Interventional News: Prostate Artery Embolization for BPH
By Shivank Bhatia, MD
Radiology Today
Vol. 20 No. 6 P. 8
A multidisciplinary approach to benign prostatic hyperplasia enhances outcomes.
Prostate artery embolization (PAE) has recently emerged as a viable option for the treatment of lower urinary tract symptoms (LUTS) associated with benign prostatic hyperplasia (BPH). Embolization of the prostatic artery induces infarction leading to selective ischemia, resulting in reduction of prostate volume. While watchful waiting and medical management may be appropriate in some patients with BPH-associated LUTS, certain clinical characteristics and the severity of the symptoms may dictate a need for more aggressive measures.
The progressive nature of BPH-associated LUTS and the potential for decline suggest that earlier treatment may alleviate symptomatic burden and improve quality of life. Such a paradigm may be facilitated by greater awareness of BPH symptoms and potential complications. Awareness of the available treatment options and understanding risks, benefits, recovery, and durability of these options is essential for patients to make informed decisions.
Initial Evaluation
A basic evaluation should be performed on every patient presenting with LUTS, ideally in collaboration with a urology colleague. The evaluation should include medical history; assessment of symptoms and impact on quality of life; physical exam, including digital rectal examination; urinalysis; and serum prostate-specific antigen (PSA) levels.1 The risks and benefits of using serum PSA testing to diagnose prostate cancer should be discussed with the patient.2 Two standardized questionnaires are evaluated: the International Prostate Symptom Score (IPSS) questionnaire, which addresses the severity of the LUTS, and the Sexual Health Inventory for Men, which assesses the baseline erectile function.1,3
The urine flow rate recording and post void residual (PVR) of urine are optional tests. Pressure flow studies are not indicated in the routine evaluation of men with LUTS but may be beneficial in cases in which maximum urine flow rate is greater than 10 mL/s. This can help determine the need for invasive therapy to relieve bladder outlet obstruction and rule out other underlying etiologies, such as bladder dysfunction; the author has been published on this subject.4 Imaging of the upper urinary tract can be indicated in patients with infection, hematuria, urolithiasis, and/or renal insufficiency.1,3
Patient education should be a focus during all encounters, starting with the initial consultation. A detailed explanation of available treatment options, including risks and benefits, must be discussed in detail.
Treatment considerations for BPH-associated LUTS are multifactorial. The severity of symptoms and associated quality of life, size of the gland, and whether there is evidence of urinary obstruction each play a prominent role. Absence of symptoms despite an enlarged prostate does not warrant treatment. Watchful waiting may be ideal for patients with no or very mild, tolerable symptoms that do not impact quality of life, and medical therapy is usually a first-line approach.
For patients exhibiting more severe symptoms with glands smaller than 80 g, transurethral resection (TURP) is considered the gold standard.3 However, TURP is associated with risk of bleeding, urine leakage, and sexual side effects, such as retrograde ejaculation and sexual dysfunction. There are numerous other options including radiofrequency, laser, or microwave ablation, although the latter seems to be falling out of favor.5 Larger glands are frequently selected for prostatectomy, which may be performed with robotic assistance in some centers or holmium laser enucleation of the prostate.
PAE
Due to the prevalence of BPH and the cost of management to the health care system, there is a growing need for minimally invasive options, preferably ones that can be performed on an outpatient basis.6 In this regard, PAE has emerged as a viable option, with particularly beneficial application in larger glands that have not responded to medical therapy.7,8 While PAE may be performed in most patients with BPH-associated LUTS, it would seem a particularly favorable option for those with very enlarged glands (>80 g in size) or an indwelling catheter, as well as those who are not surgical candidates, who are on blood thinners, or who have history of prior surgery for LUTS with recurrence.9 Patients with advanced prostate cancer or patients who have refractory bleeding from the prostate are also good candidates for embolization.10,11
The variation in the anatomy of the prostatic vessels and presence of collateral circulation to surrounding organs, such as the bladder, rectum, and penis, present a challenge.12,13 Additionally, the technical nuances and steep learning curve associated with PAE are limitations in terms of widespread adoption. However, advanced procedural tools, such as equipment with the capability to perform intraprocedural CT scans or 3D angiograms to review the anatomy, and the operator’s experience performing the procedure may mitigate the risks of the PAE procedure.
