前列腺栓塞术治疗良性前列腺增生症的近期临床应用进展

【摘要】良性前列腺增生症是男性最常见的良性肿瘤,但药物与手术治疗均有其局限性。本文综合分析了国内外前列腺栓塞术的近期文献报道,并提出我们的观点,为良性前列腺增生症的治疗提供可供选择的安全、有效的治疗途径。     

经导管动脉栓塞术在经尿道前列腺电切后出血中的应用

目的评价经导管动脉栓塞术(TAE)在治疗良性前列腺电切后难治性出血中的疗效和预后。方法 2009年2月至2011年12月收治7例良性前列腺增生患者,行经尿道前列腺电切术(TURP)后出现严重血尿,保守治疗无效,行数字减影血管造影(DSA)及TAE栓塞出血靶血管。结果 7例患者DSA造影均发现活动性动脉出血,在TAE栓塞靶血管后出血停止。术后未出现相关并发症,随访3个月,未再有血尿。结论 TAE是治疗TURP术后严重出血的一种安全有效的方法。     

超选择前列腺动脉栓塞术治疗TURP术后复发的前列腺增生的临床疗效

目的超选择前列腺动脉栓塞术（PAE）治疗经尿道前列腺电切（TURP）复发后的前列腺增生的有效性和安全性分析。 方法收集2018年1月—2020年8月经TURP治疗前列腺增生复发后行超选择前列腺动脉栓塞术的患者资料10例。采用Seldinger技术穿刺成功后,将5F的Cobra导管选择至左侧髂内动脉造影,采用同轴微导管技术将1.98F微导管超选择至左侧前列腺动脉造影。采用300~500 μm的栓塞微球对前列腺动脉进行栓塞,同样方法处理右侧前列腺动脉。比较术前和术后3、6、12个月的国际前列腺症状评分（IPSS）、生活质量评分（QoL）、最大尿流率（Qmax）和前列腺体积（PV）。 结果10例患者均成功行双侧前列腺动脉栓塞术,技术成功率100%。术后3、6、12个月的IPSS、QoL、Qmax和PV与术前比较,差别均具有统计学意义（P < 0.001）。术后4例出现了会阴部灼烧感,2例患者出现会阴部疼痛,所有的并发症在发生后1周内消失,无严重的并发症发生。 结论对于TURP复发后的良性前列腺增生的患者,PAE能明显改善IPSS、QoL、Qmax和PV,疗效明确,并且安全性好。     

前列腺动脉栓塞术后下尿路症状改善临床分析

目的 观察前列腺动脉栓塞术(PAE)后下尿路症状(LUTS)变化,分析术后LUTS特征.方法 回顾性分析2010年11月至2019年10月单中心采用PAE术治疗的77例良性前列腺增生(BPH)患者临床资料.对比PAE术前后患者国际前列腺症状评分(IPSS)、生活质量(QOL)评分、残余尿(PVR)、前列腺体积、梗阻症状...     

分心木联合动脉栓塞术治疗良性前列腺增生的临床观察

目的：评价分心木联合前列腺动脉栓塞术治疗良性前列腺增生（BPH）的可行性和有效性。 方法：选取2012年1月—2016年11月我科收治的确诊BPH患者10例,采用前列腺动脉栓塞术栓塞前列腺动脉,术后当日起,分心木2 g泡服,3次/d,连服7 d。比较术前和术后1个月、术后6个月的国际前列腺症状评分（IPSS）、生活质量评分（QOL）、最大尿流率（Qmax）和剩余尿（RU）的变化。 结果：10例患者共完成16支前列腺动脉的栓塞,单侧栓塞4例,双侧栓塞6例。相对于术前,术后6个月的IPSS显著改善[（28.30±3.27）vs.（4.40±1.17）,P<0.05],QOL显著改善[（5.10±1.52）vs.（1.00±0.47）,P<0.05],Qmax显著改善[（7.05±2.72）vs.（15.08±1.45）,P<0.05],RU显著减少[（120.00±70.18）vs.（17.50±7.55）,P<0.05]。 结论：分心木联合前列腺动脉栓塞治疗良性前列腺增生可行且有效。     

