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CASE
23
Prostate artery embolization for
benign prostate hypertrophy
Aidan Shaw and Irfan Ahmed
Expert commentary Tarun Sabharwal
Case history
A 72-year-old man with a known diagnosis of benign prostatic hyperplasia (BPH)
returned to his urologist with worsening lower urinary tract symptoms whilst on
a 5α-reductase inhibitor. He had a signicant past medical history including myocardial infarctions and coronary stents. On examination, the prostate was grossly
enlarged and had smooth margins. The International Prostate Symptom Score (IPSS)
was 28 with a quality of life score of 6.
Learning point The International Prostate Symptom Score
The IPSS is used to assess lower urinary tract symptoms in men. The first seven questions are based on
the American Urological Association seven-item symptom score (AUA-7) [1]. The questions refer to
the following urinary tract symptoms: incomplete emptying, frequency, intermittency, urgency, weak
stream, straining, and nocturia. The answers are assigned points from 0 to 5, with 5 being the most
severe. Therefore patient’s scores can range from 0 to 35 (asymptomatic to severely symptomatic).
Symptoms are then categorized (see Table 23.1).
Question 8 refers to quality of life and was added by the World Health Organization when IPSS was
adopted by the International Consensus Committee as an international questionnaire for evaluating
prostatic symptoms. Unlike the previous questions, this question ranges from 0 to 6, with 0 being
delightful and 6 being terrible. Although it does not globally assess the patient’s symptoms, it acts as a
good starter for doctor–patient conversation.
Table 23.1 International Prostate Symptom Score
Score Correlation
0–7 Mildly symptomatic
8–19 Moderately symptomatic
20–35 Severely symptomatic
The patient’s prostate specic antigen (PSA) was elevated and measured 12μg/L.
Prostate biopsies did not demonstrate any evidence of malignancy. An MRI scan
demonstrated that the prostate was grossly enlarged with a volume of 300ml and no
radiological evidence of malignancy.
Clinical tip Prostate-specific antigen
PSA is a protein produced by normal prostate cells. Elevation of PSA is thought to be due to disruption in
the prostate cellular architecture. PSA is not specific to prostate cancer but to prostate tissue, and elevation
of PSA can be due to a number of different prostate diseases as well as prostate cancer. The most
common causes of PSA elevation are BPH and prostatitis. Other causes include urinary retention, catheter
placement, prostate biopsy, and prostate examination. Prostate artery embolization has recently been
shown to cause a sharp increase in PSA following the procedure, which then resolves after a month [2].
196 Interventional radiology and endovascular procedures
Figure 23.1 CTA of the pelvis demonstrating a
grossly enlarged prostate gland
Given the patient’s anaesthetic risk, the patient was referred to interventional
radiology for consideration of prostate artery embolization (PAE). Following consultation, a computed tomography angiogram (CTA) of the abdomen and pelvis was
ordered for further evaluation of the prostatic arterial supply (Figure 23.1). The prostate arteries were identied to arise from the internal pudendal artery on the right
side and the obturator artery on the left, with no stenotic or occlusive iliac atherosclerotic lesion identied.
Expert comment Computed tomography angiography (CTA)
CTA of the abdomen and pelvis is recommended prior to prostate artery embolization as it allows
accurate assessment of any arterial atherosclerotic disease which may preclude embolization of the
prostate artery (e.g. iliac occlusion or stenosis). It also allows visualization of the prostate arteries and
pre-operative planning as there is anatomical variation in the origin of the prostatic artery on each
side as well as from individual to individual. This reduces contrast dose and the time required to
perform the procedure. The prostate arteries are very small and can be difficult to visualize. To assist
with this, the patient is given two puffs of sublingual glyceryl trinitrate (GTN) on the CT table prior to
the scan. The CT protocol for PAE is as follows:
●
120ml contrast
●
rate 3.5–5ml/sec
●
bolus triggering in the abdominal aorta
●
30ml saline given at the same rate before and after the injection of contrast
●
two puffs sublingual GTN at the time of CTA.
After informed consent had been obtained, the patient was given pre-operative
doses of cefuroxime 750mg IV and diclofenac 100mg PR. A retrograde puncture of
the right common femoral artery was performed using local anaesthetic and ultrasound guidance and a 4Fr sheath was sited. The right internal iliac artery was successfully cannulated with a cobra catheter and an angiogram conrmed that the
right prostate artery originated from the right internal pudendal artery. This was
successfully cannulated with a microcatheter and an angiogram was performed to
conrm the right prostatic arterial supply as well as to identify any aberrant arterial
supply to the rectum, penis, or bladder (Figure 23.2). The artery was embolized to
stasis using a 2ml syringe lled with polyvinyl alcohol (PVA) particles (initially PVA
100 and then PVA 200).
Figure 23.2 DSA in the postero-anterior view
demonstrating successful cannulation of the right
prostate artery
197Case 23 Prostate artery embolization for BPH
Expert comment Prostate arterial angiography
Once the internal iliac artery is cannulated, the best projection for identification of the prostate artery
and all the accessory branches is ipsilateral angulation of 350° and caudal–cranial angulation of 100°.
