José Pereira

Prostatic Arterial Supply: Anatomic and Imaging Findings Relevant for Selective Arterial Embolization

PURPOSE To describe the anatomy and imaging findings of the prostatic arteries (PAs) on multirow-detector pelvic computed tomographic (CT) angiography and digital subtraction angiography (DSA) before embolization for symptomatic benign prostatic hyperplasia (BPH). MATERIALS AND METHODS In a retrospective study from May 2010 to June 2011, 75 men (150 pelvic sides) underwent pelvic CT angiography and selective pelvic DSA before PA embolization for BPH. Each pelvic side was evaluated regarding the number of independent PAs and their origin, trajectory, termination, and anastomoses with adjacent arteries. RESULTS A total of 57% of pelvic sides (n = 86) had only one PA, and 43% (n = 64) had two independent PAs identified (mean PA diameter, 1.6 mm ± 0.3). PAs originated from the internal pudendal artery in 34.1% of pelvic sides (n = 73), from a common trunk with the superior vesical artery in 20.1% (n = 43), from the anterior common gluteal-pudendal trunk in 17.8% (n = 38), from the obturator artery in 12.6% (n = 27), and from a common trunk with rectal branches in 8.4% (n = 18). In 57% of pelvic sides (n = 86), anastomoses to adjacent arteries were documented. There were 30 pelvic sides (20%) with accessory pudendal arteries in close relationship with the PAs. No correlations were found between PA diameter and patient age, prostate volume, or prostate-specific antigen values on multivariate analysis with logistic regression. CONCLUSIONS PAs have highly variable origins between the left and right sides and between patients, and most frequently arise from the internal pudendal artery.

How to Perform Prostatic Arterial Embolization

Prostatic arterial embolization (PAE) is an experimental alternative treatment for benign prostatic hyperplasia, with promising preliminary results. In comparison with surgery, its main advantages are the minimally invasive nature, outpatient setting, rapid recovery, and low morbidity. To avoid complications and to achieve technical success it is important to know the procedural technique in detail. In addition, for good clinical results, it is important to perform a bilateral and complete prostatic embolization. In this article, the different technical steps, including the initial site of puncture and the catheters and guidewires to be used, are described. Identification of the prostatic arteries is crucial. Correlation between computed tomography angiography and digital subtraction angiography helps to solve the difficulty of such identification. The skills for superselective catheterization of the prostatic arteries, the amounts of contrast injected, the preparation and size of the used particles and the end point of the procedure are also described.

Patient Selection and Counseling before Prostatic Arterial Embolization

Prostatic arterial embolization (PAE) for relief of lower urinary tract symptoms (LUTS) in patients with prostate enlargement or benign prostatic hyperplasia (PE or BPH) is an experimental procedure with promising preliminary results. Patient evaluation and selection before PAE is paramount to improve technical and clinical results. Our inclusion criteria for PAE include: male patients, age>40 years, prostate volume>30 cm(3) and diagnosis of PE or BPH with moderate to severe LUTS refractory to medical treatment for at least 6 months (International Prostate Symptom Score [IPSS]>18, or quality of life [QoL]>3, or both) or with acute urinary retention refractory to medical therapy. Exclusion criteria include: malignancy (based on pre-embolization digital rectal and transrectal ultrasound [TRUS] examinations and prostate specific antigen [PSA] measurements with positive biopsy), large bladder diverticula, large bladder stones, chronic renal failure, tortuosity and advanced atherosclerosis of a) iliac or b) prostatic arteries on pre-procedural computed tomographic angiography (CTA), active urinary tract infection and unregulated coagulation parameters. Approximately one-third of the patients seen initially on consultation satisfy the criteria to be selected for PAE after undergoing the pre-procedural patient evaluation workflow. In the pre-procedural consultation patients are informed of all possible therapeutic options for LUTS with the investigational nature of the procedure being strongly reinforced. The major advantage of PAE relies on the minimally-invasive nature of the technique with minimal morbidity and rapid recovery,and it being performed as an outpatient procedure. However, the experimental nature and uncertain clinical outcome should also be weighed before opting for PAE. All these considerations should be explained to the patient and discussed during the informed consent before PAE.

