J.M. Pisco

Prostatic Arterial Embolization to Treat Benign Prostatic Hyperplasia

PURPOSE To evaluate whether prostatic arterial embolization (PAE) might be a feasible procedure to treat lower urinary tract symptoms associated with benign prostatic hyperplasia (BPH). MATERIALS AND METHODS Fifteen patients (age range, 62-82 years; mean age, 74.1 y) with symptomatic BPH after failure of medical treatment were selected for PAE with nonspherical 200-μm polyvinyl alcohol particles. The procedure was performed by a single femoral approach. Technical success was considered when selective prostatic arterial catheterization and embolization was achieved on at least one pelvic side. RESULTS PAE was technically successful in 14 of the 15 patients (93.3%). There was a mean follow-up of 7.9 months (range, 3-12 months). International Prostate Symptom Score decreased a mean of 6.5 points (P = .005), quality of life improved 1.14 points (P = .065), International Index of Erectile Function increased 1.7 points (P = .063), and peak urinary flow increased 3.85 mL/sec (P = .015). There was a mean prostate-specific antigen reduction of 2.27 ng/mL (P = .072) and a mean prostate volume decrease of 26.5 mL (P = .0001) by ultrasound and 28.9 mL (P = .008) by magnetic resonance imaging. There was one major complication (a 1.5-cm(2) ischemic area of the bladder wall) and four clinical failures (28.6%). CONCLUSIONS In this small group of patients, PAE was a feasible procedure, with preliminary results and short-term follow-up suggesting good symptom control without sexual dysfunction in suitable candidates, associated with a reduction in prostate volume.

Pregnancy after uterine fibroid embolization

OBJECTIVE To evaluate the outcome of pregnancy after uterine fibroid embolization (UFE). DESIGN Retrospective study. SETTING Private hospital affiliated with a university. PATIENT(S) In a single center, UFE was performed in 74 patients who wanted to become pregnant. INTERVENTION(S) Polyvinyl alcohol particles (PVA) or embozene microspheres were used to embolize the uterine arteries. Enhanced pelvic magnetic resonance was performed before UFE and 6 months after UFE in all patients. MAIN OUTCOME MEASURE(S) The number of pregnancies and their development. RESULT(S) Of the 74 women who wanted to become pregnant, 44 of them became pregnant (59.5%). There are five (11.3%) ongoing pregnancies and 39 (88.7%) finished pregnancies, with 33 successful live births (84.6%), four spontaneous abortions (10.3%), one induced abortion, and one stillbirth. There were 22 cesarean deliveries (66.6%), two preterm deliveries at 36 weeks (6.1%), and five low birth weights. CONCLUSION(S) Pregnancy after UFE appears to be safe.

Pelvic Pain after Uterine Artery Embolization: A Prospective Randomized Study of Polyvinyl Alcohol Particles Mixed with Ketoprofen versus Bland Polyvinyl Alcohol Particles

PURPOSE To evaluate whether pelvic pain following uterine artery embolization (UAE) can be decreased by using ketoprofen mixed with polyvinyl alcohol (PVA). MATERIALS AND METHODS A randomized prospective study was performed in 80 patients (age range, 25-52 years; mean age, 41 years) undergoing UAE with PVA between March and August 2006. Forty patients received PVA particles mixed with ketoprofen, and 40 received bland PVA particles. Fifty-three patients who were asymptomatic 8 hours after embolization were discharged. Pain scores were compared during the first 8 hours after the procedure, at discharge, and the following day. The results were evaluated after 6 months. RESULTS Eight hours after UAE, 13 of the 40 patients in the group without ketoprofen (32%) reported severe or very severe pain, whereas none of the patients in the group receiving ketoprofen reported severe or very severe pain, as determined with a numeric pain score scale (P = .0015). Nineteen of the 40 patients without ketoprofen (48%) were treated as inpatients, but only 10 in the ketoprofen group (25%) were treated as inpatients. The differences in the clinical outcome, as well in the uterus and fibroid sizes at discharge and at 6 months, were not statistically significant (P > .05). CONCLUSIONS The use of PVA particles mixed with ketoprofen resulted in a statistically significant reduction in pelvic pain during the first 8 hours after UAE as compared to the use of PVA alone. However, no significant differences in pain scores were seen after 8 hours. These findings may lead to a reduction in inpatient management for UAE; however, further study of this approach is warranted.

