Prostatic Artery Embolization in the Treatment of Localized Prostate Cancer: A Bicentric Prospective Proof-of-Concept Study of 12 Patients

Prostatic Artery Embolization in Patients with Advanced Prostate Cancer: A Prospective Single Center Pilot Study

PURPOSE

To assess efficacy and safety of prostatic artery embolization (PAE) in patients with advanced prostate cancer (PCa).

MATERIALS AND METHODS

In this prospective single-center, single-arm, pilot study, 9 men with advanced PCa underwent PAE. PAE was performed with the use of 250-400 µm Embozene microspheres (Boston Scientific, Natick, Massachusetts, USA). International Prostate Symptoms Score (IPSS), urinary peak flow (Qmax) and post-void residual urine volume (PVR) was assessed at 12 weeks and up to 12 months. Changes in total prostate volume (TPV) and tumor responses by PSA, changes in tumor volume and evaluation of tumor regression by multiparametric magnetic resonance imaging were assessed at 12 weeks after PAE.

RESULTS

IPSS reduction in median 6 points (0-19) and a significant decrease in PVR from median 70 (20-600) mL to 10 (0-280) mL could be achieved within 12 weeks after PAE. Median TPV and tumor volumes (TV) increased slightly from 19.7 (6.4-110.8) mL to 23.4 (2.4-66.3) mL and 6.4 (4.6-18.3) mL to 8.1 (2.4-25.6) mL at a median of 12 weeks after the procedure. Significant tumor necrosis (≥ 50%) was found in one patient. Eight patients showed > 50% of viable tumor on post-PAE MRI according to MRI. Only one Clavien-Dindo Grade 1 adverse event related to PAE occurred.

CONCLUSIONS

PAE with the use of 250-400 µm microspheres is feasible, safe and effective in some patients with advanced PCa regarding functional outcomes. A cytoreductive effect might be achieved in individual patients but must be further assessed.

TRIALS REGISTRATION

NCT03457805.

[Minimally-Invasive Surgical Techniques (MIST): Shedding Light on the Mist]

As life expectancy increases and there is growing demand for BPH treatments, innovative technologies have been developed, allowing for swift recovery, symptom relief, low complication rates, and the possibility of performing procedures on an outpatient basis, often under local anaesthesia. This review aims to describe the outcomes of newly developed minimally-invasive surgical therapies (MIST) for BPH treatment in terms of functional voiding parameters and sexual function. These therapies are categorized into primarily ablative (Aquablation [Aquabeam]), non-ablative (Prostatic Urethral Lift (PUL, Urolift), temporary implantable devices [iTind]), and secondarily ablative procedures (convective water vapor ablation, Rezum, Prostate Artery Embolization [PAE]). All MIST technologies have advanced the medical care of patients with BPH while preserving ejaculation. However, there is a shortage of long-term data specifically addressing re-intervention rates and the preservation of functional voiding parameters. Although there is promising data from regulatory trials and randomized studies, all MIST therapies are potentially associated with severe complications. Patients considering such methods must be thoroughly informed about their inferiority compared with established transurethral procedures like TUR-P and enucleation.

Prostatic Artery Embolization in Patients with Prostate Cancer: A Systematic Review

CONTEXT

Prostatic artery embolization (PAE) is increasingly performed worldwide for the treatment of lower urinary tract symptoms (LUTS) secondary to benign prostatic obstruction (BPO). In contrast, the role of PAE in patients with prostate cancer (PCa) is unclear.

OBJECTIVE

This systematic review summarizes the current available literature on PAE in patients with PCa regarding oncological and functional outcome.

EVIDENCE ACQUISITION

A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) recommendations. A structured search for the relevant literature from 1985 to 2022 was performed in Medline, Embase, and York CRD. Risk of bias and confounding assessments were performed using the ROBINS tool.

EVIDENCE SYNTHESIS

Thirteen trials (12 case series and one animal study using a canine model) were included in this systematic review. Four studies had a prospective study design. The risk of bias was rated moderate to serious in all the studies.

CONCLUSIONS

PAE in patients with PCa seems to be a safe procedure and effective regarding the improvement of LUTS. Despite PAE having been shown to be feasible in different treatment scenarios of localized or advanced PCa, the oncological benefits are debatable due to an unreliable tumor response and a lack of controlled trials including long-term follow-up.

