Prostate Artery Embolization in Patients with Prostate Volumes of 80 mL or More: A Single-Institution Retrospective Experience of 93 Patients

Two-Year Outcomes of Prostatic Artery Embolization for Symptomatic Benign Prostatic Hyperplasia: An International, Multicenter, Prospective Study

PURPOSE

To describe clinical outcomes among patients with benign prostatic hyperplasia (BPH) 24 months following prostatic artery embolization (PAE).

MATERIALS AND METHODS

This was an international, multicenter, prospective trial of males with BPH with lower urinary tract symptoms (LUTS) or acute urinary retention (AUR) treated with PAE. The primary outcome was the 12 month change in the International Prostate Symptom Score (IPSS) for patients referred for bothersome LUTS, or urinary catheter independence for patients treated for AUR. Secondary outcome measures included changes in IPSS at 3 and 24 months, changes in quality of life (QoL), changes in the Sexual Health Inventory for Men (SHIM) questionnaire, technical success rate, and adverse events (AEs). Data were summarized using descriptive statistics.

RESULTS

Four hundred seventy-eight consecutive patients underwent PAE (bothersome LUTS: N = 405; AUR: N = 73), mean age was 70 years. For patients treated for bothersome LUTS, mean total IPSS at baseline was 21.8 and decreased to 9.3, 10.6, and 11.2 at 3, 12, and 24 months following PAE, respectively (all p < 0.001); QoL at baseline was 4.7 and decreased to 2.0, 2.1, and 2.3 at 3, 12, and 24 months, respectively (all p < 0.001). The mean SHIM score at baseline and 12 months following PAE was 13.8 and 13.9, respectively. Of the 73 patients treated for AUR, 48 (65.8%) had their indwelling catheter removed within 3 months of PAE and remained catheter free at 24 months. Fifty-five patients (11.5%) experienced ≥ 1 AE and 10 (2.1%) experienced a serious AE.

CONCLUSION

PAE is a safe and effective treatment for symptomatic BPH and LUTS. Level of Evidence Level 3 Trial registration ClinicalTrials.gov NCT03527589.

Prostatic Artery Embolization as a Treatment Option for Symptomatic Benign Prostatic Hyperplasia: Results from the Prospective Follow-Up Study in Lithuania

Background: The endovascular treatment of symptomatic benign prostate hypertrophy (BPH) by prostatic artery embolization (PAE) is one of the new treatments proposed. PAE is a minimally invasive alternative that has been shown to successfully treat lower urinary tract symptoms in BPH patients by causing infarction and necrosis of hyperplastic adenomatous tissue, which decompresses urethral impingement and improves obstructive symptoms. The aim of this study was to evaluate the effectiveness and efficacy of PAE in relieving symptoms in patients with symptomatic BPH. Materials and Methods: The material for the study was collected from 2019 to 2022. A total of 70 men with BPH and PAE were studied. Patients underwent an urological examination to measure the International Prostate Symptom Score (IPSS), Quality of Life score (QoL), International Index of Erectile Function short form (IIEF-5), uroflowmetry with Qmax, prostatic volume (PV), and post-void residual volume (PVR) measurements. Statistical analysis for dependent samples was applied. Measured parameters at 2 months and 6 months follow-up were compared to baseline. Results: At baseline, the age of the male (N = 70) subjects was 74 ± 9.6 years with a median of 73.8, but fluctuated from 53 to 90 years. The mean of PV was almost 111 mL and the Qmax was close to 7.7 mL/s. The average PVR was 107.6 mL. The IPSS score mean was 21.3 points and the QoL score was 4.53 points. The IIEF-5 questionnaire score was almost 1.8 points, which shows severe erectile dysfunction. The mean value of the PSA level was 5.8 ng/mL. After 2 and 6 months of PAE, all indicators and scores except erectile function significantly improved. Conclusions: The outcomes of our study show promising results for patients with benign prostatic hyperplasia after PAE. The main prostate-related parameters (PV, Qmax, PVR, IPSS) improved significantly 6 months after embolization.

