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67
order to achieve better long- term outcomes,
bilateral PAs and all angiographically visible
arteries feeding prostate should be embolized
completely (Fig.7.8).
As mentioned in the previous discussion, the
optimal agents or size has not yet been deter-
mined. Theoretically, embolization with larger
particles results in proximal occlusion while
smaller particles result in distal embolization, but
smaller particles may increase the risk of
nontarget embolization. Bilhim et al. [46] com-
pared the impact of embolic agent size on the
outcomes of PAE of 80 patients. The clinical out-
come was better with 200-μm PV particles while
the reduction of PSA level and PV were greater
with 100- μm particles post-PAE.Moreover, they
compared the outcomes of PAE with spherical
particle polyvinyl alcohol (sPVA, 300–500μm)
and nonspherical particle polyvinyl alcohol
(nsPVA, 100–300μm), they found that the mean
proportion of prostate ischemia was 11% with
sPVA and 10% with nsPVA (P= 0.65) and the
clinical outcome was similar in both groups [4].
A study of 30 patients compared 100–300 μm
and 300–500μm Embosphere in the treatment of
BPH, they found no difference in outcomes [47].
Wang et al. [28] compared 50-μm plus 100-μm
PVA particles with 100-μm PVA particles alone
for PAE to treat BPH, they found that the combi-
nation group achieved good clinical outcomes
and no increase in complications.
Long-term efcacy of PAE remains unclear.
Despite Carnevale FC et al. [29, 45] reported
clinical benet for 4 years, prostate enlarged
again in the rst two patients measured by
MRI.The authors speculated that hypoxia of the
prostate tissue after embolization promotes the
production of peptides that could stimulate arter-
ies regeneration, thereby regenerating the pros-
tate. Further analysis of peptide growth factors
related to angiogenesis in prostate tissue, such as
vascular endothelial growth factor (VEGF) and
broblast growth factor (FGF), may help explain
these cases.
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a
*
b c
*
*
Fig. 7.8 Unilateral PAE due to severe atherosclerotic ste-
nosis of the left prostatic artery (PA). (a) Pelvic coronal
T1-weighted fat-suppressed contrast-enhanced MR
images of a 70-year-old man with LUTS due to BPH
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enced clinical improvement during 1–6months follow-up
with IPSS decreased from 25 to 11 points and he had
LUTS recurrence at 10-month after PAE with IPSS
increased to 24 points
7 Post-prostatic Arterial Embolization Management
68
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7 Post-prostatic Arterial Embolization Management
71
© Springer Nature Singapore Pte Ltd. 2021
M. Wang (ed.), Prostatic Arterial Embolization, https://doi.org/10.1007/978-981-15-6836-7_8
Comparison ofPAE withOther
Treatments inBPH
JinlongZhang, ZhijunWang, YangGuan,
JinxinFu, WenhaoJiang, LiliTian, CuiyingZhang,
andHongkaiYu
8.1 Introduction
Currently, various treatment options are avail-
able for lower urinary tract symptoms (LUTS)
secondary to benign prostatic hyperplasia (BPH),
mainly including medical therapy, open prosta-
tectomy (OP), transurethral resection of prostate
(TURP), and minimally invasive treatment, such
as holmium laser enucleation (HoLEP), green-
light laser prostatectomy, photovaporization of
the prostate, etc. [1–4]. Medical therapy, includ-
ing the use of alpha-1-Blocker and 5-alpha reduc-
tase inhibitors, has been considered rst-line
treatment [5]. Surgical treatments are used for
treatment in patients who are failed in medical
treatment [6]. European Association of Urology
suggests that TURP is considered as the stan-
dard therapy for patients with prostate volume
(PV) ranges from 30 to 80cm
3
, OP or HoLEP are
considered as the gold standard when PV larger
than 80 cm
3
[2, 3, 7]. However, each treatment
method has its advantages and disadvantages.
The medication may affect blood pressure and
sexual function. Surgical treatment is associated
with prolonged hospitalization, postoperative
pain, retrograde ejaculation, sexual dysfunction,
and hemorrhage [3, 8–10].
