Prostatic Artery Embolization for Benign Prostatic Hyperplasia: Prospective Randomized Trial of 100-300 μm versus 300-500 μm versus 100- to 300-μm + 300- to 500-μm Embospheres

Absence of Race/Ethnicity Reporting in Clinical Trials of True Minimally Invasive Surgical Therapies for the Treatment of Benign Prostatic Hyperplasia

OBJECTIVE

To assess the extent of racial reporting and enrollment in randomized controlled trials (RCTs) of minimally invasive surgical therapies (MIST) for the office-based treatment of benign prostatic hyperplasia (BPH).

METHODS

A systematic review was conducted for RCTs assessing 6 office-based MISTs: transurethral microwave thermotherapy (TUMT), prostatic artery embolization, prostatic urethral lift, temporary implantable nitinol device, water vapor thermal therapy, and Optilume. MEDLINE, Embase, and the Cochrane CENTRAL databases were searched up to November 3, 2023. Publications were excluded if they (1) did not address one of the aforementioned office-based MISTs for the treatment of BPH; (2) were not RCTs; (3) were an abstract or conference proceeding; or (4) were not published in English. In addition to study characteristics, data about racial reporting were collected. Two independent reviewers completed screening at title, abstract, and full-text levels, with conflicts resolved by consensus with a third reviewer.

RESULTS

A total of 61 publications representing 37 unique RCTs (n = 4027 unique patients) were reviewed, with publication years spanning from 1993 to 2023. TUMT was the most frequently studied MIST. Most publications (79%) were based solely in Europe or North America. Over 50% of the publications were multicenter trials. None of the included publications reported on race/ethnicity of study participants.

CONCLUSION

None of the 61 included publications of RCTs of office-based MISTs provided information on racial/ethnic composition of study participants. There is a staggering gap in the standardization of race/ethnicity reporting and enrollment within RCTs of MISTs. More granular data on race/ethnicity allow for better generalizability and equity.

Prostate Artery Embolization (PAE) with Small Beads for the Treatment of Benign Prostatic Hyperplasia (BPH)

Benign Prostatic Hyperplasia (BPH) is the most frequent cause of Lower Urinary Tract Symptoms (LUTSs) in elderly populations. Minimally invasive treatments of BPH are safe and effective and are gaining popularity among both professionals and patients. Prostate Artery Embolization (PAE) has proven to be effective in Trans-Urethral Resection of the Prostate (TURP) in terms of prostate volume reduction and LUTS relief. PAE entails the selective catheterization of the prostatic artery and later embolization of distal vessels with beads of various calibers. Universal consensus regarding the ideal particle size is yet to be defined. We retrospectively evaluated 24 consecutive patients (median age: 75 years; range: 59-86 years) treated with PAE at our institution from October 2015 to November 2022. Particles of different sizes were employed; 12 patients were treated with 40-120 µm particles, 5 with 100 µm, 5 with 100-300 µm and 2 with 250 µm. Technical success, defined as selective prostate artery catheterization and controlled release of embolizing beads, was achieved in all patients. Removal vs. retention of the urinary catheter at the first post-procedural urological visit was the main clinical objective. No major peri-procedural complications were recorded, with 56% of patients successfully removing the urinary catheter.

Prostate Artery Embolization with 4D-CT

Prostate artery embolization (PAE) is a technically challenging angiographic therapy that has been shown to have excellent clinical outcomes for men with benign prostatic hyperplasia and lower urinary tract symptoms. Although clinical outcomes have been well documented, several questions remain regarding various technical details of the procedure. This article is a brief review of indications and technical parameters of PAE as well as commonly debated topics throughout the literature. Finally, the article serves to report tips and tricks from a high-volume center.

Efficacy of High-Dose Dexamethasone in Reducing the Symptoms of Postembolization Syndrome Following Prostatic Artery Embolization: Results of a Double-Blind Randomized Controlled Trial

PURPOSE

To evaluate the efficacy of a single perioperative dose of dexamethasone in reducing postembolization syndrome following prostatic artery embolization.

MATERIALS AND METHODS

We conducted a single-center double-blind randomized controlled trial from March 2021 to May 2022 (NCT04588857). Participants were randomized to receive either i.v. 24 mg dexamethasone or saline. The primary outcome measures were temperature, pain, and quality of life in the first 5 days following prostatic artery embolization. Sample size of 60 patients was needed for the assessment of primary outcomes. Participants were followed for 6 months and assessed for a variety of secondary outcome measures including inflammatory markers and lower urinary tract symptoms severity.

RESULTS

Due to lack of clinical effect and mild symptoms in the control group, the trial was terminated early. 31 participants (16 dexamethasone vs. 15 control) were enrolled and analyzed. A difference in mean temperature was observed on day 1 (37.23 ± 0.64 °C control vs 36.74 ± 0.41 °C dexamethasone, p = 0.02, 95% CI 0.09-0.89). Difference in pain (score out of 10) was seen only on day 5 (1.48 ± 1.2 control vs. 2.9 ± 2.24 dexamethasone, p = 0.04, 95% CI - 2.78-- 0.04). A difference in C-reactive protein values was observed on day 2 (108 [54-161] mg/l control vs 10 [5-33] mg/l dexamethasone, p < 0.01). No significant differences in other outcomes were observed. No side effects were recorded.