Treating LUTS in Men with Benign Prostatic Obstruction: A Review Article

Benign prostatic obstruction (BPO) is a prevalent condition that affects men, primarily toward their old age. The condition is often accompanied by lower urinary tract symptoms (LUTS), which can significantly impair a patient's quality of life and lead to other medical complications. Accurate diagnosis of BPO is essential for effective management of complications secondary to BPO, and treatment plans should be tailored patients, and occasionally according to surgeon experience. As such, this literature review aims to analyze the current available data on male LUTS secondary to BPO by providing a comprehensive overview of relevant studies, as well as the surgical and medical management guidelines from the Canadian Urological Association (CUA), American Urological Association (AUA), and European Association of Urology (EAU). By synthesizing the existing literature, this review purports to summarize the current body of knowledge surrounding BPO and male LUTS, and support healthcare providers in making informed decisions about the management of male LUTS secondary to BPO, ultimately improving patient outcomes and quality of life.

Prostatic Arterial Embolization for Treatment of Lower Urinary Tract Symptoms Associated with Benign Prostatic Enlargement

PURPOSE OF REVIEW

Prostatic artery embolization (PAE) is an emerging minimally invasive technique for lower urinary tract symptom reduction from benign prostatic hypertrophy (BPH). While the technique is becoming increasingly popular with patients and interventional radiologists, most urologists remain skeptical of the PAE's long-term efficacy and comparative success to the gold standard transurethral resection of the prostate.

RECENT FINDINGS

PAE has been found in multiple meta-analyses to perform similarly to the gold standard transurethral resection of the prostate (TURP) with regard to patient-driven measures like IPSS and IPSS-QoL, while also performing favorably in objective measurements including Qmax and PVR out to at least 12 months post intervention. Furthermore, PAE has a demonstrated shorter hospital length of stay and fewer adverse events when compared to TURP. PAE provides patients with an alternative to transurethral options for the management of LUTS in the setting of bladder outlet obstruction. While long-term evidence demonstrating the durability of PAE is still forthcoming, the procedure has been demonstrated to be safe according to multiple meta-analyses. Patients deserve to be counseled on PAE as an alternative to surgery and made aware that while the overall treatment effect may not be as robust or durable, the procedure carries a favorable adverse event profile that is attractive to patients wishing to avoid a trans-urethral approach.

Efficacy and safety of prostate artery embolization for patients with lower urinary tract symptoms and indwelling urinary catheter: A retrospective multicenter study

PURPOSE

The purpose of this multicenter study was to evaluate the clinical success at three months of prostate artery embolization (PAE), assess PAE safety in centers with various experiences and identify factors associated with PAE success.

PATIENTS AND METHODS

This multicenter, retrospective study included patients who underwent PAE for lower urinary tract symptoms (LUTS) including those with indwelling urinary catheter. PAE clinical success was defined as either 25% improvement of the International Prostate Symptom Score (IPSS) or 1-point improvement of quality of life (QoL) score, or catheter removal at three months. Multivariable analyses were performed using a logistic regression adjusted on patient variables, technical parameters and center experience in PAE.

RESULTS

A total of 383 men (mean age, 68.4 ± 9.7 [standard deviation] years; range: 46-94) with LUTS, including 99 (25.8%) patients with indwelling urinary catheter, were included in seven centers from January 2017 to March 2019. Five patients reported major complications (1.3%), three (0.8%) penile ulceration, three (0.8%) acute urinary retention, one (0.3%) prostatic abscess, and 56 (14.6%) minor complications. Follow up data were available for 271 patients (center 1: n = 159; other centers: n = 112). Clinical success was reported in 232 patients (85.6%). In multivariable analyses, presence of cardiovascular comorbidities (diabetes, stroke history, myocardial infarction and lower limb artery disease) was the single independent variable inversely associated with PAE clinical success (odds ratio = 0.396; 95% confidence interval: 0.17-0.91; P = 0.029). There was no center effect.

CONCLUSION

Our results show that PAE is safe and effective in centers with various PAE experiences. Cardiovascular comorbidity is the single independent variable associated with PAE failure.

Contemporary surgical management of benign prostatic obstruction: does there remain a place in the toolbox for TURP?