经尿道前列腺等离子电切术160例

良性前列腺增生(BPH)是引起中老年男性排尿障碍原因中最为常见的一种良性疾病。经尿道前列腺电切术(TURP)治疗良性前列腺增生已有60余年历史,至今仍是治疗良性前列腺增生的"金标准"。近年来,在TURP的基础上出现了经尿道等离子双极电切术(PKRP)这项新的前列腺电切技术。我院从2007年开展经尿道前列腺等离子电切术(PKRP)治疗良性前列腺增生160例,疗效满意。现分析报告如下。     

经尿道1470nm激光前列腺汽化切除术与经TURP治疗良性前列腺增生的临床研究

目的 良性前列腺增生是泌尿外科常见疾病,在泌尿外科临床手术中前列腺手术占比较高,通过对比经尿道1 470 nm激光前列腺汽化切除术与经尿道前列腺电切术(TURP)治疗良性前列腺增生的临床效果,说明经尿道1 470 nm激光前列腺汽化切除术治疗良性前列腺增生的安全性和有效性。方法 分析2020年02月-2020年10月入院手术治疗的良性前列腺增生患者68例,分为经尿道1 470 nm激光组和TURP组,各34例。通过比较两组患者术前,术后的国际通用检查评分,同时对比手术时间,术中出血量,术后留置导尿管时间,术后尿失禁等并发症的发生率,分析出两种手术方法的优缺点。结果 68例患者手术均顺利完成,比较两组患者,1 470 nm激光组在术中出血量上优于TURP组,比较差异有统计学意义,其他方面比较差异无统计学意义。结论 经尿道1 470 nm激光前列腺汽化切除术与经尿道前列腺电切术治疗良性前列腺增生治疗效果无明显差异,但前者术中出血更少,手术安全性更好。     

前列腺动脉栓塞术治疗良性前列腺增生临床效果及手术入路探讨

目的 评价前列腺动脉栓塞术（PAE）治疗良性前列腺增生症（BPH）效果,探讨经肱动脉入路行PAE术的可行性和安全性。方法 采用PAE术治疗11例BPH患者。术后随访36个月以上,观察比较手术前后国际前列腺症状评分（IPSS）、生活质量（QOL）评分、前列腺容积（PV）、最大尿流率（Qmax）、残余尿（RU）水平变化。观察其中3例肱动脉入路行PAE术患者手术成功率及相关并发症。结果 PAE术远期临床成功8/10例。术后36、48、60个月分别有10例、10例、7例获随访,各时点患者IPSS、QOL评分、PV、Qmax、RU与术前比较,差异均有统计学意义（P<0.05）,各时点两两比较,差异均无统计学意义（P>0.05）。3例肱动脉入路患者均完成双侧前列腺动脉栓塞,术后症状明显改善2例,缓解1例,未见手术相关并发症发生。结论 PAE治疗BPH远期效果确切。肱动脉入路有助于栓塞双侧前列腺动脉,值得临床探索和应用。     

前列腺动脉栓塞术治疗前列腺源性血尿临床效果北大核心CSCD

目的评价前列腺动脉栓塞术(PAE)治疗前列腺源性血尿的临床效果。方法回顾性分析2016年6月至2019年8月在福建省立医院因前列腺源性血尿接受PAE治疗的21例患者临床资料、造影表现及治疗效果。PAE技术成功的定义为双侧超选择插管并栓塞前列腺动脉。止血成功定义为PAE即刻止血或术后72 h内不需进一步干预情况下血尿控制。结果PAE术后21例患者中4例DSA造影可见对比剂外渗或小动脉瘤形成。2例良性前列腺增生患者一侧前列腺动脉迂曲严重,微导管无法超选进入,其余患者均成功实施双侧超选前列腺动脉栓塞,技术成功率为90.5%(19/21);20例止血成功,肉眼血尿在24 h内消失,止血率为95.2%(20/21),1例前列腺增生患者术后3 d仍有活动性肉眼血尿,转入外科手术。结论PAE治疗前列腺源性血尿微创、有效,值得临床推广应用。     

良性前列腺增生:前列腺动脉栓塞与前列腺经尿道切除的前瞻性、随机性与临床对照研究

正摘要目的对照比较良性前列腺增生(BPH)病人的前列腺动脉栓塞(PAE)与经尿道前列腺切除(TURP)的治疗。方法此项前瞻性随机性的临床研究由学院审查委员会批准。     

Embolisation of prostatic arteries as treatment of moderate to severe lower urinary symptoms (LUTS) secondary to benign hyperplasia: results of short- and mid-term follow-up

Objectives

To evaluate the short- and medium-term results of prostatic arterial embolisation (PAE) for benign prostatic hyperplasia (BPH).