Angiographic Anatomy of the Male Pelvic Arteries

OBJECTIVE The purpose of this article is to review the CT angiographic and digital subtraction angiographic features of the male pelvic arteries. CONCLUSION An increasing number of vascular procedures are being performed in the male pelvis that require profound knowledge of the angiographic anatomy of the internal iliac artery (IIA). The major branches of the IIA in men can be used to classify the branching patterns. After the larger IIA branches are identified, identification of the smaller arteries or relevant anatomic variants becomes easier.

Prostatic Artery Embolization in the Treatment of Benign Prostatic Hyperplasia: Short and Medium Follow-up

To evaluate the short and mid-term results of prostatic artery embolization in patients with benign prostatic embolization. Retrospective study between March 2009 and June 2011 with 103 patients (mean age 66.8 years, 50-85) that met our inclusion criteria with symptomatic benign prostatic hyperplasia. The clinical outcome was evaluated by the International Prostate Symptom Score (IPSS), quality of life (QoL), International Index of Erectile Function, prostate volume (PV), prostate-specific antigen (PSA), peak urinary flow (Q(max)), and post-void residual volume (PVR) measurements at 3 and 6 months, 1 year, 18 months, and 2 years after PAE and comparison with baseline values was made. Technical and clinical successes, as well as poor clinical outcome definitions, were previously defined. In this review, we evaluate the short and mid-term clinical outcomes and morbidity of patients treated only with non-spherical polyvinyl alcohol. Six months after the procedure, the PV decreased about 23%, IPSS changed to a mean value of 11.95 (almost 50% reduction), the QoL improved slightly more than 2 points, the Q(max) changed to a mean value of 12.63 mL/s, the PVR underwent a change of almost half of the baseline value, and the PSA decreased about 2.3 ng/mL. In the mid-term follow-up and comparing to the baseline values, we still assisted to a reduction in PV, IPSS, QoL, PVR, and PSA, and an increase in Q(max). Prostatic Artery Embolization is a safe procedure with low morbidity that shows good short- and mid-term clinical outcome in our institution.

Prostatic arterial embolization: post-procedural follow-up.

Prostatic arterial embolization (PAE) gained special attention in the past years as a potential minimally invasive technique for benign prostatic hyperplasia. Treatment decisions are based on morbidity and quality-of-life issues and the patient has a central role in decision-making. Medical therapy is a first-line treatment option and surgery is usually performed to improve symptoms and decrease the progression of disease in patients who develop complications or who have inadequately controlled symptoms on medical treatment. The use of validated questionnaires to assess disease severity and sexual function, uroflowmetry studies, prostate-specific antigen and prostate volume measurements are essential when evaluating patients before PAE and to evaluate response to treatment. PAE may be performed safely with minimal morbidity and without associated mortality. The minimally invasive nature of the technique inducing a significant improvement in symptom severity associated with prostate volume reduction and a slight improvement in the sexual function are major advantages. However, as with other surgical therapies for benign prostatic hyperplasia, up to 15% of patients fail to show improvement significantly after PAE, and there is a modest improvement of the peak urinary flow.

The Role of Accessory Obturator Arteries in Prostatic Arterial Embolization

In 9 of 491 patients (1.8%) who underwent prostatic arterial embolization (PAE) for benign prostatic hyperplasia from March 2009-November 2013, prostatic arteries arose from the external iliac artery via an accessory obturator artery (AOA). Computed tomography angiography performed before the procedure identified the variant and allowed planning before the procedure. The nine AOAs were catheterized from a contralateral femoral approach. Bilateral PAE was technically successful in the nine patients. There was a mean decrease in international prostate symptom score of 6.5 points and a mean prostate volume reduction of 15.1% (mean follow-up, 4.8 mo) in the nine patients.