Level of evidence: 5

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 arterial embolization for the treatment of lower urinary tract symptoms in men with benign prostatic hyperplasia

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.

Prostate Artery Embolization for Lower Urinary Tract Symptoms Attributed to Benign Prostatic Hyperplasia-Radiology In Training

A 71-year-old man was evaluated and treated with prostate artery embolization (PAE) for lower urinary tract symptoms secondary to benign prostatic hyperplasia. Appropriate patient selection, workup, and expected treatment outcomes for PAE are discussed.

Symptomatic Improvement of Lower Urinary Tract Symptoms of Benign Prostatic Hyperplasia: A Comparative Systematic Review and Meta-Analysis of 4 Different Minimally Invasive Therapies

PURPOSE

To review and compare the outcomes of prostatic artery embolization (PAE) with 3 other minimally invasive surgical treatments for benign prostatic hyperplasia, including photoselective vaporization (PVP), prostatic urethral lift (PUL), and water vapor thermal therapy (WV).

METHODS

A literature review was used to identify 35 publications, which included 2,653 patients (studies, patients): PVP (13, 949), PUL (9, 577), WV (3, 330), and PAE (10, 728). The international prostate symptom score (IPSS) and the international index of erectile function (IIEF-5) and quality of life (QOL) scores were recorded at baseline, 6 months, and 12 months. Meta-analyses, pooling the standardized mean difference between scores recorded before and after treatment, were conducted for each modality and time point to assess the magnitude of a therapy's effect to yield pooled effect sizes. A negative score indicates IPSS and QOL improvement. A positive score indicates IIEF-5 improvement.

RESULTS

At 6 and 12 months, the IPSS and QOL were most improved after PVP, followed by that after PAE, PUL, and, lastly, WV (measured only at 12 months). Between 6 and 12 months, the IPSS and QOL improved with PAE and worsened with PVP and PUL. Only PAE demonstrated statistical improvement in the IIEF-5, which improved from 6 to 12 months.

CONCLUSIONS

PVP and PAE resulted in the largest improvements in the IPSS and QOL. Only PAE resulted in improvement of the IIEF-5.

Are all procedures for benign prostatic hyperplasia created equal? A systematic review on post-procedural PSA dynamics and its correlation with relief of bladder outlet obstruction

PURPOSE

To evaluate and provide a comprehensive literature review of Prostate specific antigen (PSA) dynamics after various surgical procedures for benign prostatic hyperplasia (BPH).

METHODS

A thorough PubMed database search was performed over last 30 years including terms "PSA" and various surgical procedures for BPH. PSA nadir after various procedure was evaluated. The post-operative improvement in International Prostate Symptom Score, maximum void rates and post-void residue after surgeries were recorded. An indirect correlation was made between PSA nadir and outcome of various BPH surgical procedures.

RESULTS

Enucleation procedures like simple prostatectomy and endoscopic enucleation of prostate (EEP) produced maximum drop in PSA level after surgery and were associated with the highest improvement in post-operative parameters. The PSA nadir following resection techniques like transurethral resection of prostate and Holmium laser resection of prostate and vaporization technique was variable and less robust when compared to EEP. Newer techniques like Aquablation, Rezum, Urolift, Prostate artery embolization and Temporary implantable nitinol devices (iTIND) produce relatively less reduction in PSA and lesser percentile improvement in post-operative parameters.

CONCLUSIONS

Various surgical procedures for BPH result in varying PSA nadirs level. Enucleation procedures and simple prostatectomy produce the most drastic and sustained decrease in PSA. There is a possible indirect evidence suggesting that the level of PSA nadir corresponds closely with the degree of post-operative improvement and durability of the procedure. Establishing the new PSA nadir at 3-6 months after the procedure is recommended as a part of routine surveillance for prostate cancer in eligible patients.

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.

Comparison of water vapor thermal therapy and prostate artery embolization for fragile patients with indwelling urinary catheters: Preliminary results from a multi-institutional study

PURPOSE

To report our preliminary experience with water vapor thermal therapy with the Rezūm™ System and Prostate Artery Embolization (PAE) for treatment of medically refractory, complete urinary retention to achieve successful cessation of catheter dependency in frail-patients.