Management of Uterine Artery Embolization for Fibroids as an Outpatient Procedure

PURPOSE To evaluate whether it is safe to perform uterine artery embolization (UAE) as an outpatient procedure. MATERIALS AND METHODS This retrospective study was approved by the institutional review board and included 234 patients (age range, 24-58 years; mean age, 40.5 years) who underwent UAE as an outpatient procedure with polyvinyl alcohol particles between January 2007 and March 2008. Patients were given acid-suppressing drugs, nonsteroidal anti-inflammatory drugs, anti-histaminic drugs, and laxatives twice on the day before UAE and once on the morning of UAE. Pain score, rated from 0 to 10, was evaluated by using a numeric pain scale during UAE, after the procedure, at discharge, at the night of discharge, and on the following morning. The outcome of UAE was evaluated at 6 months by means of pelvic magnetic resonance imaging and clinical observation. RESULTS The mean pain score was 0.9 during embolization, 2.5 4-8 hours after embolization, 0.9 at discharge, 1.1 the first night after discharge, and 0.7 the next morning. All patients were discharged from the hospital 4-8 hours after the procedure, with no overnight hospital admissions. At 6 months, 146 of 158 patients (92.4%) reported an improvement in menorrhagia, 39 of 44 (88.6%) reported an improvement in bulk symptoms, and 20 of 25 (80%) reported an improvement in pain. The volumes of the uterus and the dominant fibroid decreased 33.7% and 39.3%, respectively. CONCLUSIONS With acid-suppressing, anti-inflammatory, and anti-histaminic drugs started on the day before UAE, the procedure can be performed safely as an outpatient procedure.

Uterine Artery Embolization under Electroacupuncture for Uterine Leiomyomas

PURPOSE To evaluate whether electroacupuncture is a safe and effective alternative to pharmacologic sedation/analgesia in uterine artery embolization (UAE) for leiomyomas. MATERIALS AND METHODS A nonrandomized prospective study was undertaken in 70 consecutive patients (mean age, 39.5 years) undergoing UAE with polyvinyl alcohol (PVA) particles between August 2006 and January 2007. Thirty-three patients chose to undergo UAE under electroacupuncture anesthesia (EAA; group A) and 37 were treated under local pharmacologic anesthesia (group B). Pain scores (rated from 0 to 10) in both groups were compared during and after the procedure. The outcome of UAE was evaluated at 6 months. RESULTS Mean pain scores during embolization were 0.36 in group A and 0.84 in group B; scores after embolization and before discharge were 3.00 in group A and 4.49 in group B; and scores at discharge were 0.97 in group A and 2.11 in group B. These differences were statistically significant after embolization and at hospital discharge (P= .02 and P= .0001, respectively). All patients except one in each group were discharged from the hospital 4-8 hours after UAE; the two who remained longer had severe pain. There were no significant differences in clinical outcomes, nor in uterine and leiomyoma volumes, at discharge and at 6 months (P > 0.99 and P= .72, respectively). CONCLUSIONS There was a statistically significant postembolization pain reduction in patients treated under EAA versus local pharmacologic anesthesia and no differences in UAE outcomes between groups at 6 months.

