Comparison of prostatic artery embolisation (PAE) versus transurethral resection of the prostate (TURP) for benign prostatic hyperplasia: randomised, open label, non-inferiority trial

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 in Patients with Advanced Prostate Cancer: A Prospective Single Center Pilot Study

PURPOSE

To assess efficacy and safety of prostatic artery embolization (PAE) in patients with advanced prostate cancer (PCa).

MATERIALS AND METHODS

In this prospective single-center, single-arm, pilot study, 9 men with advanced PCa underwent PAE. PAE was performed with the use of 250-400 µm Embozene microspheres (Boston Scientific, Natick, Massachusetts, USA). International Prostate Symptoms Score (IPSS), urinary peak flow (Qmax) and post-void residual urine volume (PVR) was assessed at 12 weeks and up to 12 months. Changes in total prostate volume (TPV) and tumor responses by PSA, changes in tumor volume and evaluation of tumor regression by multiparametric magnetic resonance imaging were assessed at 12 weeks after PAE.

RESULTS

IPSS reduction in median 6 points (0-19) and a significant decrease in PVR from median 70 (20-600) mL to 10 (0-280) mL could be achieved within 12 weeks after PAE. Median TPV and tumor volumes (TV) increased slightly from 19.7 (6.4-110.8) mL to 23.4 (2.4-66.3) mL and 6.4 (4.6-18.3) mL to 8.1 (2.4-25.6) mL at a median of 12 weeks after the procedure. Significant tumor necrosis (≥ 50%) was found in one patient. Eight patients showed > 50% of viable tumor on post-PAE MRI according to MRI. Only one Clavien-Dindo Grade 1 adverse event related to PAE occurred.

CONCLUSIONS

PAE with the use of 250-400 µm microspheres is feasible, safe and effective in some patients with advanced PCa regarding functional outcomes. A cytoreductive effect might be achieved in individual patients but must be further assessed.

TRIALS REGISTRATION

NCT03457805.

[Minimally-Invasive Surgical Techniques (MIST): Shedding Light on the Mist]

As life expectancy increases and there is growing demand for BPH treatments, innovative technologies have been developed, allowing for swift recovery, symptom relief, low complication rates, and the possibility of performing procedures on an outpatient basis, often under local anaesthesia. This review aims to describe the outcomes of newly developed minimally-invasive surgical therapies (MIST) for BPH treatment in terms of functional voiding parameters and sexual function. These therapies are categorized into primarily ablative (Aquablation [Aquabeam]), non-ablative (Prostatic Urethral Lift (PUL, Urolift), temporary implantable devices [iTind]), and secondarily ablative procedures (convective water vapor ablation, Rezum, Prostate Artery Embolization [PAE]). All MIST technologies have advanced the medical care of patients with BPH while preserving ejaculation. However, there is a shortage of long-term data specifically addressing re-intervention rates and the preservation of functional voiding parameters. Although there is promising data from regulatory trials and randomized studies, all MIST therapies are potentially associated with severe complications. Patients considering such methods must be thoroughly informed about their inferiority compared with established transurethral procedures like TUR-P and enucleation.

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.

Prostatic artery embolization for intractable hematuria in patients with unregulated coagulation parameters: three case reports

INTRODUCTION

Benign prostatic hyperplasia is a prevalent disease that could be responsible of severe intractable hematuria requiring invasive surgical management.

CASE PRESENTATION

We report three high-risk cases presented with intractable hematuria of prostatic origin with high medical co-morbidities treated safely and effectively by prostatic artery embolization with favorable outcomes.

CONCLUSIONS

In non-surgical, anticoagulated patients, prostatic artery embolization represents a safe and effective intervention for the treatment of intractable hematuria related to benign prostatic hyperplasia.

Repeat Prostatic Artery Embolization with the Addition of a Liquid Embolic Agent: Short-term Results

RATIONALE AND OBJECTIVES

The long-term effectiveness of prostatic artery embolization (PAE) can be hampered by the recanalization of the previously embolized prostatic arteries (PA). The use of a liquid embolic agent (LEA) could limit this risk. The purpose of this study was to assess the safety and efficacy of repeat PAE (rePAE) using a LEA (Squid Peri) coupled with microspheres in patients experiencing recurring symptoms after initial embolization.

MATERIALS AND METHODS

This retrospective single-center study included all consecutive patients who underwent rePAE using Squid Peri coupled with microspheres. Angiographic patterns of prostatic revascularization were identified. Outcomes were assessed at the 3-month follow-up using the International Prostate Symptom Score (IPSS) and the Quality of Life (QoL) score. The primary endpoint was clinical success defined as an IPSS < 18 with > 25% decrease and a QoL score ≤ 3 with ≥ 1 point decrease. Safety was assessed by using the modified Clavien-Dindo classification.

RESULTS

30 consecutive men (mean age: 67.1 ± 9.5 years) were included. Recanalization of the previously embolized PA was found in 83.3% of patients. Technical success was 93.3%. Median follow-up was 4.9 months [IQR: 3.9 - 9.8]. Clinical success rate was 76.7%, with a mean decrease in IPSS of -9.3 ± 7.3 (p < 0.001) and a median decrease in QoL of -2 [IQR: - 4 - - 1] (p < 0.001). One patient presented with an acute urinary retention requiring readmission (grade IIIa complication).

CONCLUSION

Repeat PAE using Squid Peri coupled with microspheres is safe and effective for patients with recurring symptoms after initial embolization.

Randomized Controlled Trial Comparing Open Simple Prostatectomy or Prostate Artery Embolization in Large Prostates: Clinical and Urodynamic Assessment - PoPAE Study

OBJECTIVE

To evaluate the effects of Prostate artery embolization (PAE) and open simple prostatectomy (OP) on lower urinary tract symptoms and urodynamic parameters in subjects with prostate size >80cc³.

METHODS

PoPAE study (OP or PAE) was a randomized, open-label controlled trial performed between January 2020 and May 2022. Subjects with large prostates (>80cc³), urodynamic parameters meeting obstruction criteria (Bladder Outlet Obstruction Index-BOOI>40), and good detrusor function (Bladder contractility index>100) were included. The primary and co-primary endpoints were the variation in peak flow rate on uroflowmetry (Qmax) and BOOI. The secondary endpoints were the IPSS and ultrasonographic changes.

