Effect of Median Lobe Enlargement on Early Prostatic Artery Embolization Outcomes

PurposeTo evaluate outcomes after prostatic artery embolization (PAE) in patients with severe intravesical prostatic protrusion (IPP).Materials and MethodsThis was a retrospective, single health system, 2-hospital study from April 2015 to December 2018 of 54 patients who underwent elective PAE procedures (age mean 67.5 years; standard deviation [SD] 8.5). The cohort had a mean ellipsoid prostate volume of 100.1 cm³ (SD 56.7), a mean baseline International Prostate Symptom Score (IPSS) of 18.7 (SD 8.2), a mean baseline quality of life (QOL) score of 4.1 (SD 1.4), and a median follow-up of 38 days (range 10–656 days). Outcomes including IPSS and QOL score reduction (where a lower QOL score indicates an improvement in QOL), and clinical success were compared between severe (≥10 mm) and nonsevere (<10 mm) IPP patients. A linear regression model was used to examine the impact of IPP on these outcomes.ResultsNo significant differences in patient characteristics were found between nonsevere (n = 17) and severe (n = 37) IPP patients. Both cohorts showed IPSS reduction (nonsevere 6.0, P = .0397; severe 8.2, P < .0001) and QOL score reduction (nonsevere 1.0, P = .102; severe 2.0, P < .0001). No significant differences in IPSS or QOL score reduction were found between the cohorts (P = .431 and P = .127). Linear regression found that baseline IPP was not a significant contributor to the outcomes (IPSS: R² = .5, P < .0001; IPP: P = .702; QOL: R² = .5, P = .0003; IPP: P = .108).ConclusionsThere were no significant differences in early outcomes in PAE between patients with severe and nonsevere IPP.     

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.     

The Effect of Protective Coil Embolization of Penile Anastomoses during Prostatic Artery Embolization on Erectile Function: A Propensity-Matched Analysis

PurposeTo explore whether coil embolization of penile collateral arteries to prevent nontarget embolization during prostatic artery embolization (PAE) negatively affects erectile function.Materials and MethodsRetrospective analysis was performed on a prospectively maintained multicenter PAE database on all patients with benign prostatic hyperplasia (January 2014 to July 2016). International Index of Erectile Function (IIEF-5) scores were collected at baseline and within 12 months after the procedure. A logistic regression and nearest neighbor propensity-matched analysis (matched for age, baseline IIEF-5 scores, and use of 5α-reductase inhibitors) and paired t test were used to evaluate for differential impact on IIEF-5 scores between the group of patients who underwent (unilateral) penile collateral coil embolization and a matched control group of patients who did not.ResultsOf a total of 216 patients, 26 underwent coil protection of an accessory pudendal vessel/penile collateral. After exclusions, 22 propensity-matched pairs were identified. The mean IIEF-5 score at baseline for the coil-embolized group was 14.8 ± 8.3 (out of a possible score of 30) and that for the matched control group was 14.0 ± 7.8. At the 12-month follow-up after the procedure, the mean follow-up IIEF-5 score was 15.5 ± 8.0 for the coil-embolized group and 14.2 ± 8.2 for the matched control group. The change in IIEF-5 scores after PAE was not significantly different between the 2 groups (0.66 ± 3.8 vs 0.20 ± 2.0; P = .64; 95% CI, -1.53 to 2.44).ConclusionsWhen penile collateral arteries were identified, protective coil embolization of penile collateral/accessory pudendal vessels during PAE was unlikely to affect erectile function negatively.     

