Prostatic arterial embolization for the treatment of lower urinary tract symptoms caused by benign prostatic hyperplasia: a comparative study of medium- and large-volume prostates

The 'Prostate Embolisation AS first-line therapY compAred to meDication in treatment naïVe men with prostAte eNlargement, a randomised ControllEd trial' (P-EASY ADVANCE): a randomised controlled trial of prostate embolisation vs medication for BPH

OBJECTIVE

To compare prostate artery embolisation (PAE) to the combination of tamsulosin and dutasteride therapy as a potential first-line therapy for obstructive benign prostatic hyperplasia (BPH) in treatment-naïve patients in the 'Prostate Embolisation AS first-line therapY compAred to meDication in treatment naïVe men with prostAte eNlargement, a randomised ControllEd trial' (P-EASY ADVANCE).

PATIENTS AND METHODS

A total of 39 men with enlarged prostates, moderate-severe lower urinary tract symptoms (LUTS) and obstructed/equivocal urodynamic studies (UDS), and who had no prior treatment for BPH, were randomised to receive either combined medical therapy with tamsulosin and dutasteride (medication) or PAE. Follow-up UDS, International Prostate Symptom Score (IPSS), uroflowmetry and ultrasound were performed at short- to medium-term intervals following interventions and compared to baseline.

RESULTS

The medication and PAE treatment groups had similar baseline characteristics, including prostate volumes (87.8 and 85.4 mL respectively), maximum urinary flow rate (Qmax; 6.5 and 6.6 mL/s, respectively), IPSS (19.5 and 21, respectively) and obstructed UDS (79% and 74%, respectively). Both interventions improved voiding and bladder outflow obstruction from baseline, with more patients unobstructed after PAE (63%) compared to medication (28%) (P = 0.03). PAE patients had significantly greater reductions in prostate size (P < 0.001), incomplete emptying (P = 0.002), total IPSS (P = 0.032), Qmax (P = 0.006) and quality of life (P = 0.001). Altered ejaculation, erectile dysfunction and nausea were more common in the medication group.

CONCLUSION

Prostate artery embolisation was more effective than combined medical therapy at reducing urinary obstruction, decreasing prostate volume and improving LUTS in patients with BPH who had not previously been treated. This is the first randomised control study to compare PAE and combined medical therapy in exclusively treatment-naïve patients and raises the potential of PAE as an alternative early treatment option for BPH. Further randomised comparative trials are planned to further validate the role of PAE in mitigating obstructive BPH.

Prostate volume: does it predict patient outcomes following prostate artery embolisation? A retrospective cohort study

Prostate artery embolisation (PAE) is a minimally invasive procedure commonly performed to treat lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia. International Prostate Symptom Score (IPSS) is a validated patient questionnaire quantifying LUTS and is used for patient selection for PAE, but it is largely subjective. Prostate volume is an easily estimated objective parameter across multiple imaging modalities. No strict threshold of prostate volume is established as a selection criterion for PAE, but it is generally accepted that prostate volume should be over 40 to 50 mL.We looked at a sample of 65 cases performed at a large teaching hospital between 2017 and 2019 with a minimum of four years follow up. Embospheres between 100 to 500 microns were injected into the prostatic arteries bilaterally (if technically feasible). A 'bullet shape' model was used to estimate prostatic volume from initial CT. N = 13 had an estimated volume < 51 mL (range 31-50 mL). IPSS before and at 3 months post-procedure were collected.80% of patients indicated a beneficial response to PAE (IPSS improvement > 5). 23% of patients required further PAE procedure or surgery. No major complications were recorded. The mean change in IPSS under 51 mL compared to over 51 mL cohort was 10.2 versus 11 (standard deviation 7.5 versus 7.3) (p = 0.44, 2 tailed Student's T-test).There was no statistically significant difference in the IPSS improvement or outcome of small volume prostates under 51 mL compared to large volume. Our results suggest that prostate volume should not be used to exclude patients for PAE.

Prostatic Artery Embolization: Lessons From 551 Procedures at a Single-Center

RATIONALE AND OBJECTIVES

This retrospective study evaluates the efficacy and safety of Prostatic Artery Embolization (PAE) for the treatment of benign prostatic hyperplasia (BPH) over five years at a single center, conducted by an experienced interventional radiologist.

MATERIALS AND METHODS

We analyzed 551 PAE interventions from January 2019 to July 2023. Key metrics included patient demographics, procedural details (radiation exposure, particle size), complication rates, pre- and post-interventional prostatic volume (PV), Prostate-specific Antigen (PSA) levels, International Prostate Symptom Score (IPSS), Quality of Life (QoL) scores and International Index of Erectile Function (IIEF) scores. We assessed data normality, performed group and paired sample comparisons, and evaluated correlations.

RESULTS

For 551 men, the average patient age was 68.81 ± 8.61 years undergoing bilateral embolization. The particle size predominantly used was 100-300 µm (n = 441). PAE lead to significant (p < .001) reduction of both PV (-9.67 ± 14.52 mL) and PSA level (-2,65 ± 1.56 ng/mL) between pre- and three months after PAE. Substantial improvement were observed for IPSS (-9 points) and QoL scores (-2 points), with stable IIEF scores. Only minor complications (n = 16) were reported, and no major complications were observed. Between the first PAE in 2019 and the routinely performed PAE in 2023 significant (p < .0001) reductions in fluoroscopy (-25.2%), and procedural times (-26.1%) were observed.

CONCLUSION

In conclusion, PAE is a safe and effective treatment for BPH, offering significant improvements in lower urinary tract symptoms (LUTS) and QoL while maintaining sexual function.

Benefits and advances of Cone Beam CT use in prostatic artery embolization: review of the literature and pictorial essay

Prostatic artery embolization (PAE) has proven to be an efficacious treatment for urinary symptoms of benign prostatic hyperplasia. PAE is performed in a complex and challenging anatomical field which may pose difficulties from procedural standpoint. Cone beam computed tomography (CBCT) has been proposed as an invaluable tool during the PAE procedure. A review of different techniques and advancements, as well as demonstration of CBCT benefits via a pictorial overview of the salient examples is lacking. The techniques of CBCT are discussed herein and the virtual injection technology as an advancement in CBCT is discussed. To show the merits of CBCT in PAE, a pictorial overview of various clinical scenarios is presented where CBCT can be crucial in decision making. These scenarios are aimed at showing different benefits including identification of the origin of the prostatic artery and avoiding non-target embolization. Other benefits may include ensuring complete embolization of entire prostate gland as angiographic appearance alone can be inconclusive if it mimics a severely thickened bladder wall or ensuring adequate embolization of the median lobe to provide relief from "ball-valve" effect. Further examples include verification of embolization of the entire prostate when rare variants or multiple (> 2) arterial feeders are present.

Prostate artery embolization using n-butyl cyanoacrylate glue for symptomatic benign prostatic hyperplasia: A six-month outcome analysis in 103 patients

PURPOSE

The purpose of this study was to assess the feasibility, safety, and 6-month outcomes of prostate artery embolization (PAE) using N-butyl-cyanoacrylate (NBCA) glue as the only embolic agent in patients with benign prostatic hyperplasia (BPH)-related lower urinary tract symptoms.

