conventional TFA. It can be safely implemented by selecting patients with patent carpal circulation and adequate height.

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.

Prostatic Artery Embolization for Benign Prostatic Hyperplasia: Anatomical Aspects and Radiation Considerations from a Case Series of 210 Patients

Context Prostatic artery embolization (PAE) has been established as a safe and effective treatment option for symptomatic benign prostatic hyperplasia (BPH). Thorough knowledge of detailed prostatic artery (PA) anatomy is essential.

Aims The aim of this study was to provide a pictorial review of PA anatomy and prevalence of related anatomical variants, in addition to other anatomical and radiation dose considerations.

Settings and Design Case series and review of literature.

Materials and Methods We performed PAE for 210 patients from November 2015 to November 2020 under local anesthesia only. Anatomy, procedure duration, fluoroscopy time, radiation dose, technical success, and complications were analyzed.

Statistical Analysis Used Descriptive statistics were analyzed using Microsoft Excel software.

Results A total of 210 patients (420 sides) were analyzed. Double arterial supply on the same side was noted in 12 patients (5.7%). In 10 patients (4.7%), only a unilateral PA was identified. In two patients (0.9%), no PA could be identified. Frequencies of PA origins were calculated. Penile, rectal, and vesical anastomoses were identified with 79 (18.8%), 54 (12.9%), and 41 (9.8%) of PAs, respectively. Median skin radiation dose, procedure time, and fluoroscopy time were 505 mGy, 73 and 38 minutes, respectively. Complications occurred in nine patients (4.3%), none of them was major.

Conclusions Knowledge of PA anatomy is essential when treating BPH by PAE for optimum results. There is no enough evidence to support routine use of preoperative computed tomography angiography and intraoperative cone-beam computed tomography as means of improving safety or efficacy.

Prostate Artery Embolization - Adverse Events and Peri-Procedural Management

As prostate artery embolization (PAE) for treatment of lower urinary tract symptoms attributed to benign prostatic hyperplasia becomes more commonly performed, operator knowledge of the adverse events is essential to inform patient selection, patient preparation, and postprocedural management. The aim of this article is to discuss the incidence, presentation, and management of adverse effects after PAE.

Prostatic Artery Embolization: Variant Origins and Collaterals

Prostate artery embolization (PAE) is a minimally invasive treatment for benign prostatic hyperplasia associated lower urinary tract symptoms. The prostatic arterial anatomy, origins and collaterals, are highly variable and can lead to technical pitfalls and suboptimal results during PAE. In this paper we aim to discuss the variant prostate artery origins and collateral circulation to provide a primer on relevant anatomy for interventional radiologists performing PAE.

Angiographic Findings Relevant to Prostatic Artery Embolization in Patients with Prostate Cancer

The 2014-2018 angiograms of 58 patients with prostate cancer were retrospectively analyzed to illustrate angiographic findings during prostatic artery embolization. Arteriovenous fistulae were observed in 6 patients (6/58, 10.3%), with no difference between patients with or without prior iodine-125 seeds implantation (5/48, 10.4% vs 1/10, 10.0%; P > .05); tumor staining was not detected. The origins of the prostatic arteries included the internal pudendal artery (n = 45, 32.4%), the superior vesical artery (n = 38, 27.3%), the obturator artery (n = 28, 20.1%), the gluteal-pudendal trunk (n = 21, 15.1%), the inferior gluteal artery (n = 3, 2.2%), the accessory pudendal artery (n = 3, 2.2%), and the superior gluteal artery (n = 1, 0.7%).

Case-Control Comparison of Conventional End-Hole versus Balloon-Occlusion Microcatheter Prostatic Artery Embolization for Treatment of Symptomatic Benign Prostatic Hyperplasia

PURPOSE

To compare procedural metrics and clinical improvement for prostatic artery embolization (PAE) performed with a balloon-occlusion (BO) versus end-hole (EH) microcatheter in patients with benign prostatic hyperplasia.

MATERIALS AND METHODS

Retrospective review was performed of 129 patients undergoing PAE with 100-300 μm Embosphere microspheres from April 2013 through August 2018. Microcatheter selection was nonrandom, based on prostatic artery anatomy. Five technical failures and 5 microcatheter crossover cases were excluded. BO group (n = 46, age 72.8 y ± 9.0, gland volume 184 mL ± 83, 42% in retention) and EH group (n = 73, age 76.0 y ± 9.0, gland volume 190 mL ± 116, 44% in retention) were compared using procedural metrics (excluding 30 EH learning-curve cases); symptomatic improvement at 3, 6, and 12 months after PAE; voiding trial success; and adverse events (reported used Clavien-Dindo classification).

RESULTS

Procedural and fluoroscopy times were lower in the BO group (n = 46) vs EH group (n = 43) (152.0 min ± 34.0 vs 172.8 min ± 47.9, P < .02; 37.8 min ± 12.9 vs 50.3 min ± 18.9, P < .001). Collaterals coiled, contrast material used, and injected particle volume were similar for both groups (P = NS). International Prostate Symptom Score improvement was similar for BO group (n = 25) (before PAE 23.5 ± 6.5, 12 months after PAE 7.6 ± 6.8) and EH group (n = 30) (before PAE 20.9 ± 5.9, 12 months after PAE 6.6 ± 5.2) (P = NS). Quality-of-life improvements were also similar (BO: before PAE 4.5 ± 1.2, 12 months after PAE 1.4 ± 0.9; EH: before PAE 4.1 ± 1.0, 12 months after PAE 0.9 ± 0.7), as were 12-month postvoid residual improvements, voiding trial failure rates (EH 12%, BO 8%), and adverse event rates (grade II, III: EH 15%, BO 11%) (P = NS for all).

CONCLUSIONS

BO microcatheter use in PAE did not affect injected particle volume, contrast material use, or protective coiling and did not impact symptomatic improvement, postvoid residual improvement, voiding trial success, or adverse events after PAE. Lower procedure and fluoroscopy times with BO microcatheter were likely due to selection bias.

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.

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

In 17 patients who underwent prostate artery embolization for treatment of lower urinary tract symptoms, the accuracy of preprocedural magnetic resonance (MR) angiography was retrospectively compared with intraprocedural digital subtraction angiography (DSA) in the identification of prostatic artery origin. Of 34 vessels, 26 MR angiography identified origins (76.5%) were confirmed by DSA at the time of embolization. Although image postprocessing is required, the ability of MR angiography to accurately identify prostatic artery origins prior to embolization is useful in treatment planning and can obviate the need for separate computed tomographic angiography, thus reducing both radiation dose and time demand on patients.

Use of angioembolization in urology: a review

This review discusses current and developing indications for angioembolization (AE) techniques in urology cases, including trauma and non-trauma uses for kidney, prostate, and bladder conditions. AE methods, complications and technical and clinical outcomes are outlined for each indication for the purpose of aiding urologists in selecting ideal candidates for this procedure.

State of the art of prostatic arterial embolization for benign prostatic hyperplasia

Prostatectomy via open surgery or transurethral resection of the prostate (TURP) is the standard treatment for benign prostatic hyperplasia (BPH). Several patients present contraindication for standard approach, individuals older than 60 years with urinary tract infection, strictures, post-operative pain, incontinence or urinary retention, sexual dysfunction, and blood loss are not good candidates for surgery. Prostatic artery embolization (PAE) is emerging as a viable method for patients unsuitable for surgery. In this article, we report results about technical and clinical success and safety of the procedure to define the current status.