A recent letter published by CardioVascular and Interventional Radiology (CVIR) outlines the role of ultrasound-guided transperineal radiofrequency (RF) ablation as a potential alternative treatment for benign prostatic hyperplasia (BPH) in patients unsuitable for prostatic artery embolization (PAE).
In the letter, lead authors Thiago F Nunes (Interventix, Campo Grande, Brazil) and Denis Szejnfeld (Federal University of São Paulo, São Paulo, Brazil) and colleagues state that PAE is already proven to be safe and effective, garnering its inclusion in the latest European Association of Urology (EUA) guidelines for the management of male lower urinary tract symptoms.
However, the authors define that “extensive atherosclerotic disease or complex pelvic vascular anatomy may preclude arterial access and limit its applicability”, necessitating an alternative treatment. In these patients, Szejnfeld et al suggest that image-guided percutaneous RF ablation offers a suitable alternative for targeted debulking in selected patients for whom endovascular therapy is not “technically feasible”.
“Transperineal ablation is emerging as a practical option when embolization is not feasible, and our short- and mid-term follow-up has been encouraging,” said Nunes. “We are now implementing studies using microwave ablation and exploring a single-session hybrid technique that combines microwave ablation and embolization.”
To illustrate their experience with the technique, the authors describe a case involving an 82-year-old man with symptomatic BPH, reporting an International Prostate Symptom Score (IPSS) of 28, quality-of-life score of five and a prostate volume of 79.8cc. Computed tomography (CT) angiography demonstrated complete occlusion of the left common iliac artery, complete occlusion of the right internal iliac artery and the presence of a femorofemoral bypass graft—findings that collectively prevented safe catheterisation of the prostatic arteries, the authors state. Continuing, they note that the patient had also previously undergone UroLift (Teleflex) implantation “without symptomatic improvement”.
Following multidisciplinary evaluation, the authors considered transperineal RF ablation to be a viable alternative in this case, subsequently performing the treatment under light sedation with a periprostatic block using a biplanar transrectal ultrasound probe. Szejnfeld and colleagues note that a 17-gauge internally cooled RF electrode was advanced transperineally and was positioned within the bilateral transition zone. RF energy was applied at 40W for five minutes, “achieving intralesional temperatures of approximately 90 degrees”, they describe. The total procedure time was 25 minutes, and “no intra- or immediate post-procedural complications were observed”.
Following treatment, the team reported that contrast-enhanced prostate magnetic resonance imaging (MRI) at 30 days showed “a well-defined non-enhancing zone corresponding to coagulative necrosis of the treated transition-zone tissue”. At this follow-up period, they also note that the patient reported “substantial” symptom relief, with an IPSS that had fallen from 28 to six, alongside a quality-of-life score reduction from five to one. The authors state that imaging also demonstrated a reduction in prostate volume to 47cc, while serum prostate-specific antigen (PSA) had decreased from 2.17ng/ml to 1.02ng/ml—corresponding to an approximate 53% reduction.
In their discussion, the authors emphasise the procedural advantages of using transperineal RF ablation in this setting, underlining the ability to perform treatment on an outpatient basis using light sedation. Further, they highlight the technique’s “avoidance of contrast material, radiation exposure or angiographic navigation” as beneficial.
While thermal ablation techniques are well established in interventional oncology (IO), the authors explain that “their adaptation for functional urologic conditions remains under active investigation”. They add that the present case demonstrates that “ischaemia-driven tissue reduction may also be achieved by percutaneous image-guided techniques when PAE cannot be performed”.
Szejnfel et al state tha transperineal RF ablation “appears to be a technically feasible and clinically meaningful treatment in carefully selected patients”. They emphasise, however, that “larger studies with extended follow-up are needed to define safety, clinical durability, and comparative effectiveness within the broader spectrum of IR therapies”.
