BPH: Prostatic Artery Embolization
André Moreira de Assis
Airton Mota Moreira
Francisco Cesar Carnevale
Benign prostatic hyperplasia (BPH) is the most common benign neoplasia in males, and moderate or severe lower urinary tract symptoms (LUTS) will occur in approximately one-half of men in their 80s. Men with BPH can present with prostatic enlargement, bladder outlet obstruction, or both. LUTS due to BPH, such as urinary hesitancy, intermittency, urgency, and nocturia, can significantly impact patient quality of life and may be only partially relieved by medical management. A large number of patients will need some invasive modality of treatment, including transurethral resection of prostate (TURP), open prostatectomy, and laser enucleation, procedures associated with significant morbidities (1).
Recently, prostate artery embolization (PAE) has been adopted for the treatment of LUTS due to enlarged BPH. Previous studies have established PAE as a safe and effective treatment associated with significant prostate volume reduction, and urodynamic, symptoms and quality of life improvements (2,3,4).
Contraindications (5)
Absolute
1. Active urinary tract infection (UTI)
2. Bladder atonia
3. Neurologic bladder dysfunction or other neurologic disorder that is impacting bladder function
4. Large bladder diverticula or stones with surgical indication
5. Urethral stricture
6. Renal failure
Relative
1. Confirmed or suspected malignant neoplasm
2. Detrusor muscle hypocontractility
3. Coagulation disorders
Preprocedure Preparation
1. A multidisciplinary team of interventional radiologists, diagnostic radiologists, and urologists is involved in patient selection and follow-up.
2. The International Prostate Symptom Score (IPSS; evaluated as mild, moderate, and severe) and the International Index of Erectile Function (IIEF; evaluated as severe, moderate, mild-to-moderate, mild, and no dysfunction) are used as assessment tools. Patients also answer a quality of life (QOL) questionnaire that includes the question, “If you were to spend the rest of your life with your urinary condition just the way it is now, how would you feel about that?”
3. All patients undergo digital rectal examination and prostatic specific antigen (PSA) measurement; transrectal prostate biopsy is performed if there is suspicion of cancer.
4. A urodynamic study is performed to confirm presence of infravesical obstruction and to evaluate bladder function. Some patients can still be obstructed on follow-up urodynamic testing, despite their LUTS improvement.
5. Pelvic magnetic resonance imaging (MRI) also plays an important role in the preprocedure evaluation. Total prostate volume, central gland measurements, presence of BPH nodules, assessment of prostatic lobe symmetry, median lobe protrusion, and presence of suspicious areas in the peripheral zone can all be reviewed in detail.
a. Moreover, postcontrast sequences demonstrate prostatic parenchymal enhancement patterns and atherosclerotic changes in pelvic arteries.
b. Bladder wall thickness and diverticula, polyps, and stones can also be assessed as well as disorders of other pelvic structures.
c. Endorectal coils are not necessary in most cases.
Procedure
1. Intravenous antibiotic is administrated before PAE, usually ciprofloxacin or a third-generation cephalosporin, for example, ciprofloxacin 400 mg IV preprocedure and 500 mg orally twice a day for 7 days after PAE.
2. To provide good orientation to the prostate site and related structures in the pelvis, a Foley catheter is introduced into the bladder in every patient and the balloon is filled with a 10% to 30% iodinated contrast medium solution.
3. Procedure is performed under local anesthesia through unilateral femoral approach in the interventional radiology suite.
4. PAE for BPH can be a technically challenging procedure. Identifying and catheterizing target arterial branches are among the most technical and timeconsuming steps.
a. Atherosclerotic changes are frequent.
b. Identification of the target arteries can be difficult. Multiple origins of the inferior vesical artery and its prostatic branches have been described, including
the anterior trunk of internal iliac artery, obturator, internal pudendal arteries, and others (5).
the anterior trunk of internal iliac artery, obturator, internal pudendal arteries, and others (5).
5. A pelvic digital subtraction angiography (DSA) for assessment of global pelvic arterial anatomy (pigtail catheter in distal aorta, 20 mL contrast, 10 mL per second, 600 psi) is first performed.
6. After crossing the aortic bifurcation, an internal iliac artery DSA is performed with a 5 Fr. vertebral or cobra C2 catheter (12 mL, 4 mL per second, 300 psi).
a. The inferior vesical artery (IVA) origin is better identified on a 30- to 50-degree ipsilateral oblique view.
b. The PROVISO acronym (internal Pudendal, middle Rectal, Obturator, Vesical Inferior and Superior under Oblique view) is a very useful trick to remember the names of the arteries that should be investigated and the best projection during arteriogram (Fig. 27.1).
c. In difficult cases, a three-dimensional (3D
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