MATERIALS AND METHODS

Patients with BPH-related lower urinary tract symptoms who were treated by PAE using methacryloxysulfolane-NBCA mixed with ethiodized oil (1:8 ratio) between September 2018 and January 2023 were retrospectively included. Vascular mapping was made using cone-beam computed tomography angiography. PAEs were performed as an outpatient procedure, under local anaesthesia. Outcomes were assessed at six months using the International Prostate Symptoms Score (IPSS) and associated quality-of-life score (IPSS-QoL), prostate-specific antigen (PSA) level, prostate volume, and International Index of Erectile Function form 5 (IIEF5).

RESULTS

A total of 103 men with a mean age of 68.4 ± 6 (standard deviation [SD]) years were included. Technical success rate was 100%. The mean fluoroscopy time was 26.4 ± 12.5 (SD) min and the median radiation dose was 23 980 mGy·cm (Q1, Q3: 16 770, 38 450). Compared to baseline, statistically significant improvements were observed at six months for the IPSS (8.9 ± 6.2 [SD] vs. 20.2 ± 6.5 [SD]; P = 0.01), IPSS-QoL (2.1 ± 1.4 [SD] vs. 5.1 ± 0.9 [SD]; P = 0.01), PSA level (3.6 ± 3.2 [SD] ng/mL vs. 4.8 ± 4.2 [SD] ng/mL; P = 0.0001), and prostate volume (78.6 ± 43.5 [SD] mL vs. 119.1 ± 65.7 [SD] mL; P = 0.01). Minor adverse events developed in 19/103 (18.4%) patients. No major complications occurred. Compared to baseline, the IIEF5 did not change significantly at six months (15.3 ± 6.8 [SD] vs. 15.8 ± 6.8 [SD]; P = 0.078).

CONCLUSION

PAE with NBCA is a feasible and safe method that provides good outcomes at six months in patients with BPH-related lower urinary tract symptoms. This method deserves further evaluation in randomized trials with longer follow-up.

A correlation study between prostate necrosis rate calculated by 3D Slicer software and clinical efficacy of prostatic artery embolization, along with an analysis of predictors of clinical success after prostatic artery embolization

PURPOSE

To analyze the correlation between the prostate necrosis rate at 1-month after prostatic artery embolization (PAE) and the clinical efficacy at 1-year after PAE, and to explore potential predictors of clinical success after PAE for the treatment of lower urinary tract symptoms secondary to benign prostatic hyperplasia (BPH).

METHODS

The prostate magnetic resonance imaging data at 1-month after PAE were imported into 3D Slicer software for calculating the prostate necrosis rate and thus analyzing the relationship between the prostate necrosis rate at 1-month after PAE and the efficacy score ratio at 1-year after PAE. The 151 patients with PAE technical success were divided into a clinical success group (n = 126) and a clinical failure group (n = 25). Independent predictors of clinical success after PAE were analyzed by multifactorial logistic regression, and the predictive performance of each factor was evaluated by applying the receiver operating characteristic curve and the area under the curve (AUC).

RESULTS

There was a linear negative correlation between the prostate necrosis rate at 1-month after PAE and the efficacy score ratio at 1-year after surgery (P < 0.001). In the clinical success group, both the initial prostate volume (PV) and the prostate necrosis rate at 1-month after PAE were significantly higher than in the clinical failure group (P < 0.001), and acute urinary retention (AUR) and adenomatous-dominant BPH were also associated with clinical success (P < 0.05). Multifactorial logistic regression analysis revealed that larger initial PV, a higher prostate necrosis rate at 1-month after surgery, and AUR were independent predictors of clinical success after PAE. The AUC values for these three indicators and their combination were 0.720, 0.928, 0.599, and 0.951, respectively, in which the prostate necrosis rate at 1-month after PAE demonstrating a high predictive value.

CONCLUSION

The higher the prostate necrosis rate at 1-month after PAE, the better the clinical efficacy at 1-year after PAE is likely to be, and the prostate necrosis rate at 1-month after PAE is expected to become a predictor of clinical success after PAE.

Impact of minimally invasive surgical procedures for Male Lower Urinary Tract Symptoms due to benign prostatic hyperplasia on ejaculatory function: a systematic review

BACKGROUND

Surgical treatments for lower urinary tract symptoms (LUTS) due to benign prostatic obstruction (BPO) are affected by potentially bothersome side effects on sexual, and, above all, ejaculatory function. Several minimally invasive techniques have been proposed in the last years in order to overcome these consequences. Our aim is to summarize and evaluate the efficacy on LUTS relieve and the impact on sexual/ejaculatory function of Rezum, prostate artery embolization (PAE), implantation of a prostatic urethral lift (PUL) and the temporary implantable nitinol device (TIND).

METHODS

A systematic review of the English-language literature was conducted using the MEDLINE, Embase, and Web of Science databases from January 2000 to October 2022, according to the PRISMA guidelines (PROSPERO ID: CRD42023466515). Randomized controlled trials (RCTs), prospective studies and non-comparative or comparative studies assessing the impact on functional and ejaculatory function after minimally invasive surgical therapies for Male LUTS were evaluated. Risk of bias assessment was performed according to the Risk of Bias in Non-Randomized Studies of Interventions (ROBINS-I) tool for comparative studies, and the revised Cochrane risk-of-bias tool for randomized trials (RoB 2) for RCTs.

RESULTS

Overall, 47 studies were included (n = 4 for TIND; n = 9 for Rezum; n = 13 for PUL; n = 21 for PAE). Most studies relied on prospective patient cohorts and were rated as low risk of bias. Across studies assessing the efficacy of Rezum, a significant improvement in terms of IPSS (ranging from -47% to -56%) and Qmax (ranging from +39% to +87%) was reported. On the other hand, according to IIEF-5 score, Rezum had a minimal impact on sexual function (ranging from -1% to -3%). PUL showed a positive impact on IPSS (ranging from -35% to -58.2%) and Qmax (ranging from +49.9% to +114.7%) and sexual function. Finally, PAE showed encouraging functional results with IPSS score reducing from -12.8% to 63.3% and Qmax improving from +8% to 114.9% but the available evidence regarding the potential impact of PAE on sexual outcomes were limited.

CONCLUSION

Rezum, PAE, PUL and TIND are safe and feasible techniques associated with a significant functional improvement. While available data suggest a minimal impact of Rezum and PUL on ejaculatory function, the evidence after PAE and TIND are still limited. Therefore, our review lays the foundation for further research aiming to identify the criteria to select best candidates for uMIST to tailor the management in light of specific patient- and disease- factors.