Minimally Invasive Treatments for Benign Prostatic Hyperplasia: Systematic Review and Network Meta-Analysis

PurposeTo review and to compare indirectly the outcomes of minimally invasive therapies for the treatment of lower urinary tract symptoms secondary to benign prostatic hyperplasia.Materials and MethodsA literature search via Medline and Cochrane Central databases was completed for randomized control studies published between January 2000 to April 2020 for the following therapies: Rezum, Urolift, Aquablation, and prostatic artery embolization (PAE). Data on the following variables were included: International prostate symptom score (IPSS), maximum urinary flow rate, quality of life, and postvoid residual (PVR). Standard mean differences between treatments were compared through a meta-analysis using transurethral resection of the prostate (TURP) to assess differences in treatment effect.ResultsThere was no significant difference in outcomes between therapies for IPSS at the 3, 6, and 12-month follow ups. Although outcomes for Rezum were only available out to 3 months, there were no consistently significant differences in outcomes when comparing Aquablation versus PAE versus Rezum. TURP PVR was significantly better than Urolift at 3, 6, and 12 months. No significant differences in minor or major adverse events were noted.ConclusionAlthough significant differences in outcomes were limited, Aquablation and PAE were the most durable at 12 months. PAE has been well studied on multiple randomized control trials with minimal adverse events while Aquablation has limited high quality data and has been associated with bleeding-related complications.     

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.     

Effectiveness and Safety of Prostatic Artery Embolization for the Treatment of Lower Urinary Tract Symptoms from Benign Prostatic Hyperplasia in Men with Concurrent Localized Prostate Cancer

PurposeTo assess the effectiveness and safety of prostatic artery embolization (PAE) on lower urinary tract symptoms (LUTS) in the setting of localized prostate cancer (PCa).Materials and MethodsThis was a retrospective, single-center, institutional review board-approved study from December 2016 to June 2020 of 21 patients (median age, 72; range, 63–83 years) with moderate LUTS and localized PCa. Clinical effectiveness was evaluated at 6 and 12 weeks using International Prostate Symptom Score (IPSS) and quality of life (QoL) improvement. Seventeen patients were scheduled to receive definitive radiotherapy (RT) after PAE; 13 patients completed RT. Short-term imaging signs of oncologic progression were evaluated at 6 and 12 weeks defined by at least one of the following on magnetic resonance imaging: increased Prostate Imaging-Reporting and Data System score of index lesion(s) to at least 4, new extracapsular extension, seminal vesicle involvement, or pelvic lymphadenopathy. Nonparametric Wilcoxon signed-rank test was used for analysis.ResultsIPSS improved by a median of 12 (n = 19, P < .0001) and 14 (n = 14, P < .0001) at 6 and 12 weeks, respectively. QoL improved by a median of 2 (n = 19, P < .0001) and 3 (n = 3, P < .0001) at 6 and 12 weeks. Prostate volume decreased by a median of 24% (n = 19, P < .0001) and 36% (n = 12, P = .015) at 6 and 12 weeks. No patients demonstrated disease progression at 6 (n = 16) or 12 (n = 8) weeks by imaging. No patients experienced increased prostate-specific antigen after RT, grade ≥3 adverse events, or greater genitourinary toxicity.ConclusionsPAE is effective and safe for the treatment of men with LUTS from benign prostatic hyperplasia in the setting of concomitant, localized, non-obstructive PCa.     

Prostatic Artery Embolization for the Treatment of Recurrent Lower Urinary Tract Symptoms following Transurethral Resection of the Prostate

PurposeTo evaluate the safety and efficacy of prostatic artery embolization (PAE) in patients with recurrent lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH) who underwent a previous transurethral resection of the prostate (TURP).Materials and MethodsThis retrospective study analyzed 15 of 19 patients who underwent PAE for recurrent LUTS after TURP between February 2014 and April 2019. The technical and clinical success rates and complications related to the procedure were recorded. International Prostate Symptom Score (IPSS), quality of life (QoL), and prostatic volume (PV) were evaluated at baseline and 3- and 12-mo follow-up.ResultsThe intervals from TURP to recurrent symptoms and from TURP to PAE were 4.3 y ± 3.2 and 5.6 y ± 3.8, respectively. Technical success was achieved in all patients. The clinical success rate for LUTS relief at 12 mo was 93.3% (14 of 15). IPSS significantly reduced from 22.5 ± 4.1 at baseline to 9.9 ± 4.9 at 12-mo follow-up, and QoL score improved from 4.7 ± 1.0 to 2.1 ± 1.1 (P < .05 for both). There was a significant mean reduction of 26.6% in PV at 12 mo, improving from 100.7 cm³ ± 38.5 to 73.9 cm³ ± 29.4 (P < .05). No severe complications were encountered.ConclusionsPAE may be a safe and effective treatment option for the management of recurrent LUTS secondary to BPH in patients who have previously undergone TURP.     

