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Research Article | DOI: https://doi.org/10.31579/2768-2757/153
North Manchester General Hospital, Department of Urology, Delaunays Road, Manchester, M8 5RB, United Kingdom.
*Corresponding Author: Anthony Kodzo-Grey Venyo, North Manchester General Hospital, Department of Urology, Delaunays Road, Manchester, M8 5RB, United Kingdom.
Citation: Anthony K Venyo., (2024), Embolization of Prostate Gland as Treatment for Benign Prostatic Hyperplasia (Bph): Review and Update, Journal of Clinical Surgery and Research, 5(9); DOI:10.31579/2768-2757/153
Copyright: © 2024 Anthony Kodzo-Grey Venyo., This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Received: 02 December 2024 | Accepted: 23 December 2024 | Published: 27 December 2024
Keywords: prostate artery embolization; prostatic artery embolization; angiography; interventional radiologist; benign prostate hyperplasia; urinary retention; lower urinary tract symptoms; haematuria
Prostatic artery embolization has been emerging as an effective and safe treatment option of symptomatic benign prostatic hyperplasia. Symptomatic benign prostatic hyperplasia is a common condition which afflicts the aging population which is ensued by the development of bothersome lower urinary tract symptoms and decreased quality of life and at times urinary retention as well as haematuria. Patients who are afflicted by BPH often are treated with medication and offered surgery for persistent symptoms. Transurethral resection of the prostate is regarded as the traditional standard of care, and in cases of extremely large prostate glands prostatectomy tend to be undertaken either as retropubic or trans-vesical prostatectomy but several minimally invasive surgical treatments also are offered. Prostatic artery embolization (PAE) has emerging as an effective treatment option with few reported adverse effects, minimal blood loss, and infrequent overnight hospitalization. The procedure is offered to patients who have moderate to severe lower urinary tract symptoms and depressed urinary flow due to bladder outlet obstruction. Proper patient selection and meticulous embolization are pivotal for optimization of the outcome of PAE. In order to undertake PAE safely and to avoid non-target embolization, interventional radiologists need to be very well trained they should have a detailed understanding of the pelvic arterial anatomy. Even though the prostatic arteries often arise from the internal pudendal arteries, many anatomical variants and pelvic anastomoses are encountered. Prospective cohort studies, small randomized controlled trials, and meta-analyses had demonstrated improved symptoms after PAE treatment, with serious adverse effects occurring rarely. This article has been written to provide an update on PAE which must be understood in order to develop a thriving PAE practice. These principles include careful assessment of patients, review of surgical therapies, details of the anatomy of the arteries of the pelvis including the prostate artery including its origin and branches, basic principles of embolization, and an overview of published results.
Prostate artery embolization (PAE) has emerged as a new treatment option for patients who have symptomatic benign prostatic hyperplasia with lower urinary tract symptoms or urinary retention. The main challenges related to this procedure include the navigation of arteries with atherosclerosis and anatomical variations, and the potential risk of non-target embolization to pelvic structures related to the presence of collateral shunts and reflux of microparticles. Understanding of the classical vascular anatomy and the most common variations of the vasculature of the pelvis is pivotal for the undertaking of a safe embolization, good clinical practice, and optimal outcomes. The undertaking of PAE requires availability of a well-trained interventional radiologist as well as availability of good radiology imaging facilities. Unfortunately, there are not many interventional radiologists in various health care establishments in the world especially within the developing countries. Considering that a number of patients who have benign prostate hyperplasia may have comorbidities that would render them unfit to undergo surgical operations for their BPH problems, availability of facilities and well-trained interventional radiologist who can undertake PAE in most urology establishments in the world would be of great help to many patients globally. Considering that PAE is now developing in the world, it would be envisaged that some clinicians in the world may not be familiar with the PAE procedure. The ensuing article has been written to provide an update on PAE for BPH.
Aim
[A] Overview
General statements / definition
Benign prostatic hyperplasia (BPH), also known as benign prostatic hypertrophy, is a histological diagnosis which is characterized by proliferation of the cellular elements of the prostate, leading to an enlarged prostate gland. Chronic bladder outlet obstruction (BOO) secondary to BPH may lead to urinary retention, impaired kidney function, recurrent urinary tract infections, visible hematuria, and bladder calculi.