Evaluating the Impact of Benign Prostatic Hyperplasia Surgical Treatments on Sexual Health

Benign prostatic hyperplasia (BPH), a prevalent condition in older men, is often managed through various surgical interventions. This narrative review aims to explore the impact of these surgical treatments on sexual function, a critical aspect of patient quality of life often overlooked in BPH management. The methodology encompassed a thorough review of contemporary surgical techniques for BPH, including prostate resection, enucleation, vaporization, and minimally invasive therapies such as UroLift, Rezum, and Aquablation. Additionally, the focus was on patient-centered outcomes, with a special emphasis on sexual health following surgery. Findings reveal that, while surgical interventions effectively alleviate BPH symptoms, they often have significant repercussions in sexual function, including erectile and ejaculatory dysfunction. However, emerging techniques demonstrate potential in preserving sexual function, underscoring the need for patient-centric treatment approaches. The study highlights the complex interplay between BPH surgery and sexual health, with minimally invasive treatments showing promise in balancing symptom relief and sexual function preservation. In conclusion, the study advocates for an integrated, interdisciplinary approach to BPH treatment, emphasizing the importance of considering sexual health in therapeutic decision-making. This narrative review suggests a paradigm shift towards minimally invasive techniques could optimize patient outcomes, marrying symptom relief with quality-of-life considerations. The need for further research in this domain is evident, particularly in understanding long-term sexual health outcomes following different surgical interventions for BPH.

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.

Influence of benign prostatic hyperplasia patterns detected with MRI on the clinical outcome after prostatic artery embolization

BACKGROUND

To investigate the influence of benign prostatic hyperplasia (BPH) patterns detected with MRI on clinical outcomes after prostatic artery embolization (PAE).

MATERIALS & METHODS

This retrospective study included 71 consecutive patients with lower urinary tract symptoms (LUTS), who underwent magnetic resonance imaging (MRI) of the prostate followed by PAE at a single centre. MRI scans were evaluated and BPH patterns were determined according to Wasserman type and a modified BPH classification. Additionally, scans were evaluated regarding the presence of adenomatous-dominant benign prostatic hyperplasia (AdBPH). LUTS were assessed using the International Prostate Symptom Score (IPSS) and urinary flow rate (Qmax). Follow-up examination included MRI and clinical outcome.

RESULTS

For clinical outcome at follow-up, IPSS showed median reduction of 54% (IQR 41-75%) and Qmax improved by 4.1 ml/s. We noted significant reduction in volume, intraprostatic protrusion, and prostatic urethral angle in our collective (p < 0.01). Median volume reduction was 25% (IQR 15%-34%). Bilateral embolization was a significant predictor for volume reduction at follow-up. Multiple linear regression analysis showed significant effect of high initial volume on reduction in IPSS after treatment (p < 0.01). Presence of AdBPH was significantly associated with both, volume loss and clinical improvement in terms of IPSS reduction (p < 0.01). Neither BPH pattern based on the Wassermann type nor modified BPH classification were significantly related with postinterventional IPSS and volume loss.

CONCLUSIONS

Men benefit from PAE regardless the macroscopic BPH MRI pattern. Preinterventional prostate volume and presence of AdBPH on MRI should be considered for outcome prognosis after PAE.

Contrast-enhanced magnetic resonance angiography in the identification of prostatic arterial anatomy in patients with benign prostatic hyperplasia: prospective comparison with digital subtraction angiography

AIM

To evaluate the utility of contrast-enhanced magnetic resonance angiography (CE-MRA) for identifying prostatic artery (PA) anatomy in patients with benign prostatic hyperplasia (BPH) before PA embolisation (PAE), using digital subtraction angiography (DSA) as the reference standard.

MATERIALS AND METHODS

A total of 176 patients underwent pelvic CE-MRA at 3 T. DSA was performed within the following 7 days. Two interventional radiologists compared the CE-MRA findings with DSA findings to assess the anatomy of the PAs. The rates of correct identification of the origins and collaterals of the PAs by CE-MRA were calculated. The utility for predicting the optimal X-ray tube angle obliquity for visualising the origins of the PAs by CE-MRA was evaluated. An exact McNemar's test was used to compare the detection rates of the PAs and the collaterals with DSA versus CE-MRA. A two-sided p-value of <0.05 was considered statistically significant.

RESULTS

Of the 376 PAs identified by DSA, CE-MRA correctly identified the origins of 369 vessels (98.1%), with a 1.9% false-negative rate and no false-positive results. Of the 57 total collaterals identified by DSA, CE-MRA identified 50 vessels correctly (87.7%), with a 12.3% false-negative rate and no false-positive results. No significant differences were observed between CE-MRA and DSA in the identification of the PA origins (p=0.824) and the collaterals (p=0.327). The optimal degree for an oblique projection to visualise the origins of the PAs could be predicted accurately (100%) by pre-procedural CE-MRA.

CONCLUSION

CE-MRA before PAE can reliably predict the PA anatomy and facilitate procedural planning.

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

OBJECTIVES

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

Impact of Surgery for Benign Prostatic Hyperplasia on Sexual Function: A Systematic Review and Meta-analysis of Erectile Function and Ejaculatory Function

CONTEXT

Several sexual side effects, including erectile, ejaculatory, and orgasmic dysfunction, were reported with the majority of surgical procedures for benign prostatic obstruction (BPO).

OBJECTIVE

To systematically review current evidence regarding the impact of benign prostatic hyperplasia (BPH) surgery on sexual function.

EVIDENCE ACQUISITION

A comprehensive bibliographic search on the MEDLINE, Cochrane Library, Embase, Web of Science, and Google Scholar databases was conducted in July 2021. The population, intervention, comparator, and outcome (PICO) model was used to define study eligibility. Studies were Included if they assessed patients with BPO and related lower urinary tract symptoms (P) undergoing BPH surgery (I) with or without a comparison between surgical treatments (C) evaluating the impact on sexual function (O). Retrospective and prospective primary studies were included. A pooled analysis was conducted on studies including the postoperative assessment of International Index of Erectile Function (IIEF)-5, Male Sexual Health Questionnaire-Ejaculatory Dysfunction (MSHQ-EjD; Function and/or Bother), or retrograde ejaculation (RE) rate (PROSPERO database ID: CRD42020177907).

EVIDENCE SYNTHESIS

A total of 151 studies investigating 20 531 patients were included. Forty-eight randomized controlled trials evaluating 5045 individuals were eligible for the meta-analysis. In most studies (122, 80.8%), only erectile and/or ejaculatory function was evaluated. A substantial number of articles (67, 44.4%) also used nonvalidated tools to evaluate erectile and/or ejaculatory function. The pooled analysis showed no statistically significant changes in IIEF-5 score compared with baseline for the transurethral resection of the prostate (TURP; weighted mean difference [WMD] 0.76 pts; 95% confidence interval [CI] -0.1, 1.62; p = 0.08), laser procedure (WMD 0.33 pts; 95% CI -0.1, 0.77; p = 0.13), and minimally invasive treatment (WMD -1.37 pts; 95% CI -3.19, 0.44; p = 0.14) groups. A statistically significantly higher rate of RE was found after TURP (risk ratio [RR] 13.31; 95% CI 8.37, 21.17; p < 0.00001), other electrosurgical procedures (RR 34.77; 95% CI 10.58, 127.82; p < 0.00001), and the entire laser group (RR 17.37; 95% CI 5.93, 50.81; p < 0.00001). No statistically significant increase in RE rate was described after most of the minimally invasive procedures (p > 0.05). The pooled analysis of MSHQ-EjD scores was possible only for prostatic urethral lift, showing no statistically significant difference between baseline and post-treatment MSHQ-EjD Function scores (WMD -0.80 pts; 95% CI -2.41, 0.81; p = 0.33), but postoperative MSHQ-EjD Bother scores were significantly higher (WMD 0.76 pts; 95% CI 0.22, 1.30; p = 0.006).