Four-Year Impact of Voiding and Storage Symptoms in Patients with Benign Prostatic Hyperplasia Treated with Prostatic Artery Embolization

PurposeTo study the subscore improvement in International Prostate Symptom Scores (IPSS) after prostatic artery embolization (PAE).Materials and MethodsA single-center retrospective study was carried out with follow-up from December 2013 to July 2019 in 37 consecutive patients (66.0 ± 8.8 years old) who underwent PAE, comparing resultant scores before and after PAE. IPSS were divided into storage (IPSS-s) subscores and voiding (IPSS-v) subscores. The changes between IPSS-s and IPSS-v at 1, 3, 6, and 12 months’ follow-up as well as the last follow-up were compared with baseline scores. The changes in percentages of IPSS-s and IPSS-v and the changes in average IPSS-s-to-total IPSS ratios (IPSS-s/IPSS-t) and IPSS-v-to-IPSS-t ratios (IPSS-v/IPSS-t) were also analyzed.ResultsIn the study population, consisting of 37 patients, IPSS-t significantly decreased from 16.5 ± 7.2 at baseline to 8.3 ± 5.7 at the last follow-up (4 years later) (P < .0001). Additionally, the changes in IPSS-v symptoms were greater than the changes in IPSS-s symptoms at 1, 3, 6, and 12 months’ follow-up, reaching a statistical significance at 6 months with a decrease of 72.9% ± 42.4% for IPSS-v and a decrease of 50.1% ± 52.2% for IPSS-s (P = .009).ConclusionsPAE can successfully reduce both IPSS-s and IPSS-v with predominant IPSS-v reduction. The improvements in both subscores were sustained for up to 4 years of follow-up.     

Improving Cone-Beam CT Angiography for Prostatic Artery Embolization: Is a Low-Dose Protocol Equivalent to the Standard?

PurposeTo compare the utility of low-dose versus standard cone-beam computed tomography (CT) angiography protocols in identifying nontarget embolization (NTE) during prostatic artery embolization (PAE).Materials and MethodsA prospective, single-center, Phase-1 study (NCT02592473) was conducted for lower urinary tract symptoms in benign prostatic hyperplasia. Prostate volume, international prostate symptom score (IPSS), quality of life score (QoL), International Index of Erectile Function (IIEF), peak flow rate, UCLA Prostate Cancer Index (UCLA-PCI), and postvoid residual were recorded at baseline and 1, 3, 6, 12, and 24-months after PAE. Six-second (standard protocol, n = 29) or 5-second (low-dose protocol n = 45) rotations were made. Images were selected and matched in pairs by areas of NTE and compared by readers using a binomial generalized estimating equation model. Procedural outcomes were analyzed using a linear mixed model.ResultsSeventy-four cone-beam CT angiographies were performed in 21 patients. IPSS and QoL scores significantly improved (P <.05). There was no change in UCLA-PCI or IIEF scores. Dose area product of the low- and standard-dose protocol were 37,340.82 mGy·cm² ± 104.66 and 62,645.66 mGy·cm² ± 12,711.48, respectively, representing a dose reduction of 40.4%. A total of 120 comparisons showed no preference between the 2 protocols (P =.24). Observers identified 76 and 69 instances of NTE in the standard- and low-dose protocols, respectively (P =.125).ConclusionsLow-dose cone-beam CT angiography achieved equivalent clinical utility in identifying NTE during PAE, with the advantage of a lower radiation dose.     

