Update on Prostatic Artery Embolization
Main Article Content
Abstract
Background: Prostatic artery embolization (PAE) has emerged as a treatment option in the management of lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH). Management guidelines addressing PAE remain mixed with recommendations for more long-term trials comparing the procedure to standard therapies.
Materials and Methods: This review presents PAE indications and technical considerations. To evaluate recent updates to the PAE evidence base, a limited literature search of the last 2 years was conducted. Three recent randomized controlled trials (RCTs), comparing PAE to either transurethral resection of the prostate (TURP) or sham procedure, were identified and analyzed.
Results: PAE and TURP performed similarly in significant reductions in international prostate symptoms score (IPSS) and Quality of life (QoL) scoring at 3 and 12 months. The majority of improvement after PAE occurred within a few months, with potentially greater effect in patients with larger prostates and severe symptoms. TURP was generally superior in functional outcomes such as peak urinary flow (Qmax), prostate volume (PV) reduction and post void residual (PVR), although TURP patients underperformed in Qmax improvement in one trial. PAE was superior to sham procedure in all relevant outcomes at 6 months. Overall, complication rates were lower with PAE than with TURP.
Conclusions: PAE and TURP produced similar significant improvements in LUTS. Functional improvements favored TURP while complication rates favored PAE. Clinical improvement after PAE significantly surpassed initial placebo effects of sham procedure. Further comparative studies with longer term follow-up are still needed.
Keywords:
Prostate Artery Embolization, Benign Prostatic Hyperplasia, Prostate, Lower Urinary Tract Symptoms, IPSS
Article Details
How to Cite
BROWN, Benjamin Paul et al.
Update on Prostatic Artery Embolization.
Medical Research Archives, [S.l.], v. 8, n. 8, aug. 2020.
ISSN 2375-1924.
Available at: <https://esmed.org/MRA/mra/article/view/2195>. Date accessed: 19 apr. 2024.
doi: https://doi.org/10.18103/mra.v8i8.2195.
Section
Research Articles
The Medical Research Archives grants authors the right to publish and reproduce the unrevised contribution in whole or in part at any time and in any form for any scholarly non-commercial purpose with the condition that all publications of the contribution include a full citation to the journal as published by the Medical Research Archives.
References
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16. Shah AA, Gahan JC, Sorokin I. Comparison of Robot-Assisted Versus Open Simple Prostatectomy for Benign Prostatic Hyperplasia. Curr Urol Rep. 2018;19(9):71. doi:10.1007/s11934-018-0820-1
17. Moody JA, Lingeman JE. Holmium laser enucleation for prostate adenoma greater than 100 gm.: comparison to open prostatectomy. J Urol. 2001;165(2):459-462. doi:10.1097/00005392-200102000-00025
18. Gratzke C, Schlenker B, Seitz M, et al. Complications and early postoperative outcome after open prostatectomy in patients with benign prostatic enlargement: results of a prospective multicenter study. J Urol. 2007;177(4):1419-1422. doi:10.1016/j.juro.2006.11.062
19. Serretta V, Morgia G, Fondacaro L, et al. Open prostatectomy for benign prostatic enlargement in southern Europe in the late 1990s: a contemporary series of 1800 interventions. Urology. 2002;60(4):623-627. doi:10.1016/s0090-4295(02)01860-5
20. Rassweiler J, Teber D, Kuntz R, Hofmann R. Complications of transurethral resection of the prostate (TURP)--incidence, management, and prevention. Eur Urol. 2006;50(5):969-79; discussion 980. doi:10.1016/j.eururo.2005.12.042
21. Bilhim T, Pisco J, Rio Tinto H, et al. Unilateral versus bilateral prostatic arterial embolization for lower urinary tract symptoms in patients with prostate enlargement. Cardiovasc Intervent Radiol. 2013;36(2):403-411. doi:10.1007/s00270-012-0528-4