CONCLUSIONS

Erectile function appears to be unaffected by most surgical procedures for BPO. RE is a very common adverse event of BPH surgery, although emerging minimally invasive surgical procedures could be associated with a lower risk.

PATIENT SUMMARY

Benign prostatic hyperplasia surgery can have an impact on sexual function, mainly involving ejaculatory function.

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

PURPOSE

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

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.

MR angiography-planned prostatic artery embolization for benign prostatic hyperplasia: single-center retrospective study in 56 patients

PURPOSE

We aimed to evaluate the advantages of magnetic resonance angiography (MRA)-planned prostatic artery embolization (PAE) for benign prostatic hyperplasia (BPH).

METHODS

In this retrospective study, MRAs of 56 patients (mean age, 67.23±7.73 years; age range, 47-82 years) who underwent PAE between 2017 and 2018 were evaluated. For inclusion, full information about procedure time and radiation values must have been available. To identify prostatic artery (PA) origin, three-dimensional MRA reconstruction with maximum intensity projection was conducted in every patient. In total, 33 patients completed clinical and imaging follow-up and were included in clinical evaluation.

RESULTS

There were 131 PAs with a second PA in 19 pelvic sides. PA origin was correctly identified via MRA in 108 of 131 PAs (82.44%). In patients in which MRA allowed a PA analysis, a significant reduction of the fluoroscopy time (-27.0%, p = 0.028) and of the dose area product (-38.0%, p = 0.003) was detected versus those with no PA analysis prior to PAE. Intervention time was reduced by 13.2%, (p = 0.25). Mean fluoroscopy time was 30.1 min, mean dose area product 27,749 µGy•m2, and mean entrance dose 1553 mGy. Technical success was achieved in all 56 patients (100.0%); all patients were embolized on both pelvic sides. The evaluated data documented a significant reduction in IPSS (p < 0.001; mean 9.67 points).

CONCLUSION

MRA prior to PAE allowed the identification of PA in 82.44% of the cases. MRA-planned PAE is an effective treatment for patients with BPH.

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

OBJECTIVE

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

ANIMALS

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

PROCEDURES

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

RESULTS

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

CONCLUSIONS AND CLINICAL RELEVANCE

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

Prostate Artery Embolization-Review of Indications, Patient Selection, Techniques and Results

Lower urinary tract symptoms (LUTS) due to benign prostatic hypertrophy (BPH) are a very common problem in men ranging from mild urinary symptoms to recurrent urinary tract infections or renal failure. Numerous treatment options are available ranging from conservative medical therapies to more invasive surgical options. Prostate artery embolization (PAE) has emerged as a novel treatment option for this common problem with clinical efficacy comparable to the current surgical gold standard, transurethral resection of the prostate (TURP). PAE offers fewer complications and side effects without a need for general anesthesia or hospitalization. This review discusses the indications for prostate artery embolization in addition to LUTS, patient evaluation in patients with LUTS, PAE technique and clinical results, with an emphasis on efficacy and safety.

Prostatic artery embolization treatment for patients with benign prostatic hyperplasia who are permanent urinary catheter users ineligible for de-obstructive surgery

INTRODUCTION

Benign prostatic hyperplasia is considered the most frequent cause of lower urinary tract symptoms. Urinary catheterization is the emergency treatment for patients with urinary retention and surgery is indicated in patients refractory to medical treatment. There is a group of people with important comorbidities that make them ineligible for surgery. Prostatic arterial embolization (PAE) could be presented as a safe and effective alternative to achieve bladder emptying and spontaneous urination, thus avoiding permanent urinary catheterization in patients with significant comorbidities that represent a contraindication for surgery. In this retrospective study, we evaluated the efficacy of PAE in patients with permanent urinary catheterization who are ineligible for surgical treatment.

MATERIAL AND METHODS

Retrospective study of 26 patients with permanent urinary catheter who underwent prostatic embolization. Demographic and clinical data (age, use of anticoagulation, prostate volume, length of hospital stay, unilateral or bilateral embolization), Charlson comorbidity index evaluation and Clavien-Dindo classification for procedural complications were reviewed. Successful removal of permanent urinary catheter was analyzed at one month after the procedure.

RESULTS

A total of 26 patients were included in the review. The median age was 85 years with a median prostate volume of 90 mL. A Charlson comorbidity score above 7 was obtained in 88.5% of the subjects. Only one patient had one Clavien-Dindo III complication. Of the 26 subjects, 17 (65.4%) had spontaneous micturition and a postvoid residual lower than 100 mL at one month post procedure. Overall, catheter removal was achieved in 19 out of 26 subjects (73.1%).

CONCLUSION

PAE is a safe and effective treatment for patients with permanent urinary catheterization who are ineligible for surgical treatment.

Prostate Artery Embolization Using N-Butyl Cyanoacrylate Glue for Urinary Tract Symptoms Due to Benign Prostatic Hyperplasia: A Valid Alternative to Microparticles?

Our goal was to evaluate the feasibility, safety, and short-term outcomes of prostate artery embolization (PAE) with N-butyl cyanoacrylate (NBCA) glue as the only embolic agent in patients with benign prostatic hyperplasia (BPH)-related lower urinary tract symptoms (LUTSs). A two-center retrospective study of 50 patients (mean age, 67.6 ± 7.4 years; range, 54-85 years) treated with NBCA between 2017 and 2020 was conducted. PAE was performed using a mixture of Glubran 2 glue and Lipiodol in a 1:8 ratio, under local anesthesia, on an outpatient basis, after cone-beam computed tomography vascular mapping. Mean total injected NBCA/Lipiodol volume was 0.9 ± 0.3 mL, total injection time was 21.9 ± 7.8 s, and total radiation dose was 18,458 ± 16,397 mGy·cm. Statistically significant improvements over time occurred for the International Prostate Symptoms Score (9.9 ± 6.8 versus 20.5 ± 6.7, p = 0.0001), quality-of-life score (2.2 ± 1.5 versus 4.9 ± 1.0, p = 0.0001), prostate-specific antigen level (4.6 ± 3.0 versus 6.4 ± 3.7, p = 0.0001), and prostate volume (77.3 ± 30.5 versus 98.3 ± 40.2, p = 0.0001) at a median of 3 months versus baseline. Minor adverse events developed in 11/50 (22%) patients, but no major complications occurred. The International Index of Erectile Function did not change significantly. PAE with NBCA is feasible, safe, fast, and effective for patients with BPH-related LUTSs. Prospective comparative studies with longer follow-ups are warranted.

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.

Prostatic artery embolization treatment for patients with benign prostatic hyperplasia who are permanent urinary catheter users ineligible for de-obstructive surgery

INTRODUCTION

Benign prostatic hyperplasia is considered the most frequent cause of lower urinary tract symptoms. Urinary catheterization is the emergency treatment for patients with urinary retention and surgery is indicated in patients refractory to medical treatment. There is a group of people with important comorbidities that make them ineligible for surgery. Prostatic arterial embolization (PAE) could be presented as a safe and effective alternative to achieve bladder emptying and spontaneous urination, thus avoiding permanent urinary catheterization in patients with significant comorbidities that represent a contraindication for surgery. In this retrospective study, we evaluated the efficacy of PAE in patients with permanent urinary catheterization who are ineligible for surgical treatment.

