Lúcia Fernandes

Embolisation of prostatic arteries as treatment of moderate to severe lower urinary symptoms (LUTS) secondary to benign hyperplasia: results of short- and mid-term follow-up

AbstractObjectivesTo evaluate the short- and medium-term results of prostatic arterial embolisation (PAE) for benign prostatic hyperplasia (BPH).MethodsThis was a prospective non-randomised study including 255 patients diagnosed with BPH and moderate to severe lower urinary tract symptoms after failure of medical treatment for at least 6xa0months. The patients underwent PAE between March 2009 and April 2012. Technical success is when selective prostatic arterial embolisation is completed in at least one pelvic side. Clinical success was defined as improving symptoms and quality of life. Evaluation was performed before PAE and at 1, 3, 6 and every 6xa0months thereafter with the International Prostate Symptom Score (IPSS), quality of life (QoL), International Index of Erectile Function (IIEF), uroflowmetry, prostatic specific antigen (PSA) and volume. Non-spherical polyvinyl alcohol particles were used.ResultsPAE was technically successful in 250 patients (97.9xa0%). Mean follow-up, in 238 patients, was 10xa0months (range 1–36). Cumulative rates of clinical success were 81.9xa0%, 80.7xa0%, 77.9xa0%, 75.2xa0%, 72.0xa0%, 72.0xa0%, 72.0xa0% and 72.0xa0% at 1, 3, 6, 12, 18, 24, 30 and 36xa0months, respectively. There was one major complication.ConclusionsPAE is a procedure with good results for BPH patients with moderate to severe LUTS after failure of medical therapy.Key Points• Prostatic artery embolisation offers minimally invasive therapy for benign prostatic hyperplasia.n • Prostatic artery embolisation is a challenging procedure because of vascular anatomical variations.n • PAE is a promising new technique that has shown good results.

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

PURPOSEnTo 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).nnnMATERIALS AND METHODSnIn 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.nnnRESULTSnA 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.nnnCONCLUSIONSnPAs have highly variable origins between the left and right sides and between patients, and most frequently arise from the internal pudendal artery.

Prostatic Arterial Embolization for Benign Prostatic Hyperplasia: Short- and Intermediate-term Results

PURPOSEnTo evaluate the safety, morbidity, and short- and intermediate-term results of prostatic arterial embolization (PAE) for benign prostatic hyperplasia (BPH) after failure of medical treatment.nnnMATERIALS AND METHODSnThis prospective study was approved by the institutional review board, and informed consent was obtained from all participants. Men older than 50 years with a diagnosis of BPH and moderate-to-severe lower urinary tract symptoms that were refractory to medical treatment for 6 months were eligible. PAE with nonspherical 80-180-μm (mean, 100-μm) and 180-300-μm (mean, 200-μm) polyvinyl alcohol particles was performed by means of a single femoral approach in most cases. Effectiveness variables of International Prostate Symptom Score (IPSS), quality of life (QOL) score, peak urinary flow, postvoid residual volume, International Index Erectile Function (IIEF) score, prostate volume, and prostate-specific antigen level were assessed for up to 24 months after the procedure. Statistical analysis included the Kaplan-Meier method and random-effects generalized least squares regression with autoregressive disturbance.nnnRESULTSnEighty-nine consecutive patients (mean age, 74.1 years) were included. PAE was technically successful in 86 of the 89 patients (97%). Cumulative rates of clinical improvement in these patients were 78% in the 54 patients evaluated at 6 months and 76% in the 29 patients evaluated at 12 months. At 1-month follow-up, IPSS decreased by 10 points, QOL score decreased by 2 points, peak urinary flow increased by 38%, prostate volume decreased by 20%, postvoid residual volume decreased by 30 mL, and IIEF score increased by 0.5 point (all differences were significant at P < .01). These changes were sustained throughout the observation period. There was one major complication: Intraluminal necrotic tissue attached to the bladder, which was removed with simple surgery and did not necessitate wall reconstruction.nnnCONCLUSIONnPAE is a safe and effective procedure, with low morbidity, no sexual dysfunction, and good short- and intermediate-term symptomatic control associated with prostate volume reduction.