Role of Ultrasound Elastography in Patient Selection for Prostatic Artery Embolization

PurposeTo determine the effects of prostatic artery embolization (PAE) on prostate elasticity as assessed using ultrasound elastography (US-E) and to describe baseline US-E's potential role in patient selection.Materials and MethodsThis was a prospective investigation that included 20 patients undergoing PAE to treat lower urinary tract symptoms attributed to benign prostatic hyperplasia (BPH). US-E with measurement of the prostatic elastic modulus (EM) and shear wave velocity (SWV) was performed before PAE and at 1-month follow-up. Baseline, 3-month, and 1-year follow-up evaluations included prostate-specific antigen, uroflowmetry, pelvic magnetic resonance imaging, and clinical assessment using the International Prostate Symptom Score (IPSS) and quality of life (QoL) metrics.ResultsSeventeen patients entered statistical analysis. US-E showed a significant reduction in mean prostatic EM (34.4 kPa vs 46.3 kPa, −24.7%, P < .0001) and SWV (3.55 m/s vs 4.46 m/s, −20.0%, P < .0001) after PAE. There were moderate positive correlations between baseline EM and 1-year IPSS (R = 0.62, P = .007) and between baseline SWV and 1-year IPSS (R = 0.68, P = .002). Baseline SWV ≥ 5.59 m/s and baseline EM ≥ 50.14 kPa were associated with suboptimal IPSS and QoL outcomes after PAE with high degrees of sensitivity (100%) and specificity (69-100%).ConclusionsPAE led to a positive effect on the BPH dynamic component related to prostatic elasticity. There was a moderate positive correlation between baseline prostatic elastographic parameters and 12-month IPSS. Measurement of baseline elastographic characteristics may become useful for the evaluation and selection of patients for PAE.     

Nontarget Radiopaque Embolic Deposition during Prostatic Artery Embolization

This study evaluated detectable nontarget embolization (NTE) during prostatic artery embolization (PAE) and the safety and efficacy of using radiopaque particles in PAE. Ten patients aged >40 years with prostate glands of >50 mL and refractory lower urinary tract symptoms were analyzed. Unenhanced computed tomography scans at baseline and at 3 months after PAE, using 40–90-μm radiopaque spherical embolic beads, were compared to assess the NTE. Growth models evaluated changes from baseline to 3, 6, and 12 months in International Prostate Symptom Score (IPSS), peak urine flow rate (Qmax), quality of life (QoL), International Index of Erectile Function (IIEF), and postvoid residual (PVR). The IPSS, QoL, and Qmax improved at all time points (P < .05), with no trend in PVR or IIEF. Adverse events that occurred were minor. Radiographic NTE was seen in all patients, correlating at times with postprocedural symptoms (eg, rectal pain). Symptoms were not correlated with the NTE in some patients, whereas other patients remained asymptomatic despite NTE.     

Prostatic Artery Embolization Using 100–300-μm Trisacryl Gelatin Microspheres to Treat Lower Urinary Tract Symptoms Attributable to Benign Prostatic Hyperplasia: A Single-Center Outcomes Analysis with Medium-Term Follow-up

