Prostatic Artery Embolization: Indications, Preparation, Techniques, Imaging Evaluation, Reporting, and Complications

Prostate Artery Embolization for Benign Prostatic Hyperplasia: A Case Report and Comprehensive Literature Review

This case report describes the successful use of prostate artery embolization (PAE) in a 75-year-old male with benign prostatic hyperplasia (BPH) and severe lower urinary tract symptoms (LUTS) that did not respond to medical therapy. Despite initial treatments, the patient had persistent symptoms and significant prostate enlargement. PAE was chosen for its minimally invasive nature and advantages over traditional surgery. After the procedure, the patient experienced significant improvements, including reduced prostate volume, decreased post-void residual volume, and enhanced urinary flow. Follow-up showed a marked reduction in symptoms. This case highlights PAE as an effective alternative for patients with BPH who do not respond to medical management or are not suitable for conventional surgery. Further research is needed to evaluate long-term outcomes compared to established treatments.

Intentionally unilateral prostatic artery embolization: Patient selection, technique and potential benefits

BACKGROUND

Prostatic artery embolization (PAE) is a promising but also technically demanding interventional radiologic treatment for symptomatic benign prostatic hyperplasia. Many technical challenges in PAE are associated with the complex anatomy of prostatic arteries (PAs) and with the systematic attempts to catheterize the PAs of both pelvic sides. Long procedure times and high radiation doses are often the result of these attempts and are considered significant disadvantages of PAE. The authors hypothesized that, in selected patients, these disadvantages could be mitigated by intentionally embolizing PAs of only one pelvic side.

AIM

To describe the authors' approach for intentionally unilateral PAE (IU-PAE) and its potential benefits.

METHODS

This was a single-center retrospective study of patients treated with IU-PAE during a period of 2 years. IU-PAE was applied in patients with opacification of more than half of the contralateral prostatic lobe after angiography of the ipsilateral PA (subgroup A), or with markedly asymmetric prostatic enlargement, with the dominant prostatic lobe occupying at least two thirds of the entire gland (subgroup B). All patients treated with IU-PAE also fulfilled at least one of the following criteria: Severe tortuosity or severe atheromatosis of the pelvic arteries, non-visualization, or visualization of a tiny (< 1 mm) contralateral PA on preprocedural computed tomographic angiography. Intraprocedural contrast-enhanced ultrasonography (iCEUS) was applied to monitor prostatic infarction. IU-PAE patients were compared to a control group treated with bilateral PAE.

RESULTS

IU-PAE was performed in a total 13 patients (subgroup A, n = 7; subgroup B, n = 6). Dose-area product, fluoroscopy time and operation time in the IU-PAE group (9767.8 μGy∙m2, 30.3 minutes, 64.0 minutes, respectively) were significantly shorter (45.4%, 35.9%, 45.8% respectively, P < 0.01) compared to the control group. Clinical and imaging outcomes did not differ significantly between the IU-PAE group and the control group. In the 2 clinical failures of IU-PAE (both in subgroup A), the extent of prostatic infarction (demonstrated by iCEUS) was significantly smaller compared to the rest of the IU-PAE group.

CONCLUSION

In selected patients, IU-PAE is associated with comparable outcomes, but with lower radiation exposure and a shorter procedure compared to bilateral PAE. iCEUS could facilitate patient selection for IU-PAE.

Prevalence of internal iliac artery anatomical variants in a Mexican population

The internal iliac artery arises as a terminal extension of the common iliac artery and supplies blood to the pelvic region. This study aims to identify the anatomic variations of the internal iliac artery (IIA) in a Mexican population sample. This is a retrospective cross-sectional observational study. A total of 81 angiographies via the femoral artery approach performed on patients undergoing various medical procedures were included. Variations in the IIA branching patterns were identified by evaluating the angiographic images and grouped according to Adachi's classification into five types (I-V). A total of 139 hemipelvises were analyzed (78 right and 61 left). The frequencies of each type of variation were as follows: Type I (71.2%), Type II (10.79%), Type III (0 cases), Type IV (0.7%), Type V (12.94%), and unclassified (4.31%). The most frequent anatomical variants of the IIA in the western Mexican population sample were Type I, followed by Types V and II. Even though Type V is rare in most populations, it was the second most frequent variant in this study. Understanding the variants of the IIA branching pattern is necessary for performing invasive procedures in the pelvic region with precision and minimizing complications.

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.

Prostatic Artery Embolization as a Treatment Option for Symptomatic Benign Prostatic Hyperplasia: Results from the Prospective Follow-Up Study in Lithuania

Background: The endovascular treatment of symptomatic benign prostate hypertrophy (BPH) by prostatic artery embolization (PAE) is one of the new treatments proposed. PAE is a minimally invasive alternative that has been shown to successfully treat lower urinary tract symptoms in BPH patients by causing infarction and necrosis of hyperplastic adenomatous tissue, which decompresses urethral impingement and improves obstructive symptoms. The aim of this study was to evaluate the effectiveness and efficacy of PAE in relieving symptoms in patients with symptomatic BPH. Materials and Methods: The material for the study was collected from 2019 to 2022. A total of 70 men with BPH and PAE were studied. Patients underwent an urological examination to measure the International Prostate Symptom Score (IPSS), Quality of Life score (QoL), International Index of Erectile Function short form (IIEF-5), uroflowmetry with Qmax, prostatic volume (PV), and post-void residual volume (PVR) measurements. Statistical analysis for dependent samples was applied. Measured parameters at 2 months and 6 months follow-up were compared to baseline. Results: At baseline, the age of the male (N = 70) subjects was 74 ± 9.6 years with a median of 73.8, but fluctuated from 53 to 90 years. The mean of PV was almost 111 mL and the Qmax was close to 7.7 mL/s. The average PVR was 107.6 mL. The IPSS score mean was 21.3 points and the QoL score was 4.53 points. The IIEF-5 questionnaire score was almost 1.8 points, which shows severe erectile dysfunction. The mean value of the PSA level was 5.8 ng/mL. After 2 and 6 months of PAE, all indicators and scores except erectile function significantly improved. Conclusions: The outcomes of our study show promising results for patients with benign prostatic hyperplasia after PAE. The main prostate-related parameters (PV, Qmax, PVR, IPSS) improved significantly 6 months after embolization.

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.

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

AIM

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

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: Technical Pearls

Benign prostatic hyperplasia (BPH) is a condition that primarily affects men between the fourth and seventh decades of life, occurring due to enlargement of the prostate which subsequently causes compression of the prostatic urethra causing chronic obstruction of the urinary outflow tract. BPH can cause significant quality-of-life issues such as urinary hesitancy, intermittency, decreased urinary stream, a sensation of incomplete emptying, dysuria, urinary retention, hematuria, and nocturia. Several medical and surgical treatment modalities are available for the treatment of lower urinary tract symptoms and other BPH-related sequela; however, increasingly prostate artery embolization is being utilized in this patient population. Technical demands for this procedure in this population can be significant. This article describes the optimal techniques, tricks, and advanced imaging techniques that can be used to achieve desired technical outcomes.