Role of prostate artery embolization in the management of refractory haematuria of prostatic origin

Predictive Factors for Major Complications and Urological Cancer Diagnosis in Older Adults (≥80 Years) Admitted to the Emergency Department for Hematuria

Background: Gross Hematuria is a relevant cause of admission to the emergency department in the general population and particularly in older adults (≥80 years). This specific urological symptom is often underestimated and usually associated with benign conditions such as urinary infections or poor hydration. Nevertheless, hematuria could lead to severe acute complications or be the first symptom of urological cancers. Methods: We retrospectively analyzed clinical data from 1169 patients aged ≥80 years consecutively admitted to the emergency department for hematuria. The primary endpoint of the study was to identify risk factors for major complications, and the secondary endpoint was to analyze risk factors for urological cancer diagnosis. The median age was 85 years (IQR 82-88 years), and 908 (77%) were males. Among them, 449 (38.4%) had a past medical history of urological neoplasm (kidney, ureter, bladder, prostate, or urethral cancer). Results: Overall, 87 patients (7.4%) had major complications (patient death, septic shock, and admission to the intensive care unit). Worse vital signs at admission, fever, and confusion (p < 0.001, OR 18.0 IC 95% [5.5-58.7]; p = 0.015, OR 2.0 IC 95% [1.1-3.5]; p = <0.001, OR 4.2 IC 95% [1.9-3.5], respectively), as well as lower hemoglobin values and higher Charlson comorbidity index (p < 0.001, OR 0.8 IC 95% [0.7-0.9]), p = 0.002, OR = 1.2 [1.1-1.3]) were independent predictive factors for major complications. The multivariate analysis identified as risk factors for diagnosis of urological cancer older age, male sex and higher comorbidity (OR 1.05 IC95% [1-1.09]; OR 2.19 IC95% [1.42-3.39] and OR 1.11 IC95% [1.2-1.2], respectively); interestingly the presence of indwelling vesical catheter (IVC) (OR 0.44 IC95% [0.24-0.82]) resulted as an independent factor for absence of urological cancers. Conclusions: Hematuria is a frequent symptom in older adults admitted to the emergency department. While this is often associated with benign conditions, there are some risk factors for major complications and for urological cancer that must be taken into account to identify the patients who need further evaluation or prompt hospital admission.

Transradial Prostatic Artery Embolization as a Salvage Procedure in a Patient With Severe Deformities and Refractory Hematuria of Prostatic Origin

Benign prostatic hyperplasia is a common condition causing urinary symptoms in older men. It can sometimes lead to hematuria of prostatic origin, due to increased vascularity of the enlarged gland. If this type of hematuria is severe and refractory to conservative measures, it can be life-threatening. Prostatic artery embolization (PAE) serves as a minimally invasive alternative to traditional surgical interventions, particularly in patients with comorbidities and contraindications to surgery. We present a case of a 79-year-old male with refractory hematuria of prostatic origin (RHPO), multiple comorbidities, and significant deformities of the left upper and both lower limbs. The patient was treated with PAE via the right radial artery, a less common approach in interventional radiology. The procedure was successful and led to a complete resolution of hematuria, with no complications. This report highlights the importance of adapting treatment for complex patients and shows that PAE can be safe and effective in such cases.

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.

Emergency holmium laser enucleation of the prostate (HoLEP): a novel approach in the management of refractory hematuria for patients with benign prostatic hyperplasia (BPH): a single-institution experience

INTRODUCTION

Refractory hematuria secondary to prostatic disease typically resolves with conservative management; however, this condition may require hospitalization with extensive measures to control life-threatening bleeding. The aim of this study was to report our experience using holmium laser enucleation of the prostate (HoLEP) as an emergency treatment in this clinical setting.

METHODS

We conducted a retrospective review of all patients that presented to the emergency department with refractory hematuria of prostatic origin from October 2017 to September 2021, for whom hospitalization and conservative management failed to control bleeding. All emergency HoLEP procedures were performed by a single surgeon. Preoperative and intraoperative parameters, as well as perioperative outcomes, were collected and analyzed. Postoperative outcomes included duration of foley catheterization, length of postoperative hospital stay, and hospital readmissions.