Methods

This was a prospective non-randomised study including 255 patients diagnosed with BPH and moderate to severe lower urinary tract symptoms after failure of medical treatment for at least 6 months. The patients underwent PAE between March 2009 and April 2012. Technical success is when selective prostatic arterial embolisation is completed in at least one pelvic side. Clinical success was defined as improving symptoms and quality of life. Evaluation was performed before PAE and at 1, 3, 6 and every 6 months thereafter with the International Prostate Symptom Score (IPSS), quality of life (QoL), International Index of Erectile Function (IIEF), uroflowmetry, prostatic specific antigen (PSA) and volume. Non-spherical polyvinyl alcohol particles were used.

Results

PAE was technically successful in 250 patients (97.9 %). Mean follow-up, in 238 patients, was 10 months (range 1–36). Cumulative rates of clinical success were 81.9 %, 80.7 %, 77.9 %, 75.2 %, 72.0 %, 72.0 %, 72.0 % and 72.0 % at 1, 3, 6, 12, 18, 24, 30 and 36 months, respectively. There was one major complication.

Conclusions

PAE is a procedure with good results for BPH patients with moderate to severe LUTS after failure of medical therapy.

Key Points

? Prostatic artery embolisation offers minimally invasive therapy for benign prostatic hyperplasia. ? Prostatic artery embolisation is a challenging procedure because of vascular anatomical variations. ? PAE is a promising new technique that has shown good results.     

Prostatic Artery Embolization as a Primary Treatment for Benign Prostatic Hyperplasia: Preliminary Results in Two Patients

Symptomatic benign prostatic hyperplasia (BPH) typically occurs in the sixth and seventh decades, and the most frequent obstructive urinary symptoms are hesitancy, decreased urinary stream, sensation of incomplete emptying, nocturia, frequency, and urgency. Various medications, specifically 5-α-reductase inhibitors and selective α-blockers, can decrease the severity of the symptoms secondary to BPH, but prostatectomy is still considered to be the traditional method of management. We report the preliminary results for two patients with acute urinary retention due to BPH, successfully treated by prostate artery embolization (PAE). The patients were investigated using the International Prostate Symptom Score, by digital rectal examination, urodynamic testing, prostate biopsy, transrectal ultrasound (US), and magnetic resonance imaging (MRI). Uroflowmetry and postvoid residual urine volume complemented the investigation at 30, 90, and 180 days after PAE. The procedure was performed under local anesthesia; embolization of the prostate arteries was performed with a microcatheter and 300- to 500-μm microspheres using complete stasis as the end point. One patient was subjected to bilateral PAE and the other to unilateral PAE; they urinated spontaneously after removal of the urethral catheter, 15 and 10 days after the procedure, respectively. At 6-month follow-up, US and MRI revealed a prostate reduction of 39.7% and 47.8%, respectively, for the bilateral PAE and 25.5 and 27.8%, respectively, for the patient submitted to unilateral PAE. The early results, at 6-month follow-up, for the two patients with BPH show a promising potential alternative for treatment with PAE.     