Prostatic artery embolization (PAE) as an
alternative therapy has been used to treat BPH for
nearly a decade, and many observational studies
and meta-analyses have demonstrated the safety
and efcacy [11–14]. Furthermore, six studies
including 765 patients from various institutions
and multiple countries have carried out to com-
pare the safety and efcacy of PAE with standard
surgical treatment (TURP or OP) [3, 8, 15–18]
(Table8.1). However, to date, no comparison of
PAE with less invasive therapies, such as trans-
urethral microwave, needle ablation, urethral
stents, and prostatic urethral lift, was carried out.
8.2 Functional Outcomes
Currently, there was no standard or guideline to
evaluate the clinical efcacy of TURP and PAE
in the treatment of BPH.The efcacy was usually
assessed by functional outcomes, including
changes in international prostate symptom score
(IPSS), quality of life (QoL), peak/maximum uri-
nary ow rate (Q
max
), postvoid residual urine vol-
ume (PVR), prostate volume (PV) reduction,
prostate-specic antigen (PSA), and International
Index of Erectile Function short form (IIEF-5).
The safety was evaluated by adverse events or
J. Zhang (*) · Z. Wang · Y. Guan · J. Fu · L. Tian
C. Zhang
Department of Interventional Radiology, The First
Medical Center of Chinese PLA General Hospital,
Beijing, China
W. Jiang
The Second Hospital of Beijing, Beijing, China
H. Yu
Department of Urology, The First Medical Center of
Chinese PLA General Hospital, Beijing, China
8
72
complications. In most cases, the change of IPSS
was the primary outcome.
There is signicant heterogeneity for the ef-
cacy of PAE and the results are highly contra-
dictory previously, which is mainly due to the
various inclusion criteria, methodological aws,
and lack of certain analyses. In these compara-
tive clinical trials, the functional outcomes
improved both after PAE and surgical treatment
compared with preoperative values, however,
the functional measures of PAE were not supe-
rior to TURP and OP in all of the six studies
(Table8.2).
To date, the largest randomized controlled
trial (RCT) published by Gao et al. [15] com-
pared PAE with TURP, a total of 114 patients
were randomly assigned to each group and fol-
lowed up for 24 months. Both of the groups
achieved greater improvement in functional
assessment and reduction of PV and PSA com-
pared with pre-operation. Comparisons between
groups showed that patients underwent TURP
with greater improvement in IPSS, QoL, Q
max
,
and PVR at 1 and 3 months, and greater reduction
in PV and PSA level than patients underwent
PAR at all follow-up time points.
Recently, a randomized, open-label non-
inferiority trial carried out by Abt et al. [17]
involving 103 men (48 receiving PAE and 51
receiving TURP) with limited 12-week follow-
up. They reported that mean reduction in IPSS
was 9.23 and 10.77 after PAE and TURP at
12-week postprocedure, however, non-inferiority
for IPSS was unable to conrm. In addition,
changes in Q
max
(5.19 vs 15.34 mL/s), PVR
(-86.36 vs -199.98 mL), PV reduction (−12.17 vs
−30.27 mL) and desobstructive effectiveness
(56% vs 93%) were superior after TURP than
after PAE.
Recurrence rate is a key outcome in any evalu-
ation of treatments for BPH, and an important
consideration for patients choosing between
options. The evidence so far suggests that PAE is
far less durable than TURP. Gao et al. [15]
reported that the clinical failure rates were 9.4%
and 3.8% in patients receiving PAE and TURP,
respectively, and all received subsequent
TURP.Ray etal. [16] reported that 19.9% of the
patients receiving PAE accepted subsequent
TURP in 12 to 24 months post-PAE, while the
reoperation rate was only 5.6% of patients receiv-
ing TURP.