CONCLUSIONS

Twenty-four milligrams of dexamethasone bolus is safe but does not reduce postembolization syndrome following prostatic artery embolization.

Prostate Artery Embolization via Distal Transradial Artery Access in a 100-Year-Old Patient

Benign prostatic obstruction (BPH) is a common disease in males and surgical treatment is the gold standard for this symptomatic disease. Prostate artery embolization (PAE) is one of the emerging therapies which aims to minimize the lower urinary tract symptoms (LUTS) of BPH and the volume of enlarged prostates. We reported here a case of 100-year-old man with 90 cm3 prostate and severe symptoms secondary to BPH, who underwent a successful PAE through distal transradial access without any complications. The patient was satisfied with this treatment and no symptoms recurred after PAE. This demonstrated that PAE was a safe and effective treatment for BPH and was recommended for elderly/non-surgical candidates.

Prostatic Artery Embolization Using Polyethylene Glycol Microspheres: A 1-Year Follow-up Prospective Study Including 30 Patients

PURPOSE

To evaluate safety and effectiveness of prostatic artery embolization (PAE) using polyethylene glycol (PEG) microspheres in patients with moderate-to-severe benign prostatic hyperplasia (BPH).

MATERIALS AND METHODS

A single-center, prospective study of 30 patients who underwent PAE from August 2020 to December 2021 using PEG 400-μm microspheres was conducted. Patient evaluation data using International Prostate Symptom Score (IPSS), quality of life (QoL) score, prostate-specific antigen (PSA), peak urinary flow rate (Qmax), postvoid residual volume (PVR), and prostate volume (PV) at baseline and 3 and 12 months after PAE were obtained.

RESULTS

Bilateral PAE was performed in all patients. One patient had early clinical failure (3.3%) and another presented with lower urinary tract symptoms (LUTSs) recurrence (3.3%) at the 12-month follow-up. Twenty-eight patients (93.3%) experienced significant and durable LUTS improvement. Mean absolute (and relative) improvement at 3 and 12 months were: IPSS, 14.6 points (-69%) for both; QoL, 3.3 points (-70%) and 3.5 points (-74%); Qmax, 6.3 mL/s (+78%) and 8.6 mL/s (+100%); PSA reduction, 1.2 ng/mL (-22%) and 1.0 ng/mL (-15%); PVR reduction, 48 mL (-56%) and 58.2 mL (-49%); PV reduction, 23.4 cm3 (-29%) and 19.6cm3 (-25%); (P < .05 for all). No major adverse events were observed. Minor adverse events included urinary tract infection (4/30, 13.3%), prostatic tissue elimination (3/30, 10%), penile punctiform ulcer (1/30, 3.3%), and urinary retention (1/30, 3.3%).

CONCLUSIONS

PAE using PEG microspheres was observed to be effective with sustained LUTS improvement at the 12-month follow-up. The incidence of urinary infection and prostatic tissue elimination was higher than previously reported for other embolics.

Non-target embolic events during prostatic embolization with ethylene vinyl alcohol copolymer (EVOH)

BACKGROUND

This study evaluated nontarget embolization (NTE) during prostatic artery embolization (PAE) with ethylene vinyl alcohol copolymer (EVOH).

RESULTS

Ten consecutive patients treated by PAE with EVOH for the presence of disabling benign prostatic hyperplasia (BPH)-related lower urinary tract symptoms (LUTS) between June 22 and January 2023 were included in this prospective study. The inclusion criteria were as follows: LUTS attributed to BPH, LUTS duration ≥ 6 months, failure to respond to standard pharmacotherapy, IPSS > 18 or QoL score > 2, and prostate volume > 40 mL. Embolization was performed under general anaesthesia. According to established techniques, a microcatheter was positioned bilaterally within the feeding arteries, and EVOH was injected slowly under X-ray control. Unenhanced pelvic computed tomography scans were carried out before and after embolization to assess the NTE. The safety of the prostatic embolization procedure with EVOH was assessed by collecting adverse effects over 3 months of evaluation that included the International Prostate Symptom Score (IPSS) and quality of life (QoL) score.-up evaluations, occurring at 3, 6, and 12months, included International Prostate Symptom Score. Bilateral PAE was technically successful in 9 patients, and unilateral injection was performed in one patient. The postoperative scanner showed a distribution of the embolization material in the two lobes of the prostate in all patients. The procedure time varied from 120 to 150 (mean: 132) minutes. Eight out of 10 patients developed pollakiuria within 24 h; none of the patients had postoperative pain. Two patients required catheterization for postoperative urinary retention. Catheters were removed successfully at the end of the first day for one of these patients and on the tenth day for the other. At the 3-month follow-up, patients showed significant improvement in the International Prostate Symptom Score (n = 10; mean = -11,5; P < 0.01) and quality of life score (n = 10; mean = -3,40; P < 0.01). Only one patient presented one asymptomatic muscular NTE.

CONCLUSIONS

PAE with EVOH is safe, effective, and associated with few NTEs and no postoperative pain. Prospective comparative studies with longer follow-ups are warranted.

TRIAL REGISTRATION

IDRCB, 2021-AO29-56-35. Registered 27 May 2022, http://clinicaltrials.gov/study/NCT05395299?cond=embolization&term&rank=1 .