PATIENT SUMMARY

We investigated the literature to determine the role of prostatic artery embolization (PAE) in patients with prostate cancer regarding oncological and functional outcomes. The results suggest a similar safety profile and efficacy in terms of functional outcomes to those reported earlier for PAE in patients with lower urinary tract symptoms due to benign prostatic hyperplasia. The role of PAE regarding oncological outcomes has to be assessed further.

Canine Prostate Cancer: Current Treatments and the Role of Interventional Oncology

Prostate carcinoma is one of the most common cancers worldwide in men, with over 3 million men currently living with prostate carcinoma. In men, routine screening and successful treatment schemes, including radiation, prostatectomy, or hormone therapy, have allowed for high survivability. Dogs are recognized as one of the only mammals to spontaneously develop prostate neoplasia and are an important translational model. Within veterinary medicine, treatment options have historically been limited in efficacy or paired with high morbidity. Recently, less invasive treatment modalities have been investigated in dogs and people and demonstrated promise. Below, current treatment options available in dogs and people are reviewed, as well as a discussion of current and future trends within interventional treatment for canine PC.

[Minimally invasive treatment of benign prostatic hyperplasia : The German S2e guideline 2023-part 4]

BACKGROUND

Lower urinary tract symptoms suggestive for benign prostatic obstruction (LUTS/BPO) are one of the most frequent diseases in men and can have a significant impact on quality of life. Instrumental therapies are common, and many patients seek minimally invasive treatment options.

OBJECTIVE

Presentation and evidence-based evaluation of the minimally invasive therapy for benign prostatic syndrome.

MATERIALS AND METHODS

Summary and overview of chapters 11-13 on minimally invasive therapies for LUTS/BPO of the current long version of the German S2e guideline.

RESULTS

In case of absolute indication for surgery or after unsatisfactory or undesired medical therapy, minimally invasive treatments such as UroLift® (Neotract Inc., Pleasanton, CA, USA), Rezῡm™ (Boston Scientific, Malborough, MA, USA), iTIND™ (Olympus America Inc., Westborough, MA, USA), and prostatic artery embolization (PAE) can be considered. These indirect/delayed ablative therapies offer lower morbidity and the possibility of performing them under local anesthesia, but they are inferior to direct ablative/resective techniques in terms of effectiveness and sustainability.

CONCLUSIONS

The updated German S2e guideline summarizes evidence-based recommendations for new minimally invasive therapies for LUTS/BPO, which present alternative treatment options for selected patients.

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

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

Prostate arterial chemoembolization for treatment of refractory hematuria and urinary retention in patients with localized advanced prostate cancer

OBJECTIVES

To evaluate the safety and efficacy transcatheter arterial chemoembolization (TACE) for the treatment of refractory gross hematuria (RGH) and urinary retention (UR) secondary to localized advanced prostate cancer (PCa).

PATIENTS AND METHODS

Thirty-two patients (mean age 72.5 years, range 60-89) with advanced PCa-related RGH that failed conventional therapy were included. Twenty-two of these patients had catheter-dependent due to PCa-related UR. TACE was performed with epirubicin (EPI)-eluting HepaSpheres (HS) plus intra-arterial (IA) infusion of docetaxel. Technical success, adverse events (AEs), overall survival (OS), control of RGH, removal of indwelling catheters, and local disease control, were evaluated.

RESULTS

Technical success was achieved in 100% without major AEs. Mean follow up post-TACE was 27 months (range 8-56 months) with a mean OS of 30 months. GRH stopped within 5 days after TACE in all patients, 26 (86.7%) of these patients exhibited good bleeding control during a mean follow-up of 24 months; 17 (77.3%) of the 22 patients with UR had recovered spontaneous urination, 15 (88.2%) patients were catheter-free at their last follow-up with a mean of 24 months. BS was obtained in 73.3% (22/30) of patients at a mean follow-up of 29 months. At the last visit, 22 patients had a mean of 36 months follow-up and the mean percentage reduction in prostate volume was 55.5%, with a statistically different from baseline (P = 0.022). Negative biopsy results were obtained in 84.2% (16/19) of the patients at 12-47 months after TACE. Compared with baseline values, there was a significant improvements in IPSS, QoL, Qmax, and PVR (all P < 0.05).

CONCLUSIONS

TACE using EPI-eluting HS plus IA infusion of docetaxel is a safe and effective treatment option for the advanced PCa patients with GRH and UR, and it could be considered as an alternative if there was no other therapeutic choice.