PATIENTS AND METHODS

A multi-institutional study was conducted including all patients who underwent Rezūm™ procedure and PAE between October 2017 and June 2020. The included population focused on frail-patients unsuitable for conventional surgery with complete urinary retention. Rezūm™ patients were identified and matched (1:1) with patients who underwent PAE. The matching criteria were age, Charlson score, prostate volume and duration of follow-up. The primary outcome was catheter-free survival, defined as spontaneous voiding and release from catheter dependence.

RESULTS

Eleven patients from the Rezūm™ group were matched to 11 embolized patients. PAE and Rezūm™ patients were comparable in age (median: 77 vs. 75 years), Charlson score (median: 6 vs. 6) and prostate volume (74 vs. 60 cc). Procedures were significantly longer in the PAE group compared to the Rezūm™ procedures (median: 148 vs. 8min, P<0.001). After a median follow-up of 12 months, spontaneous voiding was conserved in all cases (100%) after the Rezūm™ procedure and in 5 cases (45.4%) after PAE (P=0.01). In catheter-free patients, the rate of benign prostatic hyperplasia medication use after procedure was 40% for PAE and 18.2% for Rezūm™ patients (P=0.54).

CONCLUSIONS

Our preliminary experience for treatment of complete urinary retention in frail-patients shows the feasibility of PAE and Rezūm™ to restore spontaneous urination without being associated with the occurrence of major complications. Early data suggests that Rezūm™ may provide superior results in terms of cessation of catheter dependence. Future studies are needed to definitively assess which treatment would be best suited for each patient.

LEVEL OF EVIDENCE

3.

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.

[An update on the most recent mini-invasive surgical and interventional techniques in the management of benign prostatic obstruction]

INTRODUCTION

New surgical techniques for the treatment of benign prostatic obstruction (BPO) have emerged in recent years. We sought to give an overview on each of these technologies.

MATERIAL

A comprehensive review of the literature between 2013 and 2020 was carried out by a panel of national experts already practicing these interventions. All the data were then discussed among all the co-authors in order to obtain a consensus with regard to the selected articles and their analysis. Finally, an inventory was drawn to provide an overview of these technological advances and their availability in France.

RESULTS

The treatment benign prostatic obstruction has diversified greatly over the past 5 years. 5 new technologies have emerged, allowing today a transurethral non-ablative treatment (UROLIFT®, ITIND®), a transurethral ablative treatment (REZUM®), a transurethral ablative treatment with robotic assistance (AQUABEAM®) or an endovascular management by embolization of the prostatic arteries. Only UROLIFT® is considered an established technology in the latest EAU-Guidelines. The other four are under evaluation and recommendations have only been issued for two of them, AQUABEAM® and the embolization of the prostatic arteries.

CONCLUSION

These new minimally invasive techniques aim to increase the therapeutic options for the management of BPO in order to offer a management more suited to the wishes of the patient. Some are positioned as an alternative to surgical or medical treatment, others between medical and surgical treatment. These technologies are not all at the same level of development, evaluation and level of proof, but have in common a limited distribution in France, in particular given their cost. Validated studies will allow them to position their subsequent use more precisely.

Prostatic arterial embolization for the treatment of lower urinary tract symptoms in men with benign prostatic hyperplasia

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.

[Surgical treatment of benign prostatic obstruction (BPO) in patients under anticoagulation: a review of the bleeding risks of established techniques]

BACKGROUND

In an aging society an increase of benign prostatic obstruction (BPO) requiring treatment is to be expected and the proportion of patients with cardiovascular comorbidities under anticoagulation is also increasing. As the operative treatment of BPO can be problematic, the hemostatic effect of the techniques is of particular importance.

OBJECTIVE

This review article discusses the data situation on the bleeding risk of established surgical techniques and the statement of the European Association of Urology (EAU) guidelines "EAU guidelines on management of non-neurogenic male lower urinary tract symptoms (LUTS), incl. benign prostatic obstruction (BPO)" on this topic.

MATERIAL AND METHODS

Data analysis from PubMed.

