Marisa Duarte

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.

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.

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

PURPOSE To 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. MATERIALS AND METHODS This 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. RESULTS Eighty-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. CONCLUSION PAE 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.

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.

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.

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.

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.

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.

Prostate Embolization as an Alternative to Open Surgery in Patients with Large Prostate and Moderate to Severe Lower Urinary Tract Symptoms.

PURPOSE To evaluate efficacy of prostate artery embolization (PAE) in patients with benign prostatic hyperplasia (BPH), prostate volume (PV) > 100 cm(3). MATERIALS AND METHODS This was a single-center retrospective cohort study. Between March 2009 and September 2014, PAE was performed in patients with a diagnosis of BPH, PV > 100 cm(3), and moderate to severe lower urinary tract symptoms (LUTS) refractory to medical treatment for at least 6 months or who had acute urinary retention. Success was defined as improved symptoms (International Prostate Symptom Score ≤ 15 and decrease of ≥ 25% from baseline score), improved quality of life (measured as score of ≤ 3 points or decrease of ≥ 1 point from baseline), and no need for additional treatment. RESULTS PAE was performed in 152 patients 48-87 years old (mean ± SD 67.4 y ± 7.5) with mean PV of 134.2 cm(3) ± 41.8 (range, 101-383 cm(3)). PAE was technically successful in 149 patients (98.0%). Symptomatic control was achieved for a median of 18 months ± 15.5 (range, 3-66 mo). There were 33 clinical failures (23.6%); 23 occurred in the short-term (≤ 6 mo), and 10 occurred in the medium-term (6-24 mo); there were no long-term failures (> 36 mo). Cumulative clinical success rates were 90%, 87.9%, 83.5%, 81.1%, and 77.8% at 1, 3, 6, 12, and 18 months and 72.4% thereafter to 66 months (5.5 y). CONCLUSIONS PAE provides sustained short-, medium-, and long-term control for LUTS in patients with BPH and PV > 100 cm(3).