PurposeTo report medium-term outcomes of prostatic artery embolization (PAE) using 100–300-μm trisacryl gelatin microspheres to treat lower urinary tract symptoms (LUTS) from benign prostatic hyperplasia (BPH) and to evaluate how cone-beam computed tomography-measured prostate gland volume (PGV), median lobe enlargement (MLE), age, and Charlson Comorbidity Index (CCI) affect these results.Materials and MethodsSeventy-four consecutive patients who underwent PAE from April 2014 through August 2018 were retrospectively reviewed. Patients had International Prostate Symptom Score (IPSS) >12, Quality of Life (QoL) score >2, prostate gland volume (PGV) >40 mL, age older than 45 years, and medical therapy failure. Twelve patients were excluded for bladder pathology or prostate cancer. Patients (n = 62, age = 71.8 ± 9.3 years, CCI = 3.5 ± 1.7, PGV = 174 ± 110 mL) had pre-procedure IPSS = 22.4 ± 5.6, QoL score = 4.4 ± 0.9, and post-void residual (PVR) = 172 ± 144 mL. Post-procedure values were compared to baseline at 1, 3, 6, 12, and 24 months. Associations between outcomes and PGV, MLE, age, and CCI were evaluated. Adverse event recording used Clavien-Dindo classification.ResultsOne month after PAE (n = 37), IPSS improved to 7.6 ± 5.2 (P < .0001) and QoL score improved to 1.7 ± 1.4 (P < .0001). At 3 months (n = 32), improvements continued, with IPSS = 6.4 ± 5.1 (P < .0001), QoL score = 1.2 ± 1.2 (P < .0001), PVR = 53 ± 41 mL (P < .001), and PGV = 73 ± 38 mL (P < .0001). Results were sustained at 6 months (n = 35): IPSS = 6.4 ± 4.1 (P < .0001), QoL score = 1.2 ± 1.2 (P < .0001), PVR = 68 ± 80 mL (P < .0001), PGV = 60 ± 19 mL (P < .001). At 12 months, patients (n = 26) had IPSS = 7.3 ± 5.5 (P < .0001), QoL score = 1.2 ± 0.8 (P <.0001), PVR = 89 ± 117 mL (P < .0001), PGV = 60 ± 48 mL (P < .01). At 24 months, patients (n = 8) had IPSS = 8.0 ± 5.4 (P < .0001), QoL score = 0.7 ± 0.5 (P < .0001), PVR = 91 ± 99mL (P = 0.17), and PGV = 30 ± 5mL (P = .11). Improvements were independent of PGV, MLE, age, and CCI. Two grade II urinary infections occurred.ConclusionsPAE with 100–300-μm microspheres produced sustained substantial improvements in LUTS, PGV, and PVR, which were independent of baseline PGV, MLE, age, or CCI.     

Angiographic Findings during Repeat Prostatic Artery Embolization

PurposeTo describe mechanisms of prostate revascularization based on imaging findings during repeat prostatic artery embolization (PAE; rPAE).Materials and MethodsThis is a retrospective analysis of 10 rPAEs performed between October 2012 and September 2018 in patients with recurrent lower urinary tract symptoms (LUTS) after PAE (mean age, 68.2 y ± 4.5). Two interventional radiologists reviewed PAE and rPAE images and defined 6 patterns of revascularization. Correlation between embolization of the posterolateral (PL) prostatic branch during previous PAE and prostate revascularization on rPAE was assessed by Fisher exact test. One hemiprostate was excluded because no detectable revascularization was observed.ResultsAll patients showed LUTS improvement after previous PAEs (P < .01 for 5 outcome measures) and had recurrence during follow-up. rPAEs were performed a mean of 40.9 months after previous PAEs (18–96 mo). Of 19 hemiprostates analyzed, 11 presented revascularization by 2 or more branches (57.9%). The PL branch (29.0%) and the recanalized main prostatic artery (25.8%) were the most frequent revascularizing branches observed, followed by distal branches of obturator (12.9%), internal pudendal (12.9%), superior vesical (12.9%), and contralateral arteries (6.5%). Embolization of the PL branch during previous PAE significantly reduced the incidence of revascularization by this branch (P = .002).ConclusionsMechanisms of revascularization in rPAE are diverse and complex. Revascularization by the PL branch and recanalization of the previously embolized prostatic artery were the most frequent patterns observed. Embolization of the PL branch may reduce the incidence of prostate revascularization and LUTS recurrence after PAE.     