Prostatic Artery Embolization Versus Transurethral Resection of the Prostate for Benign Prostatic Hyperplasia: A Cost-Effectiveness Analysis

PurposeTo compare the cost effectiveness of prostatic artery embolization (PAE) with that of transurethral resection of the prostate (TURP) for the treatment of medically refractory benign prostatic hyperplasia (BPH).Materials and MethodsA cost-effectiveness analysis with Markov modeling was performed, comparing the clinical course after PAE with that after TURP for 3 years. Probabilities were obtained from the available literature, and costs were based on Medicare reimbursements and published cost analyses. Outcomes were measured using quality-adjusted life-year (QALY). Statistical analyses included base case calculation, probabilistic sensitivity analysis, and deterministic sensitivity analysis to assess the robustness of the conclusion under different clinical scenarios.ResultsBase case calculation showed comparable outcomes (PAE, 2.845 QALY; TURP, 2.854 QALY), with a cost difference of $3,104 (PAE, $2,934; TURP, $6,038). The incremental cost-effectiveness ratio was $360,249/QALY. PAE was dominant in 23.2% and more cost effective in 48.4% of the probabilistic sensitivity analysis simulations. PAE was better if its recurrence risk was <20.4% per year and even when the TURP recurrence risk was assumed to be 0%. TURP would be more cost effective when its procedural cost was <$3,367 or the PAE procedural cost >$4,409. PAE remained cost effective when varying the risks and costs of the minor and major short-term or long-term adverse events of both procedures. TURP would be the better strategy if the utility of BPH recurrence was <0.85 QALY.ConclusionsPAE is a cost-effective strategy to treat medically refractory BPH, resulting in comparable health benefits at a lower cost than that of TURP even when accounting for extreme alterations in adverse events, costs, and recurrence rates.     

Prostatic Artery Embolization for Control of Gross Hematuria in Patients with Benign Prostatic Hyperplasia: A Single-Center Retrospective Study in 20 Patients

PurposeTo evaluate the efficacy and safety of prostatic artery embolization (PAE) performed to treat gross hematuria secondary to benign prostatic hyperplasia (BPH).Materials and MethodsBetween February 2014 and December 2017, 20 patients with gross hematuria secondary to BPH refractory to medical treatment underwent PAE in our institution. Technical success was defined as bilateral PAE. International Prostate Symptom Score (IPSS), quality of life (QoL), and clinical review were assessed before PAE and at 3 and 12 months after procedure. Short- and medium-term clinical successes were defined as resolution of gross hematuria with no recurrence at 3 and 12 months, respectively.ResultsTechnical success rate was 100%. No major adverse events were recorded. Minor complications included gluteal pain, nausea, and fever in 7 patients. At 3 months, there were improvements in IPSS (21.1 ± 6.6 to 9.8 ± 4.7, P < .001) and QoL (5.1 ± 1.7 to 2.4 ± 1.3, P < .001). At 12 months, there were improvements in IPSS (8.1 ± 2.5, P < .001) and QoL (2.1 ± 1.0, P < .001). At 3 months, recurrent hematuria was reported in 3 of 20 patients (85% short-term clinical success rate). One of the remaining 17 patients had developed recurrent hematuria by 12 months (80% medium-term clinical success rate).ConclusionsPAE is a safe and effective means of treating gross hematuria caused by BPH refractory to medical treatment. PAE offers a reasonable option for such patients who are not suitable for surgical therapy.     

Repeat Prostatic Artery Embolization for Patients with Benign Prostatic Hyperplasia

PurposeTo evaluate the safety and efficacy of repeat prostatic artery (PA) embolization (PAE) for benign prostatic hyperplasia (BPH).Materials and MethodsA single-center retrospective study was conducted from 2009 to 2018 in 108 patients with symptomatic BPH treated with repeat PAE: group A (n = 39; 36.1%) were patients who never showed a response to PAE, and group B (n = 69; 63.9%) were patients who had clinical improvement in the first 6 months following PAE but relapsing symptoms afterward. The main patterns of revascularization were 75% from the previously embolized PA and 25% from collateral vessels (superior vesical, posterior-lateral PA, penile branches). Technical outcomes and adverse events were registered. International Prostate Symptom Score (IPSS), quality of life (QOL), and clinical success were compared between groups.ResultsMedian follow-up was 18 months (range, 1–36 mo); median interval between PAE and repeat PAE was 420 days (range, 77–2,240 d). Mean procedural time was significantly longer for repeat PAE vs initial PAE (81.1 min vs 67.4 min; P = .0007). There were no major complications and no urinary incontinence. Mean IPSS/QOL improvements were greater in group B vs group A: 9.51 vs 6.13 and 1.30 vs 0.56, respectively (P < .001). The cumulative probability of clinical success after repeat PAE was higher in group B than in group A (P = .0001): 84.1% vs 46.2% at 1 month, 56.7% vs 28.2% at 12 months, and 51.9% vs 16.9% at 24–36 months.ConclusionsRepeat PAE is safe and effective for recurrence of lower urinary tract symptoms caused by BPH but has limited impact in patients who did not show a response to initial PAE.     

