Invited Commentary: Prostatic Artery Embolization for Benign Prostatic Hypertrophy—Are We Ready for Prime Time?
2021; Radiological Society of North America; Volume: 41; Issue: 5 Linguagem: Inglês
10.1148/rg.2021210032
ISSN1527-1323
Autores Tópico(s)Urologic and reproductive health conditions
ResumoHomeRadioGraphicsVol. 41, No. 5 PreviousNext Vascular and Interventional RadiologyFree AccessInvited Commentary: Prostatic Artery Embolization for Benign Prostatic Hypertrophy—Are We Ready for Prime Time?Jorge E. Lopera Jorge E. Lopera Author AffiliationsFrom the Long School of Medicine, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr, San Antonio, TX 78229.Address correspondence to the author (e-mail: [email protected]).Jorge E. Lopera Published Online:Aug 20 2021https://doi.org/10.1148/rg.2021210032MoreSectionsPDF ToolsImage ViewerAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinked In See also the article by Dias et al in this issue.Prostatic artery embolization (PAE) is rapidly emerging as a minimally invasive alternative to transurethral resection of the prostate (TURP) in patients with moderate to severe benign prostatic hyperplasia (BPH) that is causing urinary tract symptoms and/or bladder outlet obstruction. PAE is not a new technique. It was first described as early as 1976 for patients who experienced bleeding after undergoing biopsy or prostatectomy, with high success rates for bleeding control (1). PAE was later used in high-surgical-risk patients with acute urinary retention who were bladder-catheter dependent. Indwelling catheters were successfully removed in 74%–98% of patients who underwent PAE (2,3).More recently, PAE was used as an alternative to TURP for patients with moderate to severe urinary tract symptoms who wanted to avoid the adverse effects of surgery, including sexual dysfunction, retrograde ejaculation, postoperative hemorrhage, continent urinary retention, TURP syndrome, and urinary stricture (4).Randomized studies (5) that include patient experience with PAE, long-term follow-up data, and comparison of PAE and TURP show encouraging results, including rates of resolution of urinary tract symptoms similar to those at 12 months after TURP, with significant reductions in the international prostate symptoms score (IPSS), improvement in peak urinary flow (Qmax), and overall lower complication rates than those for surgery (5,6). The main advantages of PAE compared with surgery include faster recovery, no overnight stay in the hospital, no need for a bladder catheter after surgery or blood transfusion, and minimal serious or permanent adverse effects, especially those related to sexual function. PAE does not preclude future prostatic surgery, if needed.Some studies (6,7) have shown that the reduction in prostate volume and in obstruction of the bladder outlet are more effective with surgery than with PAE, and a higher rate of surgery within 2 years after PAE has been shown. Despite these limitations, approximately 80% of patients with BPH that is refractory to medical treatment can be treated with PAE, and surgery can be avoided (4). There is now strong evidence of the efficacy and safety profile of PAE for BPH, but most urologic societies currently do not endorse this technique and still consider it experimental (8,9).The article by Dias et al (10) is an excellent review of this emerging technique. The article covers all elements of the procedure, including patient selection, preprocedural imaging, a detailed description of the technique, potential complications, and results. Updated information about the use of US elastography is also presented. Tables 4 and 5 in the article summarize the most important parameters for the evaluation of the prostate with MRI before and after the procedure, with report templates that include zonal volumetry and the intravesical protrusion of the prostate, which are some of the factors that have shown a positive correlation with the degree of clinical improvement after PAE. The article also describes the use of MR angiography with anatomic and dynamic contrast-enhanced sequences that can help to identify prostatic artery origins before embolization, potentially decreasing the radiation dose and procedural time.PAE is a technically demanding procedure, given the variable anatomy, the small size of the vessels that are commonly affected by atherosclerosis, and the potential for unwanted nontarget embolization due to the extensive network of collateral vessels in the surrounding organs, including the rectum, bladder, penis, and seminal vesicles (3,10).The article by Dias et al (10) provides a detailed description of the PERFECTED (ie, proximal embolization first, then embolize distal) technique, which requires embolizing the prostatic artery proximally and then advancing the microcatheter as distally as possible into the gland, first superselecting the anteromedial branch to the central gland and then the posterolateral branch to the peripheral zone, performing additional embolization in each branch. According to the authors (10), the PERFECTED technique allows 30%–100% more embolic material to be delivered into the prostate gland, with additional embolic material injected when the catheter is retracted proximally with the “pack back” technique. The PERFECTED technique has shown promising results in the hands of the Sao Paulo group (10), but it is a technically demanding procedure and requires a high radiation dose. It also has a high potential for nontarget embolization (due to the extensive particle injections and the fact that the other shunts can be opened in those distal locations) and/or extravasation, which may occur when the microcatheter is wedged into the gland.Most institutions use the conventional PAE technique of free-flow embolization without wedged embolization inside the distal intraprostatic branches. Further multi-institutional