Prostate Artery Embolization as a New Treatment for Benign Prostate Hyperplasia: Contemporary Status in 2016

The gold standard treatment for benign prostate hyperplasia (BPH) is transurethral resection of the prostate (TURP) or open prostatectomy (OP). Recently, there has been increased interest and research in less invasive alternative treatments with less morbidity including prostate artery embolization (PAE). Several studies have shown PAE to be an effective alternative to TURP to treat lower urinary tract symptoms (LUTS) associated with BPH with decreased morbidity. Specifically, PAE has been advantageous in selected patient populations such as those with prostates too large for TURP or unsuitable surgical candidates, showing a promising potential for the future care of patients with BPH. Further studies are being done to demonstrate the clinical applications and advantages of this therapy in reduction of LUTS.     

Role of Splenic Artery Embolization in Management of Traumatic Splenic Injuries: A Prospective Study

The objective of our study was to evaluate the role of splenic artery embolization (SAE) in the management of traumatic splenic injuries. From September 2008 to September 2010, a total of 67 patients underwent nonoperative management (NOM) for blunt splenic injuries. Twenty-two patients were excluded from the study because of associated significant other organ injuries. Twenty-five patients underwent SAE followed by NOM (group A) and 20 patients underwent standard NOM (group B). Improvement in clinical and laboratory parameters during hospital stay were compared between two groups using Chi-square test and Mann–Whitney test. SAE was always technically feasible. The mean length of the total hospital stay was lower in the group A patients (5.4 vs. 6.6 day, [P = 0.050]). There was significant increase in hemoglobin and hematocrit levels and systolic blood pressure (SBP) in group A patients after SAE, whereas in group B patients there was decrease in hemoglobin and hematocrit levels and only slight increase in SBP (pre- and early posttreatment relative change in hemoglobin [P = 0.002], hematocrit [P = 0.001], and SBP [P = 0.017]). Secondary splenectomy rate was lower in group A (4 % [1/25] vs. 15 % [3/20] [P = 0.309]). No procedure-related complications were encountered during the hospital stay and follow-up. Minor complications of pleural effusion, fever, pain, and insignificant splenic infarct noted in 9 (36 %) patients. SAE is a technically feasible, safe, and effective method in the management of splenic injuries. Use of SAE as an adjunct to NOM of splenic injuries results improvement in hemoglobin, hematocrit levels, and SBP. SAE also reduces secondary splenectomy rate and hospital stay.Keyword: Trauma, Splenic artery embolisation     

A Prospective,Randomised Trial Comparing Plasmakinetic Enucleation to Standard Transurethral Resection of the Prostate for Symptomatic Benign Prostatic Hyperplasia: Three-year Follow-up Results

Background

Plasmakinetic enucleation of the prostate (PKEP) has recently been proved a safe and technically feasible procedure for benign prostatic hyperplasia (BPH). However, its long-term safety, efficacy, and durability in comparison with the gold-standard transurethral resection of the prostate (TURP) have not yet been reported.

Objective

To report the 3-yr follow-up results of a prospective, randomised clinical trial comparing PKEP with standard TURP for symptomatic BPH.

Design, setting, and participants

A total of 204 patients with bladder outflow obstruction (BOO) secondary to BPH were prospectively randomised 1:1 into either the PKEP group or the TURP group.

Intervention

The patients in each group underwent the procedure accordingly.

Measurements

All patients were assessed perioperatively and followed at 1, 3, 6, 12, 18, 24, and 36 mo postoperatively. The preoperative and postoperative parameters included International Prostate Symptom Score (IPSS), quality of life (QoL) scores, the International Index of Erectile Function (IIEF) questionnaire, maximum urinary flow rates (Q_max), transrectal ultrasound (TRUS)–assessed prostate volume, postvoid residual urine (PVRU) volume, and serum prostate-specific antigen (PSA) level. Patient baseline characteristics, perioperative data, and postoperative outcomes were compared. All complications were recorded.

Results and limitations

PKEP was significantly superior to TURP in terms of the drop in haemoglobin (0.74 ± 0.33 g/dl vs 1.88 ± 1.06 g/dl; p < 0.001), intraoperative irrigation volume (11.7 ± 4.5 l vs 15.4 ± 6.2 l; p < 0.001), postoperative irrigation volume and time (18.5 ± 7.6 l vs. 30.0 ± 11.4 l and 16.6 ± 5.2 h vs 25.3 ± 8.5 h; all p < 0.001), recovery room stay (67.3 ± 11.1 min vs 82.0 ± 16.4 min; p < 0.001), catheterisation time (51.7 ± 26.3 h vs 80.5 ± 31.6 h; p < 0.001), hospital stay (98.4 ± 20.4 h vs 134.2 ± 31.5 h; p < 0.001), and resected tissue (56.4 ± 12.8 g vs 43.8 ± 15.5 g; p < 0.001). There were no statistical differences in operation time and sexual function between the two groups. At 36 mo postoperatively, the PKEP group had a maintained and statistically significant improvement in IPSS (2.4 ± 2.2 vs 4.3 ± 2.9; p < 0.001), QoL (0.6 ± 0.5 vs 1.6 ± 1.4; p < 0.001), Q_max (28.8 ± 10.1 ml/s vs 25.1 ± 8.0 ml/s; p = 0.017), and TRUS volume (21.0 ± 7.3 ml vs 26.4 ± 6.8 ml; p < 0.001), with urodynamically proven deobstruction (Schäfer grade 0.2 ± 0.02 vs 0.8 ± 0.1; p < 0.001). More extensive clinical trials are required to validate these results.

Conclusions

PKEP is a safe and highly effective technique for relieving BOO. At 3-yr follow-up, the clinical efficacy of PKEP is durable and compares favourably with TURP.     