Table 8.1 Basic characteristics of the included studies
Author Year Country Design
Study group Interventions
PAE
Surgical
treatment PAE Surgical treatment
Gao etal. [15] 2014 China RCT 57 57
355–500 μm
polyvinyl
alcohol
microspheres
Bipolar TURP
Russo etal. [3] 2015 Italy/Russia Prospective
study, 1:1
matched-pair
analysis
80 80
300–500 μm
Embosphere
Suprapubic
transvesical
prostatectomy
Carnevale etal. [8] 2016 Brazil RCT 15 15
300–500 μm
Embosphere
Monopolar
TURP
Qiu etal. [18] 2017 China Retrospective
study
17 40
90–180 μm
Embosphere
Bipolar TURP
Ray etal. [16] 2018 United
Kingdom
Observational
study and
propensity-
matched pair
analysis
216 89 Technical
details not
specied
Monopolar (n =
45) and bipolar
(n = 44) TURP
Abt etal. [17] 2018 Switzerland RCT 48 51
250–400 μm
Embozene
Monopolar
TURP
J. Zhang et al.
73
Table 8.2 The clinical outcomes of the included studies
Parameter
Gao etal. [15]
a
Russo etal. [3]
b
Carnevale etal. [8]
b
Qiu etal. [18]
b
Ray etal. [16]
b
Abt etal. [17]
c
PAE TURP PAE OP PAE TURP PA E TURP PA E TURP PA E TURP
IPSS
−15.6 −16.3 −13.58 −19.04 −12.8 −21.5 −10.8 −14.3 −10.9 −15.2 −9.23 −10.77
QoL
−3.2 −3.2
N/A N/A
−2.5 −3.7 −2.0 −2.4 −2.6 −3.4 −2.33 −2.69
Q
max
(mL/s) +13.7 +14.8 +15.97 +9.63 +3.1 +17.4 +12.3 +14.9 +4.4 +8.6 +5.19 +15.34
PVR (mL)
−107.5 −100.2 −43.87 −58.8 −64.7 −70
N/A N/A
−40.4 −78.1 −86.36 −199.98
PV change
(%)
−46.06% −58.11%
N/A N/A
−19.21% −43.46% −34.98% −52.11% −28.26%
N/A
−23.05% −53.58%
PSA (ng/mL)
−1.6 −1.9 −1.48 −2.88 −1.2 −1.6
N/A N/A N/A N/A
−2 −3.11
IIEF-5 N/A N/A +0.68
−4.22 −1.7
+3.6 N/A N/A +1
−0.2 −0.98 −1.84
a
2-year follow-up
b
1-year follow-up
c
12-week follow-up
NA not available
8 Comparison ofPAE withOther Treatments inBPH
74
8.3 Safety
In the present study, PAE is associated with less
blood loss, less blood transfusion, shorter cathe-
terization and hospitalization, and fewer and less
severe adverse events than TURP, but longer pro-
cedure time and postprocedure pain. Unlike stan-
dard prostate surgery, PAE could be performed
under local anesthesia and the blood loss there is
minimal post-PAE.Therefore, clotting disorders,
anemia, and anticoagulant therapy are not contra-
indications to PAE. Also, PAE could be per-
formed in an outpatient without hospital
admission (Table8.3).
The mild complications regarding PAE are
usually self-limited and improved within 1–2
weeks, including embolization-related compli-
cations: acute urinary retention, urethral burn-
ing, transient hematuria, buttock or perineal
pain, gluteal paresis, and groin hematoma, and
tissues necrosis-related complications: nausea,
vomiting and low-grade fever, etc. The most
serious complications are the ischemia of blad-
der, rectal, penile, and rare complications such
as hemisection syndrome, rectovesical stula,
and skin necrosis. Of these studies, two patients
suffered self-limited penile ulcer due to nontar-
get embolization [16], one patient with ischemic
necrosis of bladder wall received transurethral
removal [17].
Preserving ejaculation function is a basic
requirement for many patients, the literature
reports that only 2 of more than 1000 cases suf-
fered ejaculation disorders for PAE while
60–65% for TURP [19]. However, Ray et al.
reported retrograde ejaculation rates were 24.1%
and 47.5% in PAE and TURP group, respectively
(24.1%) [16]. In the study of Abt and colleagues
[17], the retrograde ejaculation rates were up to
56% and 84% in patients receiving PAE and
TURP, respectively. The high incidence of retro-
grade ejaculation may attribute to the use of
questionnaire increased the sensitivity.
8.4 Conclusion
Although PAE failed to demonstrate superiority
to TURP and OP, PAE with the advantages
regarding minimally invasive nature, postopera-
tive sexual function, and shorter hospitalization
could be a worthy alternative in treating BPH in a
selected group, especially for those who contra-
indicate or refuse surgical treatment modality.
