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

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.

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

CONTEXT

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

OBJECTIVE

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

EVIDENCE ACQUISITION

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

EVIDENCE SYNTHESIS

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

CONCLUSIONS

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

PATIENT SUMMARY

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

Stereotactic body radiation therapy for prostate cancer after surgical treatment of prostatic obstruction: Impact on urinary morbidity and mitigation strategies

In the past decade, stereotactic body radiation therapy (SBRT) has emerged as a valid treatment option for patients with localized prostate cancer. Despite the promising results of ultra-hypofractionation in terms of tolerance and disease control, the toxicity profile of SBRT for prostate cancer patients with a history of surgical treatment of benign prostate hyperplasia is still underreported. Here we present an overview of the available data on urinary morbidity for prostate cancer patients treated with SBRT after prior surgical treatments for benign prostate hyperplasia. Technical improvements useful to minimize toxicity and possible treatments for radiation-induced urethritis are discussed.

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

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

Updates on Preprocedural Evaluation and Patient Selection for Prostatic Artery Embolization

Prostatic artery embolization (PAE) is a safe and effective treatment for benign prostatic hyperplasia. Patient evaluation is a critical and important part of this growing practice. History taking should include symptoms score evaluations for lower urinary tract symptoms, erectile function, and prostatitis symptoms score. The objective evaluations commonly include measurement of prostate specific antigen, postvoid residual volume, and uroflowmetry as well as urodynamic studies in selective patients. Imaging evaluation may include computed tomography angiography or magnetic resonance angiography, elucidating prostate volume, prostate gland morphology, vasculature, and prostate cancer. With evolving knowledge on PAE, we aim to discuss patient evaluation and selection based on updated evidence and discuss specific scenarios.

Surgical Treatments of Benign Prostatic Hyperplasia and Prostate Cancer Stereotactic Radiotherapy: Impact on Long-Term Genitourinary Toxicity

AIMS

Although the results on acute and late toxicity of ultrahypofractionation are encouraging, data on safety in prostate cancer patients with a medical history of transurethral resection of the prostate (TURP) or adenomectomy remain scarce, especially in cases of repeated procedures. The aim of the present study was to report on long-term toxicities after stereotactic body radiotherapy (SBRT) of prostate cancer patients with previous surgical treatment of benign prostatic hyperplasia.

MATERIALS AND METHODS

Among 150 patients treated with SBRT (median dose 36.25 Gy in five fractions) realised from 2014 to 2019 in a single-centre institution, data of 24 men with a history of TURP (n = 19) or adenomectomy (n = 5) were analysed. Repeated TURP was carried out in three patients, with a median time between surgery and SBRT of 54 months. Genitourinary toxicity was assessed using the Common Terminology Criteria for Adverse Events v4.0 grading scale.

RESULTS

With a median follow-up of 45 months, 10 of 24 (42%) patients experienced at least one episode of transient haematuria. One patient (4%) with three previous TURP presented a grade 3 acute non-infective cystitis. Late grade 2 and 3 genitourinary toxicities were observed in eight (33%) and four patients (17%) (two treated with adenomectomy, one with multiple TURP and one with a 140 cm³ prostate size), respectively, with no grade ≥4 adverse events. A complete recovery of grade 3 genitourinary toxicities was observed for all patients after hyperbaric oxygen therapy.

CONCLUSION

Prostate SBRT is feasible and well-tolerated in patients with a medical history of surgical treatments of benign hyperplasia. Patients with prior adenomectomy or multiple TURP are at higher risk of developing severe genitourinary toxicity and should be carefully evaluated before SBRT treatments.

Superselective Prostate Artery Embolization for Treatment of Severe Haematuria Secondary to Rapid Progression of Treatment-Induced Neuroendocrine Prostate Cancer: A Case Report

Background

Treatment-induced neuroendocrine prostate cancer (t-NEPC) represents a highly aggressive subtype of castration-resistant prostate cancer that commonly arises from prostate adenocarcinoma (AdPC) after continuous androgen deprivation therapy (ADT). However, current treatments for t-NEPC are limited and far from satisfactory. According to our limited knowledge, report regarding the management of t-NEPC related hemorrhage is rare. Here, we report a case of t-NEPC formation after chronic hormonal therapy accompanying with severe bleeding in primary tumor and share our experiences to deal with the severe hematuria resulting from the progression of t-NEPC tumor.

Case Presentation

An 80-year-old man with a significantly high prostate-specific antigen was diagnosed via pathology as advanced AdPC due to multiple bone metastases. He then received ADT including bicalutamide and goserelin. After 20 months of stable disease, the cancer rapidly progressed and presented with severe gross hematuria caused by bleeding of the primary tumor. The histopathologic analysis of a secondary biopsy of the primary tumor confirmed neuroendocrine prostate cancer, and subsequent genetic testing revealed germ-line mutations in the RB1 and FOXA1. To control the bleeding and relieve symptoms, the patient was treated with superselective prostate artery embolization (PAE). After the left internal pudendal artery and the right prostatic artery were embolized, hematuria was quickly alleviated and disappeared. However, the patient was not a suitable candidate to platinum-based chemotherapy due to weak constitution. Goserelin was continuously applied to maintain castration level of serum testosterone. Meanwhile, palliative radiotherapy to the prostate tumor, high-risk lymph node drainage areas (including iliac and para-aortic lymph nodes, internal iliac lymph nodes, presacral lymph nodes and obturator nerve lymph nodes) and bone metastases (right sacroiliac joint and thoracic vertebra) was performed and relieved the pain. Unfortunately, this patient eventually died of cachexia and multiple organ failure nearly 27 months after initial diagnosis.

Conclusion

To treat severe hematuria caused by progression of t-NEPC, superselective PAE may be a rapid and efficient way to stop bleeding.