Patient education regarding expectations post procedure can help manage and alleviate anxiety. Patients undergoing PAE can initially have worsening of LUTS, including dysuria, urgency, frequency, pain, and bladder spasms. These symptoms are typically self-limiting and resolve in the first two weeks post procedure, with most patients recovering within five to seven days. The rate of major complications, including urinary retention, urinary infection/sepsis, and risk of nontarget embolization with potential damage to surrounding organs, such as the bladder, rectum, and penis, is estimated to be around 1% to 2%.14 PAE is not associated with risk of bleeding, leakage, incontinence, or sexual side effects, such as erectile dysfunction or retrograde ejaculation.
PAE has traditionally been performed via a transfemoral (groin) approach. However, a transradial (wrist) approach may result in shorter postprocedure hospital stay, decreased access site complications, improved patient satisfaction, and greater flexibility to ambulate after the procedure, which in turn may also help with urination. Most patients indicated for PAE will qualify for transradial access, which can be determined using the Barbeau test and can reduce the risk of access site complications.15,16
Outcomes
A meta-analysis concluded that PAE is associated with significant improvement in IPSS and quality of life scores; with positive effects on erectile function scores, peak urinary flow, and PVR volume; and with correlating reductions in prostate volume and PSA levels.17 The researchers concluded that PAE is a well-tolerated and effective treatment of LUTS-related BPH. Compared with historical data on TURP, PAE had a lower incidence of transfusion, urinary tract infection, and urethral stricture.18
Pisco and colleagues studied outcomes post PAE in 630 patients in a single-arm study. Patients followed long term—defined as 36 to 78 months—had a 76.3% success rate with significant improvement in IPSS and quality of life, and there were no reports of treatment-associated sexual dysfunction or urinary incontinence. The study noted that most clinical failures occurred prior to 18 months post PAE; moreover, the incidence of clinical recurrence decreased as the time since PAE increased.19
Data from the multicenter UK-ROPE (Registry of Prostate Embolization) were published in April 2018. This study compared 305 patients undergoing embolization (n=216) vs the surgical gold standard (TURP; n=89) in the setting of a noninferiority study. While PAE did not outperform TURP, PAE led to significant improvements in both urinary symptoms and quality of life, without significant complications or effects on sexual function.20
Recent studies have demonstrated efficacy in patients with large prostates (>80 g), which are often difficult to treat surgically.8,19 Additionally, embolization has been successfully employed to treat hyperplasia-related chronic urinary retention requiring long-term Foley catheterization. There are reports of 80% to 90% success with removal of catheter in patients with chronic urinary retention, even in the patients who are nonsurgical candidates with significant comorbidities.9
The data noted above are encouraging and provide evidence of short-, medium-, and long-term benefit for PAE in the treatment of BPH-associated LUTS and urinary retention, even in patients with significant comorbidities. While data from large-scale, prospective, controlled, and randomized clinical trials would be welcomed, it is unclear at the present time whether such studies can be successfully enrolled. In the meantime, it behooves clinicians offering PAE to follow evidence-based practices and work in multidisciplinary settings that enhance the quality of care delivery.
Measure of Success
While interventional radiologists play an important role in performing PAE, a multidisciplinary approach to managing patients with BPH-associated LUTS adds value and quality to the care. Any IR practitioner considering implementing ambulatory clinic services will benefit from working closely with urology colleagues. A joint clinic offers patients the comfort and convenience of seeing both services on the same day. Easier communication with urology advances expertise, collaborative management, and treatment planning for the patient with BPH.
There are many training opportunities for IR specialists interested in learning about PAE, ranging from annual society meetings held by the Society of Interventional Radiology and the Cardiovascular and Interventional Radiology Society of Europe to smaller, focused conferences and industry-sponsored training. There are also software/simulation training programs aimed at advancing the anatomical knowledge and technical skills required to perform the procedure. Deep understanding of the prostate anatomy and understanding the technical challenges associated with the procedure might help to reduce the learning curve significantly.
— Shivank Bhatia, MD, is the chair of IR at the University of Miami Miller School of Medicine and an associate professor of IR and urology at the University of Miami. He has delivered more than 60 invited lectures on the topic of PAE nationally and internationally and has trained more than 300 physicians on this procedure. He can be reached at sbhatia1@miami.edu or drshivankbhatia@gmail.com.
References
1. Juliao AA, Plata M, Kazzazi A, Bostanci Y, Djavan B. American Urological Association and European Association of Urology guidelines in the management of benign prostatic hypertophy: revisited. Curr Opin Urol. 2012;22(1):34-39.
