Prostatic Artery Embolization for Intractable Hematuria in Prostate Cancer

Abstract: Hematuria due to prostatic hemorrhage secondary to malignancy can be a life threatening condition. Therapeutic options include hormonal therapy, radiation therapy, and surgery. Transarterial embolization is emerging as a minimally invasive alternative that can safely and efficiently address this condition. We report a case of intractable hematuria due to prostate cancer in a patient who failed conservative treatment and was not a candidate for surgery and was successfully treated with selective bilateral prostatic artery embolization. There was complete resolution of hematuria and hemoglobin level stabilized. 

Key words: prostate artery embolization, prostate cancer, hematuria, cone beam computed tomography

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Intractable hematuria of malignant prostatic origin raises a major therapeutic challenge. Patients may present with advanced prostate cancer that has progressed despite androgen ablation and radiation therapy or have comorbidities precluding invasive surgical options.¹ Furthermore, external radiation can result in progressive obliterative endarteritis resulting in cellular hypoxia and bleeding.² Prostatic artery embolization (PAE) can be proposed as a palliative measure to treat refractory hematuria due to malignancy or benign prostatic hyperplasia (BPH).^2-4 This minimally invasive procedure can provide immediate relief of symptoms, preventing reoperation and long-term catheterization for bleeding and obstruction. 

Case Report

A 69-year-old HIV-positive male presented to the emergency room with complaints of chest, shoulder, and back pain as well as difficulty urinating. The patient’s PSA at time of admission was greater than 5,000 nanogram/mL. Ultrasound at admission showed moderate bilateral hydronephrosis from bladder outlet obstruction due to an enlarged prostate gland. Metastatic prostatic carcinoma was suspected and Urology service was consulted. After Foley catheter placement, the patient developed intractable hematuria nonresponsive to bladder irrigation. The patient’s hemoglobin decreased from 8.2 g/dL to 6.4 g/dL despite his receiving 2 units of packed red blood cells (PRBCs). Interventional radiology was initially consulted for placement of bilateral nephrostomy catheters for urinary diversion. At arrival to the angiography suite, the patient was tachycardic but hemodynamically stable. Prostate artery embolization (PAE) for treatment of refractory hematuria was discussed as an alternative with the urology service and the patient. Both agreed to proceed and informed consent was obtained. Initially, bilateral nephrostomies were placed under ultrasound and fluoroscopic guidance without incident.

The patient underwent selective PAE for refractory hematuria. Via right common femoral artery access, pelvic angiogram was initially performed using a 5 Fr Omni flush catheter (Angiodynamics). Selective digital subtraction angiography of both internal iliac arteries was then performed with a 5 Fr Cobra catheter (Terumo) to evaluate the origin of the prostate arteries. The left prostatic artery was catheterized with a 2.8 Fr Progreat microcatheter (Terumo). Superselective left prostatic artery angiogram followed by cone beam CT angiogram showed arterial blush to the left half of the prostate. No evidence of supply was noted to surrounding organs, including the bladder and rectum (Figure 1A). Catheterization of the right prostatic artery was difficult due to common origin trunk with the inferior vesical artery. Common trunk angiogram showed vascular supply to the right half of the prostate gland and the inferior bladder (Figure 1B). The right prostatic artery was then catheterized using a 90-degree angled PX SLIM 090 microcatheter (Penumbra) and repeat angiogram did not show blush in the inferior bladder, which was confirmed on cone beam CT (see video). Cone beam CT was performed to avoid nontarget embolization. 

Embolization was performed using 300- to 500-micrometer microspheres diluted to 22 mL with equal amounts of iodinated contrast and normal saline. Injection was performed under direct fluoroscopic visualization until stasis was achieved. Post embolization angiogram was obtained to check for further supply to the prostate. Intravenous ciprofloxacin was administered before the procedure and continued orally for 7 days. Nonopiod analgesics and NSAIDs were administered as needed for pain control. After treatment, a single unit of PRBCs was transfused. No procedure related complications were noted. Hemoglobin stabilized at 8.6 g/dL. Urine cleared prior to discharge. A bone scintigraphy showed a superscan consistent with diffuse osteoblastic metastatic disease (Figure 2A). A CT scan showed multiple pelvic adenopathies with diffuse skeletal lesions. At the 6-month follow-up visit, there were no episodes of rebleeding, and the most recent PSA has dropped to 36 nanogram/mL.  