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.

Long-Term Middle Meningeal Artery Caliber Reduction Following Trisacryl Gelatine Microsphere Embolization for the Treatment of Chronic Subdural Hematoma

PURPOSE

Middle meningeal artery (MMA) particle embolization is a promising treatment of chronic subdural hematomas (CSDH). The main purpose of this study is to measure MMA proximal caliber and assess the visibility of the two main MMA branches as a surrogate for long-term distal arterial patency following MMA CSDH embolization with trisacryl gelatine microspheres (TAGM).

METHODS

This is a single-center retrospective study. All patients having undergone MMA TAGM only embolization for CSDH treatment between 15 March 2018 and 6 June 2020 with an interpretable follow-up magnetic resonance imaging (MRI) examination and no confounding factors were included. Patients were compared with controls matched for age, sex and MRI machine. Two independent readers analyzed the MRI images.

RESULTS

In this study, 30 patients having undergone embolization procedures using TAGM of 36 MMAs were included. The follow-up MRI scans were performed after a mean delay of 14.8 ± 7.1 months (range 4.9-29.4 months). The mean diameter of TAGM embolized MMAs (1 mm; 95% confidence interval, CI 0.9-1.1) was significantly smaller than the mean diameter of paired control MMAs (1.3 mm; 95% CI 1.3-1.4) (p < 0.001). The mean proximal diameter of the embolized MMAs (0.9 mm; 95% CI 0.7-1.1) was significantly smaller than the mean diameter of the contralateral MMAs in the same patients (1.4 mm; 95% CI 1.3-1.6)(p < 0.001).

CONCLUSION

Long-term follow-up MRI demonstrated a significant impact of TAGM embolization on MMA proximal caliber as well as on the visibility of the two main MMA branches. All comparisons indicated that there was a probable lasting impact of embolization on the patency of distal branches.

Update on the management of benign prostatic hyperplasia and the role of minimally invasive procedures

Lower urinary tract symptoms due to benign prostatic hyperplasia constitute a substantial burden, affecting the quality of life of those affected by this condition. While watchful waiting and medical management using a wide array of pharmaceuticals can be effective, surgery has been one of the most definite solutions for those highly affected by this condition. Transurethral resection of the prostate (TURP) is the gold standard surgical procedure, but other alternatives using laser (HoLEP and ThuLEP) and robotic water jets (Aquablation) are emerging treatments aimed at reducing postoperative morbidity. Minimally invasive procedures conducted in outpatient settings and under local anesthesia or sedation are increasingly being used, especially in those patients with high surgical risk due to comorbidities. These procedures include prostatic arterial embolization, water vapor thermal therapy (Rezum), prostatic urethral lift (Urolift), temporary implantable nitinol device (TIND/iTIND), and transurethral microwave thermotherapy (TUMT). The evidence supporting these treatments is growing, but some uncertainties remain as to what is the magnitude of their advantages and disadvantages compared to TURP. Innovations in the technologies involved in these new procedures may improve their profile for effectiveness and safety. Moreover, new devices are being investigated for marketing approval. Issues around costs and patients' preferences are also yet to be elucidated, thus their evolving role needs to be weighed against the aforementioned considerations.

Prostate Artery Embolization: Challenges, Tips, Tricks, and Perspectives

Prostatic artery embolization (PAE) consists of blocking the arteries supplying the prostate to treat benign prostate hypertrophia (BPH). Its effectiveness on both urinary symptoms and flowmetric parameters has now been amply demonstrated by around a hundred studies, including several randomized trials. The main advantage of this procedure is the very low rate of urinary and sexual sequelae, including ejaculatory, with an excellent tolerance profile. The arterial anatomy is a key element for the realization of PAE. Its knowledge makes it possible to anticipate obstacles and prevent potential complications related to nontarget embolization. Nontarget embolization can occur with a small intraprostatic shunt or reflux and has no consequences except some local inflammation symptoms that resolve in a couple of days. Nevertheless, some situations with large arterial shunts arising from the prostatic artery must be recognized (accessory rectal, bladder, or pudendal branches), and must imperatively be protected before embolization, at the risk of exposing oneself to otherwise ischemic complications that are more severe, such as bladder necrosis and skin or mucosal necrosis. This article offers a step-by-step review of the various anatomical and technical key points to ensure technical and clinical success, while avoiding the occurrence of adverse events.

Controversies in Prostate Artery Embolization: Future Best Practice

Prevalence of lower urinary tract symptoms secondary to benign prostatic hyperplasia is correlated with age. Men seeking treatment options with a low side effect profile often turn to prostate artery embolization (PAE). PAE continues to be refined with advanced tools and optimized techniques. Nonetheless, there exist controversies in terms of best practices for the management of lower urinary track symptoms (LUTS) with PAE. These controversies are essential for medical progress. Herein we suggest best practices moving forward based on currently available data. Given extensive safety data, we recommend PAE be considered alongside medical management and as a precursor to surgery. Given demonstrated efficacy across gland sizes, PAE can be performed in a single session, ideally in a hybrid angio-CT suite, without preoperative cross-sectional imaging. PAE should be initially performed with 300- to 500-μm size particles, and instead consider exploring other particles and sizes for repeat PAE. Finally, PAE can also be considered as first-line option for recurrent disease given the efficacy and excellent safety profile. This article is not meant to purport a dogma, but rather to serve as a guide to the experienced practitioner in challenging his or her own biases when performing PAE.