Intravesical Prostatic Protrusion Does Not Influence the Efficacy of Prostatic Artery Embolization

PurposeTo compare the outcomes of prostatic artery embolization (PAE) in patients with different intravesical prostatic protrusion (IPP) grades.Materials and MethodsThis retrospective single-center study included 128 patients (aged 50–86 years) who underwent PAE from 2013 to 2017. IPP grades were classified as follows: grade I (<10 mm), grade II (10–19 mm), and grade III (≥20 mm). Nineteen patients (14.8%) had grade I [mean IPP 7.8 mm, prostatic volume (PV) 64.1 cm³], 77 (60.2%) had grade II (mean IPP 14.9 mm, PV 87.0 cm³), and 32 (25%) had grade III (mean IPP 26.2 mm, PV 132.6 cm³), P < .01. The outcomes, including PV, international prostate symptom score (IPSS), and quality of life (QoL), were compared between the IPP grades at the 12-month follow-up. Clinical failure was defined as IPSS >7 or QoL >2.ResultsIPP decreased (I: ?8.2%, II: ?27.3%, and III: ?38.7%, P = .01), and all other endpoints improved (P < .01). Adjusted covariance analysis, considering baseline PV as a confounding factor, showed no correlation between the 12-month outcomes and baseline IPP. Clinical failure was observed in 17/128 patients (13.3%) and was similar in prevalence among the IPP groups (P = .20). Minor complications occurred in 43 patients (33.6%) and major in 3 (2.3%). There were statistical differences in the complications between IPP grades II and III (P < .01).ConclusionsPAE was similarly effective in all the IPP grades at the 12-month follow-up, and there was no difference in the clinical failure between the groups. Complications in IPP grade III were more frequent than those in IPP grade II.     

Prostatic Artery Embolization to Achieve Freedom from Catheterization in Patients with Acute Urinary Retention Caused by Benign Prostatic Hyperplasia

PurposeTo determine the ability of prostatic artery embolization (PAE) to achieve freedom from catheterization in patients with acute urinary retention (AUR) caused by benign prostatic hyperplasia (BPH).Materials and MethodsThis retrospective single-center study was performed between June 2014 and March 2019 in patients with lower urinary tract symptoms (LUTS) caused by BPH. PAE was performed in 154 eligible patients, of which 76 suffered from spontaneous AUR and had indwelling catheters placed and kept until the procedure, owing to clinical failure in the removal of the previous intermittent catheter. Each patient was followed for at least 12 months. The first trial without catheter was performed 3 days after PAE. Successful catheter removal within the first 30 days after PAE was considered a clinical success. The rate of patients free from catheterization, LUTS relief, prostate volume, and adverse events was recorded.ResultsClinical success was achieved in 70 (92.1%) patients. The rates of freedom from catheterization were 90.3% (65/72), 83.3% (60/72), and 80.6% (58/72) at 3-, 6-, and 12-months follow-up, respectively. The median elapsed time from PAE to catheter removal was 10 days. However, 18 patients needed further interventions. Symptom scores revealed a continuous improvement in urinary symptoms. The mean prostate volume showed a statistically significant decrease at 3 and 12 months compared with its baseline value. No severe adverse events occurred.ConclusionsPAE can achieve freedom from catheterization in patients with AUR caused by BPH.     

Prostatic Artery Embolization for Benign Prostatic Hyperplasia: Bleomycin-Eluting versus Bland Microspheres in a Canine Model

PurposeTo prospectively assess safety and efficacy of prostatic artery embolization (PAE) with bleomycin-eluting microspheres for benign prostatic hyperplasia (BPH) in a canine model.Materials and MethodsTwelve adult male beagles (mean age, 1.6 y ± 0.2; range, 1.2–2.0 y) were randomly assigned to group A (n = 6; PAE with bleomycin-eluting 30–60-μm HepaSphere microspheres) and group B (n = 6; PAE with bland 30–60-μm HepaSphere microspheres) between April 2017 and November 2018. Plasma bleomycin concentration in group A was measured within 7 days. Prostate volume (PV) and ischemic volume after PAE were measured by magnetic resonance imaging. Prostates and adjacent organs were harvested after the last magnetic resonance study and histopathologically examined.ResultsPlasma bleomycin concentration peaked at 10 minutes at 2,055.0 ng/mL ± 606.1 and lasted for 1,440 min at low levels after PAE. PV reduction percentage was greater in group A than in group B at 1 month (74.1% ± 4.3 vs 63.7% ± 3.5; P = .006) and 3 months (61.5% ± 6.7 vs 46.1% ± 3.8; P = .001) after PAE. Proportion of prostate ischemic volume was greater in group A than in group B (75.3% ± 3.0 vs 62.0% ± 7.1; P = .006) at 1 month after PAE. Proportion of prostate ischemic volume at 1 month positively correlated with PV percentage reduction at 3 months in group A (r = 0.840, P = .036) and group B (r = 0.844, P = .035). There were no complications or nontarget embolization to surrounding organs after the procedures.ConclusionsIn a canine model, PAE with bleomycin-eluting microspheres was feasible and well tolerated and caused ischemic necrosis and reduction in PV.     