Case-Control Study of Intra-arterial Verapamil for Intraprostatic Anastomoses to Extraprostatic Arteries in Prostatic Artery Embolization for Benign Prostatic Hypertrophy

Purpose

It is hypothesized that intra-arterial administration of verapamil is a safe and effective way to reverse the flow in intraprostatic anastomoses to extraprostatic arteries without compromising treatment outcomes in prostatic artery embolization (PAE) for benign prostatic hypertrophy (BPH).

MR angiography-planned prostatic artery embolization for benign prostatic hyperplasia: single-center retrospective study in 56 patients

PURPOSEWe aimed to evaluate the advantages of magnetic resonance angiography (MRA)-planned prostatic artery embolization (PAE) for benign prostatic hyperplasia (BPH).METHODSIn this retrospective study, MRAs of 56 patients (mean age, 67.23±7.73 years; age range, 47–82 years) who underwent PAE between 2017 and 2018 were evaluated. For inclusion, full information about procedure time and radiation values must have been available. To identify prostatic artery (PA) origin, three-dimensional MRA reconstruction with maximum intensity projection was conducted in every patient. In total, 33 patients completed clinical and imaging follow-up and were included in clinical evaluation.RESULTSThere were 131 PAs with a second PA in 19 pelvic sides. PA origin was correctly identified via MRA in 108 of 131 PAs (82.44%). In patients in which MRA allowed a PA analysis, a significant reduction of the fluoroscopy time (−27.0%, p = 0.028) and of the dose area product (−38.0%, p = 0.003) was detected versus those with no PA analysis prior to PAE. Intervention time was reduced by 13.2%, (p = 0.25). Mean fluoroscopy time was 30.1 min, mean dose area product 27,749 μGy·m², and mean entrance dose 1553 mGy. Technical success was achieved in all 56 patients (100.0%); all patients were embolized on both pelvic sides. The evaluated data documented a significant reduction in international prostate symptom scores (p < 0.001; mean 9.67 points).CONCLUSIONMRA prior to PAE allowed the identification of PA in 82.44% of the cases. MRA-planned PAE is an effective treatment for patients with BPH.

A profound knowledge about pelvic vessel anatomy is essential for achieving successful prostatic artery embolization (PAE), to improve the safety of PAE and to avoid major complications as non-target embolization (1–6). This knowledge can be achieved by using angiographic techniques to show pelvic artery anatomy, although the best method is still controversially discussed. In some studies, computed tomography (CT) angiography (CTA) was used for pre-interventional evaluation as it is described to have high certainty in analyzing prostatic artery (PA) anatomy (1, 3, 7). Other institutes use digital subtraction angiography (DSA) and cone beam CT (CBCT) for analysis without any pre-procedural vessel imaging (8–11). Since peri-interventional DSA findings may be ambiguous and CTA or CBCT would imply additional radiation, magnetic resonance angiography (MRA) seems to be a promising method to analyze PA origin without radiation. However, Maclean et al. (3) recommend CT for planning PAE instead of magnetic resonance imaging (MRI) as the latter is more expensive and more time-consuming. Pisco et al. (5, 12) state that MRA does not have enough resolution for clear identification of PA origin and does not provide the same information as CTA.Currently only a few studies discuss the suitability of MRA for preprocedural planning of PAE. Kim et al. (13) first investigated this subject with a sample size of 17 patients and documented an accuracy of 76.5% for PA origin analysis. However, in this study no clinical evaluation was included. Zhang et al. (4) investigated MRA analysis prior to PAE in a randomized clinical trial with 100 patients. A sensitivity of 91.5% and a significant reduction of procedure time, fluoroscopy time, radiation dose, and contrast medium volume due to pre-interventional MRA were documented. In his review, Prince (14) agrees with Zhang et al. (4) that MRA may be a suitable method for planning PAE.Because of the skeptical comments whether performing MRA prior to PAE is practical on a daily basis in a radiological institution, an assessment of these parameters in a less selective nature was necessary. In addition, contrary to Zhang et al. (4) who used MIP-reconstructions and 5° interval images for their assessment, we used a three-dimensional (3D) reconstruction of the pelvic arterial tree based on the MRA sequences. The main advantage of the 3D reconstruction is that it can be freely rotated in all directions which allowed an easy identification and tracking of the PA.In this study, the advantages and clinical outcome of pre-interventional analysis of PA via MRA as a possible radiation-free planning method and its influence on procedure time and radiation dose were investigated.     

