Four-Year Impact of Voiding and Storage Symptoms in Patients with Benign Prostatic Hyperplasia Treated with Prostatic Artery Embolization

Analysis of the efficacy of Prostatic Artery Embolization in the treatment of Benign Prostatic Hyperplasia

OBJECTIVES

To investigate the safety and efficacy of prostatic artery embolization (PAE) in the treatment of lower urinary tract symptoms (LUTS) caused by benign prostatic hyperplasia (BPH), and to investigate predictors of clinical success of PAE.

METHODS

A retrospective analysis was used to collect 107 patients [median age 81.0 (73.0,85.0)] with BPH-related LUTS treated with PAE from September 2014 to February 2022 in a hospital. Repeated measurement ANOVA was used to compare the efficacy evaluation indicators at different times before and after PAE. Univariate and multivariate analyses were used to identify potential predictors of PAE clinical success and establish the optimal joint prediction model. The Receiver Operating Characteristic curves of the quantitative predictors and multivariate model prediction probability values significantly correlated with clinical success were plotted.

RESULTS

Of the 107 cases, 103 (96.3%) successfully underwent PAE. The International Prostate Symptom Score (IPSS) decreased from a baseline mean of 24.94 to 10.19 (P < 0.05) 3 months after PAE, and the mean IPSS at 6 months, 12 months and 24 months was 10.12, 11.30 and 11.86, respectively, which were statistically significant compared with baseline (P<0.05). Predictors of clinical success were greater prostate volume (> 65 ml, P = 0.018), adenomatous-dominant benign prostatic hyperplasia (AdBPH)(P = 0.030), indwelling catheterization due to urine retention (P = 0.028), and bilateral embolization (P = 0.018).

CONCLUSION

PAE was able to significantly improve BPH-related LUTS and the outcome indicators remained stable at long-term follow-up. Preoperative urinary retention catheters, AdBPH, larger prostate volume (> 65 ml) and bilateral embolization suggest better clinical efficacy.

Short-term postoperative recovery for patients after Thulium Laser Vapoenucleation of Prostate: evaluation of the impact of lower urinary tract symptoms on quality of life

PURPOSE

We evaluated short-term postoperative recovery in patients with benign prostatic hyperplasia (BPH), especially focusing on symptoms reduction and life quality enhancement.

METHODS

We prospectively enrolled 160 BPH patients who underwent surgery and were followed up regularly for 12 weeks, collecting the International Prostate Symptom Score (IPSS), Quality of Life (QoL), and Qmax. Regression analysis and mixed effect models were used to evaluate the tendency of symptoms on recovery from the perspective of quality of life.

RESULTS

At 12 weeks, all patients recovered well with conspicuous change in IPSS, QoL and Qmax, that were 4.80 ± 4.59, 1.34 ± 1.14,20.02 ± 8.61 mL/s respectively. Voiding symptoms were significantly reduced by 79.4% at 2 weeks, whereas storage symptoms recovered slowly until 12 weeks with residual lower urinary tract symptoms (LUTS), predominantly urinary frequency and nocturia. Improvements in incomplete emptying urination and urinary frequency were significantly associated with QoL.

CONCLUSIONS

With regards to the comprehensive full-cycle treatment of LUTS patients, in addition to the objective results, more attention should also be focused on the change in following symptoms, that is, incomplete emptying urination, urine frequency and urination difficulty, which play key roles in the enhancement of patients' quality of life.

Prostatic artery embolisation versus medical treatment in patients with benign prostatic hyperplasia (PARTEM): a randomised, multicentre, open-label, phase 3, superiority trial

Background

Prostatic artery embolisation (PAE) is a minimally invasive treatment of symptomatic benign prostatic hyperplasia (BPH). Our aim was to compare patient's symptoms improvement after PAE and medical treatment.

Methods

A randomised, open-label, superiority trial was set in 10 French hospitals. Patients with bothersome lower urinary tract symptoms (LUTS) defined by International Prostatic Symptom Score (IPSS) > 11 and quality of life (QoL) > 3, and BPH ≥50 ml resistant to alpha-blocker monotherapy were randomly assigned (1:1) to PAE or Combined Therapy ([CT], oral dutasteride 0.5 mg/tamsulosin hydrochloride 0.4 mg per day). Randomisation was stratified by centre, IPSS and prostate volume with a minimisation procedure. The primary outcome was the 9-month IPSS change. Primary and safety analysis were done according to the intention-to-treat (ITT) principle among patients with an evaluable primary outcome. ClinicalTrials.gov Identifier: NCT02869971.

Findings

Ninety patients were randomised from September 2016 to February 2020, and 44 and 43 patients assessed for primary endpoint in PAE and CT groups, respectively. The 9-month change of IPSS was -10.0 (95% confidence interval [CI]: -11.8 to -8.3) and -5.7 (95% CI: -7.5 to -3.8) in the PAE and CT groups, respectively. This reduction was significantly greater in the PAE group than in the CT group (-4.4 [95% CI: -6.9 to -1.9], p = 0.0008). The IIEF-15 score change was 8.2 (95% CI: 2.9-13.5) and -2.8 (95% CI: -8.4 to 2.8) in the PAE and CT groups, respectively. No treatment-related AE or hospitalisation was noticed. After 9 months, 5 and 18 patients had invasive prostate re-treatment in the PAE and CT group, respectively.