RESULTS

A total of 40 emergency HoLEP procedures were performed. Our cohort had a median prostate volume of 110.5 cc and a median resected weight of 81 g. Twenty-seven patients (67.5%) were on anticoagulant or antiplatelet medications on admission. The urethral catheter was removed within 1 day in 95% of patients with a successful trial of void (TOV). Moreover, 92.5% of patients were discharged home within 24 h of their procedure. Two patients (5%) experienced clot retention within one-week post-discharge with a 2.5% overall readmission rate. All postoperative parameters, including International Prostate Symptom Score (IPSS), quality of life (QoL), maximum flow rate (Qmax), and post-void residual volume (PVR), showed significant improvement at 1 year follow up.

CONCLUSION

Our experience demonstrates that emergency HoLEP is an effective treatment option for patients with refractory hematuria of prostatic origin. Further studies are warranted to consolidate our results.

Safety and efficacy of transcatheter arterial embolization for management of refractory hematuria of prostatic origin

Objective

To estimate the safety and efficacy of transcatheter arterial embolization (TAE) in the treatment of refractory hematuria of prostatic origin (RHPO).

Methods

This retrospective study included 23 patients who underwent TAE for RHPO between May 2013 and August 2021. Technical and clinical success rates were calculated, and arteriogram findings and complications were detected.

Results

Embolization was performed 24 times in 23 patients. Technical success was achieved in 24/24 (100%) embolization procedures. Contrast agent extravasation was detected during 2 of the 24 angiographic procedures. Bilateral embolization was performed in 23 (95.8%) of the 24 procedures. The clinical success rate was 21/23 (91.3%), and hematuria stopped 1–4 days after TAE. No serious complications were observed.

Conclusion

TAE is a safe and effective minimally invasive technique for treating patients with RHPO.

Immediate Transurethral Plasma Kinetic Enucleation of the Prostate Gland for Treatment of Benign Prostatic Hyperplasia-Associated Massive Hemorrhage: A Single-Center Experience

Purpose: Benign prostatic hyperplasia-associated massive hemorrhage is a urological emergency. We evaluated the outcome from immediate transurethral plasma kinetic enucleation of the prostate gland (i-TUPKEP) for BHM treatment.

Methods: We retrospectively analyzed the records of 49 patients with acute BMH who underwent i-TUPKEP between January 2014 and November 2018 at our institution. The hemostatic effect, International Prostate Symptom Score (IPSS), and quality of life (QoL) score were evaluated preoperatively as well as 3, 6, and 12 months postoperatively. Postoperative follow-up also included measurement of the peak flow rate (Qmax) and post-void residual urine volume (PVR). Clinical characteristics, weight of resected tissue, duration of bladder irrigation, duration of hospital stay, complications, as well as the time required for enucleation and resection, were recorded.

Results: BMH causes were attributed to transurethral surgery (17/49, 34.7%), violent catheterization (13/49, 26.5%), cystoscopy (10/49, 20.4%), and urethral dilatation (9/49, 18.4%). Bleeding was from different sites of prostate-gland tissues during i-TURKEP. i-TUPKEP-controlled BMH effectively induced immediate, notable, and lasting improvements in the IPSS and QoL score. Qmax was close to normal, and the PVR was within the physiological range, postoperatively. Long-term complications were not observed.

Conclusion: Our preliminary data suggest that i-TUPKEP is a feasible method for controlling BHM and relieving BPH symptoms.

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.

The application of prostate artery embolization in the management of intractable prostate bleeding

Introduction

Prostate cancer is one of the most common malignancies affecting European men. Sequelae of the advanced malignancy require invasive procedures which may not be eligible especially for old, debilitated patients. The aim of this manuscript is to review the outcomes of prostate artery embolization in the management of refractory bleeding.

Material and methods

A PubMed database search was done for all English language articles on prostate artery embolization in prostate cancer, published between 2003 and 2019. For current review, information related to number, age of the patients, aetiology of the hematuria, bilateral or unilateral procedure, type of embolic material, technical and clinical success, complications, recurrent hematuria, hematocrit and hemoglobin levels were analyzed.

Results

A total of 10 original full-text comparative and non-comparative (case series) studies were reviewed. Minor complications described in the literature ranged from 10–50%. After prostate artery embolization, the recurrence of the haematuria occurred in 10–57% of the patients. Moreover, prostate artery embolization successfully treated lower urinary tract symptoms and urinary retention in prostate cancer patients.

Conclusions

The procedure appears safe, burdened with low risk of complications and accomplishes technical and clinical success. It is a promising option for patients with hemorrhage, but due to the scarcity of data further investigations are needed.

