In order to avoid major complications with prostate artery embolization, it is vital to look for collaterals to arteries of the surrounding organs to the prostate, writes João Pisco.
For patients with bothersome symptoms of benign prostatic hyperplasia, medical therapy is usually the first treatment option: alpha-blockers or 5 alpha-reductase inhibitors. The next step involves the so-called minimally invasive therapies: transurethral needle ablation; transurethral microwave thermograph; and interstitial laser ablation; or surgery. Surgery is usually the last treatment option for patients who do not respond to the above-mentioned therapies or for those who develop complications of hyperplasia. All medical and surgical treatments of hyperplasia may be associated with major complications including sexual dysfunction. Surgery may also be complicated by urinary incontinence.
Due to the safety, low morbidity and good long-term results, prostate artery embolization is well-accepted by patients with benign prostatic hyperplasia. Major complications are rare.
At St Louis Hospital, in Lisbon, Portugal, we have treated over 900 patients. From all of our treated patients, only three were referred by urologists. All the others were self-referral patients from all over the world. We have only had two major complications. There was a small (one cm²) bladder ischaemia that occurred early in our experience (it was our tenth case). It was due to the embolization of both vesical arteries. The ischaemic area was easily removed through the urethra, by the urologist working with our team. Afterwards the patient was very happy because his sexual activity improved. The other complication was a severe pelvic pain for three months. Due to this pain, the patient felt some difficulty on sitting or driving. Reviewing the embolization angiography, no cause was found for this complication. Both patients remained without any sequelae.
In order to avoid major complications, embolization needs to be planned in advance. For the purpose, a high quality pre-procedural computed tomography angiography is needed. This is important, as it gives information concerning the number of prostatic arteries, their origin, the possible anastomoses to the surrounding arteries of the penis, bladder and rectum, the degree of atherosclerosis and the probability rate of technical success. Therefore, we have to look at important collaterals to vesical, penile and rectal arteries. One should do a superselective embolization, in order to avoid those arteries, otherwise they should be embolized with coils to redirect flow away from surrounding organs and into the prostate. It is important to do a safe embolization. Patients must be informed of these facts before the procedure when making the decision to accept embolization. At the time of embolization a digital subtraction angiography is performed in order to confirm and complete all information of the pre-procedural CTA. Digital subtraction angiography needs to be repeated in the anteroposterior view to distinguish between the different vessels, particularly the vesical and the prostatic arteries.
(A) DSA of left prostatic artery arises from an accessory pudendal artery. Anastomoses to the internal pudendal artery
(B) Catheter in the anastomosis delivering coils
(C) Two delivered coils are shown
(D) Result after embolization of the prostatic artery
The prostatic artery arises from accessory pudendal arteries in up to 20% of the cases. In these cases and in most of the times, there are important anastomoses to the internal pudendal artery and to the penile artery. Such anastomoses should be embolized with coils before prostate artery embolization and patients should be informed about it as well (Figure 1).
The prostatic artery arises from the vesical trunk in about 25% of cases. In some cases, it is impossible to catheterize selectively the prostatic artery. In these cases the vesical artery should be embolized with coils before prostatic artery embolization (Figure 2).
If the middle rectal artery is shown, the microcatheter should be placed distally, or the middle rectal artery should be embolized with coils before prostate artery embolization. Apart from these cases of important anastomoses to arteries of vital organs, sometimes the prostatic arteries may give origin to small branches to the bladder and/or to the penis. In these cases the microcatheter should be placed distally to those vessels before embolization.
Even though prostate artery embolization is usually a painless procedure, one should speak to the patient during the procedure particularly in those cases of anastomoses.
In order to avoid major complications with prostate artery embolization, it is important to look for collaterals to arteries of surrounding organs to the prostate. Embolization should be performed avoiding these collaterals, either advancing the microcatheter distally into the prostate or by coil-blocking anastomoses.
(A) DSA – left prostatic artery arises from the vesical trunk
(B) Vesical artery embolized with two coils
(C) Result of prostatic artery embolization of the prostatic artery
João Pisco is director of Radiology at Saint Louis Hospital, Lisbon, Portugal. He has reported no disclosures pertinent to this article.