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Prostatic Artery
Embolization for Benign
Prostatic Hyperplasia:
A promising area for
Interventional Radiologists
Francisco Cesar Carnevale, MD. PhD.
Sao Paulo, Brazil
4:52 PM - 5:03 PM
Inte
rven
tion
al R
ad
iolo
gy
Un
itP
rosta
te U
nit
Un
ive
rsity o
f S
ao
Pa
ulo
Me
dic
al S
ch
oo
l
Benign Prostatic Hyperplasia (BPH)
Disclosure
I have no conflict of interest.
This study has been partially supported
by Biosphere Medical (Merit Medical
Systems, Inc.)
Introduction
Method
Results
Conclusion
BPH Related Symptoms
Urinary frequency
Urgency and nocturia
Hesitancy (difficulty initiating urinary stream)
Decreased or intermittent force of urinary stream
Straining (Valsalva maneuver)
Dribbling (loss of small amounts of urine)
Feeling of incomplete bladder emptying
Abdominal pain
Introduction
Method
Results
Conclusion
Emberton M et al. Urology 2003; 61:267–73.
Rassweiler J et al. Eur Urol. 2006; 50:969-79.
Surgery for BPH
25% due to failed medical therapy or complications
TURP (Transurethral Resection of the Prostate)
> 500,000 / year in USA
< 30% tissue resection
morbidity (18%) and mortality risk (0.23%)
Burnett AL. J Urol 2006; 175:S19-S24
Rassweiler J et al. Eur Urol 2006;50:969-979
http://emedicine.medscape.com
Introduction
Method
Results
Conclusion
TURP: Transurethral Resection
HoLAP: Homium Laser Ablation
PVP: Photoselective Vaporisation
HoLEP: Holmium Laser Enucleation
Woods E. Can Urol Assoc J 2010;4(5):344-346
US Medical Care, 2008
Surgery for BPH
Complications – TURP
Impotence (< 5%)
Retrograde ejaculation (50%)
Urethral stricture (2.2 – 9.8%)
Early Urinary incontinence (30 – 40%)
Voiding irritation and discomfort for 2-4 weeks
Urinary infection (1.7 – 8.2%)
Blood transfusion (0.4 – 7%)
Acute urinary retention by blood clots (2 – 5%)
Reoperation in 5 years (5%)
Burnett AL. J Urol 2006; 175:S19-S24
Rassweiler J et al. Eur Urol 2006;50:969-979
http://emedicine.medscape.com
Introduction
Method
Results
Conclusion
Surgical Therapies for BPH
http://www.usadelaware.com/medical_briefs/transurethral resection of prostate.
Introduction
Method
Results
Conclusion
Surgery and
Complication
TURP Laser TURP TUMT
(Microwave)
Efficacy 85% 75% 65%
Return to O.R. 10% 0% 0%
Transfusion <1% 0% 0%
Ejaculatory
Dysfunction
40-75% 80% 0%
Erectile
Dysfunction
<2% <2% <1%
Foley catheter
removal
1-5 days No No
Indications and Patient Selection
Prospective phase I study with patients with
acute urinary retention due to BPH managed
by indwelling urethral catheters
11 patients - prostates 30 to 90 grams (TURP)
Refractory to selective alpha-blockers
Mean age - 68.5 y/o (range, 59 to 78 y/o)
PAE – Clinical Investigation Protocol
Introduction
Method
Results
Conclusion
Patient Evaluation
Digital rectal examination
Urodynamic testing
Prostate specific antigen
Transrectal ultrasound
Magnetic resonance imaging
Prostate biopsy (PSA)
IPSS (International Prostate Symptom Score)
IIEF (International Index of Erectile Function)
PAE – Clinical Investigation Protocol
Introduction
Method
Results
Conclusion
PAE – Technique