Clinical Features
A number of individuals who have BPH, may be asymptomatic but others may manifest with symptoms some which include the ensuing:
Assessment / Diagnosis
Laboratory tests
Urine
Haematology blood tests
Biochemistry blood tests
Radiology image assessments
Ultrasound scan
Computed Tomography (CT) scan.
Magnetic Resonance Imaging (MRI) scan.
Urodynamics
Treatment:
Many treatments are made available for BPH, including medications such as α-blockers and 5α-reductase inhibitors and surgical options of treatment including transurethral resection of the prostate and prostatectomy which had been summated as follows:
Differential diagnoses
Some of the differential diagnoses of BPH include:
[B] Miscellaneeous Narrations and Discussions from Some Case Reports, Case Series, And Studies Related to Embolozation of Prostate Gland
Uflacker et al. [2] undertook a meta-analysis of available data on prostatic artery embolization (PAE). Uflacker et al. [2] undertook a meta-analysis on articles which had been published between November 2009 and December 2015. Uflacker et al. [2] included peer-reviewed studies with > 5 patients and standard deviations and/or individual-level data on one or more of the following outcomes: prostate volume (PV), peak flow rate (Qmax), postvoid residual (PVR), International Prostate Symptom Score (IPSS), quality of life (QOL) score, International Index of Erectile Function (IIEF) score, and prostate-specific antigen (PSA) level. They undertook a random-effects meta-analysis on the outcomes at 1 month, 3 months, 6 months, and 12 months after PAE compared with baseline values, with a P < .05 decision rule as the null hypothesis rejection criterion. Uflacker et al. [2] summated the results as follows:
Carnevale et al. [3] made the ensuing iterations:
Pisco et al. [4] evaluated whether prostatic arterial embolization (PAE) might be a feasible procedure to treat lower urinary tract symptoms associated with benign prostatic hyperplasia (BPH). Pisco et al. [4] selected fifteen patients, whose ages had ranged between 62 years and 82 years and whose mean age, was 74.1 years and who had symptomatic BPH after failure of medical treatment for PAE with non-spherical 200-μm polyvinyl alcohol particles. The procedure was undertaken by a single femoral approach. Technical success was considered when selective prostatic arterial catheterization and embolization was achieved on at least one pelvic side. Pisco et al. [4] summated the results as follows:
Picel et al. [5] made the ensuing iterations:
de Assis et al. [6] described the safety and efficacy of prostatic artery embolization (PAE) with spherical microparticles to treat lower urinary tract symptoms associated with benign prostatic hyperplasia in patients whose prostate volume was greater than 90 grams. de Assis et al. [6] undertook a prospective, single-centre, single-arm study in 35 patients with prostate volumes ranging from 90 grams to 252 grams. The mean age of the patients was 64.8 years and the ages of the patients had ranged between 53 years and 77 years. Magnetic resonance imaging, uroflometry, and the International Prostate Symptom Score (IPSS) were used to assess clinical and functional outcomes. de Assis et al. [6] summated the results as follows:
Carnevale et al. [7] made the ensuing iterations:
Carnevale et al. [7] reported the preliminary results for two patients with acute urinary retention due to BPH, who were successfully treated by prostate artery embolization (PAE). The patients were investigated utilising the International Prostate Symptom Score, by digital rectal examination, urodynamic testing, prostate biopsy, transrectal ultrasound (US), and magnetic resonance imaging (MRI). Uroflowmetry and post-void residual urine volume complemented the investigation at 30, 90, and 180 days after PAE. The procedure was undertaken under local anaesthesia; embolization of the prostate arteries was undertaken with a microcatheter and 300- to 500-μm microspheres utilising complete stasis as the end point. One patient was subjected to bilateral PAE and the other to unilateral PAE; they voided spontaneously pursuant to the removal of the urethral catheter, 15 days and 10 days after the procedure, respectively. At 6-month follow-up, US and MRI scan had revealed a prostate reduction of 39.7% and 47.8%, respectively, for the bilateral PAE and 25.5 and 27.8%, respectively, for the patient submitted to unilateral PAE. Carnevale et al. [7] concluded that:
Gao et al. [8] stated that prostatic arterial embolization is an effective treatment in patients with lower urinary tract symptoms due to benign prostatic hyperplasia, especially in those with benign prostatic hyperplasia with predominant prostatic arteries and a rich vasculature. Gao et al. [8] compared prostatic arterial embolization (PAE) and transurethral resection of the prostate (TURP) in the care of patients with benign prostatic hyperplasia (BPH). Gao et al. [8] undertook a prospective randomized clinical trial which was approved by the institutional review board. A total of 114 patients had provided written informed consent and were randomly assigned to undergo PAE (n = 57) or TURP (n = 57). The groups were compared regarding relevant adverse events and complications. Functional results—including improvement of International Prostate Symptom Score (IPSS), quality of life (QOL), peak urinary flow, postvoiding residual urine volume, prostate-specific antigen (PSA) level, and prostate volume—were assessed at 1 month, 3 months, 6 months, 12 months, and 24 months follow-ups between January 20, 2007, and January 31, 2012. Student t test, χ2 test, Fisher exact test, and repeated measures analysis of variance were utilised, as appropriate. Gao et al. [8] summated the results as follows:
Gao et al. [8] made the ensuing conclusions:
Pisco et al. [9] undertook a study to confirm that prostatic artery embolization (PAE) has a positive medium- and long-term effect in symptomatic benign prostatic hyperplasia (BPH). Pisco et al. [9] reported that between March 2009 and October 2014, 630 consecutive patients with BPH and moderate-to-severe lower urinary tract symptoms refractory to medical therapy for at least 6 months or who refused any medical therapy had undergone PAE. Pisco et al. [9] evaluated outcome parameters of the patients at baseline; 1 month, 3 months, and 6 months; every 6 months between 1 year and 3 years; and yearly thereafter up to 6.5 years. Pisco et al. [9] summated the results as follows:
Pisco et al. [9] made the ensuing conclusions:
Kurbatov et al. [10] investigated the clinical benefits and safety of prostatic artery embolization (PAE) in patients with prostate volume ≥80 cm3 and Charlson comorbidity index (CCI) ≥2 and affected by benign prostatic obstruction (BPO). Kurbatov et al. [10] reported that from January 2009 to January 2012, PAE was undertaken in 88 consecutive patients who were affected by clinical BPO. The inclusion criteria were symptomatic BPO refractory to medical treatment, International Prostate Symptom Score (IPSS) ≥12, total prostate volume (TPV) ≥80 cm3, Qmax <15>
Kurbatov et al. [10] concluded that:
They had demonstrated the clinical benefits of PAE for the treatment of lower urinary tract symptoms and/or BPO by reducing IPSS, TPV, PSA, PVR, and improvement in urinary flow and QoL after 1 year in patients with prostate volume ≥80 cm(3) and CCI ≥2.
Carnevale et al. [11] stated that long-term experience with prostatic artery embolization (PAE) for benign prostatic hyperplasia had remained limited. Carnevale et al. [11] evaluated the efficacy, safety, and long-term results of PAE for benign prostatic hyperplasia. Carnevale et al. [11] undertook a retrospective single-centre study from June 2008 to June 2018 in patients with moderate to severe benign prostatic hyperplasia–related symptoms. International Prostate Symptom Score (IPSS), quality-of-life score, maximum urinary flow rate, postvoid residual volume, prostate-specific antigen (PSA), and prostate volume were assessed. PAE was performed with 100–500-μm embolic microspheres. Mixed-model analysis of variance and Kaplan-Meyer method was accessed, as appropriate. Carnevale et al. [11] summated the results as follows:
Carnevale et al. [11] concluded that:
Prostatic artery embolization was found to be a safe and effective procedure for benign prostatic hyperplasia with good long-term results for lower urinary tract symptoms.