Prostatic Artery Embolisation Versus Transurethral Resection of the Prostate for Benign Prostatic Hyperplasia: 2-yr Outcomes of a Randomised,Open-label,Single-centre Trial

BackgroundProstatic artery embolisation (PAE) for the treatment of lower urinary tract symptoms secondary to benign prostatic obstruction (LUTS/BPO) still remains under investigation.ObjectiveTo compare the efficacy and safety of PAE and transurethral resection of the prostate (TURP) in the treatment of LUTS/BPO at 2 yr of follow-up.Design, setting, and participantsA randomised, open-label trial was conducted. There were 103 participants aged ≥40 yr with refractory LUTS/BPO.InterventionPAE versus TURP.Outcome measurements and statistical analysisInternational Prostate Symptoms Score (IPSS) and other questionnaires, functional measures, prostate volume, and adverse events were evaluated. Changes from baseline to 2 yr were tested for differences between the two interventions with standard two-sided tests.Results and limitationsThe mean reduction in IPSS after 2 yr was 9.21 points after PAE and 12.09 points after TURP (difference of 2.88 [95% confidence interval 0.04–5.72]; p = 0.047). Superiority of TURP was also found for most other patient-reported outcomes except for erectile function. PAE was less effective than TURP regarding the improvement of maximum urinary flow rate (3.9 vs 10.23 ml/s, difference of –6.33 [–10.12 to –2.54]; p < 0.001), reduction of postvoid residual urine (62.1 vs 204.0 ml; 141.91 [43.31–240.51]; p = 0.005), and reduction of prostate volume (10.66 vs 30.20 ml; 19.54 [7.70–31.38]; p = 0.005). Adverse events were less frequent after PAE than after TURP (total occurrence n = 43 vs 78, p = 0.005), but the distribution among severity classes was similar. Ten patients (21%) who initially underwent PAE required TURP within 2 yr due to unsatisfying clinical outcomes, which prevented further assessment of their outcomes and, therefore, represents a limitation of the study.ConclusionsInferior improvements in LUTS/BPO and a relevant re-treatment rate are found 2 yr after PAE compared with TURP. PAE is associated with fewer complications than TURP. The disadvantages of PAE regarding functional outcomes should be considered for patient selection and counselling.Patient summaryProstatic artery embolisation is safe and effective. However, compared with transurethral resection of the prostate, its disadvantages regarding subjective and objective outcomes should be considered for individual treatment choices.     

Decortication for Chronic Parapneumonic Empyema: Results of a Prospective Study

Despite advances in diagnostic methods, surgical techniques, and supportive therapy, chronic parapneumonic empyema is still associated with considerable morbidity and mortality. A prospective study was performed on a consecutive series of patients with chronic parapneumonic empyema to analyze the results of surgical treatment and identify clinical predictors of poor outcome. From 1993 to 2000 a total of 40 patients underwent decortication for chronic parapneumonic empyema. There was no mortality. All 40 patients had definitive resolution of the empyema. Altogether, 34 patients (87.5%) had an uneventful postoperative course, and 5 (12.5%) experienced complications (2 prolonged febrile syndromes, 3 cases of sepsis requiring mechanical respiratory assistance). All complications resolved well with adequate treatment without further consequences. Definitive results of the surgical procedures assessed at the 6-month follow-up examination were good in 21 patients and satisfactory in 19. No unsatisfactory results were observed in any of the patients. Univariate analysis showed that three variables predicted morbidity: co-morbidities (p = 0.039), symptom duration 60 days (p = 0.009), and duration of preoperative conservative treatment 30 days (p = 0.006). Multivariate analysis showed that only symptom duration 60 days (p = 0.041) and duration of conservative treatment 30 days (p = 0.025) were associated with morbidity. Decortication is a highly effective treatment for chronic parapneumonic empyema and may be performed with low morbidity and mortality. Because prolonged duration of symptoms and conservative treatment increase morbidity, early surgical intervention seems to be the optimal modality for the treatment of chronic parapneumonic empyema.     

Long-term Follow-up Results after Flow Diverter Therapy Using the Pipeline Embolization Device for Large or Giant Unruptured Internal Carotid Artery Aneurysms: Single-center Retrospective Analysis in the Japanese Population

Flow diverter (FD) therapy using Pipeline embolization device (PED) has become an important alternative to treat internal carotid artery (ICA) aneurysms. Herein, we report the long-term outcome for 3 years after FD therapy using PED for ICA aneurysms in Japan. The patients who underwent angiographical and/or clinical follow-up for 3 years after the FD therapy using PED of large or giant unruptured ICA aneurysms from December 2012 at our university hospital are the subjects of this study. We retrospectively reviewed the in- and outpatients’ medical charts, and written operative and radiological records. There were 84 patients with 90 aneurysms who could be clinically and/or angiographically followed up for 3 years. Of these, 7 aneurysms were only available for clinical follow-up. Of the remaining 83 aneurysms, 6 aneurysms had vessel occlusion due to stent thrombosis or parent artery occlusion, and 60 of the remaining 77 (77.9%) had complete occlusion. In multivariate analysis, older age (>70 years), wide neck, and non-adjunctive coiling contributed statistically significantly to incomplete occlusion. Of the 84 patients, 2 patients (2.4%) had delayed complications between 6 months and 3 years after the initial FD placement. Three patients (3.6%) had poor outcome due to postoperative major stroke complications, 2 of which were acute complications. The long-term results after FD therapy are good both angiographically and clinically. Endothelialization of the aneurysmal neck and intra-aneurysmal thrombosis contribute to complete occlusion. The primary reason for the somewhat low complete occlusion in Japan may be the patients are generally older.