22. Picel AC, Hsieh T-C, Shapiro RM, Vezeridis AM, Isaacson AJ. Prostatic artery embolization for benign prostatic hyperplasia: patient evaluation, anatomy, and technique for successful treatment. Radiographics. 2019;39(5):1526-1548. doi:10.1148/rg.2019180195
23. Sun F, Crisóstomo V, Báez-Díaz C, Sánchez FM. Prostatic Artery Embolization (PAE) for Symptomatic Benign Prostatic Hyperplasia (BPH): Part 2, Insights into the Technical Rationale. Cardiovasc Intervent Radiol. 2016;39(2):161-169. doi:10.1007/s00270-015-1238-5
24. Uflacker A, Haskal ZJ, Bilhim T, Patrie J, Huber T, Pisco JM. Meta-Analysis of Prostatic Artery Embolization for Benign Prostatic Hyperplasia. J Vasc Interv Radiol. 2016;27(11):1686-1697.e8. doi:10.1016/j.jvir.2016.08.004
25. Pisco JM, Bilhim T, Pinheiro LC, et al. Medium- and Long-Term Outcome of Prostate Artery Embolization for Patients with Benign Prostatic Hyperplasia: Results in 630 Patients. J Vasc Interv Radiol. 2016;27(8):1115-1122. doi:10.1016/j.jvir.2016.04.001
26. Carnevale FC, Iscaife A, Yoshinaga EM, Moreira AM, Antunes AA, Srougi M. Transurethral Resection of the Prostate (TURP) Versus Original and PErFecTED Prostate Artery Embolization (PAE) Due to Benign Prostatic Hyperplasia (BPH): Preliminary Results of a Single Center, Prospective, Urodynamic-Controlled Analysis. Cardiovasc Intervent Radiol. 2016;39(1):44-52. doi:10.1007/s00270-015-1202-4
27. Gao Y, Huang Y, Zhang R, et al. Benign prostatic hyperplasia: prostatic arterial embolization versus transurethral resection of the prostate--a prospective, randomized, and controlled clinical trial. Radiology. 2014;270(3):920-928. doi:10.1148/radiol.13122803
28. Young S, Golzarian J. Prostate embolization: patient selection, clinical management and results. CVIR Endovasc. 2019;2(1):7. doi:10.1186/s42155-019-0049-1
29. Wang MQ, Guo LP, Zhang GD, et al. Prostatic arterial embolization for the treatment of lower urinary tract symptoms due to large (>80 mL) benign prostatic hyperplasia: results of midterm follow-up from Chinese population. BMC Urol. 2015;15:33. doi:10.1186/s12894-015-0026-5
30. Kurbatov D, Russo GI, Lepetukhin A, et al. Prostatic artery embolization for prostate volume greater than 80 cm3: results from a single-center prospective study. Urology. 2014;84(2):400-404. doi:10.1016/j.urology.2014.04.028
31. Wang M, Guo L, Duan F, et al. Prostatic arterial embolization for the treatment of lower urinary tract symptoms caused by benign prostatic hyperplasia: a comparative study of medium- and large-volume prostates. BJU Int. 2016;117(1):155-164. doi:10.1111/bju.13147
32. NICE Guidance - Prostate artery embolisation for lower urinary tract symptoms caused by benign prostatic hyperplasia: © NICE (2018) Prostate artery embolisation for lower urinary tract symptoms caused by benign prostatic hyperplasia. BJU Int. 2018;122(1):11-12. doi:10.1111/bju.14404
33. Foster HE, Dahm P, Kohler TS, et al. Surgical management of lower urinary tract symptoms attributed to benign prostatic hyperplasia: AUA guideline amendment 2019. J Urol. 2019;202(3):592-598. doi:10.1097/JU.0000000000000319
34. Abt D, Hechelhammer L, Müllhaupt G, et al. Comparison of prostatic artery embolisation (PAE) versus transurethral resection of the prostate (TURP) for benign prostatic hyperplasia: randomised, open label, non-inferiority trial. BMJ. 2018;361:k2338. doi:10.1136/bmj.k2338
35. Pisco JM, Bilhim T, Costa NV, et al. Randomised clinical trial of prostatic artery embolisation versus a sham procedure for benign prostatic hyperplasia. Eur Urol. 2020;77(3):354-362. doi:10.1016/j.eururo.2019.11.010
36. Insausti I, Sáez de Ocáriz A, Galbete A, et al. Randomized Comparison of Prostatic Artery Embolization versus Transurethral Resection of the Prostate for Treatment of Benign Prostatic Hyperplasia. J Vasc Interv Radiol. 2020;31(6):882-890. doi:10.1016/j.jvir.2019.12.810
37. Zhu C., Lin W., Huang Z., Cai J. Prostate artery embolization and transurethral resection of prostate for benign prostatic hyperplasia: A prospective randomized controlled trial. Chinese Journal of Interventional Imaging and Therapy. 2018;15(3):134-138.
