Prostate artery embolisation: an all-comers, single-operator experience in 159 patients with lower urinary tract symptoms, urinary retention, or haematuria with medium-term follow-up

doi:10.1016/j.crad.2019.03.006

Clinical Radiology

Volume 74, Issue 7, July 2019, Pages 569.e1-569.e8

https://doi.org/10.1016/j.crad.2019.03.006 Get rights and content

Highlights

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PAE improves LUTS due to BPH out to at least 4 years post-embolisation.
•
PAE equally effective for LUTS in patients with concurrent prostate cancer.
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Prostate volume reduction on post-PAE MRI predicts clinical outcome.
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Patients with severe LUTS likely to derive long-lasting benefit from PAE.
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PAE is effective in treating intractable haematuria of prostatic origin.

AIM

To describe the authors' experience with prostate artery embolisation (PAE) to treat lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH) or refractory haematuria of prostatic origin (RHOPA).

MATERIALS AND METHODS

PAE was attempted in 159 patients. Procedural details, pre/post-PAE symptom scores, and pre/post-PAE magnetic resonance imaging (MRI) data were recorded. Statistical analysis was performed to determine clinical outcomes and factors predicting clinical success.

RESULTS

Technical success was achieved in 156 patients. In patients with LUTS, the International Prostate Symptom Score (IPSS) improved from a mean of 22 at baseline to 9.5 at 6-months post-PAE, then to 10.7, 10, 11.3, and 11 at 1, 2, 3, and 4 years. The quality of life (QoL) score improved from 4.6 at baseline to 2, 2.2, 2.4, 3.1, and 2.5 at the same time points. The International Index of Erectile Function (IIEF-5) scores remained stable. There was no significant difference in IPSS between bilateral or unilateral embolisation to 2 years, or between BPH alone or BPH with biopsy-proven prostate cancer to 3 years post-PAE. Percentage improvement in IPSS at 1 year correlated with percentage reduction in prostate volume on first post-PAE MRI. Percentage improvement in IPSS at 3 years correlated with initial IPSS. PAE facilitated urinary catheter removal in 13/24 patients in retention. PAE controlled bleeding in 12/12 patients with RHOPA.

CONCLUSION

PAE is safe and effective in the management of symptomatic BPH. Patients with the highest baseline IPSS and reduction in prostate volume on first post-PAE MRI are likely to derive most benefit from embolisation.

Introduction

Benign prostatic hyperplasia (BPH) causing lower urinary tract symptoms (LUTS) is a common condition in males resulting in bladder storage and voiding symptoms due to outflow obstruction. The estimated global prevalence of BPH is 26% and increases with age, particularly in those over 60 years.1, 2 Previously used only in the management of refractory haematuria of prostatic origin (RHOPA),³ prostate artery embolisation (PAE) is an emerging minimally invasive image-guided technique that has shown promising technical and clinical success in relieving symptoms of BPH, along with a reassuring safety profile.4, 5, 6 The aim of the present study was to describe a single-operator experience of PAE for the management of BPH (causing LUTS or requiring urethral catheterisation) and RHOPA in the UK, with medium-term clinical outcomes and an assessment of predictors of clinical success to complement recently published data in this area.

Section snippets

Materials and methods

Patients were reviewed by a consultant urologist prior to PAE. All elective embolisation cases were worked-up with a computed tomography (CT) arteriogram of the pelvis and discussed in a multidisciplinary team meeting. Patients were excluded if their CT arteriogram demonstrated bilateral internal iliac artery occlusion or if they had organ-confined prostate cancer and were eligible for curative resection. There were no other specific exclusion criteria; patients with metastatic prostate cancer,

Technical outcomes, dose analysis, and complications

PAE was attempted in 159 consecutive patients between January 2014 and June 2017, comprising 123 with LUTS, 24 catheterised due to urinary retention, and 12 patients with haematuria. Mean patient age at PAE was 70 years (range 49–98, standard deviation 10 years). Technical success (unilateral or bilateral embolisation) was achieved in 120 out of 123 patients with LUTS, and all 24 patients with indwelling catheter and 12 with haematuria. Of the 120 technical successes in patients with LUTS, five

Symptomatic improvement

The present data demonstrate that PAE is a safe and effective treatment option for patients with LUTS due to BPH, and that efficacy of embolisation (as measured by IPSS and QoL scores) can be sustained to 4 years post-procedure. The improvement in IPSS in the present series is similar to that reported in previous reports.6, 8, 9, 10, 11 IIEF scores remained essentially stable following PAE, and the small, but mostly not statistically significant, increase in IIEF seen is likely due to

Conflict of interest

The authors declare no conflict of interest.