Polyvinyl alcohol particle size for prostatic artery embolization: a prospective randomized study of 100 μm particles versus 200 μm particles

Purpose Evaluate whether different polyvinyl alcohol (PVA) particle sizes change the outcome of prostatic artery embolization (PAE) for Benign Prostatic Hyperplasia (BPH). Materials and Methods Randomized prospective study, 80 patients with BPH undergoing PAE (May - December 2011). PAE was performed with 100 μm particles in 40 patients (Group A); and 200 μm particles in 40 patients (Group B). Pain was measured (0 - 10) during PAE, after 4-8 hours and the week following PAE. Complication rates were compared. The outcome of PAE was evaluated by IPSS, QoL and IIEF measurements, prostate volume reduction, PSA, Qmax and PVR measurements at 3 and 6 months. Results Patients lost to follow-up: 2 (Group A); 5 (Group B). Mean baseline data between groups (age; prostate volume; PSA; IPSS/QoL; Qmax; post-void residual volume; acute urinary retention rate): 64.4 years; 78.4 mL; 5.4 ng/mL; 22.5/4.7 points; 8.1 mL/s; 106.8 mL; 7.9% (n=3) in Group A; 63.9 years; 81.9 mL; 9.0 ng/mL; 22.3/4.3 points; 10.2 mL/s; 90.9 mL; 8.6% (n=3) in Group B. Mean PVA volume used: 0.33cc in Group A; 0.4cc in Group B. Unilateral PAE - 18.4% (n=7) in Group A; 22.9% (n=8) in Group B. Mean pain scores during embolization: 3.3 (group A); 3.3 (group B); after embolization, mean pain scores: 0.1 (group A) and 0 (group B). There were no statistically significant differences in the minor complication rates, with no major complications. Mean IPSS/QoL reduction: 6.0/1.7 (Group A); 10.7/1.9 (Group B); mean prostate volume reduction: 14.7% (Group A); 6% (Group B). Poor clinical outcome: 47.4% (n=18, Group A); 25.7% (n=9, Group B); p=0.04. Conclusion No significant differences were noted in pain severity or complication rates after PAE for BPH using 100 μm or 200 μm PVA particles. The clinical outcome at 3 and 6 months was significantly better with 200 μm PVA particles, but there was a greater prostate volume and PSA reduction with 100 μm PVA particles.

Prostatic arterial embolization: can MR findings predict treatment outcome?

Purpose Evaluate if MR findings after prostatic artery embolization (PAE) for benign prostatic hyperplasia (BPH) can predict treatment outcome. Materials and Methods Prospective study (January 2012 - July 2012). Contrast-enhanced MR (injection of 0.2mmol/kg gadolinium chelate at 3mL/s) was performed using a 1.5T scanner before and after PAE for BPH in 25 patients (mean age 62.8 ± 7.9 years). Poor outcome after PAE considered when 1 criteria was met: International Prostate Symptom Score (IPSS) ≥ 20 and/or reduction Results Contrast-enhanced MR was performed 3 months after PAE in 4 patients and in the first month after PAE in the remaining 21 patients. Five patients (20%) had ischemic changes > 50% on MR (all in the first month after PAE) - Group A - all embolized with PVA 100 + 200 μm; mean prostate volume reduction of 17%; all with good clinical outcome; mean IPSS/QoL reduction of 14.2/2.4 points. Seven patients (28%) with ischemic changes Conclusion Approximately half of the patients have ischemic changes on contrast-enhanced MR in the first month after PAE. The greatest ischemic changes were found with 100 + 200 μm PVA particles. Higher ischemic changes were associated with better clinical outcome. Prostate volume reduction did not correlate with ischemic changes or clinical outcome.

Best embolic agent for prostatic artery embolization in bph patients: a prospective randomized study of 300-500 μm tris-acryl gelatin microspheres versus 100+200 μm PVA particles