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.

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.

Long-Term Outcome of Prostatic Artery Embolization for Patients with Benign Prostatic Hyperplasia: Single-Centre Retrospective Study in 1072 Patients Over a 10-Year Period

PURPOSE

Assess long-term outcomes of prostatic artery embolization (PAE) for patients with benign prostatic hyperplasia (BPH).

MATERIALS AND METHODS

Single centre retrospective study from 2009-2019 including 1072 patients who received PAE and had available follow-up. Patients were evaluated yearly at 1-10 years post PAE using the International Prostate Symptom Score (IPSS) and quality of life (QoL), prostate volume (PV), prostate-specific antigen (PSA), peak urinary flow rate (Qmax) and postvoid residual (PVR) volume. The need for prostatic medication, re-intervention rates, repeat PAE and prostatectomy rates were assessed with Kaplan-Meier survival analysis and compared between different embolic agents using Cox regression analysis.

RESULTS

Mean follow-up time was 4.39 ± 2.37 years. At last follow-up visit, mean IPSS and QoL improvements were - 10.14 ± 8.34 (p < .0001) and - 1.87 ± 1.48 (p < .0001) points, mean PV reduction was - 6.82 ± 41.11 cm³ (p = 0.7779), mean PSA reduction was - 1.12 ± 4.60 ng/mL (p = 0.9713), mean Qmax increase was 2.72 ± 6.38 mL/s (p = 0.0005), mean PVR reduction was - 8.35 ± 135.75 mL (p = 0.6786). There were 335 patients (31.3%) needing prostatic medication after PAE. Re-intervention rates were 3.4% at 1 year, 21.1% at 5 years and 58.1% at 10 years. Repeat-PAE rates were 2.3% at 1 year, 9.5% at 5 years and 23.1% at 10 years. Prostatectomy rates were 1.1% at 1 year, 11.6% at 5 years and 35.0% at 10 years. No significant differences were found between polyvinyl alcohol particles, Bead Block, Embospheres and Embozenes.

CONCLUSION

PAE induces durable long-term LUTS relief, with re-intervention rates of 20% in the first 5 years and 30%-60% > 5 years post-PAE.

Prostatic Artery Embolization for Benign Prostatic Obstruction: Single-Centre Retrospective Study Comparing Microspheres Versus n-Butyl Cyanoacrylate

PURPOSE

To compare the safety and efficacy of n-butyl cyanoacrylate glue (NBCA) versus microspheres for prostatic artery embolization (PAE) in patients with benign prostatic obstruction (BPO).

MATERIALS AND METHODS

This institutional review board-approved, single-centre, retrospective study included consecutive patients undergoing PAE from September 2017 to July 2020. Age, medical history, previous treatment, pre- and post-PAE prostatic volumes and International Prostate Symptom Scores (IPSSs) were systematically analysed. Procedural duration, dosimetry, immediate and delayed complications were recorded. Patients at the beginning of the study were treated with microspheres and patients at the end of the study with NBCA. The main outcome measures were the absolute and relative changes in IPSS at 3 months. Statistical analyses comprised unpaired t-tests, Wilcoxon tests, Chi-2 tests, uni- and multivariate linear regressions.

RESULTS

Sixty-two patients were included (median age: 65.9 years). Thirty-two patients were treated with microspheres and 30 with NBCA. There were no significant baseline differences between the two groups except for the baseline PSA (P = 0.0251). Average procedural and fluoroscopy times, and radiation exposure were significantly lower in the NBCA group versus the microspheres group (80.7 ± 22.5 versus 112 ± 42.1 min [P = 0.0011], 24.2 ± 9.6 min versus 42.1 ± 20.2 min [P = 0.0001], 12,004.6 ± 6702 uGy.m² versus 25,614.9 ± 15,749.2 uGy.m² [P = 0.0001], respectively). Immediate complications were all minor, and there were no significant differences between the two groups (4/32 [12.5%] with microspheres versus 7/30 [23.3%] with NBCA, P = 0.4335), nor for delayed complications (P = 1). No association was found between the PAE techniques and the absolute change in IPSS at 3 months (-10.2 ± 7.9 with microspheres versus -9.5 ± 7.6 with NBCA, P = 0.7157).

CONCLUSION

PAE using NBCA was safe and effective for symptomatic BPO, with faster procedures, lower radiation exposure and similar safety and efficacy compared to microspheres. Operator learning curve could have biased the procedural times and radiation exposure between groups favouring NBCA.