MATERIAL AND METHODS

Retrospective study of 26 patients with permanent urinary catheter who underwent prostatic embolization. Demographic and clinical data (age, use of anticoagulation, prostate volume, length of hospital stay, unilateral or bilateral embolization), Charlson comorbidity index evaluation and Clavien-Dindo classification for procedural complications were reviewed. Successful removal of permanent urinary catheter was analyzed at one month after the procedure.

RESULTS

A total of 26 patients were included in the review. The median age was 85 years with a median prostate volume of 90mL. A Charlson comorbidity score above 7 was obtained in 88.5% of the subjects. Only one patient had one Clavien-Dindo III complication. Of the 26 subjects, 17 (65.4%) had spontaneous micturition and a postvoid residual lower than 100mL at one month post procedure. Overall, catheter removal was achieved in 19 out of 26 subjects (73.1%).

CONCLUSION

PAE is a safe and effective treatment for patients with permanent urinary catheterization who are ineligible for surgical treatment.

Reasons to consider prostatic artery embolization

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Superselective prostatic artery embolization in the treatment of large benign prostatic hyperplasia

PURPOSE

To evaluate the use of prostatic artery embolization (PAE) as a treatment option for patients with symptomatic benign prostatic hyperplasia (BPH) with prostate volumes of 80 cc and more.

MATERIALS AND METHODS

The study included 75 patients with high anesthesia-related risks for conventional surgery (TURP). All patients were surveyed for symptom burden, using IPSS and quality of life score. The prostate volume was determined by transrectal ultrasonography (TRUS). At baseline, prostate-specific antigen (PSA) level was obtained in all patients. Urodynamics was evaluated using uroflowmetry. Clinical outcomes were assessed at follow-up 1, 3, 6, 12, and 24 months after PAE.

RESULTS

The prostate volume decreased significantly at months 1 and 3 post-treatment; the prostate continued shrinking until month 12, and the size was then stabilized. At month 24, prostate volume decreased by 40.82%, from 134.0 ± 8.3 mL at baseline to 79.3 ± 6.6 mL. Postvoid residual (PVR) urine volume was significantly decreased from 55.9 ± 5.3 mL to 22.0 ± 1.8 mL 1 month after PAE (p < 0.001). Qmax increased from 9.2 ± 0.3 mL/s to 15.7 ± 0.4 mL/s. IPSS score following PAE decreased from 28.2 ± 0.7 to 9.7 ± 0.8 (p < 0.001). QoL improvement was observed from 4.8 ± 0.2 at baseline to 1.8 ± 0.2 at month 24 (p < 0.001). Decreased activity and density of adenomatous tissue resulted in decreased total PSA levels: from 5.9 ± 1.1 ng/mL to 2.6 ± 0.2 ng/mL (p < 0.001). TURP became feasible in 35 patients due to reduction of prostate volumes below 80 mL after PAE.

CONCLUSIONS

PAE was effective in relieving LUTS and reducing prostate size, and may be considered as a preoperative approach for patients with large prostate.

Pharmacological and interventional treatment of benign prostatic obstruction: An evidence‐based comparative review

Introduction

The recommended treatment for bothersome lower urinary tract symptoms (LUTS) secondary to benign prostatic obstruction (BPO) after the failure of behavioral therapy and fluid modification includes pharmacological, minimally invasive interventional, and surgical approaches. Each option has different risk and benefit profiles, and the urologist must be aware of the unique characteristics of each option in order to be able to accurately counsel the patients based on their individual values and preferences. We provide a comparative review of the commonest pharmacological and most widely performed interventional/surgical treatments for BPO, discussing the evidence for the treatment characteristics that are most useful for the practicing urologist.

Methods

A search of the PubMed database was performed for articles reporting on the following treatments for LUTS due to BPO: α‐blockers, 5α‐reductase inhibitors, phosphpdiesterase‐5 inhibitors, prostatic urethral lift (Urolift), convective radiofrequency water vapor thermal therapy (Rezum), Temporary implantable Nitinol Device (iTIND), prostate artery embolization (PAE), transurethral resection of the prostate (TURP), photoselective vaporization of the prostate (PVP), Aquablation, and anatomical endoscopic enucleation of the prostate (AEEP). We performed a narrative review focussing on the following outcomes: efficacy, safety, durability, duration of catheterization, length of stay, re‐treatment rate, efficacy in special situations (enlarged median lobe, prostate size, urinary retention, and anticoagulant use), and sexual adverse events.

Results

AEEP offers the greatest long‐term improvement in maximum flow rate, IPSS, and prostate volume reduction, with lowest re‐treatment rate, followed by PVP, TURP, and Aquablation. Urolift, Rezum, and PAE have similar efficacy for prostate volume up to 80cc, and all are more effective than the pharmacological treatment. Urolift offers the lowest rate of sexual dysfunction, followed by Rezum, and both can be performed as a day case under local anesthesia.

Conclusion

Several treatment options exist to treat voiding LUTS due to BPO. Newer minimally invasive treatments reduce the hospital stay and postoperative complications, whereas AEEP provides the greatest long‐term symptom improvement at the expense of higher morbidity and sexual dysfunction. Men should be counseled regarding all suitable treatment options as some may favor reduced efficacy in association with reduced side effects.

Prostatic artery embolization: magnetic resonance image (MRI) findings in the early detection of prostate infarction in a canine spontaneous benign prostatic hyperplasia model

Background

The purpose was to assess the association between prostate infarction and prostate volume (PV) reduction after prostatic artery embolization (PAE) and define the best time point in detection of prostate infarction.

Methods

Ten male beagles (3.5–6.4 years) with spontaneous benign prostatic hyperplasia (BPH) underwent PAE. Magnetic resonance image (MRI) was conducted immediately before and 1 week, 2 weeks and 1 month after PAE to document prostate infarcts and measure PV. The sum of infarct areas (SUMIA) was measured and calculated using OsiriX software. Spearman’s rank correlation was used to estimate the relationship of PV reduction rate with infarction percentage and SUMIA reduction.

Results

In comparison with baseline data, significant PV reduction (P<0.001) occurred at 2 weeks and continued to decrease substantially (P=0.004) from 2 weeks to 1 month after PAE. In the same fashion, significant decrease in both SUMIA and infarction percentage was observed from 1 to 2 weeks (P=0.002), and subsequently to 1 month (P=0.039 and P=0.016, respectively). Spearman’s rank correlation test demonstrated infarction percentage at 1 week had a stronger correlation (r=0.880, P=0.001) with PV reduction rate at 1 month than infarction percentage at 2 weeks (r=0.733, P=0.016). PV reduction rate had a significant correlation with decrease in SUMIA (r=0.854, P=0.002) at 1 month after PAE.

Conclusions

One week after PAE is an ideal time point to evaluate prostate infarction. Prostate infarction percentage at 1 week is a good predictor for prostate shrinkage at 1 month after PAE.

[Surgical and interventional management of benign prostatic obstruction: Guidelines from the Committee for Male Voiding Disorders of the French Urology Association]

OBJECTIVE

The aim of the Male Lower Urinary Tract Symptoms Committee (CTMH) of the French Urology Association was to propose an update of the guidelines for surgical and interventional management of benign prostatic obstruction (BPO).