Unilateral Versus Bilateral Prostatic Arterial Embolization for Lower Urinary Tract Symptoms in Patients with Prostate Enlargement

PurposeThis study was designed to compare baseline data and clinical outcome between patients with prostate enlargement/benign prostatic hyperplasia (PE/BPH) who underwent unilateral and bilateral prostatic arterial embolization (PAE) for the relief of lower urinary tract symptoms (LUTS).MethodsThis single-center, ambispective cohort study compared 122 consecutive patients (mean age 66.7xa0years) with unilateral versus bilateral PAE from March 2009 to December 2011. Selective PAE was performed with 100- and 200-μm nonspherical polyvinyl alcohol (PVA) particles by a unilateral femoral approach.ResultsBilateral PAE was performed in 103 (84.4xa0%) patients (group A). The remaining 19 (15.6xa0%) patients underwent unilateral PAE (group B). Mean follow-up time was 6.7xa0months in group A and 7.3xa0months in group B. Mean prostate volume, PSA, International prostate symptom score/quality of life (IPSS/QoL) and post-void residual volume (PVR) reduction, and peak flow rate (Qmax) improvement were 19.4xa0mL, 1.68xa0ng/mL, 11.8/2.0 points, 32.9xa0mL, and 3.9xa0mL/s in group A and 11.5xa0mL, 1.98xa0ng/mL, 8.9/1.4 points, 53.8xa0mL, and 4.58xa0mL/s in group B. Poor clinical outcome was observed in 24.3xa0% of patients from group A and 47.4xa0% from group B (pxa0=xa00.04).ConclusionsPAE is a safe and effective technique that can induce 48xa0% improvement in the IPSS score and a prostate volume reduction of 19xa0%, with good clinical outcome in up to 75xa0% of treated patients. Bilateral PAE seems to lead to better clinical results; however, up to 50xa0% of patients after unilateral PAE may have a good clinical outcome.

Radiological Anatomy of Prostatic Arteries

One of the most challenging aspects of prostatic arterial embolization for patients with lower urinary tract symptoms and prostate enlargement or benign prostatic hyperplasia is identifying the prostatic arteries (PAs). With preprocedural computed tomography angiography it is possible to plan treatment and exclude patients when arterial anatomy is not suited, or when extensive atherosclerotic changes may affect technical success. There is an excellent correlation between the computed tomography angiography and digital subtraction angiography findings, enabling correct depiction of the male pelvic arterial anatomy (internal iliac branching patterns, relevant variants as accessory pudendal arteries, and PA anatomy). The prostate has a dual vascular arterial supply: a cranial or vesico-PA (named anterior-lateral prostatic pedicle) and a caudal PA (named posterior-lateral prostatic pedicle). These 2 prostatic pedicles may arise from the same artery in patients with only 1 PA (found in 60% of pelvic sides), or may arise independently in patients with 2 independent PAs (found in 40% of pelvic sides). The anterior-lateral prostatic pedicle vascularizes most of the central gland and benign prostatic hyperplasia nodules, frequently arises from the superior vesical artery in patients with 2 independent PAs, and is the preferred artery to embolize. The posterior-lateral prostatic pedicle has an inferior or distal origin, vascularizes most of the peripheral and caudal gland, and may have a close relationship with rectal or anal branches. In up to 60% of cases considerable anastomoses may be seen between the prostatic branches and surrounding arteries that should be taken into account when planning embolization. PAs lack pathognomonic digital subtraction angiography features; thus correct anatomical identification of the male pelvic and PAs is necessary to avoid untargeted ischemia to the bladder, rectum, anus, or corpus cavernosum.

Middle rectal artery: myth or reality? Retrospective study with CT angiography and digital subtraction angiography

This work aimed to study the prevalence and radiologic anatomy of the middle rectal artery (MRA) using computed tomographic angiography (CTA) and digital subtraction angiography (DSA). The retrospective study (October 2010–February 2012) focused in 167 male patients with prostate enlargement (mean age 64.7xa0years, range 47–81xa0years) who underwent selective pelvic arterial embolization for the relief of lower urinary tract symptoms. All patients underwent CTA previously to DSA to evaluate the vascular anatomy of the pelvis and to plan the treatment. MRAs were identified and classified according to their origin, trajectory, termination and relationship with surrounding arteries. We found MRAs in 60 (35.9xa0%) patients (23.9xa0% of pelvic sides, nxa0=xa080) and of those, 20 (12xa0%) had bilateral MRAs; 24 MRAs (30xa0%) were independent of neighbouring arteries and 56 MRAs (70xa0%) had common origins with prostatic arteries (prostato-rectal trunk). The most frequent MRA origin was the internal pudendal artery (60xa0%, nxa0=xa048), followed by the inferior gluteal artery (21.3xa0%, nxa0=xa017) and common gluteal-pudendal trunk (16.2xa0%, nxa0=xa013). In 2 patients the MRA originated from the obturator artery (2.5xa0%). Anastomoses to the superior rectal and inferior mesenteric arteries were found in 87.5xa0% of cases (nxa0=xa070). We concluded that MRAs are anatomical variants present in less than half of male patients; have variable origins and frequently share common origins with prostatic arteries. Their correct identification is likely to contribute to improve interventional radiology procedures and prostatic or rectal surgeries.

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

OBJECTIVEnThe purpose of this article is to review the CT angiographic and digital subtraction angiographic features of the male pelvic arteries.nnnCONCLUSIONnAn 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.