RESULTS

The EAU guidelines favor transurethral laser vaporization of the prostate using "greenlight", thulium or diode laser and laser enucleation using a holmium or thulium laser in this patient collective. The bipolar is superior to monopolar transurethral resection (TUR-P) in hemostasis. In the future bipolar enucleation of the prostate (BipoLEP) can be an alternative under good hemostasis. Bleeding is a rare complication after recently established minimally invasive techniques, such as Urolift®, I‑TIND© and Rezum™, the same applies to prostate artery embolization. Aqua-ablation/AquaBeam® seems to be unsuitable due to frequent hematuria. Surgical adenomectomy can be associated with a high risk of bleeding.

CONCLUSION

According to current data, transurethral laser vaporization and enucleation of the prostate are the treatment of choice for patients under anticoagulation; however, other transurethral techniques, such as BipoLEP have an acceptable risk of bleeding and can be an alternative depending on local resources. Newer minimally invasive approaches could become more important in the future.

Prostate artery embolization has long term efficacy for treatment of severe lower urinary tract symptoms from giant prostatic hyperplasia

Background

Patients with severe lower urinary tract symptoms (LUTS) from giant prostatic hyperplasia (GPH): prostate volume greater than 200 mL that do not respond to medical therapy may not be eligible for surgical treatments due to morbidities, technical challenges, and patient preference. This retrospective investigation examined the long-term efficacy and safety of prostatic arterial embolization (PAE) as a treatment option for severe LUTS due to GPH in a large patient cohort.

Methods

Of 529 patients who underwent PAE between January 2016 and January 2020, 72 patients had severe LUTS from GPH and were retrospectively evaluated. PAE was performed with two embolic agents in sequence: 100–250 μm particles followed by 2 mm and 3 mm coils. Clinical assessment was performed with international prostate symptoms score (IPSS), quality of life (QoL), peak flow rate (Qmax), post-void residual volume (PVR), and prostate specific antigen (PSA) measurements before and 12 months and 24 months after PAE. Prostate volume (PV) was measured by multiparametric magnetic resonance (MR) imaging before and 12 months and 24 months after PAE.

Results

Patients with severe LUTS from GPH experienced significant clinical improvements in IPSS, QoL, Qmax, PVR, PSA, and PV at 12 months and 24 months after PAE. Mean IPSS decreased from 26.5 to 18.0 (P < 0.01) to 10.5 (P < 0.01). Mean QoL decreased from 6.0 to 4.0 (P < 0.01) to 2.0 (P < 0.01). Mean Qmax increased from 8.0 to 14 mL/s (P < 0.01) to 18 mL/s (P < 0.01). Mean PVR decreased from 198.0 to 152.0 mL (P < 0.01) to 90 mL (P < 0.01). Mean PV decreased from 303.0 mL to 258.0 mL (P < 0.01) to 209.0 mL (P < 0.01). Mean PSA decreased from 11.2 ng/mL to 9.5 ng/mL (P < 0.05) to 7.9 ng/mL (P < 0.05). No major complications occurred.

Conclusions

PAE is a safe treatment with long term efficacy for severe LUTS from GPH. PAE may be a viable therapeutic option for patients with severe LUTS from GPH whom fail medical therapy and are not candidates for surgical treatments.

Benign Prostatic Hyperplasia: Clinical Manifestations, Imaging, and Patient Selection for Prostate Artery Embolization

Prostate artery embolization (PAE) has been shown to be safe and effective at treating lower urinary tract symptoms (LUTS), urinary retention, and hematuria caused by benign prostatic hyperplasia (BPH). To distinguish from other causes of these symptoms, a multidisciplinary evaluation by a urologist and interventional radiologist should include a complete history to screen for any nonprostate causes of LUTS. The International Prostate Symptom Score is a useful objective measure to quantify the patient's urinary complaints. A physical exam should be performed to evaluate a patient's candidacy for angiography, and baseline laboratory evaluation should ensure that the patient's coagulation and kidney function are adequate. In certain situations, patients may benefit from cystoscopy and urodynamic evaluation to ensure their symptoms are related to BPH. A review of the patient's imagining can be the most important component of the evaluation of a patient prior to PAE, because a patient's gland size is often a primary driver of what procedural options available are to him. Men with small glands (≤30 mL) can be treated with several of the available minimally invasive transurethral procedures, but larger glands (≥80-120 mL) may be limited to holmium laser enucleation of prostate, thulium laser enucleation of prostate, surgical prostatectomy, or PAE, depending on institutional practice patterns. Secondary considerations include medical comorbidities, the risks for sexual side effects, the risk for bleeding, and the possible adverse events associated with the procedure, which are all low for PAE. Most patients suffering from symptomatic BPH resulting in LUTS, retention, or hematuria will benefit from PAE.

