Prostatic artery embolization as an alternative to indwelling bladder catheterization to manage benign prostatic hyperplasia in poor surgical candidates: Beyond the Abstract

While numerous methods exist for the medical and surgical management of benign prostatic hyperplasia (BPH), treatment options are extremely limited for patients that have failed medical management and are ineligible for surgical intervention. For many of these patients, compression of the prostatic urethra can result in urethral trauma during clean intermittent catheterization, and indwelling bladder catheterization (IBC) is their only option for bladder management. In addition to increasing the risk of urinary tract infection (UTI), IBC can have a significant impact upon quality of life.

Prostate artery embolization (PAE) was initially reported to reduce prostate volume in 2000, when a patient underwent embolization of the prostatic arteries to control hemorrhage due to BPH [1]. Since then, the procedure has been performed in a variety of niche patient populations, including elderly patients, those with prostate sizes in excess of 500 grams, and those reliant upon IBC, and has been shown to reduce prostate volume, improve lower urinary tract symptoms due to BPH, and improve urodynamic metrics [2-5]. The present study is notable for its severely comorbid patient population; of the 43 patients enrolled, 32 (74.4%) had hypertension, 16 (37.2%) had congestive heart failure, 12 (27.9%) had chronic obstructive pulmonary disease, 9 (20.9%) had renal disease, and 12 (27.9%) were undergoing concomitant therapies for active malignancies. All patients were dependent upon IBC for bladder management, and all had been deemed ineligible for surgery due to their clinical status. 

Of the 43 patients enrolled, bilateral embolization was performed in 33 (76.7%), unilateral embolization was performed in 8 (18.6%), and 2 patients (4.7%) could not be embolized due to atherosclerotic pelvic vasculature. During follow-up episodes of acute urinary retention requiring temporary catheter placement were observed in six patients (14.6%), and UTI treated with ciprofloxacin in 3 patients (7.3%). Nine patients (22.0%) experienced mild to moderate dysuria – a known symptom of post embolization syndrome – in the first 48 hours following embolization. IBC removal was achieved in 33 patients (80.5%) at 15 days of follow-up. By 6 months of follow-up, mean prostate volume reduction was 19.6%, mean IPSS reduction was 40.1%, mean Qmax was 9.2 mL/s, and mean PVR was 49.7 mL.

These results indicate that PAE may have potential as a salvage therapy for catheter-dependent patients without other therapeutic options. As PAE can be performed under local anesthesia, it may be suitable for patients at elevated risk of complications from general anesthesia. Furthermore, the embolization procedure can be performed without interrupting concomitant therapies to manage severe comorbidities, including cardiovascular and respiratory conditions, and concurrent cancer diagnoses. Very few investigations have compared PAE to surgical interventions, and prospective, randomized trials will be necessary to rigorously compare these therapies in appropriate populations [6-8]. In patients ineligible for surgery who are no longer benefitting from medical management, PAE ought to be considered as an alternative method of reducing prostate volume to relieve bladder outlet obstruction and lower urinary tract symptoms.  


Sagital (1.A) and Coronal (1.B) MRI of prostatic gland in patient with indwelling bladder catheter.


(2.A) Digital Subtraction Angiography: Vascular anatomy of left hypogastric artery


Digital Subtraction Angiography: Vascular anatomy of left hipogastric artery
(UA- umbilical artery, SVA- superior vescical artery, IVA- Inferior vescical artery, mR- medial retal artery, oB- Obturatory, iP- internal pudendal artery)



(3.A,B,C) Superselettive catheterization of Type I left prostatic artery. (3.D) left prostatic lobe parenchimography

Written By: Aldo Bocciardi, MD, Chief of Urology Department, Niguarda Hospital, Milan, Italy; Antonio Rampoldi, MD, Chief of Interventional Radiology, Niguarda Hospital, Milan, Italy; Michele Spinelli, Chief of Neuro-Urology, Niguarda Hospital, Milan, Italy; Francisco Cesar Carnevale, Chief of Interventional Radiology, University of Sao Paolo Hospital, Brazil

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References:
  1. DeMeritt JS, Elmasri FF, Esposito MP, et al. Relief of benign prostatic hyperplasia-related bladder outlet obstruction after transarterial polyvinyl alcohol prostate embolization. J Vasc Interv Radiol 2000; 11:767-770.
  2. Antunes AA, Carnevale FC, da Motta Leal Filho JM, et al. Clinical, laboratorial, and urodynamic findings of prostatic artery embolization for the treatment of urinary retention related to benign prostatic hyperplasia: a prospective single-center pilot study. Cardiovasc Intervent Radiol 2013; 36(4):978-86.
  3. Bhatia S, Kava B, Pereira K, et al. Prostate artery embolization for giant prostatic hyperplasia. J Vasc Interv Radiol 2015; 26(10):1582-1585.
  4. Grosso M, Balderi A, Arnò M, et al. Prostatic artery embolization in benign prostatic hyperplasia: preliminary results in 13 patients. Radiol Med 2014; 120(4):361-368.
  5. MQ Wang, Wang Y, Yan JY, et al. Prostatic artery embolization for the treatment of symptomatic benign prostatic hyperplasia in men ≥75 years: a prospective single-center study. World J Urol 2016; 34(9):1275-83.
  6. Carnevale FC, Iscaife A, Yoshinaga EM, et al. Transurethral resection of the prostate (TURP) versus original and PErFecTED prostate artery embolization (PAE) due to benign prostatic hyperplasia (BPH): preliminary results of a single center, prospective, urodynamic-controlled analysis. Cardiovasc Intervent Radiol 2015; 39(1):44-52.
  7. Russo GI, Kurbatov D, Sansalone S, et al. Prostatic arterial embolization vs open prostatectomy: a 1-year matched-pair analysis of functional outcomes and morbidities. Urol 2015; 86(2):343-348.
  8. Gao YA, Huang Y, Zhang R, et al. Benign prostatic hyperplasia: prostatic arterial embolization versus transurethral resection of the prostate – a prospective, randomized, and controlled clinical trial. Radiol 2014; 270(3):920-928.
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