Angiography
Superselective
Study
(Bilaterally)
superior vesical artery
obturatory artery
inferior vesical artery
middle rectal artery
internal pudenda artery
PAE – Technical Goals
Inferior Vesical Artery Left Prostatic Lobe
Opacification
Prostatics Branches Stasis
Prostatic Vascularization
Obturatory Artery
Prostatic Vascularization
Superior Vesical Artery
Prostatic Vascularization
Internal Pudendal and Middle Rectal Arteries
Prostatic Artery Embolization
Clinical Success = 91% (10/11)
Catheter removal: 4 to 25 days (mean, 12.1 days)
Failure: patient embolized
billaterally twice
Introduction
Method
Results
Conclusion
91%
(n=10)
9%
(n=1)
PAE – Imaging Results
Introduction
Method
Results
Conclusion
Magnetic Resonance Imaging
Before PAE – 75g 30 days – 46g (38.7%)
Prostatic Artery Embolization
Side Effects and Complications
Side Effect
Mild
Pain
Perineal
Mild
Pain
Retropubic
Mild
Pain
Urethral
Diarrhea
12 PAE n = 5 n = 3 n = 3 n = 2
% 41.7 25 25 16.7
ComplicationInguinal
Hematoma
Rectal
Bleeding
Bladder
Ischemia
12 PAEn = 1 n = 3 n = 1
% 8.3 25 8.3
Prostatic Artery Embolization
MRI 30 days MRI 90 days
Introduction
Method
Results
Conclusion
Complications
Hematuria (9° day) and Bladder Ischemia
Prostatic Artery Embolization
Prostate Volume Reduction (mean)
Follow-up 1 month 3 months 6 months 12
months
18
months
Number
of
Patients
10 10 9 3 2
US 27.3% 34.3% 36% 25.9% 29.6%
MRI 25.7% 29.7% 32.4% 24.6% 32.9%
Prostatic Artery Embolization
International Prostate Symptom Score
Symptoms: Mild = 0-7 Moderate = 8-19 Severe = 20-35
IPSS
4.0
2.22.42.7
7.1
0
2
4
6
8
30 90 180 365 545
Days
Clin
ica
l Fo
llow
-up
:
fro
m 5
mo
nth
s to
3 y
ea
rs
Prostatic Artery Embolization
Erectile Function
Severe = 0-6 Moderate = 7-12 Moderate to Mild: 13-18
Mild = 19-24 No dysfunction = 25-30
IIEF
25.522
19.316.715.5
0
5
10
15
20
25
30
30 90 180 365 545
Days
Clin
ica
l Fo
llow
-up
:
fro
m 5
mo
nth
s to
3 y
ea
rs
Prostatic Artery Embolization
Clinical Follow-up
Delighted: 0 Pleased = 1 Terrible = 6
QUOL
1.10.6
0.1 0.25 0.5
0
1
2
3
4
5
6
30 90 180 365 545
Days
Clin
ica
l Fo
llow
-up
:
fro
m 5
mo
nth
s to
3 y
ea
rs
Potential Benefits of PAE
PAE advantages:
Local anesthesia and an outpatient procedure
Does not manipulate the urethra avoiding
urethral stenosis
Can be rembolized, if necessary
In patients with acute or chronic urinary retention
PAE advantages:
Patients with history of TURP or pelvic trauma
with alterations in pelvic anatomy
For different prostate sizes
Poor surgery candidates or ASA class group V
Before other treatments to reduce the risk of
bleeding or improve results
Potential Benefits of PAE
Feasible, safe and effective
Lower complication rates
Prostate volume reduction of 30%
with LUTS relief
Excellent preliminary results
Prostatic Artery Embolization for BPH
Introduction
Method
Results
Conclusion
A promising area for
Interventional Radiologists
A promising area for
Interventional RadiologistsIntroduction
Method
Results
Conclusion
…a multidisciplinary approach
must be enrolled
to obtain the best results.
Prostatic Artery Embolization for BPH