Bagla et al. [12] rereported early findings from a prospective United States clinical trial to evaluate the efficacy and safety of prostatic artery embolization (PAE) for benign prostatic hyperplasia (BPH). Bagla et al. [] reported that from January 2012 to March 2013, 72 patients were screened and 20 patients had undergone treatment. The patients were evaluated at baseline and selected intervals (1 month, 3 months, and 6 months) for the following efficacy variables: American Urological Association (AUA) symptom score, quality of life (QOL)–related symptoms, International Index of Erectile Function score, peak urine flow rate, and prostate volume (on magnetic resonance imaging at 6 months). The complications were monitored and reported per Society of Interventional Radiology guidelines. Bagla et al. [12] summated the results as follows:
Bagla et al. [12] concluded that:
Grosso et al. [13] reported the clinical outcome after prostatic artery embolization (PAE) in 13 consecutive patients with benign prostatic hyperplasia (BPH) and lower urinary tract symptoms (LUTS). Grosso et al. [13] reported that from May 2012 to October 2013, they had undertaken PAE in 13 consecutive patients, whose mean age was 75.9 years, and who had with BPH and LUTS and refractory to medical therapy; seven patients had an indwelling urinary bladder catheter. Clinical follow-up (mean follow-up time 244 days) was undertaken using the international prostate symptoms score (IPSS), quality of life (QoL), the international index of erectile function (IIEF), blood prostatic specific antigen (PSA) testing and transrectal prostatic ultrasound (US) scan with volume and weight calculation at 3, 6 and 12 months. Pre-procedural CT angiography (CTA) was undertaken for vascular mapping. Embolization was undertaken utilising Embosphere (300–500 micron). Technical success was defined when the selective prostatic arterial embolization was completed in at least one pelvic side. Clinical success was defined when symptoms and quality of life were improved. Grosso et al. [13] summated the results as follows:
Grosso et al. [13] made the ensuing conclusions:
Bilhim et al. [14] undertook a study which was designed to compare baseline data and clinical outcome between patients with prostate enlargement/benign prostatic hyperplasia (PE/BPH) who underwent unilateral and bilateral prostatic arterial embolization (PAE) for the relief of lower urinary tract symptoms (LUTS). Bilhim et al. [14] reported that their single-centre, ambispective cohort study had compared 122 consecutive patients whose mean age was 66.7 years, with unilateral versus bilateral PAE undertaken from March 2009 to December 2011. Selective PAE was undertaken with 100- and 200-μm nonspherical polyvinyl alcohol (PVA) particles by a unilateral femoral approach. Bilhim et al. [14] summated the results as follows:
Bilhim et al. [14] made the ensuing conclusions:
Bhatia et al. [15] determined if coil embolization is a safe adjunctive measure to prevent nontarget embolization during prostatic artery embolization (PAE). Bhatia et al. [15] undertook a retrospective analysis of patients who had undergone PAE with coil embolization (cPAE) or without coil embolization (nPAE) between January 2014 and June 2016. They compared adverse events, identified in accordance with SIR guidelines, and procedural variables between the 2 cohorts. Bhatia et al. [15] summated the results as follows:
Bhatia et al. [15] made the ensuing conclusion:
Sun et al. [16] made the ensuing iterations:
Kuang et al. [17] summarized current evidence on outcomes and complications of prostatic artery embolization as a treatment for patients with lower urinary tract symptoms secondary to benign prostatic hyperplasia. Kuang et al. [17] undertook a database search of MEDLINE, Embase, Web of Science, and Cochrane Library for published literature up to August 2015 concerning PAE in the treatment of BPH. Inclusion and exclusion criteria were applied by two independent reviewers, and disagreements were resolved by consensus. Peer-reviewed studies concerning PAE with BPH with a sample size >10 and at least one measured parameter were included. Kuang et al. [17] summated the results as follows:
Kuang et al. [17] concluded that:
Abt et al. [18] made the ensuing iterations:
Abt et al. [18] concluded that:
Moreira et al. [19] made the ensuing iterations:
Moreira et al. [19] undertook a review of adverse events related to prostatic artery embolization to treat urinary bladder outflow obstruction and they iterated that low adverse events rates had been reported following prostate artery embolization and which may include dysuria, urinary infection, haematuria, hematospermia, acute urinary retention and rectal bleeding. They pointed out that even though most complaints had been reported as side effects, complications could also be superimposed. They made the ensuing summating educative discussions:
Dias et al. [20] made the ensuing iterations:
Amouyal et al. [21] stated that prostatic artery embolization (PAE) had been undertaken for a few years, but there had not been any report on PAE before 2016, using the PErFecTED technique outside from the team that initiated this approach. Amouyal et al. [21] reported their single-centre retrospective open label study reports of their experience and clinical results on patients who were suffering from symptomatic BPH, who had undergone PAE aiming at utilising the PErFecTED technique. Amouyal et al. [21] reported that they had treated 32 consecutive patients, whose mean age was 65 years and whose ages had ranged between 52 years and 84 years of age between December 2013 and January 2015. The patients were referred for PAE after failure of medical treatment and refusal or contra-indication to surgery. They were treated utilising the PErFecTED technique, when feasible, with 300–500 µm calibrated microspheres (two-night hospital stay or outpatient procedure). Follow-up assessment was undertaken at 3 months, 6 months, and 12 months. Amouyal et al. [21] summated the results as follows:
Amouyal et al. [21] made the ensuing conclusions:
Christidis et al. [22] made the ensuing iteratins:
Christidis et al. [22] undertook a review of the literature. Christidis et al. [22] searched medical databases which included PubMed, EMBASE, and Cochrane databases, that were limited to English, peer-reviewed articles. Their search terms included prostatic artery embolization, lower urinary tracts symptoms, minimally invasive therapies, interventional radiology prostate, and benign prostatic hyperplasia. Articles were screened by two independent reviewers for content on development, methods, outcomes, and complications of PAE. Christidis et al. [22] summated the results as follows:
Christidis et al. [22] made the ensuing conclusions:
Zhang et al. [23] described the prostatic arterial supply using Cone-beam computed tomography (CT) and digital subtraction angiography (DSA) before prostatic arterial embolization (PAE) for benign prostatic hyperplasia (BPH). Zhang et al. [23] undertook a retrospective study from January 2012 to January 2014, 55 male patients (110 hemipelves) with BPH who underwent PAE were evaluated by Cone-beam CT in addition to pelvic DSA during embolization planning. Each hemipelvis was evaluated regarding the number of prostatic arteries (PA) and their origins, diameters, territorial perfusion, and anastomoses with adjacent arteries.