38. Jiang Y-L, Qian L-J. Transurethral resection of the prostate versus prostatic artery embolization in the treatment of benign prostatic hyperplasia: a meta-analysis. BMC Urol. 2019;19(1):11. doi:10.1186/s12894-019-0440-1
39. Malling B, Røder MA, Brasso K, Forman J, Taudorf M, Lönn L. Prostate artery embolisation for benign prostatic hyperplasia: a systematic review and meta-analysis. Eur Radiol. 2019;29(1):287-298. doi:10.1007/s00330-018-5564-2
40. Pyo JS, Cho WJ. Systematic review and meta-analysis of prostatic artery embolisation for lower urinary tract symptoms related to benign prostatic hyperplasia. Clin Radiol. 2017;72(1):16-22. doi:10.1016/j.crad.2016.10.009
41. Abt D, Müllhaupt G, Mordasini L, et al. Outcome prediction of prostatic artery embolization: post hoc analysis of a randomized, open-label, non-inferiority trial. BJU Int. 2019;124(1):134-144. doi:10.1111/bju.14632
42. Barry MJ, Cockett AT, Holtgrewe HL, McConnell JD, Sihelnik SA, Winfield HN. Relationship of symptoms of prostatism to commonly used physiological and anatomical measures of the severity of benign prostatic hyperplasia. J Urol. 1993;150(2 Pt 1):351-358. doi:10.1016/s0022-5347(17)35482-4
43. Cornu J-N, Ahyai S, Bachmann A, et al. A Systematic Review and Meta-analysis of Functional Outcomes and Complications Following Transurethral Procedures for Lower Urinary Tract Symptoms Resulting from Benign Prostatic Obstruction: An Update. Eur Urol. 2015;67(6):1066-1096. doi:10.1016/j.eururo.2014.06.017
44. Alexander CE, Scullion MM, Omar MI, et al. Bipolar versus monopolar transurethral resection of the prostate for lower urinary tract symptoms secondary to benign prostatic obstruction. Cochrane Database Syst Rev. 2019;12:CD009629. doi:10.1002/14651858.CD009629.pub4
45. Zumstein V, Binder J, Güsewell S, et al. Radiation exposure during prostatic artery embolisation: A systematic review and calculation of associated risks. Eur Urol Focus. May 2020. doi:10.1016/j.euf.2020.04.012
46. Bilhim T, Costa NV, Torres D, Pisco J, Carmo S, Oliveira AG. Randomized Clinical Trial of Balloon Occlusion versus Conventional Microcatheter Prostatic Artery Embolization for Benign Prostatic Hyperplasia. J Vasc Interv Radiol. 2019;30(11):1798-1806. doi:10.1016/j.jvir.2019.06.019
2. McVary KT, Roehrborn CG, Avins AL, et al. Update on AUA guideline on the management of benign prostatic hyperplasia. J Urol. 2011;185(5):1793-1803. doi:10.1016/j.juro.2011.01.074
3. Foster HE, Barry MJ, Dahm P, et al. Surgical management of lower urinary tract symptoms attributed to benign prostatic hyperplasia: AUA guideline. J Urol. 2018;200(3):612-619. doi:10.1016/j.juro.2018.05.048
4. Homma Y, Gotoh M, Kawauchi A, et al. Clinical guidelines for male lower urinary tract symptoms and benign prostatic hyperplasia. Int J Urol. 2017;24(10):716-729. doi:10.1111/iju.13401
5. Oelke M, Bachmann A, Descazeaud A, et al. EAU guidelines on the treatment and follow-up of non-neurogenic male lower urinary tract symptoms including benign prostatic obstruction. Eur Urol. 2013;64(1):118-140. doi:10.1016/j.eururo.2013.03.004
6. Ray AF, Powell J, Speakman MJ, et al. Efficacy and safety of prostate artery embolization for benign prostatic hyperplasia: an observational study and propensity-matched comparison with transurethral resection of the prostate (the UK-ROPE study). BJU Int. 2018;122(2):270-282. doi:10.1111/bju.14249
7. Ahyai SA, Gilling P, Kaplan SA, et al. Meta-analysis of functional outcomes and complications following transurethral procedures for lower urinary tract symptoms resulting from benign prostatic enlargement. Eur Urol. 2010;58(3):384-397. doi:10.1016/j.eururo.2010.06.005