Guiding the prostatic artery embolization procedure with computational uid dynamics

Benign prostatic hyperplasia (BPH) is a common disease associated with lower urinary tract symptoms and the most frequent benign tumor in men. To reduce BPH therapy complications, prostatic artery embolization (PAE) was developed to replace the surgical options. PAE is a minimally invasive technique in which emboli are injected into the prostate arteries (PA), obstructing the blood flow in the hypervascular nodules. In this work, a personalized PAE treatment strategy was proposed using patient-specific computational fluid dynamics (CFD). First, the hemodynamics environment in the iliac arterial tree considering a large network of bifurcations was studied. The results showed complex blood flow patterns in the iliac arterial network. Subsequently, the transport of embolic particulates during PAE for the standard horizontal and a hypothetical vertical patient positioning was simulated using Lagrangian particle tracking. Emboli with different sizes were released at various locations across the iliac arterial tree. The emboli entering the PA were mapped back to their initial location to create emboli release maps (ERMs). The obtained ERMs during the standard patient positioning for smaller emboli at certain release locations showed distinct regions in which if the emboli were released within these regions, all of them would reach the PA without non-target embolization. During the hypothetical vertical patient positioning, the larger emboli formed a larger coherent region in the ERMs. Our patient-specific model can be used to find the best spatial location for emboli injection and perform the embolization procedure with minimal off-target delivery.

Particle Distribution in Embolotherapy, How Do They Get There? A Critical Review of the Factors Affecting Arterial Distribution of Embolic Particles

Embolization has tremendously evolved in recent years and has expanded to treatment of a variety of pathologic processes. There has been emerging evidence that the level of arterial occlusion and the distribution of embolic particles may play an important role in the clinical outcome. This is a comprehensive literature review to identify variables that play important role in determination of level of occlusion of blood vessels and distribution of embolic particles. The literature searches between 1996 to 2020 through PubMed and Ovid-MEDLINE yielded over 1030 articles of which 30 studies providing details on the level of occlusion are reviewed here. We divided the playing factors into characteristics of the particles, solution/injection and vascular bed. Accordingly, particle size, type and aggregation, compressibility/deformability, and biodegradability are categorized as the factors involving particles' behavioral nature. Infusion rate and concentration/dilution of the medium are related to the carrying solution. Hemodynamics and the arterial resistance are characteristics of the vascular bed that also play an important role in the distribution of embolic particles. Understanding and predicting the level of embolization is a complex multi-factor problem that requires more evidence, warranting further randomized controlled trials, and powered human and animal studies.

Nontarget Radiopaque Embolic Deposition during Prostatic Artery Embolization

This study evaluated detectable nontarget embolization (NTE) during prostatic artery embolization (PAE) and the safety and efficacy of using radiopaque particles in PAE. Ten patients aged >40 years with prostate glands of >50 mL and refractory lower urinary tract symptoms were analyzed. Unenhanced computed tomography scans at baseline and at 3 months after PAE, using 40-90-μm radiopaque spherical embolic beads, were compared to assess the NTE. Growth models evaluated changes from baseline to 3, 6, and 12 months in International Prostate Symptom Score (IPSS), peak urine flow rate (Qmax), quality of life (QoL), International Index of Erectile Function (IIEF), and postvoid residual (PVR). The IPSS, QoL, and Qmax improved at all time points (P < .05), with no trend in PVR or IIEF. Adverse events that occurred were minor. Radiographic NTE was seen in all patients, correlating at times with postprocedural symptoms (eg, rectal pain). Symptoms were not correlated with the NTE in some patients, whereas other patients remained asymptomatic despite NTE.

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 (PAE) Using Polyethylene Glycol Microspheres: Safety and Efficacy in 81 Patients

PURPOSE

To evaluate the safety and efficacy of prostatic artery embolization (PAE) using polyethylene glycol microspheres (PEGM) in patients with lower urinary tract symptoms secondary to benign prostatic hyperplasia (BPH).

MATERIALS AND METHODS

This multicentric prospective study enrolled 81 patients who underwent PAE with 400 ± 75 µm PEGM (HydroPearl®, Terumo, Japan). Results from baseline and 1-, 3-, 6-, and 12-month follow-ups were assessed for subjective outcomes including International Prostate Symptoms Score (IPSS), Quality of life (QoL), and International Index of Erectile Function, and objective outcomes such as peak urinary flow (Qmax) and post-void residual volume (PVR). The visual analogue scale, satisfaction questionnaire, prostatic volume, and prostatic specific antigen levels were also evaluated. Complications were documented using the modified Clavien-Dindo classification.

RESULTS

Technical success was obtained in all patients. Clinical success was achieved in 78.5% of patients. Before PAE, 54.3% of patients had an indwelling catheter which was removed in 75% of them after procedure. A statistically significant decrease was observed in IPSS and QoL from baseline to 12 months (20.14 vs 5.89; 4.8 vs 0.63, P < .01), respectively. Objective outcomes also showed a statistically significant improvement in Qmax (+ 114.9%; P < .01), achieving a maximum urinary flow of 14.2 mL/sec, and PVR (decrease 58%; P < .05) at 12 months. Minor complications (Clavien-Dindo grades I-II) occurred in 13.6% of patients, without major complications observed.

CONCLUSION

PAE with PEGM is safe and effective treatment in patients with symptomatic BPH, with a significant improvement in both subjective and objective outcomes.