METHODS

All available data published on PubMed® between 2018 and 2020 were systematically searched and reviewed. All papers assessing surgical and interventional management of adult patients with benign prostatic obstruction (BPO) were included for analysis. After studies critical analysis, conclusions with level of evidence and French guidelines were elaborated in order to answer the predefined clinical questions.

RESULTS/GUIDELINES

Offer a trans-uretral incision of the prostate to treat patients with moderate to severe lower urinary tract symptoms (LUTS) with a prostate volume<30cm³, without a middle lobe. TUIP increases the chances of preserving ejaculation. Propose mono- or bipolar trans-urethral resection of the prostate (TURP) to treat patients with moderate to severe LUTS with a prostate volume between 30 and 80cm³. Vaporization by Greenlight™ or by bipolar energy can be offered as an alternative to TURP. Offer a Greenlight™ laser vaporization to patients at risk of bleeding. Offer endoscopic prostate enucleation to surgically treat patients with moderate to severe LUTS as an alternative to TURP and open prostatectomy (OP). Minimally invasive prostatectomy is an alternative to OP in centers without access to adequate endoscopic procedures. Embolization of the prostatic arteries may be offered in the event of a contraindication or refusal of surgery for prostates with a volume>80cm³. Prostatic uretral lift is an alternative in patients interested in preserving their ejaculatory function and with a prostate volume<70cm³ without a middle lobe. Aquablation and Rezum™ are under evaluation and should be offered in research protocols.

CONCLUSION

Major changes in surgical management of BPO have occurred and aim at reducing morbidity and improving quality of life of patients.

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.

Predictors of technical outcome for prostatic artery embolisation using pre-procedural CT angiography

OBJECTIVES

Predicting patients that will pose procedural technical challenges in prostate artery embolisation (PAE) remains difficult, with prolonged procedural times impacting on both patient dose and resource planning. Understanding the factors that influence these parameters as well as the likelihood of technical success is therefore important in effective patient selection and procedural planning.

METHODS

Data were collected retrospectively for 75 consecutive patients who underwent PAE. Multiple patient predictor variables available from planning computed tomography angiography (CTA) were identified and measured objectively. The vessel angles navigated during the procedure, prostate volume, prostate artery (PA) diameter, PA origin, aortic atheroma, iliac tortuosity and baseline demographics were correlated with outcome variables (fluoroscopy time, air kerma (AK), dose area product (DAP), the number of cone beam CTs (CBCTs)) performed and whether bilateral embolisation was possible (technical success). Data were analysed using linear regression, ANOVA, t tests and chi-squared tests.

RESULTS

Aortic atheroma severity significantly increased fluoroscopy time (p = 0.004), whilst air kerma (AK) was significantly greater in patients with smaller prostatic arteries (p = 0.009) and smaller pre-procedural prostate volumes (p = 0.038). Increased vascular tortuosity and prostatic artery origin were not shown to significantly affect fluoroscopy time or DAP. Smaller prostate artery size (p = 0.007) also increases the likelihood of either unilateral embolisation or technical failure.

CONCLUSIONS

Pre-operative prediction of technical outcome measures in PAE remains challenging. However, vascular calcification, prostatic artery diameter and prostate volume are likely to be important factors when considering the risk/benefits of PAE.

KEY POINTS

• Increased severity of atheroma and the presence of small prostate arteries increase fluoroscopy time and AK respectively during prostate artery embolisation. • Lower pre-procedural prostate volume increases the AK during procedures. • Smaller prostate artery size increases the likelihood of either unilateral embolisation or technical failure.

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.

Clinical predictive factors in prostatic artery embolization for symptomatic benign prostatic hyperplasia: a comprehensive review

Prostatic artery embolization (PAE) has been established as a routine treatment for symptomatic benign prostatic hyperplasia (BPH) all over the world. With increasing clinical experience in the last decade, investigators have sufficient data to assess predictive factors with the purpose to guide patient selection and counseling for PAE or to individualize therapeutic plans after PAE. This paper is a comprehensive review to introduce the concept of clinical predictors and give a systemic classification of various predictive factors in PAE. The authors review each individual factor and its predictive capability and discuss the possible reasons for the inconsistent or conflicting findings in the literature. Based on current evidence, the baseline prostate volume, in particular the transition zone volume and transition zone index; 24 h post-PAE prostate-specific antigen (PSA) level; and prostate infarction and prostate volume reduction at 1–3 months have potential in prediction of treatment outcomes. Patients with Adenomatous-dominant BPH or with indwelling bladder catheter before PAE may have more benefits from PAE. Baseline intravesical prostatic protrusion (IPP), C-reactive protein (CRP) level at 48 h and early detection of prostate infarct at 1 day and 1 week after PAE need further investigating.

Sexual and functional outcomes of prostate artery embolisation: A prospective long-term follow-up, large cohort study

AIM OF THE STUDY

Among minimally invasive procedures for treating benign prostate hyperplasia (BPH) prostate artery embolisation (PAE) is described as safe and effective. Aim of this study is to report our results, focusing on sexual outcomes (erectile and ejaculatory functions sparing) of PAE in patients suffering from bladder outlet obstruction (BOO) secondary to BPH.

METHODS

We prospectively enrolled and submitted to PAE subjects suffering from BOO secondary to BPH. All patients were not suitable for surgery or declined invasive approaches. All subjects were preoperatively and postoperatively (3, 6, 12 and 18 months after) evaluated by urinary flowmetry, post voiding residual volume, prostate volume, serum PSA levels, International Index of Erectile Function, International Prostate Symptom Score and QoL scores.

RESULTS

PAE was performed in 147 patients (mean age 72.5 y.o.). PAE was technically successful in all patients. The procedure lasted a mean time of 94.3 minutes, with a mean fluoroscopic time of 42.5 minutes. Twelve months follow-up data were available for all patients, while 126 patients (85%) completed the 18 months follow up. At 12 months follow up, the mean IPSS and QoL scores significantly decreased, and all the objective parameters (mean Qmax, PVR and prostate volume) reported a significant improvement. A total of 130 patients (88.5%) at 12 months reported the antegrade ejaculation preserved, and a slight not significant improvement of IIEF scores. The 18 months after PAE outcomes confirmed the significant improvement of all the variables evaluated (even for PSA values and IIEF scores). No major complications occurred.

CONCLUSIONS

Our results evidence prostate artery embolisation as highly feasible and safe procedure with interesting outcomes. In particular, in our study PAE reported promising results in preserving antegrade ejaculation and erectile function. Our data are in line with the literature, confirming how PAE reduces obstructive symptoms in BPH patients not suitable or refusing standard surgical approaches.

[Novel surgical techniques for treatment of benign prostatic hyperplasia]

In recent years new surgical techniques to treat benign prostatic hyperplasia have been introduced into urological practice and evaluated in clinical studies. Complications of standard procedures, e.g. transurethral resection of the prostate (TURP), can be avoided while maintaining equivalent clinical outcomes. The main goal is preservation of erectile and ejaculatory function. Furthermore, outpatient treatment associated with a rapid patient recovery would be desirable. This article presents the course of the interventions, the mechanisms of action and current clinical evidence for novel mechanical approaches of recanalization, water-based ablation as well as prostate artery embolization. Initial study results partially indicate that in the future practically all patients can be offered an individualized surgical technique, which provides optimal symptomatic and functional improvements with a minimized risk of complications.