8. Al-Rawashdah SF, Pastore AL, Salhi YA, et al. Prospective randomized study comparing monopolar with bipolar transurethral resection of prostate in benign prostatic obstruction: 36-month outcomes. World J Urol. 2017;35(10):1595-1601. doi:10.1007/s00345-017-2023-7
9. Sønksen J, Barber NJ, Speakman MJ, et al. Prospective, randomized, multinational study of prostatic urethral lift versus transurethral resection of the prostate: 12-month results from the BPH6 study. Eur Urol. 2015;68(4):643-652. doi:10.1016/j.eururo.2015.04.024
10. Reich O, Gratzke C, Bachmann A, et al. Morbidity, mortality and early outcome of transurethral resection of the prostate: a prospective multicenter evaluation of 10,654 patients. J Urol. 2008;180(1):246-249. doi:10.1016/j.juro.2008.03.058
11. Skolarikos A, Rassweiler J, de la Rosette JJ, et al. Safety and Efficacy of Bipolar Versus Monopolar Transurethral Resection of the Prostate in Patients with Large Prostates or Severe Lower Urinary Tract Symptoms: Post Hoc Analysis of a European Multicenter Randomized Controlled Trial. J Urol. 2016;195(3):677-684. doi:10.1016/j.juro.2015.08.083
12. Samir M, Tawfick A, Mahmoud MA, et al. Two-year Follow-up in Bipolar Transurethral Enucleation and Resection of the Prostate in Comparison with Bipolar Transurethral Resection of the Prostate in Treatment of Large Prostates. Randomized Controlled Trial. Urology. 2019;133:192-198. doi:10.1016/j.urology.2019.07.029
13. McWilliams JP, Bilhim TA, Carnevale FC, et al. Society of Interventional Radiology Multisociety Consensus Position Statement on Prostatic Artery Embolization for Treatment of Lower Urinary Tract Symptoms Attributed to Benign Prostatic Hyperplasia: From the Society of Interventional Radiology, the Cardiovascular and Interventional Radiological Society of Europe, Société Française de Radiologie, and the British Society of Interventional Radiology: Endorsed by the Asia Pacific Society of Cardiovascular and Interventional Radiology, Canadian Association for Interventional Radiology, Chinese College of Interventionalists, Interventional Radiology Society of Australasia, Japanese Society of Interventional Radiology, and Korean Society of Interventional Radiology. J Vasc Interv Radiol. 2019;30(5):627-637.e1. doi:10.1016/j.jvir.2019.02.013
14. Shim SR, Kanhai KJK, Ko YM, Kim JH. Efficacy and Safety of Prostatic Arterial Embolization: Systematic Review with Meta-Analysis and Meta-Regression. J Urol. 2017;197(2):465-479. doi:10.1016/j.juro.2016.08.100
15. Kuntz RM, Lehrich K, Ahyai SA. Holmium laser enucleation of the prostate versus open prostatectomy for prostates greater than 100 grams: 5-year follow-up results of a randomised clinical trial. Eur Urol. 2008;53(1):160-166. doi:10.1016/j.eururo.2007.08.036
16. Shah AA, Gahan JC, Sorokin I. Comparison of Robot-Assisted Versus Open Simple Prostatectomy for Benign Prostatic Hyperplasia. Curr Urol Rep. 2018;19(9):71. doi:10.1007/s11934-018-0820-1
17. Moody JA, Lingeman JE. Holmium laser enucleation for prostate adenoma greater than 100 gm.: comparison to open prostatectomy. J Urol. 2001;165(2):459-462. doi:10.1097/00005392-200102000-00025
18. Gratzke C, Schlenker B, Seitz M, et al. Complications and early postoperative outcome after open prostatectomy in patients with benign prostatic enlargement: results of a prospective multicenter study. J Urol. 2007;177(4):1419-1422. doi:10.1016/j.juro.2006.11.062