Prostatic Artery Embolization: Indications, Preparation, Techniques, Imaging Evaluation, Reporting, and Complications

Benign prostatic hyperplasia (BPH) is a noncancerous growth of the transitional zone of the prostate, which surrounds the prostatic urethra. Consequently, it can cause lower urinary tract symptoms (LUTS) and bladder outlet obstruction symptoms that may substantially reduce a patient's quality of life. Several treatments are available for BPH, including medications such as α-blockers and 5α-reductase inhibitors and surgical options including transurethral resection of the prostate and prostatectomy. Recently, prostatic artery embolization (PAE) has emerged as a minimally invasive treatment option for selected men with BPH and moderate to severe LUTS. Adequate pre- and postprocedural evaluations with clinical examinations and questionnaires, laboratory tests, and urodynamic and imaging examinations (particularly US, MRI, and CT) are of key importance to achieve successful treatment. Considering that the use of PAE has been increasing in tertiary hospital facilities, radiologists and interventional radiologists should be aware of the main technical concepts of PAE and the key features to address in imaging reports in pre- and postprocedural settings. An invited commentary by Lopera is available online. Online supplemental material is available for this article. ^©RSNA, 2021.

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.

Using prostate contrast retention (PCR) as the procedural endpoint in prostatic artery embolization for benign prostatic hyperplasia

OBJECTIVES

The failure rate following prostate artery embolization (PAE) is around 20%, which may in part result from inadequate embolization. Prostate contrast retention (PCR) adequacy on immediate post-embolization cone-beam CT may provide better assessment of embolization completeness than arterial contrast stasis seen on fluoroscopy alone. The aim of this study was to evaluate outcomes of PAE using PCR adequacy as the procedural endpoint.

METHODS

A retrospective cohort study of all PAE cases using this technique at a single large volume center was conducted. Following initial embolization of the main prostatic arteries, if PCR was inadequate, additional embolization was performed. Technical success (adequate PCR) was defined as > 75% global prostate gland contrast staining. Clinical success was determined in accordance to CIRSE standards of practice.

RESULTS

One hundred sixty-five patients (mean age 68 ± 8.4 years) underwent PAE from June 2017 to March 2019. Technical and clinical success rates were 98.8% and 96.4% respectively. Clinical success rate was significantly higher in patients with adequate PCR. International Prostate Symptom Scores (IPSS) and Quality of Life (QoL) scores significantly improved at 1-, 3-, 6-, and 12-month follow-up when compared to baseline. Prostate volume (PV) and post-voiding residual bladder volume were significantly reduced at 3, 6, and 12 months in comparison to baseline. Mild (Clavien-Dindo grade I/II) and moderate (grade III) complication rates were 12.1% and 3.6% respectively.

CONCLUSIONS

By using PCR adequacy as a guide to determine the procedure endpoint for PAE, it may be possible to achieve more complete embolization and thus higher clinical success rates.

KEY POINTS

• By using PCR adequacy as a guide to determine the procedure endpoint for PAE, it may be possible to achieve more complete embolization and thus higher clinical success rates.

Progress of gelatin-based microspheres (GMSs) as delivery vehicles of drug and cell

Gelatin has various attractive features as biomedical materials, for instance, biocompatibility, low immunogenicity, biodegradability, and ease of manipulation. In recent years, various gelatin-based microspheres (GMSs) have been fabricated with innovative technologies to serve as sustained delivery vehicles of drugs and genetic materials as well as beneficial bacteria. Moreover, GMSs have exhibited promising potentials to act as both cell carriers and 3D scaffold components in tissue engineering and regenerative medicine, which not only exhibit excellent injectability but also could be integrated into a macroscale construct with the laden cells. Herein, we aim to thoroughly summarize the recent progress in the preparations and biomedical applications of GMSs and then to point out the research direction in future. First, various methods for the fabrication of GMSs will be described. Second, the recent use of GMSs in tumor embolization and in the delivery of cells, drugs, and genetic material as well as bacteria will be presented. Finally, several key factors that may enhance the improvement of GMSs were suggested as delivery vehicles.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

KEY POINTS

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

Immobilized thrombin on X-ray radiopaque polyvinyl alcohol/chitosan embolic microspheres for precise localization and topical blood coagulation

Trans-catheter arterial embolization (TAE) plays an important role in treating various diseases. The available embolic agents lack X-ray visibility and do not prevent the reflux phenomenon, thus hindering their application for TAE therapy. Herein, we aim to develop a multifunctional embolic agent that combines the X-ray radiopacity with local procoagulant activity. The barium sulfate nanoparticles (BaSO₄ NPs) were synthesized and loaded into the polyvinyl alcohol/chitosan (PVA/CS) to prepare the radiopaque BaSO₄/PVA/CS microspheres (MS). Thereafter, thrombin was immobilized onto the BaSO₄/PVA/CS MS to obtain the thrombin@BaSO₄/PVA/CS MS. The prepared BaSO₄/PVA/CS MS were highly spherical with diameters ranging from 100 to 300 μm. In vitro CT imaging showed increased X-ray visibility of BaSO₄/PVA/CS MS with the increased content of BaSO₄ NPs in the PVA/CS MS. The biocompatibility assessments demonstrated that the MS were non-cytotoxic and possessed permissible hemolysis rate. The biofunctionalized thrombin@BaSO₄/PVA/CS MS showed improved hemostatic capacity and facilitated hemostasis in vitro. Additionally, in vivo study performed on a rabbit ear embolization model confirmed the excellent X-ray radiopaque stability of the BaSO₄/PVA/CS MS. Moreover, both the BaSO₄/PVA/CS and thrombin@BaSO₄/PVA/CS MS achieved superior embolization effects with progressive ischemic necrosis on the ear tissue and induced prominent ultrastructural changes in the endothelial cells. The findings of this study suggest that the developed MS could act as a radiopaque and hemostatic embolic agent to improve the embolization efficiency.