Purpose Compare the clinical outcome of prostatic artery embolization (PAE) for Benign Prostatic Hyperplasia (BPH) using 300-500 μm tris-acryl gelatin microspheres versus 100+200 μm PVA particles. Materials and Methods Randomized prospective study, 80 patients with BPH undergoing PAE (January-May 2012). PAE was performed with 300-500 μm tris-acryl gelatin microspheres (MS) in 40 patients (Group A); and 100+200 μm PVA particles in 40 patients (Group B). Pain was measured (0 - 10) during PAE, after 4-8 hours and the week following PAE. Complication rates were compared. The outcome of PAE was evaluated by IPSS, QoL and IIEF measurements, prostate volume reduction, PSA, Qmax and PVR measurements at 3 and 6 months. Results Patients lost to follow-up: 5 (Group A); 7 (Group B). Mean embolic volume used: 0.6mL MS in Group A; 0.5mL PVA in Group B. Mean pain scores during embolization: 1.5 (group A); 3.2 (group B); after embolization, mean pain scores: 0.1 (group A) and 0.2 (group B). There were no statistically significant differences in the minor complication rates, with no major complications. Mean IPSS/QoL reduction: 11.2/2.0 (Group A); 12/2.3 (Group B); mean prostate volume reduction: 19% (Group A); 24% (Group B). Poor clinical outcome: 21.2% (Group A); 22% (Group B). Conclusion No significant differences were noted in pain severity, complication rates or clinical outcome after PAE for BPH using 300-500 μm MS or 100+200 μm PVA particles.

Predictive factors of poor clinical outcome after prostatic arterial embolization for bph

Purpose Analyze the individual baseline parameters to predict the outcome of prostatic artery embolization (PAE) for benign prostatic hyperplasia (BPH). Materials and Methods Retrospective study (March 2009 - March 2012). Poor outcome after PAE considered when 1 criteria was met: International Prostate Symptom Score (IPSS) ≥ 20 and/or reduction Results PAE performed in 172 patients (mean follow-up 9.6 months; range 3-24 months). Poor outcome (Group A): 53 patients (30.8%, mean follow-up 11.0 months); Good outcome (Group B): 119 patients (69.2%, mean follow-up 9.0 months). In Group A 11.3% (n=6) and in Group B 12.6% (n=15) of patients were under acute urinary retention before PAE (p=0.5). In Group A 37.7% (n=20) and in Group B 28.6% (n=34) of patients were medicated with 5-alpha reductase inhibitors before PAE (p=0.3). Mean baseline parameters (age/prostate volume/PSA/IPSS/QoL/Qmax/Post-void residual volume - PVR) - Group A: 67.3 years / 81.1 mL / 4.9 ng/mL / 23.9 / 4.5 / 9.0 mL/s / 100.0 mL; Group B: 64.7 years / 84.0 mL / 5.9 ng/mL / 23.5 / 4.2 / 9.3 mL/s / 97.6 mL (p>0.05). Unilateral embolization performed in 11 patients from Group A (20.8%) and 14 patients from Group B (11.8%) (p=0.2). PAE performed with 100 μm PVA particles in 45.3% (Group A) and 32.8% (Groups B) of patients; PAE performed with 200 μm PVA particles in 22.6% (Group A) and 32.8% (Groups B) of patients; PAE performed with 100 + 200 μm PVA particles in 18.9% (Group A) and 21.9% (Groups B) of patients; PAE performed with 300-500 μm microspheres in 13.2% (Group A) and 12.6% (Groups B) of patients (p=0.4). In Group A there were 40 (75.5%) non-responders and 13 (24.5%) relapses. Conclusion Approximately 30% of patients may have poor outcome in the first year after PAE for BPH and most are non-responders. There were no statistically significant differences in the baseline parameters between patients with poor and good clinical outcome. Unilateral embolization and PAE with 100 μm PVA particles were more frequent in patients with poor clinical outcome.

628 Clinical outcome of prostatic arterial embolization for patients with benign prostatic hyperplasia and moderate to severe lower urinary tract symptoms – 365 cases

follow-up is 6 months. Mean Qmax, PVR, IPSS, and QoL significantly improved (p 0.001) within the first month and either improved further or remained unchanged. Sexual function maintained and even improved. There were no case of SUI or retrograde ejaculation postoperative. The patient who received 2nd implants is integrated in the evaluation. Two patients underwent TURP due an unsatisfactory initial outcome. CONCLUSIONS: PUL is a minimal invasive surgical technique to alleviate BPH and voiding symptoms. These results are comparable with published clinical studies. It can be performed under LA and does not cause retrograde ejaculation or SUI. A larger patient group comparing treatment outcomes and follow-up are necessary.