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

PURPOSE

This study compared the safety and efficacy of prostatic arterial embolization (PAE) with that of trisacryl gelatin microspheres of different sizes for treatment of benign prostatic hyperplasia (BPH).

MATERIALS AND METHODS

This study consisted of a single-center, randomized controlled clinical trial in 138 patients who underwent PAE for BPH between July 2015 and December 2016. Patients were randomized to PAE using microspheres of different sizes: group A patients were treated with microspheres 100-300 μm, group B with 300-500 μm, and group C with 100-300 μm followed by 300-500 μm. All patients were evaluated before and at 1, 3, 6, 12, and 18 months after PAE. Baseline data were comparable across the 3 groups, using the following mean International Prostate Symptom Score/quality of life (IPSS/QoL); prostate volume (PV) scores, respectively: 23.0/4.14; 87.9 cm³ (group A); 23.0/4.09; 89.0 cm³ (group B); and 24.2/4.29; 81.0 cm³ (group C) (P > 0.05).

RESULTS

Mean IPSS/QoL scores; PV after PAE were: 9.98/2.49; 65.1 cm³ (group A); 8.24/2.26; 63.1 cm³ (group B); and 10.1/2.69; 53.1 cm³ (group C) (P = 0.23; P = 0.39; P = 0.24). There were 26 clinical failures. The cumulative probabilities of clinical success at 18 months were 76.7% in group A, 82.6% in group B, and 83.3% in group C (P = 0.68). Nontarget embolization was prevented in 6 patients by coil embolization. All adverse events were mild and self-limited with rates of 86.0% in group A (37 of 43); 41.3% in group B (19 of 46); and 58.3% in group C (28 of 48) (P < 0.001). Dysuria was the most frequent adverse event (28 of 137 [20.4%]).

CONCLUSIONS

PAE outcomes were not significantly different among microspheres of different sizes. The use of 100- to 300-μm microspheres was associated with an increased risk of minor adverse events.

Development of Research Agenda in Prostate Artery Embolization: Summary of Society of Interventional Radiology Consensus Panel

PURPOSE

To summarize the Society of Interventional Radiology Foundation's Research Consensus Panel development of a research agenda on prostate artery embolization (PAE).

MATERIALS AND METHODS

PAE for the treatment of lower urinary tract symptoms has been shown to be safe and effective in decreasing symptoms and prostate size. Lack of randomized controlled trials (RCTs) on PAE in the United States has prevented inclusion in American Urologic Association guideline recommendations for treatment of lower urinary tract symptoms resulting from benign prostatic hyperplasia. Recognizing the need for well-designed trials, the SIR Foundation funded a Research Consensus Panel to prioritize a research agenda. The panel included interventional radiologists, urologists, SIR Foundation leadership, and industry representatives. The goal of the meeting was to discuss weaknesses with current data and study design for development of US trials to report long-term outcomes data.

RESULTS

Final consensus on a research design could not be made because the group was split on 3 research designs: (i) RCT of PAE versus sham with crossover of the sham group. (ii) RCT of PAE versus simple prostatectomy. (iii) RCT of PAE versus holmium laser enucleation of the prostate/thulium laser enucleation of the prostate. The panel recommended a nonindustry-funded registry to obtain real-world data.

CONCLUSIONS

Level 1 data are required to be included in the American Urologic Association guidelines for treatment of benign prostatic hyperplasia. Because of concerns with all 3 study designs, the panel did not reach a consensus. Further meetings are planned with the panel to select among these research designs.

Prostatic Artery Embolization-Anatomic Predictors of Technical Outcomes

PURPOSE

To determine if cone-beam CT and digital subtraction angiography analysis of pelvic arterial anatomy has predictive value for radiation exposure and technical success of prostatic artery embolization (PAE).

MATERIALS AND METHODS

This prospective, nonrandomized, single-center study included 104 consecutive patients with lower urinary tract symptoms secondary to benign prostatic hyperplasia. Cone-beam CT was performed in 160/208 (76.9%) hemipelves to determine prostatic artery (PA) origin. Classification of pelvic arterial tortuosity was possible in 73/104 (70.2%) patients. Learning curves of 2 interventionalists who performed 86.5% of PAEs were analyzed.

RESULTS

Tortuosity of pelvic arteries was classified as mild in 25 (34.2%) patients median age 64 years, moderate in 40 (54.8%) patients median age 69 years, and severe in 8 (11.0%) patients median age 70 years (mild vs moderate, P = .002; mild vs severe, P = .019); median fluoroscopy times were 24, 36, and 46 minutes (P = .008, P = .023); median contrast volumes were 105, 122.5, and 142 mL (P = .029, P = .064); and bilateral PAE rates were 84.0%, 77.5%, and 62.5% (P = .437), respectively. PA origin from superior vesical artery was most frequent (27.5%) and showed higher dose area product (median 402.4 vs 218 Gy ∙ cm², P = .033) and fluoroscopy time (median 42.5 vs 27 min, P = .01) compared with PA origin from obturator artery, which was least frequent. Interventionalist experience revealed significant impact on procedure times (median 159 vs 130 min, P = .006).

CONCLUSIONS

Tortuosity of pelvic arteries was more frequent in older patients and predicted worse technical outcomes of PAE. PA origin from obturator artery was associated with lower dose area product and fluoroscopy time, especially compared with PA origin from superior vesical artery. Interventionalist experience showed significant influence on technical outcome.

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

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

Minimizing Sexual Dysfunction in BPH Surgery

Purpose of Review

To review the prevalence and risks of sexual dysfunction associated with current treatment options for benign prostatic hyperplasia and to characterize techniques and methods to manage postoperative sexual dysfunction-related side effects.

Recent Findings

Current surgical therapies available for the treatment of benign prostatic hyperplasia are associated with a substantial risk of both ejaculatory and erectile function. However, many of the novel minimally invasive treatment alternatives have demonstrated the ability to preserve postoperative sexual function to a better degree, all while providing significant relief of lower urinary tract symptoms in an equally safe and efficacious manner.

Summary

Benign prostatic hyperplasia remains a highly prevalent disease among the aging population. While surgical treatments are often necessary to relieve bothersome urinary symptoms, these procedures are associated with an increased risk of sexual dysfunction. As such, there has been an increased interest in the development of minimally invasive therapies, such as the UroLift®, Rezum®, and Aquablation®, with the hopes of achieving similar symptomatic relief while maintaining sexual function. Aside from reporting lower rates of sexual dysfunction, these procedures have also demonstrated comparable safety, durability, and efficacy to current gold standard therapies. Some procedures can even be performed in an outpatient setting, avoiding the need for general anesthesia altogether. Overall, an individualized, shared decision-making approach is necessary to determine the ideal treatment option for each patient.