Prostatic Artery Embolization in Refractory Hematuria of Prostatic Origin

Hematuria of prostatic origin has multiple etiologies including benign prostatic hyperplasia (BPH), iatrogenic urological trauma, prostate cancer, and radiation therapy. Hematuria secondary to benign prostatic hyperplasia can occur because of the increased vascularity of the primary gland, itself, or because of the vascular re-growth following a transurethral resection of the prostate. Prostatic hematuria usually resolves with conservative measures; however, refractory hematuria of prostatic origin may require hospitalization with treatment with blood transfusions, repeated indwelling urinary catheterization, and continuous bladder irrigation. Prostate artery embolization is an emerging minimally invasive procedural therapy for men with BPH that was originally utilized for the treatment of refractory hematuria of prostatic origin . This article aims to summarize the currently available evidence around prostate artery embolization for the treatment of refractory hematuria of prostatic origin.

Palliative MRI-guided transurethral ultrasound ablation for symptomatic locally advanced prostate cancer

PURPOSE

Locally advanced prostate cancer can cause bladder outlet obstruction, gross hematuria and frequent hospitalization. While these complications are commonly treated by palliative transurethral resection of the prostate, the improvement is often insufficient. The purpose of this study was to evaluate the safety and feasibility of MRI-guided transurethral ultrasound ablation as an alternative palliative treatment option (pTULSA) for men suffering from symptomatic locally advanced prostate cancer.

METHODS

This prospective, phase one study included 10 men in need of palliative surgical intervention due to urinary retention and gross hematuria caused by locally advanced prostate cancer. Patients were followed for 1 year at 3-month intervals. Time without catheter, time without hematuria, reduction in hospitalization time, and adverse events were measured.

RESULTS

Ten patients with locally advanced prostate cancer were enrolled, all having continuous catheterization due to urinary retention and nine had gross hematuria before treatment. At 1 week post-pTULSA five patients were catheter-free. At last follow-up catheter-free and gross hematuria-free rates were 70% and 100%, respectively. Average hospitalization time from local complications reduced from 7.3 to 1.4 days in the 6 months before and after pTULSA. No > Grade 2 treatment related adverse events were reported, with all five being urinary tract infections.

CONCLUSIONS

pTULSA appears safe and feasible for palliative ablation of locally advanced prostate cancer. The therapy seems to accomplish long-term hematuria control, can relieve bladder outlet obstruction in selected patients, and seems to reduce the burden of hospitalization due to local complications. Trial Registration Number: NCT03350529.

Large inoperable leiomyosarcoma of the prostate: treated by transcatheter arterial chemoembolization with drug-eluting microspheres

Background

Prostatic leiomyosarcoma (LMS) has a poor prognosis with a median overall survival (OS) of 15-18 months. For patients with metastatic disease, radical surgical resection, with or without adjuvant systemic chemotherapy and radiation therapy, unfortunately provides limited therapeutic benefit. Novel approaches for this lethal disease are urgently needed.

Objectives

To evaluate the feasibility and efficacy of transarterial chemoembolization (TACE) with doxorubicin-eluting HepaSpheres (HS) for inoperable LMS of the prostate.

Methods

This case series included 12 patients (median age 57 years, range 32-74) with inoperable LMS of the prostate who were treated with TACE using doxorubicin-eluting HS. All patients were pathologically proved by fine-needle biopsy. Symptomatic relief, complications, OS, and local disease control based on modified Response Evaluation Criteria in Solid Tumors (mRECIST) criteria were evaluated.

Results

Symptomatic relief, including control of the gross hematuria, removal of indwelling catheters, improvement of constipation and perineal pain, were obtained in 100%, 75%, 100%, and 86%, respectively after TACE, without any major complications. At the last follow-up after TACE, the percentage of the tumor necrosis and volume reduction were present with a median value of 90% and 84%, respectively. TACE after two to four sessions allowed subsequent surgical resection in five (41.7%) patients. The median follow-up time was 29 months; the survival rate at 1, 2, and 3 years was 91.7%, 83.3%, and 41.7%, respectively, and the median OS was 29 months (range 9-49 months).

Conclusions

TACE of inoperable LMS of the prostate appears to be safe and effective in providing tumor necrosis, shrinkage, and symptom relief; that could improve the quality of life and the survival rate of these patients.