Postembolization Syndrome after Prostatic Artery Embolization: A Systematic Review

Postembolization syndrome (PES) is the most common side effect of vascular embolization of solid organs. The aim of this review was to determine the incidence of PES and its individual components after prostatic artery embolization (PAE). A systematic review with a pre-specified search strategy for PubMed, Embase, Web of Science and Cochrane Library was performed according to PRISMA guidelines. Studies in English regarding PAE in humans with 10 or more participants were eligible for inclusion. No restrictions on participant demographics or PAE technique were imposed. The search returned 378 references, of which 32 studies with a total of 2116 patients met the inclusion criteria. The results for overall PES frequency and individual PES components were presented as median (interquartile range, (IQR)). Overall median PES frequency was 25.5% (12.5–45.8). The two most frequent individual PES components were dysuria/urethral burning and local pain, with a median frequency of 21.7% (13.8–33.3) and 20% (5.4–29.4), respectively. Most outcome measures were characterized by a marked lack of uniformity and inconsistency in reporting across studies. Development of a uniform reporting system would help the clinicians recognize and treat PES accordingly.

Indications, techniques, and role of new minimally invasive benign prostate hyperplasia surgical options

Novel emerging techniques for the surgical treatment of benign prostate hyperplasia (BPH) related to lower urinary tract symptoms are being investigated very seriously to help search for a better method, and the studies are getting their place in the literature. In this review article, UroLift^® system, (i)TIND^®, Aquablation^®, Rezūm® system, and prostatic artery embolization have been discussed according to the literature and both European and American urological guidelines. All related randomized controlled trials are discussed under the appropriate headings. Indications, technique, and the role of these minimally invasive surgical options for BPH are assessed. These methods, which are still being studied, are promising for the future. As the studies get completed, the indications will become clearer, and these techniques will find their respective places as the personalized treatment options.

Initial Canadian Experience of Prostate Artery Embolization for Symptomatic Benign Prostatic Hyperplasia: Midterm Outcomes

INTRODUCTION

This study aimed to assess the midterm outcomes and safety of prostate artery embolization (PAE) for the treatment of benign prostatic hyperplasia (BPH).

METHODS

A single-center, retrospective review of PAE performed for BPH was performed. Validated International Prostate Symptom Score (IPSS), quality of life (QoL) index, and International Index for Erectile Function (IIEF-5) questionnaires were completed at baseline and at least 12 months post-procedure. Prostate imaging was performed preprocedure as well as 3 months and 12 months post-procedure to assess prostate volume (PV). Uroflowmetry was also performed at baseline and 12 months post-procedure to assess urine flow rate (Q_max) and post-void residual (PVR) volume. Adverse events were graded according to Society of Interventional Radiology (SIR) guidelines.

RESULTS

Eighty male patients underwent the PAE procedure (mean age 69 years). Prostate volume decreased significantly from a mean volume 156 to 107 mL after 12 months post-procedure, commensurate with a mean reduction of 27.5% (P < .05). Significant improvements were seen in IPSS (21.8 vs 10.5) and QoL (4.5 vs 2.0) from baseline to 12 months post-procedure (P < .05). There was no significant change in IIEF-5 score. There was a significant reduction in PVR (202 vs 105 mL) and improvement in Q_max (5.9 vs 10.0 mL/s) between baseline and 12 months post-procedure (P < .05). No major complications occurred; 4 minor complications occurred (SIR grade A or B).

CONCLUSION

Prostate artery embolization achieved a clinically and statistically significant prostate volume reduction, symptom and QoL improvement, and enhanced uroflowmetry parameters in patients with BPH.