Introduction of prostate artery embolization (PAE) in Sweden

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

Effectiveness of Contrast-enhanced MR Angiography for Visualization of the Prostatic Artery prior to Prostatic Arterial Embolization

Background A major technical challenge of prostatic arterial embolization (PAE) is the identification and catheterization of the prostatic arteries (PAs). Recently, MR angiography has been shown to help visualize PAs, but the clinical utility of MR angiography for this purpose is not known. Purpose To determine the efficacy of contrast material-enhanced MR angiography in identifying the PA and to evaluate its role in PAE for benign prostatic hyperplasia (BPH). Materials and Methods In this prospective study, 100 consecutive men who were scheduled to undergo PAE for BPH from January 2015 to May 2017 were assigned by using a randomized block design to either group A (n = 50; mean age, 71.7 years ± 11.9 [standard deviation]) without MR angiography or group B (n = 50; mean age, 72.3 years ± 12.2) with MR angiography prior to PAE. MR angiography findings of the PA anatomy were compared with those of digital subtraction angiography (DSA). The Student t test and Wilcoxon rank-sum test were used to compare the differences between the parameters indicating the performance of PAE. Results The mean age of the 100 men in the study was 72.0 years ± 11.8 (range, 51-88 years). Compared with DSA as the reference standard, MR angiography identified PAs with a sensitivity of 91.5% (97 of 106) and a positive predictive value of 100% (97 of 97). With the knowledge of tube obliquity and anatomy, group B had lower procedure times than group A (82.3 minutes ± 5.4 vs 123.9 minutes ± 12.4, P < .001) and shorter fluoroscopy times (13.8 minutes ± 2.7 vs 28.5 minutes ± 8.0, P < .001). Additionally, radiation dose was reduced for group A versus group B, from a median of 920 to 339 mGy (P = .004). Conclusion Contrast-enhanced MR angiography can accurately show anatomy for the prostate arteries, leading to shorter prostatic artery embolization times and lower radiation dose than when preprocedural prostate MR angiography is not performed. Published under a CC BY 4.0 license. Online supplemental material is available for this article. See also the editorial by Prince in this issue.

Technical and Imaging Outcomes from the UK Registry of Prostate Artery Embolization (UK-ROPE) Study: Focusing on Predictors of Clinical Success

INTRODUCTION

The UK Registry of Prostate Artery Embolization (UK-ROPE) was a prospective, multicentre study comparing PAE against surgical therapies for symptomatic benign prostatic hyperplasia (BPH). A wealth of data was collected supplementary to the main study outcomes which provide a snapshot of UK PAE practice. We aimed to interpret these data in the hope of providing insight into factors which affect clinical outcome and radiation dose.

METHODS

216 patients (mean age 66, mean IPSS 21.3) undergoing PAE at 20 British centres from July 2014 to January 2016 were prospectively followed up to 12 months with retrospective analysis of the data. Technical outcome was evaluated based on procedural and fluoroscopy times, skin dose and dose area product (DAP). Clinical outcome was evaluated through collection of Qmax, IPSS reduction and prostate volume reduction. Multiple analysis of variance (MANOVA) was used to assess the significance of various patients and procedural factors on clinical outcome and patient dose.

RESULTS

Significant predictors of technical outcome which affected patient skin dose included severity of CTA-detected atheroma (p < 0.001), the practitioner (p < 0.001) and use of protective coil embolization (p = 0.019). Predictors of clinical outcome included initial prostate size (dichotomized into groups > 80 ml and = <80 ml, d = 1, p = 0.0138), embolic agent (spherical particles < 300 nm performed best, p = 0.01) and number of arteries embolized (IPSS reduction of 32.9% in unilateral PAE versus 54.4% for bilateral PAE, p = 0.026).

CONCLUSION

We have identified several important factors which are associated with improved clinical outcome and increased patient dose which we hope will facilitate optimal patient selection and encourage improved embolization technique.

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

OBJECTIVES

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

Seminal vesicle abnormalities following prostatic artery embolization for the treatment of benign prostatic hyperplasia

Background

Prostatic artery embolization (PAE) has been proved effective in the treatment of lower urinary tracts (LUTS) secondary to benign prostatic hyperplasia (BPH) with low complications, and most of the them are due to non-target embolization of adjacent organs, such as bladder, rectum, seminal vesicles and penis. Aim of this study was to present seminal vesicle (SV) abnormalities following prostatic artery embolization (PAE) for the treatment of symptomatic benign prostatic hyperplasia.

Methods

We reviewed 139 BPH patients who received PAE during the period of February 2009 and January 2015 at a single institution, highlighting seminal vesicle abnormalities and their clinical relevance after PAE. PAE was performed using 90~ 180-μm (mean 100-μm) polyvinyl alcohol foam particles.

Results

Nine of 139 patients with SV abnormalities (6.5%) were identified by magnetic resonance imaging (MRI), including subacute haemorrhage in 3 patients and ischaemia in 6 patients. Using cone-beam computed tomography (CB-CT), the seminal vesicle arteries were identified 8 of the 9 patients. All 9 patients complained of a few episodes of mild haematospermia during the 1–4 weeks after PAE; the haematospermia disappeared spontaneously without any treatment.

Conclusion

SV haemorrhage and ischaemia may occur after PAE, and these patients may present with transient and self-limited haematospermia.

Prostatic Artery Embolization versus Standard Surgical Treatment for Lower Urinary Tract Symptoms Secondary to Benign Prostatic Hyperplasia: A Systematic Review and Meta-analysis

CONTEXT

Prostatic artery embolization (PAE) has been introduced into clinical practice for the treatment of lower urinary tract symptoms secondary to benign prostatic hyperplasia (BPH-LUTS) despite a lack of high-level evidence.

OBJECTIVE

To perform a systematic review and meta-analysis of clinical trials comparing efficacy and safety of PAE versus established surgical therapies.

EVIDENCE ACQUISITION

Medline, Embase, and York CRD were searched up to June 23, 2018. Only comparative studies were included. The risk of bias was assessed by the Cochrane Collaboration tool. Meta-analyses were performed using RevMan 5.3.

EVIDENCE SYNTHESIS

Five studies including 708 patients met the selection criteria. Risk of bias was rated high for most of the studies. Mean reduction in the International Prostate Symptom Score was lower after PAE compared with standard surgical therapies (mean difference 3.80 points [95% confidence interval: 2.77-4.83]; p<0.001). PAE was less efficient regarding improvements in all functional parameters assessed including maximum urinary flow, post void residual, and reduction of prostate volume. In contrast, patient-reported erectile function (International Index of Erectile Function 5) was better after PAE and significantly fewer adverse events occurred after PAE.

CONCLUSIONS

Moderately strong evidence confirms efficacy and safety of PAE in the treatment of BPH-LUTS in the short term. Significant advantages regarding safety and sexual function, but clear disadvantages regarding all other patient-reported and functional outcomes were found for PAE. Large-scale randomized controlled trials including longer follow-up periods are mandatory before PAE can be considered as a standard therapy and to define the ideal indication for PAE in the management of BPH-LUTS.

PATIENT SUMMARY

We reviewed the role of prostatic artery embolization (PAE) in the treatment of symptoms associated with benign overgrowth of the prostate. The results suggest that PAE is not as effective as established surgical therapies but has fewer side effects. Further research is required to determine whether PAE is the best treatment for certain types of patients. PAE should, therefore, not yet be considered a standard treatment.