L. Fernandes

Medium- and Long-Term Outcome of Prostate Artery Embolization for Patients with Benign Prostatic Hyperplasia: Results in 630 Patients.

PURPOSE To confirm that prostatic artery embolization (PAE) has a positive medium- and long-term effect in symptomatic benign prostatic hyperplasia (BPH). MATERIALS AND METHODS Between March 2009 and October 2014, 630 consecutive patients with BPH and moderate-to-severe lower urinary tract symptoms refractory to medical therapy for at least 6 months or who refused any medical therapy underwent PAE. Outcome parameters were evaluated at baseline; 1, 3, and 6 months; every 6 months between 1 and 3 years; and yearly thereafter up to 6.5 years. RESULTS Mean patient age was 65.1 years ± 8.0 (range, 40-89 y). There were 12 (1.9%) technical failures. Bilateral PAE was performed in 572 (92.6%) patients and unilateral PAE was performed in 46 (7.4%) patients. The cumulative clinical success rates at medium- and long-term follow-up were 81.9% (95% confidence interval [CI], 78.3%-84.9%) and 76.3% (95% CI, 68.6%-82.4%). There was a statistically significant (P < .0001) change from baseline to last observed value in all clinical parameters: International Prostate Symptom Score (IPSS), quality-of-life (QOL), prostate volume, prostate-specific antigen, urinary maximal flow rate, postvoid residual, and International Index of Erectile Function. There were 2 major complications without sequelae. CONCLUSIONS PAE had a positive effect on IPSS, QOL, and all objective outcomes in symptomatic BPH. The medium- (1-3 y) and long-term (> 3-6.5 y) clinical success rates were 81.9% and 76.3%, with no urinary incontinence or sexual dysfunction reported.

Surgical Treatment: Prostate Artery Embolization

Prostate artery embolization (PAE) induces peri-urethral prostate tissue necrosis relieving the urethral obstruction with an overall reduction in prostate size associated with lower smooth muscle tone. These changes lead to symptomatic relief and increase of peak urinary flowrate (Qmax) in patients with symptomatic benign prostatic hyperplasia (BPH). Knowledge of the male pelvic and prostatic arterial anatomy is relevant to perform PAE safely. The number of independent prostate arteries, their origins and the presence of anastomoses are key aspects to perform a selective embolization of the prostate avoiding untargeted embolization of the bladder, rectum or penis. Prostate volume failed to be a predictor of technical or clinical outcome. Thus, large prostates do no translate into easier PAE procedures or better clinical outcomes after embolization. PAE has shown to be safe and effective for patients with BPH and prostates larger than 100 cm3, with a mean prostate volume reduction from 110–140 cm3 down to 71–91 cm3 (31–58%). Mean international prostate symptom score (IPSS) improvement ranging from 13–20 points (49–85%); mean Quality-of-life (QoL) improvement ranging from 1.8–3.5 points (40–73%) and mean Qmax increase ranging from 4–9.6 mL/s (40–132%). PAE is a safe and effective technique to treat symptomatic BPH, with durable results up to at least 4 years that can be used in patients that are unwilling or unfit to undergo surgery, regardless prostate size. PAE can also be used as a downsizing technique for large prostates to avoid open prostatectomy and allowing safer endoscopic prostatic surgery.

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.