•

Excellent in vitro and in vivo visibility of BaSO₄/PVA/CS MS.

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Excellent cytocompatibility and hemocompatibility of BaSO₄/PVA/CS MS.

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Enhanced hemostatic capacity and hemostasis of thrombin@BaSO₄/PVA/CS MS.

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Potential application of thrombin@BaSO₄/PVA/CS MS for in vivo embolization.

A state-of-art review on the preservation of sexual function among various minimally invasive surgical treatments for benign prostatic hyperplasia: Impact on erectile and ejaculatory domains

There is a strong association between benign prostatic hyperplasia (BPH)/lower urinary tract symptoms (LUTS) and sexual dysfunction. While transurethral resection of the prostate (TURP) is considered the standard BPH treatment, it is however associated with a high rate of erectile and ejaculatory dysfunctions. Over the past decade, new and novel minimally invasive BPH therapies have been shown to improve various parameters of voiding domains while minimizing adverse sexual effects. These minimally invasive BPH therapies can be largely be divided into those with cavitating technology (Rezum, Histotripsy, Aquablation), intra-prostatic injections (Botulinum neurotoxin Type A, Fexapotide Triflutate, prostate specific antigen-activated protoxin PRX-302), and mechanical devices which include intraprostatic stents (Urospinal 2™, Memotherm™, Memokath™, and Allium triangular prostatic stent™) and intraprostatic devices (iTIND™, Urolift™), as well as prostatic artery embolization. Published literature on these technologies showed reasonable preservation of erectile function with limited data reported on ejaculatory domain. Further validation of the performance of these novel minimally invasive treatment options for LUTS due to BPH in well-designed and multi-centre studies are desired, to evaluate their role (or lack of such a role) in clinical practice and whether these BPH therapies can provide equivalent standard or better than TURP.

A Systematic Review of Reported Ejaculatory Dysfunction in Clinical Trials Evaluating Minimally Invasive Treatment Modalities for BPH

PURPOSE OF REVIEW

To explore the sexual outcomes following the novel minimally invasive surgical procedures for benign prostatic hyperplasia- (BPH-) related lower urinary tract symptoms (LUTS), with an emphasis on ejaculatory dysfunction (EjD).

RECENT FINDINGS

A database search with a 10-year time restriction was carried out until February 20, 2020 using MEDLINE through the PubMed Platform evaluating minimally invasive treatment modalities for BPH and their effect on EjD. After the article selection, we retrieved data for men randomized in 19 different studies with results in 40 separate published articles investigating minimally invasive BPH surgery and reporting EjD rates. To date, water vapor thermal therapy or Rezūm, prostatic urethral lift (PUL) or UroLift®, prostate artery embolization (PAE), and Aquablation showed acceptable rates (< 2%) of retrograde ejaculation by 1 year and had very low adverse events related to the procedure. Both PUL and Rezūm demonstrated lower rates when compared with PAE and Aquablation. With comparable sexual side effect profiles postoperatively, clinicians may determine which therapeutic modality is optimal for patients based on efficacy and cost-benefit. Further randomized clinical trials are required to directly compare the effect of novel minimally invasive surgical procedures for BPH-related LUTS on ejaculation and sexual function.

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.

Current Debates Regarding Optimal Patient Evaluation and Procedural Technique for Prostatic Artery Embolization

There are active debates surrounding patient evaluation and procedural techniques of prostate artery embolization. This review evaluates the available evidence on the value of urodynamics, the effect of prostate gland size, the benefits of pre- and intraprocedural cross-sectional imaging, the utility of a balloon-occlusion microcatheter, the differences among embolic particle sizes and types, and the merits of radial versus femoral arterial access.

Prostatic Artery Embolization: Equipment, Procedure Steps, and Overcoming Technical Challenges

In the last decade, prostatic artery embolization (PAE) established itself as a safe and effective treatment option for lower urinary tract symptoms (LUTS) attributed to benign prostate hyperplasia (BPH), with reproducible results across multiple centers and endorsement by important international societies. However, PAE is also known to be a technically demanding procedure. Accompanying the prevalence of benign prostate hyperplasia, the procedure is usually performed in older patients, in whom atherosclerosis and comorbidities are common features. Also, prostatic vascular anatomy is described to be complex and variable, and pelvic structures are deeply interconnected by anastomosis. Thus, PAE demands a deep familiarization with materials and devices, intraprocedure imaging techniques, microcatetherization skills and with the pelvic vascular anatomy. Especially in the beginning of the learning curve, the procedure can be time-consuming and related to high radiation exposure for both medical team and the patient. In this article, the main points of technical concern during PAE are described and discussed, such as the equipment needed, the effect of different embolic materials, patient's preparation for the procedure, arterial access sites, identifying and catheterizing the prostatic arteries, the embolization techniques, among others. Finally, the most frequent technical challenges are presented, and the possible strategies to overcome them are exemplified and discussed.

