Prostatic Artery Embolization for Benign Prostatic Hyperplasia With Lower Urinary Tract Symptoms: Articles From the Official Show Daily for Synergy 2015

The standard management of benign prostatic obstruction (BPO) is based on the overall health of the patient, on the severity of the lower urinary tract symptoms (LUTS), and on quality-of-life considerations. Voiding difficulties attributable to BPO can be quantified with the International Prostate Symptom Score (IPSS). Various medications like alpha blockers can decrease the severity of voiding symptoms secondary to BPO, however impotence, decreased libido, and ejaculatory disorders are known side effects.

According to the American Society of Urology (AUA), patients with mild LUTS secondary to benign prostatic hyperplasia (BPH; AUA-SI [IPSS] score <8) and patients with moderate or severe symptoms (AUA-SI [IPSS] score ≥8) who are not bothered by their LUTS should be managed using a strategy of watchful waiting. If the patient elects interventional therapy and there is sufficient evidence of obstruction, the patient and urologist should discuss the benefits and risks of the various interventions.

Transurethral resection of the prostate (TURP) is still the gold standard of interventional treatment, but it can be associated with bleeding, erectile dysfunction, and ejaculatory disorders in up to 10% and 65% of patients, respectively. The substantial prevalence of BPO and its therapies is underscored by the tremendous impact of this condition on the health and quality of life of men. Increasingly, BPO therapy trends are moving away from the gold standard operation of TURP and toward less invasive pharmacologic options and minimally invasive procedures provided in an outpatient setting. The proof of concept for the prostatic artery embolization (PAE) technique has been widely reported since the Cardiovascular and Interventional Radiological Society of Europe meeting in 2008. With nearly 4 years of follow-up, the multidisciplinary team at University of Sao Paulo is encouraged by this minimally invasive alternative treatment for patients with LUTS.

At the University of Miami, PAE has been offered since 2014. A multidisciplinary approach with urologists forms a strong team to offer the best possible option for men with BPH related LUTS. 

Advantages

Prostatic artery embolization is a minimally invasive procedure performed under local anesthesia and moderate sedation as an outpatient procedure. It can be indicated in patients with small or large prostates and does not involve manipulation of the urethra, thereby avoiding urethral stenosis. Severe comorbidities such as heart disease, atherosclerosis, and patients with metallic implants, penile prosthesis, severe urethral stricture, artificial urinary sphincter, or ASA class group V are not contraindications for PAE (as also applicable to other surgical options). Prostatic artery embolization can also convert an open prostatectomy (prostate volumes greater than 80 mL to 100 mL) to a laser or TURP procedure after reducing the prostate size and avoiding their related complications. The procedure is similar to other surgical options as it can be repeated in the future, if necessary. This procedure has been shown to be safe, effective, and with low rate of complications. In addition, the overall cost of the procedure is lower than other surgical therapies.

Possible Complications

More than 30% of patients were asymptomatic during PAE and the others complained of mild retropubic pain, referred to as a burning sensation, for 24 hours. For patients without indwelling catheters, urethral burning during voiding and frequent urination is the most common symptom after PAE. It usually lasts 3 days to 7 days and has been treated with nonopioid analgesic and nonsteroidal anti-inflammatory drugs. Complications after PAE are related to non-target embolization to the bladder, rectum, and genitals due to the proximity of these organs to the prostate and their vascular communications. In our experience, we have observed a few cases where a minimal amount of blood mixed in the stool or urine. These complications may be avoided using a microcatheter to perform distal embolization and calibrated microspheres for a predictable embolization. Cone-beam computed tomography is a very useful tool for this procedure.

Physician Expertise

This is a procedure to be performed by an experienced physician trained in interventional radiology techniques. Superselective microvessel catheterization is recommended to optimally navigate the tortuous and atherosclerotic arteries. A strong understanding of the pelvic vascular anatomy is needed to perform this type of embolization. In addition, imaging evaluation based on MRI and objective assessment based on urodynamic parameters are essential. Lastly, a collaborative group effort with urologists is key to successful PAE. 

The Future of Embolization for the Prostatic Artery

Minimally invasive treatments for BPH continue to be part of the therapeutic armamentarium for managing LUTS; however, cost, changing reimbursement, quality of life, and unanswered questions regarding durability of success have tempered the initial enthusiasm for this class of therapy. PAE has emerged as a new alternative for treatment of symptomatic patients. 

All care must be taken for a better understanding of BPH disease and the best PAE technique to be used. Future larger studies with long-term follow-up and more data supporting PAE are necessary to validate initial observations. Current data suggest that PAE can be a minimally invasive alternative of treatment for patients with symptomatic BPH and a promising area for interventional radiologists, but a multidisciplinary approach with urologists, diagnostic radiologists, and interventional radiologists provides optimum continuity of care.  

Editor’s note: This article first appeared in the Synergy Daily conference newspaper, available to attendees of the Synergy Miami interventional oncology meeting, published November 6, 2015. This article did not undergo peer review. Dr. Bhatia reports consultancy to Merit Medical. Dr. Carnevale reports no disclosures.

Suggested citation: Carnevale FC, Bhatia S. Prostatic artery embolization for benign prostatic hyperplasia with lower urinary tract symptoms: articles from the official show daily for Synergy 2015. Intervent Oncol 360. 2016;4(2):E24-E26.