Table 8.3 Incidence of treatment-related complications after PAE and surgical treatment
Gao etal. [15] Russo etal. [3]
Carnevale
etal. [8]
Qiu
etal. [18] Ray etal. [16] Abt etal. [17]
PAE TURP PA E OP PAE TURP PA E TURP PAE TURP PA E TURP
Blood
transfusion
0% 3.8% 0 6.25% 0 0 N/A N/A 0.5% N/A N/A N/A
urinary retention 25.9% 5.7% N/A N/A N/A N/A N/A N/A N/A N/A 2.1% 6.25%
Voiding
irritation
1.85% 0 N/A N/A 13.33% 0 N/A N/A N/A N/A 31.25% 49.02%
hematuria 0% 7.5% 0 5.0% 13.3% 100% N/A N/A 18.6% 63.9% 8.33% 21.57%
Urinary tract
infection
1.9% 3.8% 1.25% 3.75% N/A N/A N/A N/A 5% 1.6% 20.83% 37.25%
Urethral/bladder
stricture
0% 4.2% 0 2.5% N/A N/A N/A N/A N/A N/A 0 3.92%
Urinary
incontinence
N/A N/A 0 3.75% 0 26.7% N/A N/A 1% 3.3% 0 5.88%
hematospermia N/A N/A 1.25% 0 6.7% 6.7% N/A N/A 12.6% 1.6% N/A N/A
Retrograde
ejaculation
N/A N/A N/A N/A N/A 100% N/A N/A 24.1% 47.5% 56% 84%
Sepsis N/A N/A N/A N/A N/A N/A N/A N/A 0.5% 2.2% N/A N/A
Penile ulcer N/A N/A N/A N/A N/A N/A N/A N/A 0.9% N/A N/A N/A
Bladder necrosis N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A 2.1% N/A
NA not available
J. Zhang et al.
75
More randomized controlled clinical studies
are needed to evaluate the long-term efcacy and
safety of PAE and to select the ideal spectrum of
indications.
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8 Comparison ofPAE withOther Treatments inBPH
77
© Springer Nature Singapore Pte Ltd. 2021
M. Wang (ed.), Prostatic Arterial Embolization, https://doi.org/10.1007/978-981-15-6836-7_9
PAE intheTreatment ofHematuria
ofProstatic Origin
FengDuan, XiujunZhang, ZhijunWang,
BingYuan, JinxinFu, HuanMa, LiangLi,
andHaixianQu
9.1 Introduction
Prostatic hematuria is one of the common emer-
gencies in male urinary diseases [1, 2]. Refractory
hematuria of prostatic origin (RHPO) is dened
as repeated active bleeding after conservative
methods, such as drug treatment, bladder irriga-
tion, or cystoscopy. Although the overall inci-
dence rate of RHPO is low, it causes severe
problems for the quality of life, even life threat-
ening. Additionally, this cohort of patients are
mainly elderly people who usually combined
with multiple comorbidities and with poor gen-
eral appearance, radical surgery is not always
feasible. Transcatheter arterial embolization has
been used for the treatment of urinary bleeding
for more than 40 years. Also, it has been success-
fully used to treat prostatic hematuria and
achieved good clinical results [1–10].
9.2 Causes ofProstatic
Hematuria
The common causes of hematuria are prostate
malignancy, benign prostatic hyperplasia
(BPH), iatrogenic bleeding, and radiation
therapy [1, 2]. The incidence of hematuria
caused by benign prostatic hyperplasia (BPH)
is 2.5%, and it is up to 2–16% in patients post-
urinary retention with BPH [2]. Prostatic
hyperplasia can promote the proliferation of
prostate acinar and stromal cells with the
angiogenesis, even slight activity may disrupt
these blood vessels, leading to spontaneous
prostate bleeding, especially when combined
with iatrogenic injury and repeated insertion
of the catheter, the incidence of bleeding is
higher [3].
The iatrogenic injury mainly includes prostate
biopsy, transurethral resection of prostate
(TURP), and urethral catheterization. The inci-
dence of hematuria after prostate biopsy is 0.7%–
62%, 12% after transurethral resection of prostate
(TURP) and 0.4%–7.1% of them required blood
transfusion, the incidence of hematuria after radi-
cal prostatectomy is 0.5–1.6% [3–7].
The incidence of hematuria caused by prostate
cancer is 0.7%, and up to 5.1% after radiation
therapy, mainly due to acute edema, telangiecta-
sia and occlusive endarteritis after radiotherapy,
resulting in mucosal ischemia, ulcer, and intrac-
table bleeding [4].