Minimally Invasive Procedures in the Diagnosis and Treatment of Localized Prostate Cancer: an Interventional Radiologist's Perspective

PURPOSE OF REVIEW

Minimal invasive procedures, including targeted biopsy (TB) and focal therapy (FT), are increasingly used in diagnosis and treatment of localized prostate cancer. Here, we review the current role of these procedures, from a perspective of an interventional radiologist.

RECENT FINDINGS

TB is an established part of current guidelines for diagnosis of PCa. Several modalities of FT are gaining prevalence in recent years, as a tissue-preserving alternative for definitive treatment of localized PCa. FT is currently at early research stages, offered to selected patients in clinical trials settings. TB and FT are minimally invasive procedures used by multidisciplinary teams for diagnosis and treatment of localized PCa.

Procedural description and prospective evaluation of short-term outcome for the use of prostatic artery embolization in dogs with carcinoma of the prostate

OBJECTIVE

To describe the procedure of prostatic artery embolization (PAE) in dogs with prostatic carcinoma and to evaluate the short-term outcome for treated dogs.

ANIMALS

20 client-owned dogs with prostatic carcinomas between May 2014 and July 2017.

PROCEDURES

In this prospective cohort study, dogs with carcinoma of the prostate underwent PAE with fluoroscopic guidance. Before and after PAE, dogs underwent CT and ultrasonographic examinations of the prostate, and each owner completed a questionnaire about the dog's clinical signs. Results for before versus after PAE were compared.

RESULTS

Prostatic artery embolization was successfully performed in all 20 dogs. Tenesmus, stranguria, and lethargy were significantly less common 30 days after PAE (n = 2, 1, and 0 dogs, respectively), compared with before PAE (9, 10, and 6 dogs, respectively). Median prostatic volume was significantly less 30 days after PAE (14.8 cm3; range, 0.4 to 48.1 cm3; interquartile [25th to 75th percentile] range, 6.7 to 19.5 cm3), compared with before PAE (21.7 cm3; range, 2.9 to 77.7 cm3; interquartile range, 11.0 to 35.1 cm3). All dogs had a reduction in prostatic volume after PAE, with a median prostatic volume loss of 39.4% (95% CI, 20.3% to 59.3%).

CONCLUSIONS AND CLINICAL RELEVANCE

Prostatic artery embolization was associated with decreased prostate volume and improved clinical signs in this cohort. The short-term response to PAE appears promising, and evaluation of the long-term impact on survival time is needed.

Prostate artery chemoembolization in prostate cancer: A proof of concept study in spontaneous prostate cancer in a canine model

PURPOSE

The purpose of this study was to assess the feasibility and efficacy of docetaxel-loaded bead chemoembolization in spontaneous prostate cancer in a canine model.

MATERIALS AND METHODS

Five pet dogs with histopathologically proven prostate cancer were referred for prostate artery chemoembolization (PACE). After PACE, all animals were followed, including pharmacokinetic study and clinical and biological evolution, until death. Pelvic contrast-enhanced computed tomography examination was performed at one and two months. Animals were subjected to pathological examination after death.

RESULTS

Both prostate arteries were successfully chemoembolized in all dogs. A median dose of 18 mg (Q1, Q3; 11.8, 20 mg) docetaxel loaded in 3 mL of 50-100 µm super absorbent polymer beads was injected into each dog. At one month, four of the five dogs were still alive and the median prostate volume was 51% lower (prePACE median prostate volume, 18.4 mL [Q1, Q3; 12, 32.1 mL] vs. postPACE median prostate volume, 6.2 mL [Q1, Q3; 6.2, 11 mL]). At two months, three dogs died because of disease progression. The two remaining dogs showed a 70% median decrease in prostate volume. Prostate pathological examination showed 73% of necrosis. No worsening of urinary symptoms was observed. Pharmacokinetic analysis showed limited systemic passage of docetaxel. All dogs died of metastatic spread at nine months.

CONCLUSION

This study suggests that PACE is feasible and safe for the treatment of spontaneous prostate cancer in a canine model and may provide a new approach to treat selected patients with prostate cancer.

Yttrium-90 Radioembolization to the Prostate Gland: Proof of Concept in a Canine Model and Clinical Translation

PURPOSE

To investigate the feasibility, safety, and absorbed-dose distribution of prostatic artery radioembolization (RE) in a canine model.