Acknowledgements

The authors thank Amit Gupta and Shahzad Ilyas (Department of Interventional Radiology, Guys & St Thomas' NHS Foundation Trust, London UK), Kathie A. Wong and Meghana Kulkarni (Department of Urology, Guy's & St Thomas' NHS Foundation Trust, London, UK) for assistance in data collection.

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Cited by (9)

Comparison of 24-Month Clinical Outcomes after Prostatic Artery Embolization in Prostate Glands Larger versus Smaller than 80 mL: A Systematic Review
2023, Journal of Vascular and Interventional Radiology
This review was undertaken to compare the clinical outcomes of prostatic artery embolization (PAE) in patients with >80 versus <80 mL prostatic volume (PV) at the 24-month follow-up to determine whether PV predicted the effectiveness or durability of PAE.
The PubMed/MEDLINE database was searched for articles published between 2010 and 2022 using the search term “(prostat∗ artery embolization) AND (long term OR follow-up OR 24-month).” Articles were included if they discussed PAE for benign prostatic hyperplasia (BPH) and reported a minimum follow-up of 24 months. Articles with <10 patients were excluded. A subgroup analysis was performed to evaluate for any difference in clinical outcomes at the 24-month post-PAE follow-up between studies with a mean PV of >80 mL and those with a mean PV of <80 mL.
A total of 14 studies with 2,260 patients were included, all of which demonstrated significant reduction in symptoms at the 24-month follow-up after PAE. Four studies were included as part of the >80-mL PV subgroup (n = 467), and 10 studies were included as part of the <80-mL PV subgroup (n = 1,793). There was a statistically significant difference between the mean preprocedural PV (128.5 vs 64.0 mL; P = .015). At the 24-month follow-up, there were no significant differences between groups across any of the compared parameters. The collective incidence of major adverse events reported in the studies within this review was <1%.
PAE is both safe and durable for patients suffering from BPH and can be effective across a wide range of baseline PVs.
Comparison of water vapor thermal therapy and prostate artery embolization for fragile patients with indwelling urinary catheters: Preliminary results from a multi-institutional study
2022, Progres en Urologie
Citation Excerpt :
In the present series, only 45.4% of catheterized patients who underwent PAE were catheter-free after 12 months of follow-up. Similar to our results, Thulasidasan found that among 24 patients with indwelling urethral catheter who underwent PAE, 11 had unsuccessful trial without catheter after PAE and one required re-catheterisation 6 months post-PAE, resulting in a catheter-free survival rate of 50% at 12 month [18]. Conversely, our results compare unfavorably with previous data from Yu et al. [19], Rampoldi et al. [20], and Ayyagari et al. [21] who were able to achieve successful TWOC in 87.5%, 80.5%, and 87% of patients, respectively.
To report our preliminary experience with water vapor thermal therapy with the Rezūm™ System and Prostate Artery Embolization (PAE) for treatment of medically refractory, complete urinary retention to achieve successful cessation of catheter dependency in frail-patients.
A multi-institutional study was conducted including all patients who underwent Rezūm™ procedure and PAE between October 2017 and June 2020. The included population focused on frail-patients unsuitable for conventional surgery with complete urinary retention. Rezūm™ patients were identified and matched (1:1) with patients who underwent PAE. The matching criteria were age, Charlson score, prostate volume and duration of follow-up. The primary outcome was catheter-free survival, defined as spontaneous voiding and release from catheter dependence.
Eleven patients from the Rezūm™ group were matched to 11 embolized patients. PAE and Rezūm™ patients were comparable in age (median: 77 vs. 75 years), Charlson score (median: 6 vs. 6) and prostate volume (74 vs. 60 cc). Procedures were significantly longer in the PAE group compared to the Rezūm™ procedures (median: 148 vs. 8 min, P < 0.001). After a median follow-up of 12 months, spontaneous voiding was conserved in all cases (100%) after the Rezūm™ procedure and in 5 cases (45.4%) after PAE (P = 0.01). In catheter-free patients, the rate of benign prostatic hyperplasia medication use after procedure was 40% for PAE and 18.2% for Rezūm™ patients (P = 0.54).
Our preliminary experience for treatment of complete urinary retention in frail-patients shows the feasibility of PAE and Rezūm™ to restore spontaneous urination without being associated with the occurrence of major complications. Early data suggests that Rezūm™ may provide superior results in terms of cessation of catheter dependence. Future studies are needed to definitively assess which treatment would be best suited for each patient.
3.
Rapporter notre expérience préliminaire de la thérapie à la vapeur d’eau via le système Rezūm™ et de l’embolisation des artères prostatiques (EAP) dans le traitement de la rétention aiguë d’urine (RAU) complète et médicalement réfractaire pour permettre le sevrage de la sonde urinaire chez les patients fragiles.
Une étude multi-institutionnelle incluant tous les patients traités par Rezūm™ et EAP a été conduite entre octobre 2017 et juin 2020. Seuls les patients fragiles avec RAU réfractaire étaient éligibles. Les patients Rezūm™ ont été identifiés et appariés (1:1) avec les patients embolisés. Les critères d’appariement étaient : age, score de Charlson, volume prostatique et durée de suivi. Le critère de jugement principal était la survie sans cathéter, définie comme une miction spontanée sans dépendance à une sonde urinaire.
Onze patients du groupe Rezūm™ ont étaient appariés à onze patients embolisés. Les groupes EAP et Rezūm™ étaient comparables en âge (77 vs. 75 ans), score de Charlson (6 vs. 6) et volume prostatique (74 vs. 60 cc). Les interventions étaient significativement plus longues dans le groupe EAP (148 vs. 8 min, p < 0,001). Après une durée de suivi médiane de 12 mois, une miction spontanée étaient conservée chez tous les patients du groupe Rezūm™ (100 %) et chez 5 patients (45,4 %) embolisés (p = 0,01). Chez les patients sans sonde urinaire, le taux de consommation de médicaments de l’HBP était de 40 % et 18,2 %, respectivement dans les groupes EAP et Rezūm™ (p = 0,54).
Notre expérience préliminaire du traitement de la RAU réfractaire chez les patients fragiles montre la faisabilité du Rezūm™ et de l’EAP pour restaurer une miction spontanée sans être associés à la survenue de complications majeures. Les données précoces suggèrent que le Rezūm™ fournirait des résultats supérieurs dans le sevrage de la sonde urinaire. De futures études sont nécessaires pour définitivement évaluer quel traitement est le plus adapté pour chaque patient.
3.
Prostate Artery Embolization in the Treatment of Massive Intractable Bleeding from Prostatic Neoplasms: A Case Report and Systematic Review
2024, Journal of Clinical Medicine
Long-Term Efficacy and Recurrence Prediction of Prostatic Artery Embolization for Lower Urinary Tract Symptoms Secondary to Benign Prostatic Hyperplasia
2022, CardioVascular and Interventional Radiology
Retrospective observation of the efficacy and safety of prostatic artery embolization combined with transurethral resection of the prostate and simple transurethral resection of the prostate in the treatment of large (> 100 mL) benign prostatic hyperplasia
2021, Abdominal Radiology
Initial Canadian Experience of Prostate Artery Embolization for Symptomatic Benign Prostatic Hyperplasia: Midterm Outcomes
2021, Canadian Association of Radiologists Journal