F. Duan (*) · Z. Wang · B. Yuan · J. Fu · H. Ma
Department of Interventional Radiology, The First
Medical Center of Chinese PLA General Hospital,
Beijing, China
X. Zhang
Interventional Department, Tianjin Hospital of
ITCWM Nankai Hospital, Tianjin, China
L. Li
Department of Interventional Vascular Surgery, The
980th Hospital Joint Logistic Support Force of PLA,
Shijiazhuang, China
H. Qu
Department of Radiology, Hainan Hospital of PLA
General Hospital, Sanya, Hainan, China
9
78
9.3 Diagnosis
Patients who suspected prostatic hematuria
should be evaluated by cystoscopy, upper urogra-
phy, urine culture, and urine cytology to deter-
mine the cause and site of the bleeding [1, 2].
9.4 Prostatic Hematuria: General
Principles ofTreatment
The management of serious prostatic hematuria
is in a stepwise manner from least to more inva-
sive treatment methods. Conservative treatment,
including continuous bladder irrigation (CBI),
use of 5-alpha reductase inhibitors, and blood
transfusion, could cease the bleeding in usual
[1–4]. If conservative treatment fails, the second-
line therapies with limited efcacy, including
intravesical instillations of alum, silver nitrate,
and formalin, could be used. And then, fulgura-
tion or TURP as more invasive minor surgical
therapies are the best choices. Packing the pros-
tatic fossa through open surgery under either
local or general anesthesia is the most invasive
and the last therapy, which is complicated and
dangerous in patients with serious hematuria,
because many of them are at high risk for general
anesthesia and surgery [5–7]. Superselective
transarterial embolization has been successfully
used in the treatment of hemorrhage in various
organ systems. Similarly, prostatic arterial embo-
lization (PAE) may avoid the need for surgical
procedures in patients with RHPO, thereby
reducing signicant morbidity [1–4].
9.5 Prostatic Arterial
Embolization forProstatic
Hematuria: Basic Principles
The basic principles and techniques of PAE for
prostatic hematuria are similar to transarterial
embolization for bleeding in other organs, but
there are a few key differences. Firstly, in other
organs, embolization is usually performed only
when the distinct source of bleeding is identied
(i.e., contrast extravasation and pseudoaneu-
rysm), but for prostatic hematuria, PAE is per-
formed even if there is no evidence of active
bleeding. It is mainly due to that prostatic arterial
angiography rarely demonstrates a distinct source
of bleeding, the purpose of PAE is to completely
occlude the arterial blood supply to the prostate,
thereby reducing blood perfusion and stopping
bleeding [5–7]. Secondly, PAE could completely
block the blood supply to the prostate by emboli-
zing the bilateral prostate arteries. Although uni-
lateral internal iliac arterial embolization has
been successfully used to treat RHPO in some
cases [2–4], bilateral embolization remains a
standard technique because of the presence of
communications between bilateral pelvic arter-
ies, which may cause recurrent bleeding.
9.6 The History ofPAE
intheTreatment ofProstatic
Hemorrhage
In 1974, Hald and Mygind [8] rst reported that
hypogastric artery embolization was used in the
treatment of fatal bladder hemorrhage. In 1988,
Appleton etal. [9] used the IIA embolization to
treat 2 patients with massive hemorrhage after
prostatectomy with the prompt cessation of the
bleeding. In 2000, DeMeritt et al. reported a
patient with hemorrhage and acute urinary reten-
tion secondary to BPH who was unsuitable for
surgical treatment underwent prostatic artery
embolization. No complications and sexual dys-
function occurred and the prostate volume
reduced by 40% at 12 months after treatment. In
2008, Rastinehad etal. reported their study of 8
patients diagnosed as RHPO who underwent
PAE, the technical success was 100% (8/8) and
the gross hematuria stopped immediately and last
up to 20 months [4].
In 2010, Jeong etal. [7] performed transarte-
rial embolization to treat 4 patients with serious
postoperative bleeding following radical prosta-
tectomy using an enbucrilate: ethiodized poppy
seed oil = 1:3 mixture. All patients were treated
successfully with transarterial embolization with
no treatment-related adverse event. In 2016,
Kably etal. [3] used prostatic artery embolization
F. Duan et al.