19. Serretta V, Morgia G, Fondacaro L, et al. Open prostatectomy for benign prostatic enlargement in southern Europe in the late 1990s: a contemporary series of 1800 interventions. Urology. 2002;60(4):623-627. doi:10.1016/s0090-4295(02)01860-5
20. Rassweiler J, Teber D, Kuntz R, Hofmann R. Complications of transurethral resection of the prostate (TURP)--incidence, management, and prevention. Eur Urol. 2006;50(5):969-79; discussion 980. doi:10.1016/j.eururo.2005.12.042
21. Bilhim T, Pisco J, Rio Tinto H, et al. Unilateral versus bilateral prostatic arterial embolization for lower urinary tract symptoms in patients with prostate enlargement. Cardiovasc Intervent Radiol. 2013;36(2):403-411. doi:10.1007/s00270-012-0528-4
22. Picel AC, Hsieh T-C, Shapiro RM, Vezeridis AM, Isaacson AJ. Prostatic artery embolization for benign prostatic hyperplasia: patient evaluation, anatomy, and technique for successful treatment. Radiographics. 2019;39(5):1526-1548. doi:10.1148/rg.2019180195
23. Sun F, Crisóstomo V, Báez-Díaz C, Sánchez FM. Prostatic Artery Embolization (PAE) for Symptomatic Benign Prostatic Hyperplasia (BPH): Part 2, Insights into the Technical Rationale. Cardiovasc Intervent Radiol. 2016;39(2):161-169. doi:10.1007/s00270-015-1238-5
24. Uflacker A, Haskal ZJ, Bilhim T, Patrie J, Huber T, Pisco JM. Meta-Analysis of Prostatic Artery Embolization for Benign Prostatic Hyperplasia. J Vasc Interv Radiol. 2016;27(11):1686-1697.e8. doi:10.1016/j.jvir.2016.08.004
25. Pisco JM, Bilhim T, Pinheiro LC, et al. Medium- and Long-Term Outcome of Prostate Artery Embolization for Patients with Benign Prostatic Hyperplasia: Results in 630 Patients. J Vasc Interv Radiol. 2016;27(8):1115-1122. doi:10.1016/j.jvir.2016.04.001
26. Carnevale FC, Iscaife A, Yoshinaga EM, Moreira AM, Antunes AA, Srougi M. Transurethral Resection of the Prostate (TURP) Versus Original and PErFecTED Prostate Artery Embolization (PAE) Due to Benign Prostatic Hyperplasia (BPH): Preliminary Results of a Single Center, Prospective, Urodynamic-Controlled Analysis. Cardiovasc Intervent Radiol. 2016;39(1):44-52. doi:10.1007/s00270-015-1202-4
27. Gao Y, Huang Y, Zhang R, et al. Benign prostatic hyperplasia: prostatic arterial embolization versus transurethral resection of the prostate--a prospective, randomized, and controlled clinical trial. Radiology. 2014;270(3):920-928. doi:10.1148/radiol.13122803
28. Young S, Golzarian J. Prostate embolization: patient selection, clinical management and results. CVIR Endovasc. 2019;2(1):7. doi:10.1186/s42155-019-0049-1
29. Wang MQ, Guo LP, Zhang GD, et al. Prostatic arterial embolization for the treatment of lower urinary tract symptoms due to large (>80 mL) benign prostatic hyperplasia: results of midterm follow-up from Chinese population. BMC Urol. 2015;15:33. doi:10.1186/s12894-015-0026-5
30. Kurbatov D, Russo GI, Lepetukhin A, et al. Prostatic artery embolization for prostate volume greater than 80 cm3: results from a single-center prospective study. Urology. 2014;84(2):400-404. doi:10.1016/j.urology.2014.04.028
31. Wang M, Guo L, Duan F, et al. Prostatic arterial embolization for the treatment of lower urinary tract symptoms caused by benign prostatic hyperplasia: a comparative study of medium- and large-volume prostates. BJU Int. 2016;117(1):155-164. doi:10.1111/bju.13147
32. NICE Guidance - Prostate artery embolisation for lower urinary tract symptoms caused by benign prostatic hyperplasia: © NICE (2018) Prostate artery embolisation for lower urinary tract symptoms caused by benign prostatic hyperplasia. BJU Int. 2018;122(1):11-12. doi:10.1111/bju.14404
