Prostate artery embolization (PAE) may become the standard of care procedure for the management of symptomatic benign prostatic hyperplasia (BPH), proposed Tiago Bilhim (CHULC, Saint Louis Hospital, Lisbon, Portugal), due to “good clinical results” presented at the 2019 annual meeting of the Cardiovascular and Radiological Society of Europe (CIRSE; 7–11 September, Barcelona, Spain).
The investigators set out to evaluate the outcome of PAE for symptomatic BPH patients with moderate to severe lower urinary tract symptoms (LUTS). The single-centre, retrospective study examined data on 1,550 patients, prospectively-collected between March 2009 and February 2019.
“Subjective and objective parameters were assessed”, Bilhim said. The International Prostate Symptom Score (IPSS), quality of life (QoL) score, and international index of erectile function (IIEF-5) were categorised as subjective measures, whilst the investigators also calculated changes in prostate volume (PV) using trans-rectal ultrasound, peak urinary flowrate (Qmax), post-void urinary residual (PVR), and prostate specific antigen (PSA) concentration. All of these were assessed before PAE, and one, six, and 12 months after PAE, then yearly for up to 10 years.
There was a statistically significant change from baseline in the evaluated parameters (p<0.001) across all time scales. In the short-term, defined as one to 12 months after PAE, the mean cumulative clinical success rate was 88.1% (range: 77.6–92.4%). In the medium-term, two to five years after the procedure, this was 85.1% (range: 71.3–93.1%), and over the long-term, from six to ten years post-PAE, the mean cumulative clinical success rate was 76.8% (range: 69.1–84.6%). Bilhim described the change in cumulative clinical success rate from short- to longterm—88.1% to 76.8%—as “not that much of a drop” over ten years.
Mean IPSS reduction was 13.5±6.9 in the short-term, 14.1±7.3 in the medium-term, and 13.9±8.7 in the long-term. Mean quality of life improvement was also consistent out to ten years: 1.8±1.2 in the short-term, 2.1±1.3 in the medium-term, and 1.7±1.5 in the long-term. Prostate volume reduction was also observed out to ten years, with the mean long-term reduction being 16.9±26.6cm3, and a short-term reduction of 18.3±27.9cm3.
From the 156 patients in acute urinary retention (AUR), 140 (89.7%) had the bladder catheter removed between two days and three months; 10 had repeated successful PAEs, and six had surgery. For the 312 patients with prostates larger than 100mL, there was a high rate of clinical success: in 80.7% of patients (252 individuals) over the short-term; 77.6% of patients (242 individuals) over the medium-term; 75.3% of patients (235 individuals) in the long term. Bilhim reported three major complications: a bladder wall ischaemia, a perineal pain for three months without sequela, and a patient had expelled prostate fragments and AUR treated by trans-urethral resection of the prostate (TURP) without sequela.
Describing the technical outcomes, Bilhim reported that in 90% of patients (1,324 people), the interventionalist gained access to the vasculature through the femoral artery. Since 2016, interventional radiologists at Saint Louis Hospital in Lisbon, Portugal, have been using left radial access, so 10% of the cohort (148 patients) experienced this. “This is our first-line approach”, he said of the technique, adding that now they are using it “more and more”.
Enrolled patients were 40 or older (with no upper limit on age; mean age was 65.1 years), and “severely symptomatic”, with an IPSS greater than 18 (mean IPSS: 21.8), a prostate volume greater than 30mL, and a peak urinary flowrate less than 15mL per second. The prostate was larger than 100cm3 in 312 patients, and 156 patients were in acute urinary retention (AUR). In the initial phase of the trial, only patients failing medical therapy were accepted, meaning that 65% of the cohort were given medical therapy prior to PAE. However, Bilhim said that “a significant proportion” (35%) of patients had no medical therapy pre-PAE, as “they do not want the adverse events” attributed with the alpha-blockers and 5-alpha-reductae inhibitors, such as retrograde ejaculation.