View all citing articles on Scopus

View full text

Prostate artery embolisation: an all-comers, single-operator experience in 159 patients with lower urinary tract symptoms, urinary retention, or haematuria with medium-term follow-up

Highlights

AIM

MATERIALS AND METHODS

RESULTS

CONCLUSION

Introduction

Section snippets

Materials and methods

Technical outcomes, dose analysis, and complications

Symptomatic improvement

Conflict of interest

Acknowledgements

J Urol

Urology

J Vasc Interv Radiol

J Vasc Interv Radiol

J Vasc Interv Radiol

J Vasc Interv Radiol

Eur Urol

Clin Radiol

The global burden of lower urinary tract symptoms suggestive of benign prostatic hyperplasia: a systematic review and meta-analysis

Sci Rep

Midterm follow-up after prostate embolization in two patients with benign prostatic hyperplasia

Cardiovasc Interv Radiol

The “PErFecTED technique”: proximal embolization first, then embolize distal for benign prostatic hyperplasia

Cardiovasc Interv Radiol

Prostatic arterial embolization for the treatment of lower urinary tract symptoms due to large (>80 ml) benign prostatic hyperplasia: results of midterm follow-up from Chinese population

BMC Urol

Prostate artery embolization in patients with prostate volumes of 80 ml or more: a single-institution retrospective experience of 93 patients

J Vasc Interv Radiol