Interpretation

In patients with BPH ≥50 ml and bothersome LUTS resistant to alpha-blocker monotherapy, PAE provides more urinary and sexual symptoms benefit than CT up to 24 months.

Funding

French Ministry of Health and a complementary grant from Merit Medical.

Long-Term PAE Results: What Do We Know

Prostatic artery embolization (PAE) is a minimally invasive technique with proven safety and efficacy to treat lower urinary tract symptoms (LUTS) due to benign prostatic obstruction (BPO) or benign prostatic hyperplasia (BPH). In this review, we discuss the required level of evidence to implement and adopt treatment options for patients with LUTS due to BPO/BPH. Focus is given on the long-term (>3 years) data after PAE with reported outcomes including cohort sizes, follow-up times, reintervention rates (repeat PAE and prostatectomy), need for LUTS/BPO medical therapy, and improvements in International Prostate Symptom Score/quality of life score, peak flow rate (Qmax), postvoid residual, prostate volume, and prostate-specific antigen. The durability of treatment effects after PAE and need for prostatic reinterventions need to be taken into consideration when discussing treatment options with patients and referring colleagues from other medical specialties. Developments in medical devices used for PAE have allowed for a continuous drop in unilateral PAE rates over the last 12 years and will probably play a role in optimizing technical and thus clinical outcomes for patients with LUTS due to BPH/BPO.

Long-Term Efficacy and Recurrence Prediction of Prostatic Artery Embolization for Lower Urinary Tract Symptoms Secondary to Benign Prostatic Hyperplasia

PURPOSE

To explore the efficacy of prostatic artery embolization (PAE) for lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH) during long-term follow-up and analyze predictors related to LUTS recurrence.

METHODS

This was a single-center retrospective study involving 125 BPH patients with LUTS who underwent PAE from February 2014 to February 2020. The median follow-up was 36 months. Clinical success was defined as reductions in the International Prostate Symptom Score (IPSS) and quality of life (QoL) score and no need for any other treatment for LUTS; otherwise, it was regarded as a clinical failure. Recurrence was defined as a clinical failure that occurred after an initial success. Cumulative clinical success rates, recurrence rates and re-intervention rates were evaluated. Friedman test was performed to compare differences in IPSS, QoL and prostatic volume (PV) among baseline and follow-up times. Predictors for LUTS recurrence were analyzed with the univariate and multivariate Cox regression model.

RESULTS

Technical success (bilateral PAE) rate was 92.8% (116/125). Significant differences in IPSS, QoL and PV were observed between baseline and follow-up time points (P < 0.001). The cumulative clinical success rates at 2, 3, 4 and 5 years were 82.4%, 65.5%, 52.4% and 37.4%. The cumulative recurrence rates and re-intervention rates at 1, 2 and 5 years were 6.8%, 12.7%, 60.4% and 5.9%, 10.2%, 50.8%, respectively. Unilateral PAE was an significant predictor of recurrence (P < 0.05).

CONCLUSIONS

PAE is an effective treatment option for LUTS. Unilateral PAE is a significant independent predictor of LUTS recurrence.

Influence of Prostate Artery Embolization on Different Qualities of Lower Urinary Tract Symptoms Due to Benign Prostatic Obstruction

BACKGROUND

Prostate artery embolization (PAE) is an increasingly used minimally invasive treatment for lower urinary tract symptoms secondary to benign prostatic obstruction (BPO) OBJECTIVE: To analyze the impact of PAE on voiding and storage symptoms.

DESIGN, SETTING, AND PARTICIPANTS

Between July 2014 and May 2019, 351 consecutive men with BPO who underwent PAE were included in a single-center study.

INTERVENTION

PAE is an interventional radiological procedure embolizing the prostatic arteries with microspheres.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The primary endpoint represented assessment of the International Prostatic Symptom Score (IPSS) at baseline and at 1, 3, 6, 12, and 24 mo after PAE. Secondary endpoints comprised assessment of IPSS quality of life (QoL), International Index of Erectile Function, peak urinary flow rate, postvoid residual volume, prostate volume, and prostate-specific antigen at the same time points. Data were analyzed using standard statistical methods, generalized estimating equations (symptom improvement over time as odds ratios), and McNemar-Bowker test (degree of improvement compared between symptoms).