Prostatic Artery Embolization Using 100-300-μm Trisacryl Gelatin Microspheres to Treat Lower Urinary Tract Symptoms Attributable to Benign Prostatic Hyperplasia: A Single-Center Outcomes Analysis with Medium-Term Follow-up

PURPOSE

To report medium-term outcomes of prostatic artery embolization (PAE) using 100-300-μm trisacryl gelatin microspheres to treat lower urinary tract symptoms (LUTS) from benign prostatic hyperplasia (BPH) and to evaluate how cone-beam computed tomography-measured prostate gland volume (PGV), median lobe enlargement (MLE), age, and Charlson Comorbidity Index (CCI) affect these results.

MATERIALS AND METHODS

Seventy-four consecutive patients who underwent PAE from April 2014 through August 2018 were retrospectively reviewed. Patients had International Prostate Symptom Score (IPSS) >12, Quality of Life (QoL) score >2, prostate gland volume (PGV) >40 mL, age older than 45 years, and medical therapy failure. Twelve patients were excluded for bladder pathology or prostate cancer. Patients (n = 62, age = 71.8 ± 9.3 years, CCI = 3.5 ± 1.7, PGV = 174 ± 110 mL) had pre-procedure IPSS = 22.4 ± 5.6, QoL score = 4.4 ± 0.9, and post-void residual (PVR) = 172 ± 144 mL. Post-procedure values were compared to baseline at 1, 3, 6, 12, and 24 months. Associations between outcomes and PGV, MLE, age, and CCI were evaluated. Adverse event recording used Clavien-Dindo classification.

RESULTS

One month after PAE (n = 37), IPSS improved to 7.6 ± 5.2 (P < .0001) and QoL score improved to 1.7 ± 1.4 (P < .0001). At 3 months (n = 32), improvements continued, with IPSS = 6.4 ± 5.1 (P < .0001), QoL score = 1.2 ± 1.2 (P < .0001), PVR = 53 ± 41 mL (P < .001), and PGV = 73 ± 38 mL (P < .0001). Results were sustained at 6 months (n = 35): IPSS = 6.4 ± 4.1 (P < .0001), QoL score = 1.2 ± 1.2 (P < .0001), PVR = 68 ± 80 mL (P < .0001), PGV = 60 ± 19 mL (P < .001). At 12 months, patients (n = 26) had IPSS = 7.3 ± 5.5 (P < .0001), QoL score = 1.2 ± 0.8 (P <.0001), PVR = 89 ± 117 mL (P < .0001), PGV = 60 ± 48 mL (P < .01). At 24 months, patients (n = 8) had IPSS = 8.0 ± 5.4 (P < .0001), QoL score = 0.7 ± 0.5 (P < .0001), PVR = 91 ± 99mL (P = 0.17), and PGV = 30 ± 5mL (P = .11). Improvements were independent of PGV, MLE, age, and CCI. Two grade II urinary infections occurred.

CONCLUSIONS

PAE with 100-300-μm microspheres produced sustained substantial improvements in LUTS, PGV, and PVR, which were independent of baseline PGV, MLE, age, or CCI.

Prostatic Artery Embolization in Nonindex Benign Prostatic Hyperplasia Patients: Single-center Outcomes for Urinary Retention and Gross Prostatic Hematuria

OBJECTIVE

To present outcomes for prostatic artery embolization (PAE) to treat urinary retention and gross prostatic hematuria in nonindex benign prostatic hyperplasia patients.

MATERIALS AND METHODS

Seventy-five patients undergoing PAE from December 2013 to August 2018 (age = 77.5 ± 8.6, age-adjusted Charlson comorbidity index = 4.6 ± 2.0, prostate volume = 224 mL ± 135 mL) for retention (n = 46) and/or gross prostatic hematuria (n = 55) were retrospectively reviewed. Twenty-six patients had both problems. Urinary retention patients (UR, n = 46, catheterization = 162.4 ± 148.1 days) underwent voiding trials 1-2 months post-PAE, with International Prostate Symptom Score (IPSS), Quality of Life (QoL), and postvoid residual (PVR) recorded at 3, 6, 12, 24, and 36 months. Pre- and post-PAE hematuria-related visits were compared for gross hematuria patients (GH, n = 39), as were transfusion rates for severe hematuria patients requiring bladder irrigation (SH, n = 16). Ninety-day adverse event tabulation used Clavien-Dindo classification.