MATERIALS AND METHODS

Fourteen male castrated beagles received dihydroandrosterone/estradiol to induce prostatic hyperplasia for the duration of the study. Each dog underwent fluoroscopic prostatic artery catheterization. Yttrium-90 (⁹⁰Y) microspheres (TheraSphere; Boston Scientific, Marlborough, Massachusetts) were delivered to 1 prostatic hemigland (dose escalation from 60 to 200 Gy), with the contralateral side serving as a control. Assessments for adverse events were performed throughout the follow-up (Common Terminology Criteria for Adverse Events v5.0). Positron emission tomography/magnetic resonance (MR) imaging provided a confirmation after the delivery of absorbed-dose distribution. MR imaging was performed before and 3, 20, and 40 days after RE. Tissue harvest of the prostate, rectum, bladder, urethra, penis, and neurovascular bundles was performed 60 days after RE.

RESULTS

All the animals successfully underwent RE. Positron emission tomography/MR imaging demonstrated localization to and good coverage of only the treated hemigland. No adverse events occurred. The MR imaging showed a significant dose-dependent decrease in the treated hemigland size at 40 days (25%-60%, P < .001). No extraprostatic radiographic changes were observed. Necropsy demonstrated no gross rectal, urethral, penile, or bladder changes. Histology revealed RE-induced changes in the treated prostatic tissues of the highest dose group, with gland atrophy and focal necrosis. No extraprostatic RE-related histologic findings were observed.

CONCLUSIONS

Prostate ⁹⁰Y RE is safe and feasible in a canine model and leads to focal dose-dependent changes in the gland without inducing unwanted extraprostatic effects. These results suggest that an investigation of nonoperative prostate cancer is warranted.

Effectiveness and Safety of Prostatic Artery Embolization for the Treatment of Lower Urinary Tract Symptoms from Benign Prostatic Hyperplasia in Men with Concurrent Localized Prostate Cancer

PURPOSE

To assess the effectiveness and safety of prostatic artery embolization (PAE) on lower urinary tract symptoms (LUTS) in the setting of localized prostate cancer (PCa).

MATERIALS AND METHODS

This was a retrospective, single-center, institutional review board-approved study from December 2016 to June 2020 of 21 patients (median age, 72; range, 63-83 years) with moderate LUTS and localized PCa. Clinical effectiveness was evaluated at 6 and 12 weeks using International Prostate Symptom Score (IPSS) and quality of life (QoL) improvement. Seventeen patients were scheduled to receive definitive radiotherapy (RT) after PAE; 13 patients completed RT. Short-term imaging signs of oncologic progression were evaluated at 6 and 12 weeks defined by at least one of the following on magnetic resonance imaging: increased Prostate Imaging-Reporting and Data System score of index lesion(s) to at least 4, new extracapsular extension, seminal vesicle involvement, or pelvic lymphadenopathy. Nonparametric Wilcoxon signed-rank test was used for analysis.

RESULTS

IPSS improved by a median of 12 (n = 19, P < .0001) and 14 (n = 14, P < .0001) at 6 and 12 weeks, respectively. QoL improved by a median of 2 (n = 19, P < .0001) and 3 (n = 3, P < .0001) at 6 and 12 weeks. Prostate volume decreased by a median of 24% (n = 19, P < .0001) and 36% (n = 12, P = .015) at 6 and 12 weeks. No patients demonstrated disease progression at 6 (n = 16) or 12 (n = 8) weeks by imaging. No patients experienced increased prostate-specific antigen after RT, grade ≥3 adverse events, or greater genitourinary toxicity.

CONCLUSIONS

PAE is effective and safe for the treatment of men with LUTS from benign prostatic hyperplasia in the setting of concomitant, localized, non-obstructive PCa.

Reasons to consider prostatic artery embolization

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Early Results of Unilateral Prostatic Artery Embolization as a Focal Therapy in Patients with Prostate Cancer under Active Surveillance: Cancer Prostate Embolisation, a Pilot Study

PURPOSE

To evaluate the feasibility of prostatic artery embolization in patients with low-risk prostate cancer (PC) under active surveillance (AS).

METHODS

This monocentric prospective pilot study, running from June 2018 to June 2019, included 10 patients with low-risk PC under AS, median age 72 years (range, 62-77 years), with a unilateral focal lesion visible on magnetic resonance (MR) imaging, with Prostate Imaging Reporting and Data System v2 score ≥3/5 confirmed by multiparametric MR imaging-targeted biopsy and Gleason score 6. The patients underwent unilateral prostatic artery embolization with 300-500 μm Embospheres in the affected prostatic lobe. The primary endpoint was technical feasibility (prostate and no off-target ischemia in the imaging). The secondary endpoints included safety, negative biopsies/MR imaging response/functional outcomes at 6 months, and oncologic efficacy at 1 year.