2. Abrams P, Chapple C, Khoury S, Roehrborn C, de la Rosette J; International Scientific Committee. Evaluation and treatment of lower urinary tract symptoms in older men. J Urol. 2009;181(4):1779-1787.
3. McVary KT, Roehrborn CG, Avins AL, et al. Update on AUA guideline on the management of benign prostatic hyperplasia. J Urol. 2011;185(5):1793-1803.
4. Gomez C, Bhatia S, Carnevale FC, Narayanan G. Role of urodynamic studies in management of benign prostatic obstruction: a guide for interventional radiologists. J Vasc Interv Radiol. 2017;28(1):126-133.
5. Cornu JN, Ahyai S, Bachmann A, et al. A systematic review and meta-analysis of functional outcomes and complications following transurethral procedures for lower urinary tract symptoms resulting from benign prostatic obstruction: an update. Eur Urol. 2015;67(6):1066-1096.
6. Wei JT, Calhoun E, Jacobsen SJ. Urologic diseases in America project: benign prostatic hyperplasia. J Urol. 2005;173(4):1256-1261.
7. Pisco J, Bilhim T, Pinheiro LC, et al. Prostate embolization as an alternative to open surgery in patients with large prostate and moderate to severe lower urinary tract symptoms. J Vasc Interv Radiol. 2016;27(5):700-708.
8. Bhatia S, Sinha VK, Harward S, Gomez C, Kava BR, Parekh DJ. 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. 2018;29(10):1392-1398.
9. Bhatia S, Sinha VK, Kava BR, et al. Efficacy of prostatic artery embolization for catheter-dependent patients with large prostate sizes and high comorbidity scores. J Vasc Interv Radiol. 2018;29(1):78-84.e1.
10. Pereira K, Halpern JA, McClure TD, et al. Role of prostate artery embolization in the management of refractory haematuria of prostatic origin. BJU Int. 2016;118(3):359-365.
11. Emberton M, Fitzpatrick JM, Garcia-Losa M, Qizilbash N, Djavan B. Progression of benign prostatic hyperplasia: systemic review of the placebo arms of clinical trials. BJU Int. 2008;102(8):981-986.
12. Bhatia S, Sinha VK, Abdul-Rahim O, Harward S, Narayanan G. Rare prostatic artery origins and the importance of collateral circulation in prostate artery embolization: a pictorial essay. Can Assoc Radiol J. 2018;69(2):220-229.
13. Bhatia S, Sinha V, Bordegaray M, Kably I, Harward S, Narayanan G. Role of coil embolization during prostatic artery embolization: incidence, indications, and safety profile. J Vasc Interv Radiol. 2017;28(5):656-664.e3.
14. Moreira AM, de Assis AM, Carnevale FC, Antunes AA, Srougi M, Cerri GG. A review of adverse events related to prostatic artery embolization for treatment of bladder outlet obstruction due to BPH. Cardiovasc Intervent Radiol. 2017;40(10):1490-1500.
15. Isaacson AJ, Fischman AM, Burke CT. Technical feasibility of prostatic artery embolization from a transradial approach. AJR Am J Roentgenol. 2016;206(2):442-444.
16. Bhatia S, Harward SH, Sinha VK, Narayanan G. Prostate artery embolization via transradial or transulnar versus transfemoral arterial access: technical results. J Vasc Interv Radiol. 2017;28(6):898-905.
17. Wang XY, Zong HT, Zhang Y. Efficacy and safety of prostate artery embolization on lower urinary tract symptoms related to benign prostatic hyperplasia: a systematic review and meta-analysis. Clin Interv Aging. 2016;11:1609-1622.
18. Lim KB. Epidemiology of clinical benign prostatic hyperplasia. Asian J Urol. 2017;4(3):148-151.
19. Pisco J, Bilhim T, Pinheiro LC, et al. Prostate embolization as an alternative to open surgery in patients with large prostate and moderate to severe lower urinary tract symptoms. J Vasc Interv Radiol. 2016;27(5):700-708.
20. Ray AF, Powell J, Speakman MJ, et al. Efficacy and safety of prostate artery embolization for benign prostatic hyperplasia: an observational study and propensity-matched comparison with transurethral resection of the prostate (the UK-ROPE study). BJU Int. 2018;122(2):270-282.