Zhang et al. [23] summated the results as follows:
Frenk et al. [24] assessed and described the MRI findings after prostatic artery embolization for the treatment of benign prostatic hyperplasia. Frenk et al. [24] retrospectively evaluated 17 patients who had undergone prostatic artery embolization as part of different prospective studies to evaluate this alternative treatment of benign prostatic hyperplasia. Frenk et al. [24] evaluated the clinical results by assessment of urinary catheterization and International Prostate Symptom Score (IPSS). Frenk et al. [24] performed serial MRI examinations, and they also evaluated the prostatic central gland and peripheral zone for signal intensity changes and the presence and characteristics of infarcted areas. Frenk et al. [24] undertook statistical analysis with ANOVA for repeated measures and Student t test. Frenk et al. [24] summated the results as follows:
Nil
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Dear Monica Gissare, - Editorial Coordinator of Nutrition and Food Processing. ¨My testimony with you is truly professional, with a positive response regarding the follow-up of the article and its review, you took into account my qualities and the importance of the topic¨.
Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, The review process for the article “The Handling of Anti-aggregants and Anticoagulants in the Oncologic Heart Patient Submitted to Surgery” was extremely rigorous and detailed. From the initial submission to the final acceptance, the editorial team at the “Journal of Clinical Cardiology and Cardiovascular Interventions” demonstrated a high level of professionalism and dedication. The reviewers provided constructive and detailed feedback, which was essential for improving the quality of our work. Communication was always clear and efficient, ensuring that all our questions were promptly addressed. The quality of the “Journal of Clinical Cardiology and Cardiovascular Interventions” is undeniable. It is a peer-reviewed, open-access publication dedicated exclusively to disseminating high-quality research in the field of clinical cardiology and cardiovascular interventions. The journal's impact factor is currently under evaluation, and it is indexed in reputable databases, which further reinforces its credibility and relevance in the scientific field. I highly recommend this journal to researchers looking for a reputable platform to publish their studies.
Dear Editorial Coordinator of the Journal of Nutrition and Food Processing! "I would like to thank the Journal of Nutrition and Food Processing for including and publishing my article. The peer review process was very quick, movement and precise. The Editorial Board has done an extremely conscientious job with much help, valuable comments and advices. I find the journal very valuable from a professional point of view, thank you very much for allowing me to be part of it and I would like to participate in the future!”
Dealing with The Journal of Neurology and Neurological Surgery was very smooth and comprehensive. The office staff took time to address my needs and the response from editors and the office was prompt and fair. I certainly hope to publish with this journal again.Their professionalism is apparent and more than satisfactory. Susan Weiner
My Testimonial Covering as fellowing: Lin-Show Chin. The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews.
My experience publishing in Psychology and Mental Health Care was exceptional. The peer review process was rigorous and constructive, with reviewers providing valuable insights that helped enhance the quality of our work. The editorial team was highly supportive and responsive, making the submission process smooth and efficient. The journal's commitment to high standards and academic rigor makes it a respected platform for quality research. I am grateful for the opportunity to publish in such a reputable journal.
My experience publishing in International Journal of Clinical Case Reports and Reviews was exceptional. I Come forth to Provide a Testimonial Covering the Peer Review Process and the editorial office for the Professional and Impartial Evaluation of the Manuscript.