Perioperative Blood Loss after Preoperative Prostatic Artery Embolization in Patients Undergoing Simple Prostatectomy: A Propensity Score‒Matched Study

PurposeTo assess perioperative blood loss following prostatic artery embolization (PAE) before surgery in patients undergoing simple prostatectomy.MethodsA retrospective chart review was used to identify 63 patients (mean age, 65.3 ± 8.0 years) with prostatic hypertrophy and severe lower urinary tract symptoms who underwent prostatectomy from September 2014 to December 2019, 18 (28.5%) of whom underwent PAE before surgery. Demographic data, pertinent laboratory results, procedural or operative information, hospital course details, and pathology reports were obtained. A 2:1 propensity score‒matching analysis was performed to compare intraoperative blood loss in patients who underwent prostatectomy alone with intraoperative blood loss in those who first underwent bilateral PAE before surgery.ResultsSixteen (89%) of the 18 patients underwent bilateral PAE before surgery. Thirty-two patients who underwent prostatectomy without embolization before surgery were selected for the 2:1 propensity score‒matched analysis based on age, race, surgery type, prostate gland size, and comorbidities. The mean estimated blood loss (EBL) for prostatectomy alone was 545 ± 380 mL (mean ± standard deviation). There was a statistically significant reduction in the EBL for patients who underwent bilateral PAE (303 ± 227 mL, P < .01). The operative time was also significantly decreased for patients who underwent PAE before surgery (P < .05). For patients who underwent PAE, there were no complications related to the procedure.ConclusionsBilateral PAE before surgery appears to be safe and may be effective in reducing perioperative bleeding and operative time.     

Comparison of 24-Month Clinical Outcomes after Prostatic Artery Embolization in Prostate Glands Larger versus Smaller than 80 mL: A Systematic Review

PurposeThis review was undertaken to compare the clinical outcomes of prostatic artery embolization (PAE) in patients with >80 versus <80 mL prostatic volume (PV) at the 24-month follow-up to determine whether PV predicted the effectiveness or durability of PAE.Materials and MethodsThe PubMed/MEDLINE database was searched for articles published between 2010 and 2022 using the search term “(prostat1 artery embolization) AND (long term OR follow-up OR 24-month).” Articles were included if they discussed PAE for benign prostatic hyperplasia (BPH) and reported a minimum follow-up of 24 months. Articles with <10 patients were excluded. A subgroup analysis was performed to evaluate for any difference in clinical outcomes at the 24-month post-PAE follow-up between studies with a mean PV of >80 mL and those with a mean PV of <80 mL.ResultsA total of 14 studies with 2,260 patients were included, all of which demonstrated significant reduction in symptoms at the 24-month follow-up after PAE. Four studies were included as part of the >80-mL PV subgroup (n = 467), and 10 studies were included as part of the <80-mL PV subgroup (n = 1,793). There was a statistically significant difference between the mean preprocedural PV (128.5 vs 64.0 mL; P = .015). At the 24-month follow-up, there were no significant differences between groups across any of the compared parameters. The collective incidence of major adverse events reported in the studies within this review was <1%.ConclusionsPAE is both safe and durable for patients suffering from BPH and can be effective across a wide range of baseline PVs.     