RESULTS

Twenty three and 25 subjects underwent PAE and OP were evaluated, respectively. At baseline, the 2 groups have shown similar clinical, radiological, laboratory, and urodynamic parameters. After 6 months, Qmax improved 8,3 ± 4.17 mL/sec in PAE and 15.1 ± 8.04 mL/sec in OP (mean difference 6.78 in favor of PE; P = .012 [CI -9.00 to -3.00]). After treatment, 88% of those men underwent OP were classified as unobstructed or equivocal (BOOi<40). On the other hand, 70% of subjects underwent PAE remained obstructed (BOOI>40) and none of them shifted to unobstructed status (BOOI<20). It was observed a similar reduction in IPSS and PVR in both groups.

CONCLUSION

PAE was inferior to conventional surgery for releasing BOO and improving peak urinary flow in large prostates. Nevertheless, PAE was able to improve symptoms and PVR, and might be an alternative method in selected patients.

Value of magnetic resonance angiography before prostatic artery embolization for intervention planning

Knowledge about anatomical details seems to facilitate the procedure and planning of prostatic artery embolization (PAE) in patients with symptomatic benign prostatic hyperplasia (BPS). The aim of our study was the pre-interventional visualization of the prostatic artery (PA) with MRA and the correlation of iliac elongation and bifurcation angles with technical success of PAE and technical parameters. MRA data of patients with PAE were analysed retrospectively regarding PA visibility, PA type, vessel elongation, and defined angles were correlated with intervention time, fluoroscopy time, dose area product (DAP), cumulative air kerma (CAK), contrast media (CM) dose and technical success of embolization. T-test, ANOVA, Pearson correlation, and Kruskal-Wallis test was applied for statistical analysis. Between April 2018 and March 2021, a total of 78 patients were included. MRA identified the PA origin in 126 of 147 cases (accuracy 86%). Vessel elongation affected time for catheterization of right PA (p = 0.02), fluoroscopy time (p = 0.05), and CM dose (p = 0.02) significantly. Moderate correlation was observed for iliac bifurcation angles with DAP (r = 0.30 left; r = 0.34 right; p = 0.01) and CAK (r = 0.32 left; r = 0.36 right; p = 0.01) on both sides. Comparing the first half and second half of patients, median intervention time (125 vs. 105 min.) and number of iliac CBCT could be reduced (p < 0.001). We conclude that MRA could depict exact pelvic artery configuration, identify PA origin, and might obviate iliac CBCT. Vessel elongation of pelvic arteries increased intervention time and contrast media dose while the PA origin had no significant influence on intervention time and/or technical success.

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.

Safety of Prostatic Artery Embolization via Transradial Access versus Transfemoral Access

PURPOSE

To compare prostatic artery embolization (PAE) via transradial access (TRA-PAE) versus transfemoral access (TFA-PAE) to assist access selection.

MATERIAL AND METHODS

Procedural outcomes and adverse events were evaluated in 998 patients who underwent PAE at a single center from April 2014 to August 2022; 821 (82%) underwent TRA-PAE (Group R) and 177 (18%) underwent TFA-PAE (Group F). Mean age and prostate size of Groups R and F were 69.2 years (SD ± 8.4) and 117.4 g (SD ± 63.1) and 75.2 years (SD ± 12.1) and 127.2 g (SD ± 83.6), respectively (P < .01 and P = .16; postpropensity matching: P = .38 and P = .35, respectively). Indications for PAE included lower urinary tract symptoms, acute or chronic urinary retention, and hematuria. Procedural and patient-specific metrics were reviewed. Technical success was defined as bilateral PAE. Adverse events were recorded according to the Society of Interventional Radiology (SIR) adverse events classification. Statistical significance was defined as P < .05.

RESULTS

Technical success was achieved in 798 (97.2%) patients in Group R and 165 (93.2%) patients in Group F. Mean procedural time, single- and continuous-rotation fluoroscopy time, dose area product, and air kerma were significantly lower in Group R than in Group F (P < .001). Moreover, 6 (0.7%) patients in Group R and 9 (5.5%) patients in Group F had access site ecchymoses, whereas 5 (0.6%) patients in Group R and 6 (3.6%) in Group F had access site hematomas. Two patients experienced transient ischemic attacks (TIAs) after TRA-PAE and recovered without intervention. Two occult radial artery occlusions were noted, but no patient experienced hand ischemia.

CONCLUSIONS

In a large single interventional radiologist cohort, TRA-PAE demonstrated similar technical success to that of TFA-PAE with lower access site hemorrhagic complications and radiation requirements; however, TIA and occult radial artery occlusions remain a concern.

Multicenter Quantification of Radiation Exposure and Associated Risks for Prostatic Artery Embolization in 1476 Patients

Background Prostatic artery embolization (PAE) is a safe, minimally invasive angiographic procedure that effectively treats benign prostatic hyperplasia; however, PAE-related patient radiation exposure and associated risks are not completely understood. Purpose To quantify radiation dose and assess radiation-related adverse events in patients who underwent PAE at multiple centers. Materials and Methods This retrospective study included patients undergoing PAE for any indication performed by experienced operators at 10 high-volume international centers from January 2014 to May 2021. Patient characteristics, procedural and radiation dose data, and radiation-related adverse events were collected. Procedural radiation effective doses were calculated by multiplying kerma-area product values by an established conversion factor for abdominopelvic fluoroscopy-guided procedures. Relationships between cumulative air kerma (CAK) or effective dose and patient body mass index (BMI), fluoroscopy time, or radiation field area were assessed with linear regression. Differences in radiation dose stemming from radiopaque prostheses or fluoroscopy unit type were assessed using two-sample t tests and Wilcoxon rank sum tests. Results A total of 1476 patients (mean age, 69.9 years ± 9.0 [SD]) were included, of whom 1345 (91.1%) and 131 (8.9%) underwent the procedure with fixed interventional or mobile fluoroscopy units, respectively. Median procedure effective dose was 17.8 mSv for fixed interventional units and 12.3 mSv for mobile units. CAK and effective dose both correlated positively with BMI (R2 = 0.15 and 0.17; P < .001) and fluoroscopy time (R2 = 0.16 and 0.08; P < .001). No radiation-related 90-day adverse events were reported. Patients with radiopaque implants versus those without implants had higher median CAK (1452 mGy [range, 900-2685 mGy] vs 1177 mGy [range, 700-1959 mGy], respectively; P = .01). Median effective dose was lower for mobile than for fixed interventional systems (12.3 mSv [range, 8.5-22.0 mSv] vs 20.4 mSv [range, 13.8-30.6 mSv], respectively; P < .001). Conclusion Patients who underwent PAE performed with fixed interventional or mobile fluoroscopy units were exposed to a median effective radiation dose of 17.8 mSv or 12.3 mSv, respectively. No radiation-related adverse events at 90 days were reported. © RSNA, 2024 See also the editorial by Mahesh in this issue.