Spontaneous Pregnancy with a Live Birth after Conventional and Partial Uterine Fibroid Embolization

Purpose To determine pregnancy rates after conventional and partial uterine fibroid embolization (UFE). Materials and Methods The study received institutional review board approval and all patients gave written informed consent. A retrospective analysis of data collected prospectively was performed between June 2004 and June 2014 in a cohort of 359 women (mean age, 35.9 years ± 4.8) with uterine fibroids and/or adenomyosis who were unable to conceive. The median follow-up period was 69 months (range, 6-126 months). Under local anesthesia, both uterine arteries were embolized. In 160 patients, partial embolization was intentionally performed to preserve fertility, which may be decreased after conventional UFE. In partial UFE, only the small arterial vessels to the fibroids were embolized, leaving the large vessels of the fibroids patent. The Kaplan-Meier method and Cox regression were used for the statistical analysis. Results During follow-up, 149 women became pregnant, 131 women had live births, and 16 women had several pregnancies, resulting in a total of 150 live newborns. It was the first pregnancy for 85.5% (112 of 131) of women. Spontaneous pregnancy rates at 1 year and 2 years after UFE were 29.5% and 40.1%, respectively. The probability of successful pregnancy with live birth at 1 year and 2 years was 24.4% and 36.7%, respectively. Clinical success for fibroid-related symptoms was 78.6% (282 of 359). A dominant submucosal fibroid and ischemia greater than or equal to 90% had greater likelihood of spontaneous pregnancy. Complication rates in patients treated with partial UFE (14.6%) were not greater than rates in patients treated with conventional UFE (23.1%, P = .04). Conclusion Conventional and partial UFE may be safe and effective outpatient procedures for women with uterine fibroids who want to conceive.

Dieulafoy's Lesion: The Role of Endoscopic Ultrasonography as a Roadmap

body and fundus. Repeated UGE showed no mucosal defect. Radial endoscopic ultrasound (EUS) was performed, indicating a submucosal vessel arising in the greater curvature of the proximal gastric body which identified a Dieulafoy’s lesion as the possible source of bleeding. Considering clinical stability, EUS-guided therapy with linear scope was planned for the next morning when the scope was available, but rebleeding occurred. UGE was performed with a therapeutic scope, as the site of bleeding was already identified and active bleeding was expected. Thus, the advantages of a dual channel scope, which is more easily maneuvered, would outweigh the advantages of using the echoendoscope, which has the main benefit when the Dieulafoy’s lesion cannot be identified on UGE because it is no longer bleeding. UGE revealed an adherent clot in the suspected Dieulafoy’s lesion location previously described on EUS. After the first clip deployment, massive bleeding occurred. Hemostasis was achieved after adrenalin and polidocanol injection and clipping. EUS was performed to confirm vessel obliteration but still identified a large caliber (2.5 mm) feeding vessel arising

MP71-10 UNILATERAL VERSUS BILATERAL PROSTATIC ARTERIAL EMBOLIZATION IN PATIENTS WITH BENIGN PROSTATIC HYPERPLASIA

Purpose: To evaluate whether total splenic artery embolization (TSAE) for patients with hypersplenism delivers better long-term outcomes than partial splenic embolization (PSE). Materials and Methods: Sixty-one patients with hypersplenism eligible for TSAE (n 1⁄4 27, group A) or PSE (n 1⁄434, group B) were enrolled into the trial, which included clinical and computed tomography (CT) follow-up. Data on technical success, length of hospital stay, white blood cell (WBC) and platelet (PLT) counts, splenic volume and complications were collected at 2 wk, 6 mo, and 1, 2, 3, 4 years postoperatively. Results: Both TSAE and PSE were technically successful in all patients. Complications were significantly fewer (P 1⁄4 0.001), and hospital stay significantly shorter (P 1⁄4 0.007), in group A than in group B. Post-procedure WBC and PLT counts in group A were significantly higher than those in group B from 6 mo to 4 years (P 1⁄4 0.001), and post-procedure residual splenic volume in group A was significantly less than that observed in group B at 1, 2, 3 and 4 years post-procedure (P 1⁄4 0.001). No significant differences were observed in red blood cell counts and liver function parameters between the two groups following the procedure. Conclusion: Our results indicate that TSAE for patients with hypersplenism not only delivers a better long-term outcome, but is also associated with lower complication rates and a shorter hospital stay than PSE.