Randomized Comparison of Prostatic Artery Embolization versus Transurethral Resection of the Prostate for Treatment of Benign Prostatic Hyperplasia

PurposeTo compare clinical and functional outcomes of prostatic artery embolization (PAE) with those of transurethral resection of the prostate (TURP) for the treatment of lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH).Materials and MethodsNoninferiority randomized trial was conducted involving men over 60 years of age with LUTS secondary to BPH. From November 2014 to January 2017, 45 patients were randomized to PAE (n = 23) or to TURP (n = 22). PAE was performed with 300- to 500-μm microspheres with the patient under local anesthesia, whereas bipolar TURP was performed with the patients under spinal or general anesthesia. Primary outcomes were changes in peak urinary flow (Q_max) and international prostate symptoms score (IPSS) from baseline to 12 months. Quality of life (QoL), and prostate volume (PV) changes from baseline to 12 month were secondary outcomes. Adverse events were compared using the Clavien classification.ResultsMean Q_max increased from 6.1 mL/s in the PAE group and from 9.6 mL/s in the TURP patients (P = .862 for noninferiority), and mean IPSS reduction was 21.0 points for PAE and 18.2 points for TURP subjects (P = .080) at 12 months. A greater QoL improvement was reported in the PAE group (3.78 points for PAE and 3.09 points for TURP; P = .002). Mean PV reduction was 20.5 cm³ (34.2%) for PAE subjects and 44.7 cm³ (71.2%) for TURP subjects (P < .001). There were fewer adverse events reported in the PAE group than in the TURP group (n = 15 vs n = 47; P < .001).ConclusionsReduction of LUTS in the PAE group was similar to that in the TURP group at 12 months, with fewer complications secondary to PAE. Long-term follow-up is needed to compare the durability of the symptomatic improvement from each procedure.     

Robotic-Assisted Versus Manual Prostatic Arterial Embolization for Benign Prostatic Hyperplasia: A Comparative Analysis

Prostatic artery embolization (PAE) is a safe and efficacious procedure for benign prostatic hyperplasia (BPH), though is technically challenging. We present our experience of technical and clinical outcomes of robotic and manual PAE in patients with BPH. IRB-approved retrospective study of 40 consecutive patients 49–81 years old with moderate or severe grade BPH from May 2014 to July 2015: 20 robotic-assisted PAE (group 1), 20 manual PAE (group 2). Robotic-assisted PAE was performed using the Magellan Robotic System. American Urological Association (AUA-SI) score, cost, technical and clinical success, radiation dose, fluoroscopy, and procedure time were reviewed. Statistical analysis was performed within and between each group using paired t test and one-way analysis of variance respectively, at 1 and 3 months. No significant baseline differences in age and AUA-SI between groups. Technical success was 100% (group 1) and 95% (group 2). One unsuccessful subject from group 2 returned for a successful embolization using robotic assistance. Fluoroscopy and procedural times were similar between groups, with a non-significant lower patient radiation dose in group 1 (30,632.8 mGy/cm2 vs 35,890.9, p = 0.269). Disposable cost was significantly different between groups with the robotic-assisted PAE incurring a higher cost (group 1 $4530.2; group 2 $1588.5, p < 0.0001). Clinical improvement was significant in both arms at 3 months: group 1 mean change in AUA-SI of 8.3 (p = 0.006), group 2: 9.6 (p < 0.0001). No minor or major complications occurred. Robotic-assisted PAE offers technical success comparable to manual PAE, with similar clinical improvement with an increased cost.