One-year outcomes after prostate artery embolization versus laser enucleation: A network meta-analysis

Background

Although holmium laser enucleation (HoLEP) is considered a size-independent procedure for treatment of an enlarged prostate, prostate artery embolization (PAE) is emerging as an alternative modality to treat moderate and large benign prostatic hyperplasia. This study aims to compare the early post-operative and short-term efficacy of PAE and HoLEP.

Methods

PubMed, Cochrane Library and EMBASE databases were searched. Network meta-analysis was performed following PRISMA-N-guidelines. Post-operative parameters analysed include international prostate symptom score (IPSS), quality of life (QOL), post-void residual urine (PVR), maximal uroflow rate (Qmax) and serious adverse events (SAE). Random effects model calculated weighted mean differences (WMD). If 95%CI crossed the line of no effect (WMD = 0), evidence indicated no statistically significant difference between treatments compared.

Results

Qualitative and quantitative syntheses included 20 and 18 studies with 1991 and 1606 patients, respectively. At 3 months, there was no statistically significant difference between PAE and HoLEP in IPSS score improvement [WMD: -2.21: 95%CI: (-10.20, 5.78), favouring PAE], QoL score improvement [WMD: -0.22:95%CI: (-1.75, 1.32), favouring PAE] and PVR improvement [WMD: 26.97: 95%CI: (-59.53, 113.48), favouring HoLEP]. However, PAE was found inferior to HoLEP for Qmax improvement [WMD: 8.47, 95%CI: (2.89, 14.05), favouring HoLEP]. At 1-year follow-up, there was no statistically significant was found between PAE and HoLEP for IPSS score improvement [WMD:6.03, 95%CI: (-1.30, 13.35)], QoL score improvement [WMD: 0.03, 95%CI: (-1.19, 1.25)], PVR improvement [WMD:4.11, 95%CI: (-32.31, 40.53)] and Qmax improvement [WMD:2.60, 95%CI: (-2.20, 7.41)] with all differences favouring HoLEP. PAE was superior to HoLEP for SAE [PAE vs. HoLEP-OR: 0.68, 95%CI: (0.25, 1.37)].

Conclusion

HoLEP was superior to PAE at 3 months for Qmax improvement. There was no significant difference in IPSS, QoL, PVR and Qmax improvement at 1 year between PAE and HoLEP. PAE was also associated with lesser SAE compared to HoLEP. Studies on the long-term outcome of PAE are needed to establish the durability of early outcomes after PAE.

Comparing prostatic artery embolization to surgical and minimally invasive procedures for the treatment of benign prostatic hyperplasia: a systematic review and meta-analysis

BACKGROUND

To summarize current evidence to report a comparative systematic review and meta-analysis of prostatic artery embolization (PAE) with transurethral resection of the prostate (TURP) and open simple prostatectomy (OSP) for the treatment of benign prostatic hyperplasia (BPH).

METHODS

A systematic literature search was performed to identify studies published from inception until August 2021. The search terms used were (prostate embolization OR prostatic embolization) AND (prostatic hyperplasia OR prostatic obstruction) as well as the abbreviations of PAE and BPH. Risk of bias was assessed using the Cochrane Risk of Bias tool for randomized controlled trials (RCTs) and the Risk of Bias in Non-randomized Studies-of Interventions (ROBINS-I) tool for observational studies. Random-effects meta-analysis was performed using Revman 5.4.

RESULTS

Seven studies were included with 810 patients: five RCTs and one observational study compared PAE with TURP, and one observational study compared PAE with OSP. The included studies had considerable risk of bias concerns. TURP and OSP were associated with more statistically significant improvements in urodynamic measures and BPH symptoms compared to PAE. However, PAE seems to significantly improve erectile dysfunction compared to OSP and improve other outcome measures compared to TURP, although not significantly. PAE appeared to reduce adverse events and report more minor complications compared with TURP and OSP, but it is unclear whether PAE is more effective in the long-term.

CONCLUSION

PAE is an emerging treatment option for patients with symptomatic BPH who cannot undergo surgery or have undergone failed medical therapy. Overall, PAE groups reported fewer adverse events. Future ongoing and longer-term studies are needed to provide better insight into the benefit of PAE compared to other treatment options.

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.

[Minimally invasive treatment of benign prostatic hyperplasia : The German S2e guideline 2023-part 4]

BACKGROUND

Lower urinary tract symptoms suggestive for benign prostatic obstruction (LUTS/BPO) are one of the most frequent diseases in men and can have a significant impact on quality of life. Instrumental therapies are common, and many patients seek minimally invasive treatment options.

OBJECTIVE

Presentation and evidence-based evaluation of the minimally invasive therapy for benign prostatic syndrome.

MATERIALS AND METHODS

Summary and overview of chapters 11-13 on minimally invasive therapies for LUTS/BPO of the current long version of the German S2e guideline.

RESULTS

In case of absolute indication for surgery or after unsatisfactory or undesired medical therapy, minimally invasive treatments such as UroLift® (Neotract Inc., Pleasanton, CA, USA), Rezῡm™ (Boston Scientific, Malborough, MA, USA), iTIND™ (Olympus America Inc., Westborough, MA, USA), and prostatic artery embolization (PAE) can be considered. These indirect/delayed ablative therapies offer lower morbidity and the possibility of performing them under local anesthesia, but they are inferior to direct ablative/resective techniques in terms of effectiveness and sustainability.

CONCLUSIONS

The updated German S2e guideline summarizes evidence-based recommendations for new minimally invasive therapies for LUTS/BPO, which present alternative treatment options for selected patients.

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.