A pump injection is performed using 6ml of contrast at a rate of 4ml/sec. Once the prostate artery is
cannulated, ipsilateral oblique and postero-anterior views are obtained to identify collateral vessels
and confirm parenchymal supply. Again, this is performed with an injection pump connected directly
to the microcatheter using 4ml of contrast at a rate of 2ml/sec and a pressure of 300psi.
The contralateral internal iliac artery and prostate artery were then cannulated
and embolized using the same technique (Figure 23.3). The puncture site was then
compressed manually. The patient was discharged later that day with no abdominal
pain. He was prescibed ibuprofen 400mg three times daiy and cephalexin 500mg
twice daily for seven days.
Expert comment Preparing
the PVA
PVA 100 and PVA 200 are used
for PAE and only a few millilitres
are required to complete the
embolization. Separate pots are
used for the PVA 100 and PVA 200.
The embolic agent is prepared
by mixing a ‘pinch’ of PVA with
20ml of IV contrast and 20ml of
saline. The embolization is then
performed using a 2ml syringe.
Figure 23.3 DSA of the left internal iliac artery
with 350° ipsilateral angulation and 100° caudal–
cranial angulation demonstrating the prostate artery
(arrow) originating from the left obturator artery
198 Interventional radiology and endovascular procedures
One month later the patient was well and the IPSS had fallen from 28 to 14. A
follow-up CT two months later demonstrated that the volume of the prostate gland
had signicantly reduced and there was low attenuation in both lobes of the prostate
gland in keeping with post-embolization change (Figure 23.4)
Figure 23.4 Follow-up CT demonstrating
significant volume reduction of the prostate with
low attenuation in both lobes consistent with
post-embolization change.
Evidence base Prostate artery embolization
Portugal
●
PAE performed since 2010.
●
Short- and medium-term results of a study including 255 patients have recently been published
[3]. Technical success was defined as a completed PAE on at least one side, and clinical success was
defined as improving symptoms (IPSS) and quality of life:
●
Technical success rate of 98%
●
Clinical success rate of 81% at one monthand 72% at three months with only one major complication.
●
Concluded PAE is a safe and effective procedure with low morbidity and no sexual dysfunction [3,4].
Brazil
●
PAE performed since 2010.
●
A prospective study of patients with acute urinary retention due to BPH has been performed.
Clinical and urodynamic parameters improved significantly following PAE. Ten out of eleven
patients urinated spontaneously following Foley catheter removal at a mean of 12 days following
PAE [2,5].
●
Outcomes of unilateral versus bilateral embolization were also compared. The clinical outcome
is better if bilateral embolization is achieved (75%); however, 50% of patients still achieved a good
clinical outcome despite only unilateral success.
United Kingdom
●
University Hospital Southampton was the first hospital in the UK to perform PAE. Twenty patients
with BPH were treated.
●
The results were presented at the British Society of Interventional Radiology Meeting 2013.
●
IPSS decreased by 51% at one month, and was sustained at 46% at six months
●
Persistent improvements were found in IPSS, quality of life scores, and flow rates at one, six, and
twelve months with no significant complications.
●
The UK-ROPE (Registry of Prostate Embolization) trial has been launched in the UK in which 100
patients will be recruited from multiple centres across the UK
Discussion
As the prostate gland enlarges in BPH, it starts to compress and obstruct the
urethra, causing lower urinary tract symptoms (hesitancy, urgency, frequency,
poor stream, and incomplete emptying). Once obstruction becomes complete it
causes acute urinary retention. Indeed, over half the patients who present with a
histological diagnosis of BPH have moderate to severe lower urinary tract symptoms (LUTS).
Patients presenting with mild or moderate LUTS can initially be managed with a
trial of lifestyle modications and oral medication (alpha blockers and 5α-reductase
inhibitors). First-line treatment with alpha-blockers and 5α -reductase inhibitors as
monotherapies or in combination have both proved effective in controlling LUTS
with BPH [6,7].
If conservative management fails and LUTS are severe, surgical management will
be offered. A number of different surgical options are available depending on the
patient and the size of the prostate. All modern treatments favour conservation of
the prostate and minimally invasive endosopic procedures rather than open prostatectomy. In addition to transurethral resection of the prostate (TURP), newer surgical
options include holmium laser ablation of the prostate (HoLAP), microwave or radiofrequency ablation, and transurethral electrovaporization of the prostate (TUEVP).
TURP is associated with signicant risk of morbidity (18%) and mortality (0.23%).
It is regarded as the gold standard of surgery and is often successful. Patients usually
stay overnight and are discharged the following day. However, the procedure has
signicant risks:
●
signicant blood loss requiring blood transfusion and prolonged hospital stay
●
clot retention requiring bladder washouts
●
urethral strictures
●
70% risk of retrograde ejaculation
●
nerve injury resulting in impotence
●
transurethral resection (TUR) syndrome (a rare but potentially life-threatening
condition where hypotonic irrigation uid is absorbed, causing severe electrolyte
imbalance with neurological and cardiovascular manifestations).