33. Foster HE, Dahm P, Kohler TS, et al. Surgical management of lower urinary tract symptoms attributed to benign prostatic hyperplasia: AUA guideline amendment 2019. J Urol. 2019;202(3):592-598. doi:10.1097/JU.0000000000000319
34. Abt D, Hechelhammer L, Müllhaupt G, et al. Comparison of prostatic artery embolisation (PAE) versus transurethral resection of the prostate (TURP) for benign prostatic hyperplasia: randomised, open label, non-inferiority trial. BMJ. 2018;361:k2338. doi:10.1136/bmj.k2338
35. Pisco JM, Bilhim T, Costa NV, et al. Randomised clinical trial of prostatic artery embolisation versus a sham procedure for benign prostatic hyperplasia. Eur Urol. 2020;77(3):354-362. doi:10.1016/j.eururo.2019.11.010
36. Insausti I, Sáez de Ocáriz A, Galbete A, et al. Randomized Comparison of Prostatic Artery Embolization versus Transurethral Resection of the Prostate for Treatment of Benign Prostatic Hyperplasia. J Vasc Interv Radiol. 2020;31(6):882-890. doi:10.1016/j.jvir.2019.12.810
37. Zhu C., Lin W., Huang Z., Cai J. Prostate artery embolization and transurethral resection of prostate for benign prostatic hyperplasia: A prospective randomized controlled trial. Chinese Journal of Interventional Imaging and Therapy. 2018;15(3):134-138.
38. Jiang Y-L, Qian L-J. Transurethral resection of the prostate versus prostatic artery embolization in the treatment of benign prostatic hyperplasia: a meta-analysis. BMC Urol. 2019;19(1):11. doi:10.1186/s12894-019-0440-1
39. Malling B, Røder MA, Brasso K, Forman J, Taudorf M, Lönn L. Prostate artery embolisation for benign prostatic hyperplasia: a systematic review and meta-analysis. Eur Radiol. 2019;29(1):287-298. doi:10.1007/s00330-018-5564-2
40. Pyo JS, Cho WJ. Systematic review and meta-analysis of prostatic artery embolisation for lower urinary tract symptoms related to benign prostatic hyperplasia. Clin Radiol. 2017;72(1):16-22. doi:10.1016/j.crad.2016.10.009
41. Abt D, Müllhaupt G, Mordasini L, et al. Outcome prediction of prostatic artery embolization: post hoc analysis of a randomized, open-label, non-inferiority trial. BJU Int. 2019;124(1):134-144. doi:10.1111/bju.14632
42. Barry MJ, Cockett AT, Holtgrewe HL, McConnell JD, Sihelnik SA, Winfield HN. Relationship of symptoms of prostatism to commonly used physiological and anatomical measures of the severity of benign prostatic hyperplasia. J Urol. 1993;150(2 Pt 1):351-358. doi:10.1016/s0022-5347(17)35482-4
43. Cornu J-N, Ahyai S, Bachmann A, et al. A Systematic Review and Meta-analysis of Functional Outcomes and Complications Following Transurethral Procedures for Lower Urinary Tract Symptoms Resulting from Benign Prostatic Obstruction: An Update. Eur Urol. 2015;67(6):1066-1096. doi:10.1016/j.eururo.2014.06.017
44. Alexander CE, Scullion MM, Omar MI, et al. Bipolar versus monopolar transurethral resection of the prostate for lower urinary tract symptoms secondary to benign prostatic obstruction. Cochrane Database Syst Rev. 2019;12:CD009629. doi:10.1002/14651858.CD009629.pub4
45. Zumstein V, Binder J, Güsewell S, et al. Radiation exposure during prostatic artery embolisation: A systematic review and calculation of associated risks. Eur Urol Focus. May 2020. doi:10.1016/j.euf.2020.04.012
46. Bilhim T, Costa NV, Torres D, Pisco J, Carmo S, Oliveira AG. Randomized Clinical Trial of Balloon Occlusion versus Conventional Microcatheter Prostatic Artery Embolization for Benign Prostatic Hyperplasia. J Vasc Interv Radiol. 2019;30(11):1798-1806. doi:10.1016/j.jvir.2019.06.019