Features of patients referring to the outpatient office due to benign prostatic hyperplasia: analysis of a national prospective cohort of 5815 cases

BACKGROUND

Evidence on clinical presentation of benign prostatic hyperplasia (BPH) is scarce, and studies involving outpatients are lacking. We aimed to provide an insight into the contemporary Italian scenario of BPH-affected outpatients using symptom scores (International Prostate Symptom Score [IPSS], BPH Impact Index [BII]), and to compare characteristics of patients with known BPH and those first-diagnosed at the visit.

METHODS

"IMPROVING THE PATH" project working group designed a questionary prospectively administered to BPH-affected outpatients by urologists. A cross-sectional study was performed. Data were adjusted for patient age as a potential confounding factor.

RESULTS

Of 5815 patients enrolled, BPH was already diagnosed in 4144 (71.3%), and not in 1671 (28.7%). Patients with known BPH, compared to newly diagnosed, were older (median 68 versus [vs] 55), had more frequent smoking (smoker 27.2 vs 22.6%, and ex-smoker 16.4 vs 12.5%) and drinking habits (55.4 vs 45.1%), were more frequently affected by hypertension (60.0 vs 42.4%), obesity (15.3 vs 9.6%), diabetes (17.9 vs 12.5%), and cardiovascular diseases (14.2 vs 9.5%), p < 0.001. At IPSS, moderate and severe symptoms correlated with already known BPH (56.1 vs 47.3% and 24.8 vs 7.8%), whereas newly diagnosed patients showed milder symptoms (44.9 vs 19.1%), all p < 0.001. At BII, concern for one's health and time lost due to urinary problems were higher in patients with known BPH (p < 0.001). For these patients, the urologist changes at least one of the ongoing medications in 63.5%. For patients newly diagnosed, supplements/phytotherapeutics, alpha-blockers, and 5-alfa reductase inhibitors were prescribed in 54.6%, 21.6%, and 7.1%, respectively.

CONCLUSIONS

Despite medical treatment, natural history of BPH leads to a progressive deterioration of symptoms. This may reflect the difference between newly diagnosed patients and those with known BPH in lifestyle and associated comorbidities. A healthy lifestyle and treatments including local anti-inflammatory agents may delay worsening of symptoms and improve quality of life.

Minimally invasive surgical therapies (MISTs) for lower urinary tract symptoms (LUTS): promise or panacea?

ABSTRACT

The increasing importance of treatment of lower urinary tract symptoms (LUTS), while avoiding side effects and maintaining sexual function, has allowed for the development of minimally invasive surgical therapies (MISTs). Recently, the European Association of Urology guidelines reported a paradigm shift from the management of benign prostatic hyperplasia (BPH) to the management of nonneurogenic male LUTS. The aim of the present review was to evaluate the efficacy and safety of the most commonly used MISTs: ablative techniques such as aquablation, prostatic artery embolization, water vapor energy, and transperineal prostate laser ablation, and nonablative techniques such as prostatic urethral lift and temporarily implanted nitinol device (iTIND). MISTs are becoming a new promise, even if clinical trials with longer follow-up are still lacking. Most of them are still under investigation and, to date, only a few options have been given as a recommendation for use. They cannot be considered as standard of care and are not suitable for all patients. Advantages and disadvantages should be underlined, without forgetting our objective: treatment of LUTS and re-treatment avoidance.

Treating LUTS in Men with Benign Prostatic Obstruction: A Review Article

Benign prostatic obstruction (BPO) is a prevalent condition that affects men, primarily toward their old age. The condition is often accompanied by lower urinary tract symptoms (LUTS), which can significantly impair a patient's quality of life and lead to other medical complications. Accurate diagnosis of BPO is essential for effective management of complications secondary to BPO, and treatment plans should be tailored patients, and occasionally according to surgeon experience. As such, this literature review aims to analyze the current available data on male LUTS secondary to BPO by providing a comprehensive overview of relevant studies, as well as the surgical and medical management guidelines from the Canadian Urological Association (CUA), American Urological Association (AUA), and European Association of Urology (EAU). By synthesizing the existing literature, this review purports to summarize the current body of knowledge surrounding BPO and male LUTS, and support healthcare providers in making informed decisions about the management of male LUTS secondary to BPO, ultimately improving patient outcomes and quality of life.

Prostatic Arterial Embolization for Treatment of Lower Urinary Tract Symptoms Associated with Benign Prostatic Enlargement

PURPOSE OF REVIEW

Prostatic artery embolization (PAE) is an emerging minimally invasive technique for lower urinary tract symptom reduction from benign prostatic hypertrophy (BPH). While the technique is becoming increasingly popular with patients and interventional radiologists, most urologists remain skeptical of the PAE's long-term efficacy and comparative success to the gold standard transurethral resection of the prostate.

RECENT FINDINGS

PAE has been found in multiple meta-analyses to perform similarly to the gold standard transurethral resection of the prostate (TURP) with regard to patient-driven measures like IPSS and IPSS-QoL, while also performing favorably in objective measurements including Qmax and PVR out to at least 12 months post intervention. Furthermore, PAE has a demonstrated shorter hospital length of stay and fewer adverse events when compared to TURP. PAE provides patients with an alternative to transurethral options for the management of LUTS in the setting of bladder outlet obstruction. While long-term evidence demonstrating the durability of PAE is still forthcoming, the procedure has been demonstrated to be safe according to multiple meta-analyses. Patients deserve to be counseled on PAE as an alternative to surgery and made aware that while the overall treatment effect may not be as robust or durable, the procedure carries a favorable adverse event profile that is attractive to patients wishing to avoid a trans-urethral approach.

Summary Paper on the 2023 European Association of Urology Guidelines on the Management of Non-neurogenic Male Lower Urinary Tract Symptoms

CONTEXT

Lower urinary tract symptoms (LUTS) are common, often bothersome, and have multifactorial aetiology.

OBJECTIVE

To present a summary of the 2023 version of the European Association of Urology guidelines on the management of male LUTS.

EVIDENCE ACQUISITION

A structured literature search from 1966 to 2021 selected the articles with the highest certainty evidence. The Delphi technique consensus approach was used to develop the recommendations.