RESULTS

Embolization was successfully achieved in all patients; prostate ischemia was confirmed on multiparametric MR imaging, and no off-target ischemia was reported. No major complications were reported. Four patients (40%) presented with both negative targeted and systematic biopsies at 6 months. No lesions were seen on the MR imaging in 30% of patients. The mean International Prostate Symptom Score and International Index of Erectile Function score were 7 and 19 and 5 and 20 at baseline and 6 months, respectively, with no significant difference. Nine patients (90%) were still under AS at 1 year. One patient (10%) had PC progression outside the target lesion and was switched over to curative radiotherapy.

CONCLUSIONS

Prostatic artery embolization is feasible and appears safe for prostate cancer patients under AS, with no impact on erectile function or continence status. These results justify the pursuit of further studies.

Prostatic Artery Embolization Is Safe and Effective for Medically Recalcitrant Radiation-Induced Prostatitis

Purpose

Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) represents 90% of all chronic prostatitis cases and may occur after radiation therapy (RT) for localized prostate cancer. Medical therapy is effective in approximately 50% of cases, with no therapy demonstrating consistent efficacy in refractory cases. Prostatic artery embolization (PAE) is effective in men with lower urinary tract symptoms and benign prostatic hyperplasia. We report clinical improvement after PAE in a case series of men with CP/CPPS after RT.

Methods and Materials

Nine men (median age 72 years; range, 61-83 years) with CP/CPPS after RT for prostate cancer underwent PAE. Baseline International Prostate Symptom Score was recorded in 5 patients (median 23; range, 4-26), Chronic Prostatitis Symptom Index score in 6 patients (median 22.5; range, 6-34), and quality of life (QoL) score in 8 patients (median 5; range, 2-6). Median baseline prostate volume was 49 cm³ (range, 22-123 cm³). Patients were followed up at 6 and 12 weeks with QoL, International Prostate Symptom Score, and/or Chronic Prostatitis Symptom Index score and magnetic resonance imaging.

Results

Technical success (ie, bilateral embolization) was achieved in 78% (n = 7) of patients with the other 2 patients having undergone unilateral embolization with no major complications. Clinical success was seen in 89% (n = 8) of patients and QoL improved in 78% (n = 7) during the follow-up period.

Conclusion

CP/CPPS after RT for localized prostate cancer is a highly morbid condition, with medical therapy successful in only 50% of cases. PAE may be a successful therapy for medically recalcitrant CP/CPPS, and further studies are necessary to understand the best patient selection and scenario for PAE in the setting of CP/CPPS.

[A (new) revolution in the treatment of benign prostatic hyperplasia? Aqua-ablation and prostate embolization]

Surgical treatment of benign prostatic obstruction (BPO) is one of the most common procedures in urology. Numerous alternative methods have been developed in recent years to overcome the potential limitations of transurethral resection of the prostate (TURP) while providing comparable effectiveness and less morbidity. In a randomized study with a currently available follow-up of 3 years, the Aquabeam® system has shown comparable functional results with a lower rate of adverse events compared to TURP. Sufficient functional results were also found in a cohort study in patients with prostate volumes up to 150 ml. However, the rate of transfusions raises the question of optimal coagulation. Further cohort studies with short-term follow-up confirmed the results of the randomized studies. Prostate artery embolization (PAE) has been compared to TURP in several randomized trials. In randomized studies, the reduction of BPO-associated symptoms after PAE is only slightly inferior to that after TURP. In contrast, the improvement of functional parameters after embolization is inferior to that after TURP. This is primarily due to the inferior desobstruction. In addition, long-term results from randomized studies are lacking, so that no final assessment has yet been possible with regard to the durability of the desobstruction. In summary, both Aquabeam® and PAE are potential alternatives to standard methods, which-in case of adequate patient selection-can supplement the operative armamentarium in the wider concept of an individualized therapy of BPO.

Large inoperable leiomyosarcoma of the prostate: treated by transcatheter arterial chemoembolization with drug-eluting microspheres

Background

Prostatic leiomyosarcoma (LMS) has a poor prognosis with a median overall survival (OS) of 15-18 months. For patients with metastatic disease, radical surgical resection, with or without adjuvant systemic chemotherapy and radiation therapy, unfortunately provides limited therapeutic benefit. Novel approaches for this lethal disease are urgently needed.