199Case 23 Prostate artery embolization for BPH
A final word from the expert
PAE has been performed for many years for intractable haematuria and has recently come
to the forefront as a novel treatment for BPH. There are many advantages of PAE over
surgical treatment options. The procedure takes around one to two hours and therefore
can be performed as a daycase with the patient discharged later the same day provided
that he is well. PAE can be performed on any size of prostate and does not involve urethral
manipulation, therefore avoiding the risk of urethral strictures. Severe coorbidities that
increase the anaesthetic risk are not a contraindication to the procedure. Patients can be
converted to an open procedure following volume reduction. The only major complaint
following PAE is retropubic pain and urethral burning, which are well managed on oral nonsteroidal anti-inflammatory drugs. The main risk of the procedure is non-target embolization;
however, only one patient worldwide has required surgical repair of the bladder following
focal ischaemia. The procedure preserves the bladder neck and avoids nerve injury. This
makes PAE particularly appealing to young male patients who are keen to preserve sexual
function, as the risks of retrograde ejaculation and potential impotence are avoided.
The current results for PAE have shown the procedure to a safe, effective, and minimally invasive
treatment option for BPH. More studies and follow-up are required to investigate the long-term
outcomes, but given the results so far the procedure continues to have an exciting future.
200 Interventional radiology and endovascular procedures
References
1. Barry M J, Fowler FJ Jr, O’Leary MP, et al. The American Urological Association symptom
index for benign prostatic hyperplasia. J Urol 1992;148(5): 1549–57, 1564.
2. Antunes AA, Carnevale FC, da Motta Leal Filho JM, et al. Clinical, laboratorial, and
urodynamic ndings 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. Pisco JM, Rio Tinto H, Campos Pinheiro L, et al. Embolisation of prostatic arteries as
treatment of moderate to severe lower urinary symptoms (LUTS) secondary to benign
hyper plasia: results of short- and mid-term follow-up. Eur Radiol 2013; 23(9): 2561–72.
4. Pisco J, Campos Pinheiro L, Bilhim T, et al. Prostatic ar terial embolization for benign
prostatic hyperplasia: short- and intermediate-term results. Radiology 2013; 266(2):
6 6 8 – 7 7.
5. 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
urinar y retention caused by benign prostatic hyperplasia. J Vasc Interv Radiol 2013; 24(4):
535–42.
6. Greco KA, McVary KT. The role of combination medical therapy in benign prostatic
hyperplasia. Int J Impot Re S 2008; 20(Suppl 3): S33–43.
7. Logan YT, Belgeri MT. Monotherapy versus combination drug therapy for the treatment
of benign prostatic hyperplasia. Am J Geriatr Pharmacother 2005; 3(2): 103–14.
SECTION 4
Non-vascular
procedures and
interventional
oncology
Case 24 Lung tumour radiofrequency ablation: what are the
success factors?
Case 25 Tracheobronchial stenting: covered versus uncovered
Case 26 Early-stage hepatocellular carcinoma: the percutaneous
approach
Case 27 Small renal tumours: is radiofrequency ablation better
than surgery?
Case 28 Malignant biliary strictures: covered or uncovered stents?
Case 29 Vertebroplasty of the cervical spine
Case 30 Percutaneous neurolytic coeliac plexus block
Case 31 Vertebral augmentation techniques and pain
management: is there a role in metastatic disease?
CASE
24
Lung tumour radiofrequency
ablation: what are the success
factors?
Victoria St Noble
Expert commentary Nicos Fotiadis
Case history
A 37-year-old female was referred with a past medical history of a testosteronesecreting adrenocortical carcinoma, resected 14 years previously. This recurred 5
years later within the adrenalectomy bed, prompting removal of the residual tumour
along with unilateral nephrectomy, splenectomy, and distal pancreatectomy. Shortly
afterwards, she was found to have several small lung metastases, two of which were
treated by metastatectomy. A further ve pulmonary metastases followed, which
have been stable in number and slow-growing. The patient planned to become pregnant, and a decision to treat the metastatic disease radically before she conceived
was made at a multidisciplinary meeting.
She was referred to the interventional radiology department for radiofrequency
ablation (RFA) of the pulmonary metastases. She was asymptomatic at this time
with no respiratory compromise or chest pain. Her biochemistry was normal with
no evidence of hypersecretory state.
Staging chest CT showed a total of ve lung lesions, with a size range from
7 to 21mm, located in four different lobes (Figures 24.1 and 24.2). There was no
thoracic lymphadenopathy or evidence of metastatic disease elsewhere in the
bod y.
96 mm
Figure 24.1 Axial CT lung reconstructions showing a right upper lobe (left image) and two left upper
lobe (middle and right image) metastases.
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