EVIDENCE SYNTHESIS

The assessment of men with LUTS should be practical. A careful medical history and physical examination are essential. Validated symptom scores, urine test, uroflowmetry, and postvoid urine residual, as well as frequency-volume charts for patients with nocturia or predominately storage symptoms should be used. Prostate-specific antigen should be ordered if a diagnosis of prostate cancer changes the treatment plan. Urodynamics should be performed for selected patients. Men with mild symptoms are candidates for watchful waiting. Behavioural modification should be offered to men with LUTS prior to, or concurrent with, treatment. The choice of medical treatment depends on the assessment findings, predominant type of symptoms, ability of the treatment to change the findings, and the expectations to be met in terms of the speed of onset, efficacy, side effects, and disease progression. Surgery is reserved for men with absolute indications, and for patients who fail or prefer not to receive medical therapy. Surgical management has been divided into five sections: resection, enucleation, vaporisation, and alternative ablative and nonablative techniques. The choice of surgical technique depends on patient's characteristics, expectations, and preferences; surgeon's expertise; and availability of modalities.

CONCLUSIONS

The guidelines provide an evidence-based approach for the management of male LUTS.

PATIENT SUMMARY

A clinical assessment should identify the cause(s) of symptoms and define the clinical profile and patient's expectations. The treatment should aim to ameliorate symptoms and reduce the risk of complications.

Novel minimally invasive treatments for lower urinary tract symptoms: a systematic review and network meta-analysis

PURPOSE

To review and compare the effectivity of novel minimally invasive treatments (MITs) to transurethral resection of the prostate (TURP) for the treatment of lower urinary tract symptoms (LUTS) in men.

METHODS

Medline, Embase, and Cochrane databases were searched from January 2010 to December 2022 for randomized controlled trials (RCTs) evaluating MITs, compared to TURP or sham, in men with LUTS. Studies were assessed by risk of bias tool, and evidence by GRADE. Functional outcomes by means of uroflowmetry and IPSS were the primary outcomes, safety and sexual function were secondary outcomes. As part of this review, a network meta-analysis (NMA) was conducted. MITs were ranked based on functional outcome improvement probability.

RESULTS

In total, 10 RCTs were included, evaluating aquablation, prostatic urethral lift, prostatic artery embolization (PAE), convective water vapor thermal treatment or temporary implantable nitinol device. All MITs showed a better safety profile compared to TURP. Functional outcome improvement following aquablation were comparable to TURP. In the NMA, aquablation was ranked highest, PAE followed with the second highest probability to improve functional outcomes. Other novel MITs resulted in worse functional outcomes compared to TURP. Level of evidence was low to very low.

CONCLUSIONS

Five MITs for treatment of LUTS were identified. Aquablation is likely to result in functional outcomes most comparable to TURP. Second in ranking was PAE, a technique that does not require general or spinal anesthesia. MITs have a better safety profile compared to TURP. However, due to high study heterogeneity, results should be interpreted with caution.

Ultrasound-guided perineal laser ablation versus prostatic arterial embolization for benign prostatic hyperplasia: two similar short-term efficacies

BACKGROUND

There are many ways to treat prostatic hyperplasia; these are currently more inclined to minimally invasive treatment. We mainly compared the differences between two treatment methods， ultrasound-guided transperineal laser ablation (US-TPLA) and prostatic artery embolization (PAE).

PURPOSE

To evaluate the efficacy and safety of US-TPLA and PAE in the treatment of benign prostatic hyperplasia (BPH).

MATERIAL AND METHODS

The clinical information for 40 patients with BPH admitted to our hospital between June 2018 and January 2021 were retrospectively analyzed. The changes in International Prostate Symptom Score (IPSS), quality of life (QoL), maximum urinary flow rate (Qmax), postvoid residual (PVR), prostate volume (PV), and the incidence of complications were compared between groups.

RESULTS

The IPSS (P < 0.001; P < 0.001), QoL (P < 0.001; P < 0.001), Qmax (P < 0.001; P < 0.001), PVR (P < 0.001; P < 0.001), and PV (P < 0.001; P < 0.001) at three and six months after US-TPLA and PAE improved with respect to those before surgery. There was no significant difference in IPSS (P = 0.235; P = 0.151), QoL (P = 0.527; P = 0.294), Qmax (P = 0.776; P = 0.420), PVR (P = 0.745; P = 0.607), and PV (P = 0.527; P = 0.573) between the groups at three and six months after surgery. No serious complications occurred in either group.

CONCLUSION

US-TPLA and PAE seem to have a similar short-term efficacy. The efficacy of the two procedures is comparable, and neither is associated with serious complications. US-TPLA and PAE are both effective complementary measures for the treatment of BPH.

Six novel minimally invasive therapies for benign prostatic hyperplasia

Benign prostatic hyperplasia (BPH) is the most common cause of lower urinary tract symptoms in men. When drug treatment is ineffective or conventional surgery is not suitable, novel minimally invasive therapies can be considered. These include prostatic urethral lift, prostatic artery embolisation, water vapor thermal therapy, Aquablation-image guided robotic waterjet ablation, temporary implantable nitinol device and prostatic stents. These novel therapies can be performed in outpatient setting under local anesthesia, with shorter operative and recovery times, and better protection of ejaculatory function and erectile function. General conditions of the patient and advantages and disadvantages of the each of these therapies should be fully considered to make individualized plans.

Benefits of Repeat Prostatic Artery Embolization on Persistent or Recurrent Lower Urinary Tract Symptoms in Patients with Benign Prostatic Hyperplasia

OBJECTIVES

To evaluate the benefits of repeat prostatic artery embolization (rePAE) for patients with persistent or recurrent symptoms after initial prostatic artery embolization (PAE).

MATERIALS AND METHODS

This is a single-center retrospective study of all patients who underwent a rePAE between December 2014 and November 2020 for persistent or recurrent lower urinary tract symptoms. Symptoms were assessed before and after PAE and rePAE, using the International Prostate Symptom Score and quality of life (QoL) questionnaires. Patient characteristics, anatomical presentations, technical success rates, and complications of both procedures were collected. Clinical failure was defined as one of the following: less than 2 points' decrease in QoL, a QoL score higher than 3, acute urinary retention, and secondary surgery.

RESULTS

A total of 21 consecutive patients (mean age: 63.8 ± 8.1; [40-75] years) who underwent rePAE were included. The median follow-up after PAE was 27.7 [18.1-36.9]) months and 8.9 [3.4-10.8] months after rePAE. rePAE was performed at a mean of 19 ± 11.1 [6.9-49.6] months following PAE, and the overall clinical success rate was 33% (7/21). In patients undergoing rePAE because of persistent symptoms, the clinical success rate (18%) was non-significantly lower than that for patients treated for recurrent symptoms (50%) [OR 4.5 (95% CI 0.63-32 P = 0.13)]. The main anatomical revascularization pattern was recanalization of the native prostatic artery (29/45, 66%).