Discussion

Prostate cancer is the most common cancer affecting men in the West and ranks second after lung cancer in cancer-related causes of death among men in the United States.³ Prostate cancer can be found in about 6% of patients presenting with severe hematuria. Persistent hematuria despite conventional therapy can pose a therapeutic dilemma, especially in the context of locoregionally advanced prostatic cancer.¹ Typically these patients are older, have radiation cystitis or bladder invasion, and have comorbidities making them unsuitable for invasive surgeries.  

Initial treatment may require repeat hospitalization for bladder irrigation and multiple blood transfusions, with the associated costs and risks.⁵ Other approaches include irrigation with formalin, silver nitrate or alum solution, intravesical carboprost tromethamine instillation, endoscopic diathermy, and radical prostatectomy. 

The first case of successful therapeutic embolization for hematuria from carcinoma of the prostate was reported in 1977.⁶ Embolization provides immediate control of hemorrhage, decreasing the need for further transfusions, cystoscopy, and bladder irrigation.¹ 5-alpha-reductase inhibitors, which reduce the microvascular density in periurethral tissue, can be helpful and are used in hematuria secondary to benign prostatic hyperplasia (BPH). There are no data regarding their efficacy in cancer.³

External-beam radiotherapy also can be used to decrease hematuria from prostate cancer, with a lasting effect 2 years after treatment; however, repeat bleedings seems to be more frequent in the presence of radiation cystitis.¹ Furthermore, refractory hematuria with radiation cystitis is associated with generalized telangiectatic dilatation of mucosal vessels, which can add to the complexity of the management.⁵ Tranexamic acid, a plasminogen activator inhibitor that enhances thrombosis, has been used to treat hematuria secondary to BPH, menstrual bleeding, and bleeding after orthopedic surgeries and can potentially be applied in cancer. Patients with advanced prostate cancer that has progressed despite androgen ablation and radiation therapy are less likely to respond to these options in cases of recurrence of hematuria.³ For patients failing the first line of conservative management, palliative transurethral resection of the prostate, focal cryoablative therapy, and high-intensity focused ultrasound can treat locally advanced disease and alleviate obstructive symptoms.³ 

Although these invasive procedures can provide immediate symptomatic relief, they may have to be repeated, may require long-term catheterization, and may not be applied to debilitated patients with advanced-stage disease who cannot tolerate such an invasive procedure under general anesthesia.⁵ Transarterial embolization has already been applied safely in managing malignant hematuria of renal and pelvic origin, as well as in benign prostatic hyperplasia.^2,7,8 Embolization of the vesical arteries and internal iliac arteries was used to control hematuria from large invasive bladder tumors and from hemorrhagic cystitis.¹ The technique described by Carnevale et al⁹ combined with cone beam CT, allowed us in a context of emergent bleeding, without a prior pelvic CT angiogram, the recognition and superselective catheterization of fourth- and fifth-order branches, permitting safe cut-off of blood supply to the prostate alone, and immediate resolution of the bleeding. The use of 300- to 500-micrometer particles has also been reported to decrease the complication rate given that smaller particles carry a greater risk of nontarget embolization.⁹ Bilateral PAE leads to better clinical results.⁵ Unilateral embolization is associated with a higher risk of rebleeding.¹ Prostate artery embolization with cone beam CT is very safe; in a recent series of 20 patients, no complications were reported using selective embolization.¹⁰ There is no study to date evaluating the therapeutic benefit of embolization in primary prostate cancer. Because embolization does not currently have a defined role in the management of patients with prostate cancer, further randomized prospective studies are needed to better determine the role of PAE in prostate cancer.

Conclusion

With recent advances in the anatomic knowledge of prostatic vascularity, and selective prostatic arteries embolization^4,9 PAE is emerging as a minimally invasive alternative that can be proposed to those patients with refractory hematuria of malignant origin who are nonresponsive to conservative management and are not surgical candidates. 

Editor’s note: Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest Dr. Narayanan reports consultancy for BTG, Angiodynamics Inc., and Boston Scientific Corporation. Dr. Bhatia reports consultancy and grants from Merit Medical. Dr. Kably reports no related disclosures.

Address for correspondence: Issam Kably, MD, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Department of Radiology. 1611 NW 12th Ave, Miami FL 33136. USA. Email: ikably@med.miami.edu

Suggested citation: Kably IM, Bhatia SS, Narayanan G. Prostatic artery embolization for intractable hematuria in prostate cancer. Intervent Oncol 360. 2015;3(3):E30-E35.

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