Clinical Outcomes of a Pharmacomechanical Catheter-Directed Venous Thrombolysis Strategy that Included Rheolytic Thrombectomy in a Multicenter Randomized Trial

PurposeTo describe the clinical outcomes of a pharmacomechanical catheter-directed venous thrombolysis (PCDT) strategy that included AngioJet rheolytic thrombectomy.MethodsIn the Acute Venous Thrombosis: Thrombus Removal with Adjunctive Catheter-Directed Thrombolysis multicenter randomized trial, physicians at 33 sites designated AngioJet as their preferred device for PCDT. In these sites, 364 patients with acute proximal lower-extremity deep vein thrombosis (DVT) were randomized to a strategy of PCDT that incorporated either AngioJet along with anticoagulation or anticoagulation alone. Relief from presenting DVT symptoms was evaluated over 30 days of follow-up. Postthrombotic syndrome (PTS), quality of life (QOL), recurrent venous thromboembolism (VTE), and safety were evaluated over 24 months of follow-up.ResultsWithin 30 days, AngioJet-PCDT led to a greater improvement in leg swelling (mean difference calf circumference 0.55 cm, P = .009), venous QOL (mean difference 6.5 Venous Insufficiency Epidemiologic and Economic Study [VEINES]-QOL points, P = .0073), and venous symptoms (mean difference 5.6 VEINES-symptoms points, P = .0134) than control, with differences most apparent in iliofemoral DVT. AngioJet-PCDT reduced PTS at 6 months (24% with AngioJet-PCDT vs 40% with control, P = .003) but did not influence PTS or QOL between 12 and 24 months. Major bleeding, pulmonary embolism, renal failure, and bradycardia were infrequent with AngioJet-PCDT (<2% each), but 24-month VTE recurrence may have been more frequent (13.9% with AngioJet-PCDT vs 6.8% with control, P = .03)ConclusionsIn patients with acute proximal DVT, a treatment strategy that included first-line AngioJet-PCDT was reasonably safe and led to an improved symptom status and venous QOL at 1 month and reduced PTS at 6 months compared with anticoagulation alone. However, AngioJet-PCDT did not influence PTS or the QOL beyond 6 months and may have increased recurrent VTE.     

Early Results of Unilateral Prostatic Artery Embolization as a Focal Therapy in Patients with Prostate Cancer under Active Surveillance: Cancer Prostate Embolisation,a Pilot Study

PurposeTo evaluate the feasibility of prostatic artery embolization in patients with low-risk prostate cancer (PC) under active surveillance (AS).MethodsThis monocentric prospective pilot study, running from June 2018 to June 2019, included 10 patients with low-risk PC under AS, median age 72 years (range, 62–77 years), with a unilateral focal lesion visible on magnetic resonance (MR) imaging, with Prostate Imaging Reporting and Data System v2 score ≥3/5 confirmed by multiparametric MR imaging-targeted biopsy and Gleason score 6. The patients underwent unilateral prostatic artery embolization with 300–500 μm Embospheres in the affected prostatic lobe. The primary endpoint was technical feasibility (prostate and no off-target ischemia in the imaging). The secondary endpoints included safety, negative biopsies/MR imaging response/functional outcomes at 6 months, and oncologic efficacy at 1 year.ResultsEmbolization was successfully achieved in all patients; prostate ischemia was confirmed on multiparametric MR imaging, and no off-target ischemia was reported. No major complications were reported. Four patients (40%) presented with both negative targeted and systematic biopsies at 6 months. No lesions were seen on the MR imaging in 30% of patients. The mean International Prostate Symptom Score and International Index of Erectile Function score were 7 and 19 and 5 and 20 at baseline and 6 months, respectively, with no significant difference. Nine patients (90%) were still under AS at 1 year. One patient (10%) had PC progression outside the target lesion and was switched over to curative radiotherapy.ConclusionsProstatic artery embolization is feasible and appears safe for prostate cancer patients under AS, with no impact on erectile function or continence status. These results justify the pursuit of further studies.