CONCLUSION

Patients who experience recurrent symptoms after PAE may benefit more from rePAE than those with persistent symptoms after PAE. Clinical success rates seem to be relatively low in both clinical scenarios.

Comparison of traditional outcome measures and self-assessed goal achievement in patients treated surgically for benign prostatic hyperplasia

PURPOSE

To determine self-assessed goal achievement (SAGA) outcomes in men treated surgically for lower urinary tract symptoms (LUTS) due to benign prostatic obstruction (BPO) and compare them to the traditional outcome measures.

METHODS

Single-center analysis of prospective database of men undergoing surgical treatment of LUTS/BPO at a single institution between July 2019 and March 2021. We assessed individual goals, traditional questionnaires, and functional outcomes prior to treatment, and at first follow-up after 6-12 weeks. We compared SAGA outcomes 'overall goal achievement' and 'satisfaction with treatment' to subjective and objective outcomes using Spearman's rank correlations (rho).

RESULTS

A total of sixty-eight patients completed the individual goal formulation prior to surgery. Preoperative goals varied between different treatments and individuals. IPSS correlated with 'overall goal achievement' (rho = - 0.78, p < 0.001) and 'satisfaction with treatment' (rho = - 0.59, p < 0.001). Similarly, the IPSS-QoL was correlated with overall goal achievement (rho = - 0.79, p < 0.001) and satisfaction with treatment (rho = - 0.65, p < 0.001). No correlation was seen between SAGA outcomes and functional outcomes Qmax and PVR.

CONCLUSIONS

SAGA represents a uniquely patient-specific outcome measure. Our study is, to our knowledge, the first to assess patient-specific goals prior to surgery and examine SAGA outcomes following treatment in men suffering from LUTS/BPO. The correlation of SAGA outcomes with IPSS and IPSS-QoL highlight the importance of this well-established questionnaire. Functional outcomes do not necessarily reflect patient's goals and may rather be considered physician-directed outcomes.

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.

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

CONTEXT

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

OBJECTIVE

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

EVIDENCE ACQUISITION

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

EVIDENCE SYNTHESIS

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

CONCLUSIONS

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

PATIENT SUMMARY

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

Public Awareness of Interventional Radiology: Population-Based Analysis of the Current State of and Pathways for Improvement

PURPOSE

To evaluate the awareness of interventional radiology (IR) among the public and identify methods for improvement.

MATERIALS AND METHODS

Participants (N = 1,000) were anonymously surveyed using Amazon's Mechanical Turk crowdsourcing platform about medical and IR-specific knowledge, preferred methods of acquisition of medical information, and suggestions for improving awareness of IR. The survey consisted of 69 questions, including both Likert Scale and free text questions.

RESULTS

Of the participants, 92% preferred undergoing a minimally invasive procedure over surgery. However, 39.8% recognized IR as a medical specialty, and less than 50% of these participants correctly identified IR as procedurally oriented. Of those who discussed or underwent an IR procedure (n = 113), most were also offered to undergo the procedure performed by a surgeon (n = 66). Furthermore, 71% (n = 20) of those who underwent the procedure performed by a surgeon reported that lack of awareness of IR played a role in their decision. Almost half of the respondents (n = 458) were interested in learning more about IR, particularly the diseases treated and procedures performed (42% and 37%, respectively). Short (<10-minute) educational videos and increased patient education by primary care providers (PCPs) were among the most suggested ways to improve awareness. Regarding the ambiguity of the name "interventional radiology," most respondents (n = 555) reported this to be true, and "minimally invasive radiologist" was the most preferred alternative (21.18%).

CONCLUSIONS

Lack of awareness of IR may underlie underutilization. When presented with the knowledge that IR improves patient outcomes, minimally invasive procedures by an interventional radiologist are more often desired by the public than surgical options. Educational videos and patient education by PCPs may increase awareness of IR.

A Scientometric Visualization Analysis for Benign Prostatic Hyperplasia from 2016 to 2022

BACKGROUND

Benign prostatic hyperplasia (BPH) is a common urological disorder leading to dysuria in middle-aged and elderly men and significantly reduces the quality of life of patients. Technology for BPH has made a great progress, while there is still a lack of visual and summary literature to make the summary.

SUMMARY

The aims of the study were to identify the cooperation of authors, countries, institutions, and explore hot topics' prospects regarding research of BPH. Relevant original articles were obtained from the Web of Science (WoS) database between 2016 and 2022. CiteSpace software was used to perform the analysis and visualization of scientific productivity and emerging trends.

KEY MESSAGES

A total of 4,738 articles related to study of BPH were identified. We observed a gradual increase in the number of publications from 2016 to 2022. The USA dominated the field in all countries. Shanghai Jiao Tong University was the most productive institution in 6 years. Active cooperation between countries and between institutions was not observed. Journal of Urology was the most co-cited journal. Roehrborn CG (41 papers) was the most productive author and had the largest numbers of citations (820 co-citations) during the past 6 years. Close collaboration was not observed between the different authors. The main hot topics included matters related to BPH, urinary tract symptom, prostatic urethral lift, thermal therapy, and prostatic neoplasms. This scientometric study comprehensively reviewed publications related to BPH during the past 6 years using quantitative and qualitative methods, which can be used to forecast future research developments in BPH.

Prostatic arterial embolization versus holmium laser enucleation of the prostate: 1-year outcomes

PURPOSE

Holmium Laser Enucleation of the Prostate (HoLEP) and Prostatic Artery Embolization (PAE) are novel techniques for the treatment of benign prostatic hyperplasia lower urinary tract symptoms (BPH-LUTS). The objective of this study was to describe and compare the functional results and complications of these two techniques at one year follow-up.

MATERIALS AND METHODS

We performed a retrospective, monocentric study of all patients consecutively treated in our center with HoLEP or PAE for symptomatic or complicated BPH between January 2016 and December 2019. Data regarding patient and perioperative characteristics, follow-up biological results, functional questionnaires and uroflowmetry were collected from medical records.