RESULTS AND LIMITATIONS

Clinical success rates for PAE were 68%, 73%, and 66% at 1, 12, and 24 mo, respectively. The median IPSS improved significantly from 22 to 10 points after 2 yr (p < 0.001). Storage (-50%) and voiding (-58%) symptoms improved similarly (each p < 0.001), with nocturia decreasing least frequently but significantly (p < 0.001). After 1 and 2 yr, 35% (95% confidence interval [CI] 29-41%) and 30% (95% CI 21-40%) of patients reported alleviated storage, and 39% (95% CI 33-45%) and 38% (95% CI 29-49%) reported alleviated voiding symptoms, respectively. QoL improved from 5 to 2 points (p < 0.001). The main limitation is the number of patients lost during follow-up.

CONCLUSIONS

PAE significantly improved voiding and storage symptoms to a similar extent. This study may aid in counseling patients about this minimally invasive BPO treatment.

PATIENT SUMMARY

Prostate artery embolization (PAE) is a minimally invasive treatment option for patients with voiding and storage symptoms from benign prostate enlargement. Our analysis shows that PAE improves relevant lower urinary tract symptoms.

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 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.

Voiding and Storage Domain-Specific Symptom Score Outcomes After Prostate Artery Embolization for Lower Urinary Tract Symptoms and Urinary Retention

OBJECTIVE

To characterize voiding and storage symptom domain-specific outcomes after prostate artery embolization (PAE) to treat lower urinary tract symptoms (LUTS) or urinary retention caused by benign prostatic hyperplasia (BPH).

METHODS

Two hundred forty patients (age = 74.5 ± 8.6 years) underwent PAE between May 2013 and March 2020 at a single center for LUTS (n = 161) or urinary retention (n = 79). Total International Prostate Symptom Score (IPSS-t), voiding domain score (IPSS-v), storage domain score (IPSS-s), and Quality of Life score (QoL) were obtained pre-PAE for LUTS patients (IPSS-t = 21.7 ± 6.2, IPSS-v = 11.9 ± 4.3, IPSS-s = 9.6 ± 3.1, QoL = 4.5 ± 1.2), and post-PAE through 36 months (mean = 22.9 ± 15.2 months) for LUTS and retention patients. Mean relative changes in IPSS-t, IPSS-v, IPSS-s, and QoL were calculated for LUTS patients. Mean voiding or storage component scores were calculated for retention patients.

RESULTS

For evaluable LUTS patients (n = 147), IPSS-t showed sustained substantial improvement through 36 months (6.3 ± 4.2-8.6 ± 7.6), as did QoL (1.1 ± 1.1-1.8 ± 1.5). One month after PAE, improvements in IPSS-v (69% ± 29%) were greater than in IPSS-s (46% ± 33%; P < .000001), and remained so through 36 months (68% ± 31% vs 53% ± 28%, P = .004). Among evaluable retention patients (n = 75), 84% passed voiding trials. Both IPSS-t (6.0 ± 3.9-8.2 ± 6.7) and QoL (0.9 ± 1.2-1.5 ± 1.6) remained low through 36 months. One month after PAE, mean IPSS-v component score (0.9 ± 1.3) was lower than mean IPSS-s component score (1.7 ± 1.4; P = .003) and remained so through 24 months (0.9 ± 1.2 vs 1.3 ± 1.1, P = .02), with similar trend at 36 months (0.7 ± 1.1 vs 1.1 ± 1.1, P = .07).

CONCLUSIONS

PAE effectively treated BPH-related LUTS and retention. IPSS-v improved more than IPSS-s in LUTS patients, and remained lower in LUTS and retention patients through 36 months.

Prostatic Artery Embolization (PAE) and Transurethral Resection of the Prostate (TURP) have a Differential Impact on Lower Urinary Tract Symptoms (LUTS): Retrospective Analysis of the Multicentre UK-ROPE (UK Register of Prostate Embolization) Study

PURPOSE

To compare the relative IPSS (International Prostate Symptom Score) improvement in storage and voiding symptoms between prostatic artery embolization (PAE) and transurethral resection of the prostate (TURP).

METHOD

Retrospective analysis of the UK-ROPE (UK Register of Prostate Embolization) multicentre database was conducted with inclusion of all patients with full IPSS questionnaire score data. The voiding and storage subscore improvement was compared between interventions. Student's t-test (paired and unpaired) and ANOVA (Analysis of variance) were used to identify significant differences between the groups.

RESULTS

146 patients (121 PAE, 25 TURP) were included in the analysis. Storage symptoms were more frequently the most severe symptom ('storage' in 75 patients vs 'voiding' in 17 patients). Between groups, no significant difference was seen in raw storage subscore improvement (TURP 4.9 vs PAE 4.2; p = 0.34) or voiding subscore improvement (TURP 8.4 vs PAE 6.7; p = 0.1). ANOVA demonstrated a greater proportionate reduction (relative to total IPSS) towards voiding symptoms in the TURP group (27.3% TURP vs 9.9% PAE, p = 0.001).

CONCLUSION

Although both TURP and PAE improve voiding symptoms more than storage, a significantly larger proportion of total symptom reduction is due to voiding in the TURP cohort, with PAE providing a more balanced improvement between voiding and storage.

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.