RESULTS

Three months post-PAE, 33/38(87%) UR patients were catheter-free (IPSS = 8.9 ± 5.3, QoL = 1.6 ± 1.7, PVR = 158 mL ± 207 mL). Results were similar at 6 months (catheter-free = 26/28(93%), IPSS = 6.5 ± 4.4, QoL = 1.1 ± 0.9, PVR = 149 mL ± 139 mL), 12 months (catheter-free = 19/20(95%), IPSS = 4.7 ± 4.8, QoL = 0.6 ± 0.9, PVR = 125 mL ± 176 mL), 24 months (catheter-free = 11/12(92%), IPSS = 4.4 ± 3.0, QoL = 0.9 ± 0.8, PVR = 66 mL ± 68 mL), and 36 months (catheter-free = 5/6(83%), IPSS = 5.8 ± 3.8, QoL = 0.8 ± 1.0, PVR =99 mL ± 71 mL). Out of 37, 34(92%) GH patients remained hematuria-free at 483 ± 137 days, with 22 hematuria-related visits pre-PAE vs none post-PAE. Hematuria resolved <48 hours post-PAE in 14/16(87.5%) SH patients, with 36 blood units transfused pre-PAE, 4 units transfused <48 hours post-PAE, and none thereafter. Subsequently, 13/16(81%) remained hematuria-free at 500 ± 501 days; 2/16(13%) required fulguration; 1/16(6%) developed bladder tumor. There were 2 deaths <30 days post-PAE, and 8(11%) Grade-II urinary infections.

CONCLUSION

PAE provided safe, effective, and durable treatment for retention and gross hematuria in nonindex benign prostatic hyperplasia patients.

Prostate Artery Embolization for Giant Prostatic Enlargement: Short-Term Efficacy and Safety

Eight patients with giant prostatic enlargement > 200 mL and lower urinary tract symptoms who underwent bilateral prostatic artery embolization (PAE) were reviewed. Mean prostate volume decreased from 318.2 mL to 212.2 mL (P < .01). At 5-month mean follow-up, International Prostate Symptom Score decreased by 16.7 points (P < .05), and urinary quality of life improved by 3.0 points (P < .01). Three of 4 catheter-dependent patients no longer needed catheterization after the procedure. No major complications were encountered. Preliminary results suggest PAE is safe and effective in patients with giant prostatic enlargement > 200 mL.

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.

Introduction of prostate artery embolization (PAE) in Sweden

Background: Transurethral resection of the prostate (TURP) is 'Gold Standard' treatment for moderate-to-severe lower urinary tract symptoms (LUTS) due to benign prostate hyperplasia (BPH) with bladder-outlet obstruction (BOO). However, TURP is associated with a risk of complications, so minimally invasive methods have been developed. Prostate artery embolization (PAE) is a new minimally invasive procedure. This study reports the outcomes of PAE when introduced in a 'real life' clinical setting in a Swedish County hospital. Methods: A prospective, single-center, single-arm study in a consecutive vascular-anatomy 'all comers' population, eligible for TURP or adenomaenukleation, but unsuitable for this, treated with PAE from January 2015 to June 2018. Defined improvement of IPSS/QoL scores, or freedom from urinary catheter if previous urinary catheter-dependent, or clean intermittent catheterization (CIC) were considered as clinically successful treatments. PAE was performed until arterial stasis using the Perfected technique. Most patients were treated during a day-care procedure. Results: Of 37 treated men, bilateral PAEs were achieved in 32 patients, unilateral PAEs in four patients, and bilateral failure in one patient due to difficult vascular anatomy. Clinically successful treatment was achieved in 84%, without serious adverse events. Conclusions: PAE was introduced in Sweden, showing PAE as a novel and good minimally invasive alternative in treatment of symptomatic BPH, possible to perform as a day-care procedure.