RESULTS

A total of 490 and 57 patients were treated with HoLEP and PAE, respectively. The demographic and clinical characteristics of the two groups were similar. The operative time was significantly higher for PAE (p < 0.001) and hospitalization time longer after HoLEP (p = 0.0006). The urinary catheterization time was longer after PAE (p < 0.001). The prostatic volume treated was higher with HoLEP than with PAE (56% versus 26%, p < 0.001). The mean difference in IPSS from baseline to 12 months was significantly higher after HoLEP than after PAE: - 17.58 versus - 8 (p < 0.001). The mean difference in QoL-IPSS from baseline to 12 months was significantly higher after HoLEP: - 4.09 versus - 2.27 (p < 0.001). The rate of postoperative adverse events in the first three months was similar between the two groups:35% after HoLEP and 33% after PAE (p = 0.88).

CONCLUSIONS

HoLEP and PAE both significantly improved BPH-LUTS, with HoLEP having an advantage over PAE.

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

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

Prostatic artery embolization using reflux-control microcatheter: prospective experience addressing feasibility

PURPOSE

To evaluate the efficacy and safety of Prostatic Artery Embolization (PAE) using a reflux control microcatheter.

MATERIALS AND METHODS

This is a prospective, single-center investigation that included 10 patients undergoing PAE for treatment of lower urinary tract symptoms (LUTS) attributed to benign prostate hyperplasia (BPH). Baseline, 3-month, and 12-month efficacy endpoints were obtained for all patients and included prostate-specific antigen (PSA), uroflowmetry, pelvic magnetic resonance imaging (MRI), and clinical assessment using the International Prostate Symptom Score (IPSS) questionnaire and the IPSS-Quality of life (QoL) item. Complications were assessed using the Cirse classification system.

RESULTS

Ten patients entered statistical analysis and presented with significant LUTS improvement 12 months after PAE, as follows: mean IPSS reduction of 86.6% (2.8 vs. 20.7, - 17.9, P < 0.001), mean QoL reduction of 79.4% (1.1 vs. 5.4, - 4.3, P < 0.001), mean prostatic volume reduction of 38.4% (69.3 cm³ vs. 112.5 cm³, - 43.2 cm³, P < 0.001), mean peak urinary flow (Qmax) increase of 199.4% (19.9 mL/s vs. 6.6 mL/s, + 13.3 mL/s, P = 0.006) and mean PSA reduction of 50.1% (3.0 ng/mL vs. 6.1 ng/mL, - 3.0 ng/mL, P < 0.001). One patient (10%) needed transurethral resection of the prostate (TURP) after PAE due to a ball-valve effect. One microcatheter (10%) needed to be replaced during PAE due to occlusion. Non-target embolization was not observed in the cohort.

CONCLUSION

This initial experience suggests that PAE using a reflux control microcatheter is effective and safe for the treatment of LUTS attributed to BPH.

Prostatic Artery Embolization Versus Transurethral Resection of the Prostate for Benign Prostatic Hyperplasia: A Cost-Effectiveness Analysis

PURPOSE

To compare the cost effectiveness of prostatic artery embolization (PAE) with that of transurethral resection of the prostate (TURP) for the treatment of medically refractory benign prostatic hyperplasia (BPH).

MATERIALS AND METHODS

A cost-effectiveness analysis with Markov modeling was performed, comparing the clinical course after PAE with that after TURP for 3 years. Probabilities were obtained from the available literature, and costs were based on Medicare reimbursements and published cost analyses. Outcomes were measured using quality-adjusted life-year (QALY). Statistical analyses included base case calculation, probabilistic sensitivity analysis, and deterministic sensitivity analysis to assess the robustness of the conclusion under different clinical scenarios.

RESULTS

Base case calculation showed comparable outcomes (PAE, 2.845 QALY; TURP, 2.854 QALY), with a cost difference of $3,104 (PAE, $2,934; TURP, $6,038). The incremental cost-effectiveness ratio was $360,249/QALY. PAE was dominant in 23.2% and more cost effective in 48.4% of the probabilistic sensitivity analysis simulations. PAE was better if its recurrence risk was <20.4% per year and even when the TURP recurrence risk was assumed to be 0%. TURP would be more cost effective when its procedural cost was <$3,367 or the PAE procedural cost >$4,409. PAE remained cost effective when varying the risks and costs of the minor and major short-term or long-term adverse events of both procedures. TURP would be the better strategy if the utility of BPH recurrence was <0.85 QALY.

CONCLUSIONS

PAE is a cost-effective strategy to treat medically refractory BPH, resulting in comparable health benefits at a lower cost than that of TURP even when accounting for extreme alterations in adverse events, costs, and recurrence rates.

The State of Evidence in Prostate Artery Embolization

Prostate artery embolization (PAE) has emerged over the past two decades as a minimally invasive, nonsurgical treatment for benign prostatic hypertrophy (BPH). While the majority of evidence for PAE stems from retrospective cohort studies, several seminal randomized controlled trials have been performed comparing short-term outcomes of PAE to transurethral resection of prostate (TURP) and against a sham procedure. Across clinical trials, PAE demonstrates consistent improvement in urological symptoms and quality of life in patients with BPH with low complication rates. When compared to TURP, the results are comparable, but there is a trend for better outcomes in certain clinical parameters with TURP. PAE is a suitable option for patients who are not surgical candidates, prefer nonsurgical treatment with an earlier return to routine activities, and wish to better preserve sexual function.

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.

Long-Term PAE Results: What Do We Know

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

Radiation dose of prostatic artery embolization for benign prostatic hyperplasia: A protocol for systematic review

BACKGROUND

Increasing evidence supports the efficacy and safety of prostatic artery embolization (PAE) in the treatment of benign prostatic hyperplasia. However, PAE relies on ionizing radiation, which has not been studied systematically so far. Therefore, the potential associated risks remain largely unknown and are subject to intense debate. We performed a protocol for systematic review and meta-analysis to evaluate the clinical benefits of different radiation doses in patients with benign prostatic hyperplasia undergoing PAE.

METHODS

A comprehensive search of several databases from 1966 to October 2022 was conducted. The databases include Ovid Medline In-Process & Other Non-Indexed Citations, Ovid MEDLINE, Ovid EMBASE, Ovid PsycINFO, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, and PubMed. Risk of bias of the included studies was assessed by the "Risk of Bias Assessment Tool" of the Cochrane Handbook for randomized controlled trials. All data were analyzed using the Comprehensive Meta-Analysis software package (Biostat, Engelwood, NJ).