studies are needed to determine the best techniques for PAE, including embolic particle size.PAE is a complex technical procedure that uses steep oblique images, requires multiple digital subtraction sequences, and involves bilateral superselective embolization of the prostatic branches, sometimes with coil embolization of collateral vessels, which results in high radiation doses.The article by Dias et al (10) provides important advice for reduction of radiation, including the use of cone-beam CT, with advanced navigation tools to help decrease the fluoroscopy time and the risk of nontarget embolization. The discussion of the potential complications of PAE is also relevant and comprehensive, with an emphasis on standardized reporting, and is enhanced by excellent illustrations.PAE is a promising technique for the treatment of urinary tract symptoms secondary to BPH. The comprehensive reviews provided in this article (10) and in an article by Picel et al (3) are relevant reading material for the interventional radiologist performing the procedure and the radiologist interpreting the images before and after embolization. Adequate patient selection, meticulous attention to the technical details, superb catheter skills, and a multidisciplinary approach that includes the active participation of the urologist are crucial components required for PAE to achieve a higher acceptance in the general population, particularly among the urology community.The author has disclosed no relevant relationships.References1. Mitchell ME, Waltman AC, Athanasoulis CA, Kerr WS Jr, Dretler SP. Control of massive prostatic bleeding with angiographic techniques. J Urol 1976;115(6):692–695. Crossref, Medline, Google Scholar2. Carnevale FC, da Motta-Leal-Filho JM, Antunes AA, et al. Quality of life and clinical symptom improvement support prostatic artery embolization for patients with acute urinary retention caused by benign prostatic hyperplasia. J Vasc Interv Radiol 2013;24(4):535–542. Crossref, Medline, Google Scholar3. Picel AC, Hsieh TC, Shapiro RM, Vezeridis AM, Isaacson AJ. Prostatic Artery Embolization for Benign Prostatic Hyperplasia: Patient Evaluation, Anatomy, and Technique for Successful Treatment. RadioGraphics 2019;39(5):1526–1548. Link, Google Scholar4. Pisco JM, Bilhim T, Pinheiro LC, et al. Medium- and long-term outcome of prostate artery embolization for patients with benign prostatic hyperplasia: results in 630 patients. J Vasc Interv Radiol 2016;27(8):1115–1122. Crossref, Medline, Google Scholar5. Insausti I, Sáez de Ocáriz A, Galbete A, et al. Randomized Comparison of Prostatic Artery Embolization versus Transurethral Resection of the Prostate for Treatment of Benign Prostatic Hyperplasia. J Vasc Interv Radiol 2020;31(6):882–890. Crossref, Medline, Google Scholar6. Malling B, Røder MA, Brasso K, Forman J, Taudorf M, Lönn L. Prostate artery embolisation for benign prostatic hyperplasia: a systematic review and meta-analysis. Eur Radiol 2019;29(1):287–298. Crossref, Medline, Google Scholar7. 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. Crossref, Medline, Google Scholar8. Foster HE, Dahm P, Kohler TS, et al. Surgical management of lower urinary tract symptoms attributed to benign prostatic hyperplasia: AUA Guideline Amendment 2019. J Urol 2019;202(3):592–598. Crossref, Medline, Google Scholar9. Young S, Golzarian J. Prostate Artery Embolization: State of the Evidence and Societal Guidelines. Tech Vasc Interv Radiol 2020;23(3):100695. Crossref, Medline, Google Scholar10. Dias US, de Moura M Ruettimann Liberato, Cavalcante Viana PC, et al. Prostatic artery embolization: Indications, Preparation, Techniques, Imaging Evaluation, Reporting, and Complications. RadioGraphics 2021;41(5):1509–1530. Link, Google ScholarArticle HistoryReceived: Feb 13 2021Accepted: Feb 18 2021Published online: Aug 20 2021Published in print: Sept 2021 FiguresReferencesRelatedDetailsAccompanying This ArticleProstatic Artery Embolization: Indications, Preparation, Techniques, Imaging Evaluation, Reporting, and ComplicationsAug 20 2021RadioGraphicsRecommended Articles Prostatic Artery Embolization: Indications, Preparation, Techniques, Imaging Evaluation, Reporting, and ComplicationsRadioGraphics2021Volume: 41Issue: 5pp. 1509-1530Prostatic Artery Embolization for the Treatment of Lower Urinary Tract Symptoms Due to Benign Prostatic Hyperplasia: 10 Years’ ExperienceRadiology2020Volume: 296Issue: 2pp. 444-451Prostatic Artery Embolization for Benign Prostatic Hyperplasia: Patient Evaluation, Anatomy, and Technique for Successful TreatmentRadioGraphics2019Volume: 39Issue: 5pp. 1526-1548Predictors of Clinical Outcome after Prostate Artery Embolization with Spherical and Nonspherical Polyvinyl Alcohol Particles in Patients with Benign Prostatic HyperplasiaRadiology2016Volume: 281Issue: 1pp. 289-300Prostate Artery Embolization for Lower Urinary Tract Symptoms Attributed to Benign Prostatic Hyperplasia—Radiology In TrainingRadiology2022Volume: 304Issue: 1pp. 31-37See More RSNA Education Exhibits Benign Prostatic Hyperplasia Treatments: A Review of the Fundamentals to Assist in Optimal Prostate Artery Embolization Patient SelectionDigital Posters2022Prostatic Artery Embolization (PAE): A Quest To Find The Prostatic Artery And Management Of Benign Prostatic HyperplasiaDigital Posters2021Treatment Strategies For Benign Prostatic Hyperplasia And Post-treatment MR Imaging AppearancesDigital Posters2021 RSNA Case Collection Pulmonary Arteriovenous MalformationRSNA Case Collection2021Peripheral Zone Prostate Cancer with PseudocapsuleRSNA Case Collection2022Persistent Sciatic ArteryRSNA Case Collection2022 Vol. 41, No. 5 Abbreviations Abbreviations: BPH benign prostatic hyperplasia PAE prostatic artery embolization TURP transurethral resection of the prostate Metrics Altmetric Score PDF download
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