Objectives

To evaluate the feasibility and efficacy of transarterial chemoembolization (TACE) with doxorubicin-eluting HepaSpheres (HS) for inoperable LMS of the prostate.

Methods

This case series included 12 patients (median age 57 years, range 32-74) with inoperable LMS of the prostate who were treated with TACE using doxorubicin-eluting HS. All patients were pathologically proved by fine-needle biopsy. Symptomatic relief, complications, OS, and local disease control based on modified Response Evaluation Criteria in Solid Tumors (mRECIST) criteria were evaluated.

Results

Symptomatic relief, including control of the gross hematuria, removal of indwelling catheters, improvement of constipation and perineal pain, were obtained in 100%, 75%, 100%, and 86%, respectively after TACE, without any major complications. At the last follow-up after TACE, the percentage of the tumor necrosis and volume reduction were present with a median value of 90% and 84%, respectively. TACE after two to four sessions allowed subsequent surgical resection in five (41.7%) patients. The median follow-up time was 29 months; the survival rate at 1, 2, and 3 years was 91.7%, 83.3%, and 41.7%, respectively, and the median OS was 29 months (range 9-49 months).

Conclusions

TACE of inoperable LMS of the prostate appears to be safe and effective in providing tumor necrosis, shrinkage, and symptom relief; that could improve the quality of life and the survival rate of these patients.

Ejaculatory disorders after prostatic artery embolization: a reassessment of two prospective clinical trials

Purpose

This study aims to specify and explain the previous findings of unexpectedly high rates of ejaculatory disorders, i.e. 56%, found after prostatic artery embolization (PAE) in a randomized controlled trial comparing safety and efficacy of PAE and transurethral resection of the prostate (TURP).

Patients and methods

Case report forms of the randomized controlled trial were analyzed to specify the grade of postoperative ejaculatory dysfunction 3 months postoperatively.

In addition, study participants with assessable ejaculation were asked to complete the four-item Male Sexual Health Questionnaire-Ejaculation Dysfunction Short Form (MSHQ-EjD) referring to their ejaculatory function at present, as well as before treatment and 3 months after. Potential explanations for ejaculatory disorders after PAE were derived from histological examination of five radical prostatectomy specimens of patients that underwent PAE 6 weeks before radical prostatectomy within a proof-of-concept trial at the study site, St. Gallen Cantonal Hospital. An experienced uropathologist systematically examined the whole-gland embedded tissue with focus on structures that are involved into ejaculation.

Results

While patients after TURP predominantly suffered from anejaculation (52%), diminished ejaculation was found more often after PAE (40%). Significantly higher MSHQ-EjD scores were found 3 months after PAE and at a median follow-up of 31 months.

Histological examination showed marked changes of structures involved into ejaculation (e.g., prostatic glands, seminal vesicles, ejaculatory ducts) after PAE.

Conclusion

Although anejaculation occurs less frequently after PAE (16%) compared to TURP (52%), patients have to be informed about the relevant risk of ejaculatory disorders, especially diminished ejaculation.

Modern imaging and image-guided treatments of the prostate gland: MR and ablation for cancer and prostatic artery embolization for benign prostatic hyperplasia

Multiparametric MRI (mpMRI) has proven to be an essential tool for diagnosis, post-treatment follow-up, aggressiveness assessment, and active surveillance of prostate cancer. Currently, this imaging technique is part of the daily practice in many oncological centres. This manuscript aims to review the use of mpMRI in the set of prostatic diseases, either malignant or benign: mpMRI to detect and stage prostate cancer is discussed, as well as its use for active surveillance. Image-guided ablation techniques for prostate cancer are also reviewed. The need to establish minimum acceptable technical parameters for prostate mpMRI, standardize reports, uniform terminology for describing imaging findings, and develop assessment categories that differentiate levels of suspicion for clinically significant prostate cancer led to the development of the Prostate Imaging Reporting and Data System that is reviewed. Special focus will also be given on the most up-to-date evidence of prostatic artery embolization (PAE) for symptomatic benign prostatic hyperplasia (BPH). Management of patients with BPH, technical aspects of PAE, expected outcomes and level of evidence are reviewed with the most recent literature. PAE is a challenging technique that requires dedicated anatomical knowledge and comprehensive embolization skills. PAE has been shown to be an effective minimally-invasive treatment option for symptomatic BPH patients, that can be viewed between medical therapy and surgery. PAE may be a good option for symptomatic BPH patients that do not want to be operated and can obviate the need for prostatic surgery in up to 80% of treated patients.

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

OBJECTIVES

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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