RESULTS

The results will be submitted to a peer-reviewed journal once completed.

CONCLUSION

This review will provide reliable evidence for extensive application of PAE for benign prostatic hyperplasia and determine the most rational radiation dose for these patients.

Safety Profile of Ambulatory Prostatic Artery Embolization after a Significant Learning Curve: Update on Adverse Events

Background: to report the safety of outpatient prostatic artery embolization (PAE) after a significant learning curve. Methods: a retrospective bi-institutional study was conducted between June 2018 and April 2022 on 311 consecutive patients, with a mean age of 69 years ± 9.8 (47–102), treated by outpatient PAE. Indications included lower urinary tract symptoms, acute urinary retention, and hematuria. When needed, 3D-imaging and/or coil protection of extra-prostatic supplies were performed to avoid non-target embolization. Adverse events were monitored at 1-, 6-, and 12-month follow-ups. Results: bilateral PAE was achieved in 305/311 (98.1%). Mean dose area product/fluoroscopy times were 16,408.3 ± 12,078.9 (2959–81,608) μGy.m²/36.3 ± 1.7 (11–97) minutes. Coil protection was performed on 67/311 (21.5%) patients in 78 vesical, penile, or rectal supplies. Embolization-related adverse events varied between 0 and 2.6%, access-site adverse events between 0 and 18%, and were all minor. There was no major event. Conclusion: outpatient PAE performed after achieving a significant learning curve may lead to a decreased and low rate of adverse events. Experience in arterial anatomy and coil protection may play a role in safety, but the necessity of the latter in some patterns may need confirmation by additional studies in randomized designs.

Contemporary surgical management of benign prostatic obstruction: does there remain a place in the toolbox for TURP?

Level of evidence: 5

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Comparison of effectiveness and postoperative complications of different surgical methods in the treatment of benign prostatic hyperplasia: a systematic review and meta-analysis based on randomized controlled trials

Background

More and more new surgical procedures for the treatment of benign prostate hyperplasia (BPH) are proposed creatively. However, the existing clinical evidence shows that the effectiveness and safety of various procedures exist inconsistent.

Methods

The randomized controlled trials comparing the international prostate score, length of hospital stay, maximum urinary flow rate, operation time, and complication rates of prostatic artery embolization (PAE), Greenlight-XPS Laser prostate vaporization procedure (GLL PVP), diode laser enucleation of prostate (DILEP) and plasmakinetic resection of the prostate (PKRP), transurethral resection of the prostate (TURP) in patients with BPH were screened out in databases. The primary outcome was pooled using a restricted maximum likelihood-based random-effect model and inverse variance-based fixed-effect model. Cochrane Q statistics and I2 statistics were computed to quantify between-study heterogeneity. The risk of bias of each included study was assessed using the revised Cochrane risk of bias tool.

Results

This meta-analysis ultimately included 14 original research papers, with 1,940 participants enrolled. Eight studies were considered to be at moderate risk of bias, while the others were at mild risk of bias. Although the improvement in functional outcome of the DILEP procedure was equivalent to that of the PKRP procedure, the DILEP procedure group had fewer hospital stays than the PKRP group (P=0.01). In addition, even though the performance of the GLL PVP procedure in the improvement of functional outcome was inferior to the counterpart of TURP (P=0.64), it had a much fewer hospital stays (P=0.01). Moreover, there is still insufficient evidence for the improvement of subjective functional indicators of postoperative patients with PAE compared with TURP [international prostate symptom score (IPSS): P=0.73; IPSS QoL: P=0.91], but achieved less satisfactory objective functional outcomes (Qmax: P=0.06; PVR: P=0.00).

Discussion

New surgical procedures such as GLL PVP, PAE, and DILEP were safer than traditional TURP procedures. However, it is not superior to traditional surgery in the improvement of clinical symptoms. In clinical practice, the pros and cons of the new operation and the traditional operation should be carefully weighed, and the operation that is most suitable for the patient's condition should be selected.

[Minimally Invasive Therapy: What Is The Status In 2021 - What's Coming, What's Going?]

Due to the large number of men affected and a variable clinical presentation, the widespread disease "benign prostatic syndrome" requires individual treatment options tailored to the patient's specific clinical characteristics and wishes. If surgical treatment is indicated, there is a wide range of invasive procedures available. For a long time, transurethral resection of the prostate and simple prostatectomy were considered the gold standard, but these procedures are associated with increased morbidity and limitations in sexual function. Therefore, there is now an increasing call for minimally invasive treatment options that will provide effective and safe treatment in the outpatient setting. Over the past years, a variety of technologies and procedures have been developed and tested, but only a few of them have found their way into clinical practice, mostly due to insufficient functional results. For instance, transurethral needle ablation, transurethral microwave thermotherapy, intraprostatic botulinum toxin A or PRX302 injections as well as prostatic stents are no longer recommended. In contrast, the European Association of Urology is currently recommending UroLift, Aquablation and prostatic artery embolisation, which achieve significant long-term improvements in functional parameters while providing a good safety profile and preserved sexual function. Promising data are also available for the temporarily implanted nitinol device (iTIND), Rezūm, intraprostatic injection of fexapotide triflutate and transperineal laser ablation of the prostate, but the efficacy and safety of these procedures need to be confirmed in further studies.

Prostatic Artery Embolisation: Do We Still Need It and for Whom?

Prostatic artery embolisation (PAE) is now endorsed by international evidence-based guidelines as a treatment for lower urinary tract symptoms presumed secondary to benign prostatic obstruction (LUTS/BPO) for selected patients. PAE is a truly minimally invasive technique, with proven efficacy and safety demonstrated for the short- to mid-term. As it has a unique treatment approach (endovascular instead of transurethral), its profile and ideal application differ clearly from other treatments for LUTS/BPO, which must be considered for patient selection. This mini review examines the role of PAE in the treatment of LUTS/BPO on the basis of current evidence. PATIENT SUMMARY: For properly selected patients, prostatic artery embolisation (PAE), in which arteries feeding the prostate are blocked in a nonsurgical procedure, is one of the treatment options for obstruction of urine outflow caused by benign enlargement of the prostate. This article examines the role of PAE according to the evidence available in the literature.