Interventional therapy in malignant conditions of the prostate

Interventional therapies are emerging modalities for the treatment of localized prostate cancer. Their aim is to reduce the morbidity associated with radical therapies (rT) by minimizing damage to non-cancerous tissue, with priority given to sparing key structures such as the neurovascular bundles, external sphincter, bladder neck, and rectum, while maintaining local cancer control. Interventional ablative technologies deliver energy in different ways to destroy cancer cells. The most widely investigated techniques are brachytherapy, external beam radiotherapy, cryotherapy, and high-intensity focused ultrasound. Although functional outcomes of focal therapies have been encouraging, with generally low rates of urinary incontinence and erectile dysfunction, robust medium- and long-term oncological outcomes are not available for all techniques. To date, major controversies in focal therapy concern appropriate patient selection, efficacy of focal therapies, as well as treatment paradigms based on the dominant index lesion hypothesis. This review articles discusses the current status of interventional therapies and the oncological and functional outcomes.

Case-Control Comparison of Conventional End-Hole versus Balloon-Occlusion Microcatheter Prostatic Artery Embolization for Treatment of Symptomatic Benign Prostatic Hyperplasia

PURPOSE

To compare procedural metrics and clinical improvement for prostatic artery embolization (PAE) performed with a balloon-occlusion (BO) versus end-hole (EH) microcatheter in patients with benign prostatic hyperplasia.

MATERIALS AND METHODS

Retrospective review was performed of 129 patients undergoing PAE with 100-300 μm Embosphere microspheres from April 2013 through August 2018. Microcatheter selection was nonrandom, based on prostatic artery anatomy. Five technical failures and 5 microcatheter crossover cases were excluded. BO group (n = 46, age 72.8 y ± 9.0, gland volume 184 mL ± 83, 42% in retention) and EH group (n = 73, age 76.0 y ± 9.0, gland volume 190 mL ± 116, 44% in retention) were compared using procedural metrics (excluding 30 EH learning-curve cases); symptomatic improvement at 3, 6, and 12 months after PAE; voiding trial success; and adverse events (reported used Clavien-Dindo classification).

RESULTS

Procedural and fluoroscopy times were lower in the BO group (n = 46) vs EH group (n = 43) (152.0 min ± 34.0 vs 172.8 min ± 47.9, P < .02; 37.8 min ± 12.9 vs 50.3 min ± 18.9, P < .001). Collaterals coiled, contrast material used, and injected particle volume were similar for both groups (P = NS). International Prostate Symptom Score improvement was similar for BO group (n = 25) (before PAE 23.5 ± 6.5, 12 months after PAE 7.6 ± 6.8) and EH group (n = 30) (before PAE 20.9 ± 5.9, 12 months after PAE 6.6 ± 5.2) (P = NS). Quality-of-life improvements were also similar (BO: before PAE 4.5 ± 1.2, 12 months after PAE 1.4 ± 0.9; EH: before PAE 4.1 ± 1.0, 12 months after PAE 0.9 ± 0.7), as were 12-month postvoid residual improvements, voiding trial failure rates (EH 12%, BO 8%), and adverse event rates (grade II, III: EH 15%, BO 11%) (P = NS for all).

CONCLUSIONS

BO microcatheter use in PAE did not affect injected particle volume, contrast material use, or protective coiling and did not impact symptomatic improvement, postvoid residual improvement, voiding trial success, or adverse events after PAE. Lower procedure and fluoroscopy times with BO microcatheter were likely due to selection bias.

Palliative Embolization for Refractory Bleeding

Bleeding is a common and often challenging complication of malignancy. Etiologies of hemorrhage in this patient population vary, and bleeding may present as an acute, life-threatening emergency or a chronic, low-volume blood loss. For patients with advanced malignancies, interventions to manage bleeding must be balanced by the patient's life expectancy and quality of life. As such, minimally invasive procedures such as transarterial embolization are useful therapeutic options in appropriately selected patients. There is a rich history of palliative transarterial embolization for refractory bleeding in cancer patients. This technique was first applied in the 1970s and has since become an established treatment tool for malignancy-related bleeding throughout the body. While the preponderance of published data comprised case reports and small retrospective studies, the use of embolization continues to expand as experience grows and techniques are refined. In this review, we summarize the literature and provide our perspective on embolization for refractory bleeding in cancer patients.