Prostate Artery Embolization: State of the Evidence and Societal Guidelines

Medically refractory benign prostatic hyperplasia induced lower urinary tract symptoms is an extremely prevalent issue in older men. The current gold standard therapy transurethral resection of the prostate does produce urologic improvements but is also associated with higher than desired morbidity. This has led to the need to develop new minimally invasive means to treat this disease; prostate artery embolization (PAE) has emerged as one minimally invasive treatment option for these patients. The body of evidence which supports the use of PAE has grown quickly and substantially over the last decade. The goal of this review is to introduce and summarize the published urologic outcomes for PAE when utilized to treat benign prostatic hyperplasia induced lower urinary tract symptoms as well as document the established complication profile. Finally, the paper reviews current societal recommendations as they relate to 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.

Position Paper of the German Society for Interventional Radiology (DeGIR) on Prostatic Artery Embolization

BACKGROUND

 In recent years prostate artery embolization (PAE) evolved into a clinically established minimally invasive endovascular treatment option for lower urinary tract symptoms caused by benign prostate syndrome (BPS).

METHODS

 In this interdisciplinary position paper, initiated by the steering group for research of the German Society for Interventional Radiology (IR), the method of PAE is presented and discussed in the context of current evidence.

RESULTS

 PAE is a safe IR procedure for the treatment of BPS. In terms of symptom relief, measured with the IPSS (International Prostate Symptom Score), the PAE has comparable effect, similar to the historic gold standard, transurethral resection (TUR) of the prostate. With regard to reducing subvesical obstruction PAE is inferior to TUR, but does not limit subsequent surgery. Based on current evidence, PAE is recommended by the British National Institute for Health and Care Excellence as an alternative therapy. The feasibility under local anaesthesia and the preservation of sexual function are important arguments for patients in favour of interventional therapy. Patient selection and therapy concepts require close interdisciplinary collaboration between urologists and radiologists.

CONCLUSION

 Effectiveness and safety of PAE for the treatment of BPS are proven. Further randomized trials should focus on long term outcome and help to identify most suitable indications for PAE.

KEY POINTS

  · PAE, an endovascular procedure, is a patient-friendly, minimally invasive, alternative therapy option of the BPS. · PAE can reduce the symptoms of the lower urinary tract (LUTS), comparable to transurethral resection (TUR). The deobstructive and volume-reducing potential of the PAE is inferior to that of the TUR. · The main advantages of PAE are use of local anesthesia (no general anesthesia required), short patient recovery and maintenance of sexual function, including antegrade ejaculation.. · Based on current evidence PAE should be considered after conservative drug therapy and before TUR.. · The role of PAE in the context of other minimally invasive procedures (MIST) requires further evaluation with an open minded approach towards PAE.. · PAE is carried out by interventional radiologists, usually on a referral basis from urologists, and requires close interdisciplinary cooperation..

CITATION FORMAT

· Kovacs A, Bücker A, Grimm M et al. Position Paper of the German Society for Interventional Radiology (DeGIR) on Prostatic Artery Embolization. Fortschr Röntgenstr 2020; 192: 835 - 846.

Prostatic Artery Embolization for the Treatment of Lower Urinary Tract Symptoms Due to Benign Prostatic Hyperplasia: 10 Years' Experience

Background Long-term experience with prostatic artery embolization (PAE) for benign prostatic hyperplasia remains limited. Purpose To evaluate the efficacy, safety, and long-term results of PAE for benign prostatic hyperplasia. Materials and Methods This retrospective single-center study was conducted from June 2008 to June 2018 in patients with moderate to severe benign prostatic hyperplasia-related symptoms. International Prostate Symptom Score (IPSS), quality-of-life score, maximum urinary flow rate, postvoid residual volume, prostate-specific antigen (PSA), and prostate volume were assessed. PAE was performed with 100-500-μm embolic microspheres. Mixed-model analysis of variance and Kaplan-Meyer method was accessed, as appropriate. Results A total of 317 consecutive men (mean age ± standard deviation, 65 years ± 8) were treated. Follow-up ranged from 3 months to 96 months (mean, 27 months). Bilateral and unilateral PAE was performed in 298 (94%) and 19 (6%) men, respectively. Early clinical failure occurred in six (1.9%) and symptom recurrence in 72 (23%) men at a median follow-up of 72 months. Mean maximum improvement was as follows: IPSS, 16 points ± 7; quality-of-life score, 4 points ± 1; prostatic volume reduction, 39 cm³ ± 39 (39% ± 29); maximum urinary flow rate, 6 mL/sec ± 10 (155% ± 293); and postvoid residual volume, 70 mL ± 121 (48% ± 81) (P < .05 for all). Unilateral PAE was associated with higher recurrence (42% vs 21%; P = .04). Baseline PSA was inversely related with recurrence (hazard ratio, 0.9 per nanograms per milliliter of PSA; 95% confidence interval [CI], 0.8, 0.9; P < .001). Embolization with combined particle sizes (100-500 μm) did not relate to symptom recurrence (hazard ratio, 0.4; 95% CI: 0.2, 1.1 for 100-500-μm group vs 300-500-μm group and hazard ratio, 0.4; 95% CI: 0.1, 1.5 for 100-500-μm group vs 100-300-μm group; P = .19).None of the patients presented with urinary incontinence or erectile dysfunction. Conclusion Prostatic artery embolization was a safe and effective procedure for benign prostatic hyperplasia with good long-term results for lower urinary tract symptoms. © RSNA, 2020 Online supplemental material is available for this article.

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.