Prostatic artery embolization for patients with lower urinary symptoms due to benign prostatic hyperplasia: preliminary results from a single center
The aim of this study is to investigate safety and clinical outcome of prostatic artery embolization (PAE) in patients with symptomatic bladder outlet obstruction (BOO) due to benign prostatic hyperplasia (BPH).
Materials and Methods
PAE is a one-day-stay procedure, performed by an interventional radiologist. Some day before an AngioCT is accomplished, in order to evaluate the detailed anatomy of the hypogastric region. Before and/or during embolization, analgesic and anti-inflammatory drugs are administered intravenously. Embolization is performed under local anesthesia with a unilateral access approach, in most cases, via the right femoral artery. A 5-F Cobra-shaped catheter is introduced into the right femoral artery to catheterize the left hypogastric artery and then its anterior division. Angiography of the anterior division of the hypogastric artery is performed in the ipsilateral oblique view to visualize the anatomy of prostatic arteries. The prostatic vessels are then selectively catheterized with a 3-F, coaxial microcatheter (Progreat Terumo TM) or with a Renegade microcatheter and a 0.14 guidewire (Boston ScientificTM). Another angiogram is obtained to confirm the position of the catheter in the prostatic artery before embolization. The endpoint chosen for embolization is slow flow or “near stasis” in the prostatic vessels, with interruption of the arterial flow and prostatic gland opacification. From January 2013 to January 2015 we performed PAE in 11 consecutive patients (mean age 79.3 years, range 75-84 y) affected by clinical BPH and lower urinary tract symptoms (LUTS) refractory to medical treatments (3 of them had an indwelling bladder catheter). Magnetic resonance imaging (MRI) or transrectal prostatic ultrasound (TRUS), uroflowmetry (UFM), International Prostate Symptoms Score (IPSS) were performed pre-operatory and at 3, 6 and 12 months to evaluate clinical and functional outcomes. Clinical success was considered as symptoms improvement (IPSS reduction at least 25% of the total score and lower than 15 points), quality of life improvement (reduction of Qol at least 1 point and or equal or lower to 3 points) and no need of medical therapy or any other treatment after PAE.
Bilateral embolization was technically successfully in 9 out of 11 patients (81.8%). Clinical success was reported in 88.8% of patients (8/9 pts). All patients had their catheter removed after the procedure (median 13 days, range 10 to 21), but one of them experienced acute urinary retention, requiring again an indwelling bladder catheter. Two patients required a longer hospital stay due to transient fever. We observed a reduction of International Prostate Symptoms Score at 12 months (12.3 points), a prostate volume reduction (mean 24%), a reduction of Qol (1 point ) and an increase of Qmax (mean 4,3). No major complications were reported.
Although several drugs are presently avalaible for the management of BPH, in case of progression the disease can be treated only by surgery, endoscopic or open (in case of larger prostates). PAE can represent an attractive mininvasive alternative, requiring local anesthesia and short hospital stay. Anyway, it requires a highly skilled professional to selectively catheterize the distal branches of the hypogastric arteries, mainly in vasculopatic, elderly patients. Although the procedure is presently offered to the high-risk subject, early experiences adumbrate better results for younger and healthier men, with a more patent arterial system, prone to an extensive occlusion of the prostatic arterial supply.
PAE appears to be a safe and feasible (although technically demanding) nonoperative procedure. Preliminary results indicate a potential for meaningful clinical benefits, mainly in larger prostates. Patients can be treated safely by PAE with low rates of side effects, reducing prostate volume with clinical symptoms and quality of life improvement. A multidisciplinary approach with urologists and interventional radiologists is essential to achieve better results. Nevertheless, our experience is too limited to draw extensive conclusions, although presently it is encouraging in terms of short term outcome. We showed clinical benefits, feasibility and safety of this procedure, although more randomized clinical trials are necessary to validate the efficacy and safety of PAE.
Pisco JM, Pinheiro LC, Bilhim T, et al. Prostatic arterial embolization to treat benign prostatic hyperplasia. J Vasc Interv Radiol. 2011;22:11-19.Argomenti: ipertrofia prostatica