Prostate Artery Embolization

Benign prostatic hypertrophy (BPH) is the most common benign neoplasm in men, affecting more than 50% of men aged 60–69 years and as many as 90% aged 70–89 years. Prostate artery embolization (PAE) has emerged as a promising treatment modality for lower urinary tract symptoms (LUTS) in men secondary to BPH since 2000, when its therapeutic effects were first documented in a case report. Since then, multiple studies have shown the efficacy and safety of PAE. Although transurethral resection of the prostate (TURP) remains the gold standard, new data from randomized control trials comparing PAE with surgical techniques continues to emerge. Data suggests that PAE is not only the better option for select patient populations, but is also associated with fewer major adverse effects, shorter recovery times, and similar outcomes as measured by quality of life and improvements in the International Prostate Symptom Score (IPSS). This chapter discusses the clinical approach to a patient with BPH from the interventional radiologist perspective, the technical aspects and complications of PAE, current literature, and the future potential applications of PAE.

Indications

Historically, the main indication for PAE has been irreversible hematuria of prostatic origin. However, evidence shows that men suffering from LUTS secondary to BPH may also benefit from PAE, which is the focus of this chapter. LUTS can be divided into two categories: dynamic and static components. The static component is secondary to enlargement of the prostate resulting in urethral compression and comprises urinary frequency, urinary urgency, incontinence, and nocturia. The dynamic component is due to tension of the prostatic smooth muscle in the prostate and bladder neck causing obstructive symptoms and is composed of inability to urinate, difficulty starting urination, weak urine stream, intermittent urine flow, and incomplete emptying of bladder. When working up a patient for PAE, a multidisciplinary approach to the patient involving the patient’s urologist is imperative. PAE is more often the treatment of choice for elderly patients, poor surgical candidates, and patients who do not want to risk potential adverse effects from TURP such as retrograde ejaculation, urinary incontinence, or transfusion. Recommended evaluation includes a medical review focused on urinary symptoms and medical history, digital rectal examination, urinalysis, prostate specific antigen (PSA) measurement, postvoid residual (PVR) test, transrectal ultrasound, magnetic resonance imaging, and urodynamic evaluation.

Workup for Potential Prostate Artery Embolization

The IPSS is the standard screening tool and consists of seven questions used to quantify symptom severity into three categories (mild, moderate, severe) and guide treatment ( Table 49.1 ). If the patient’s score is greater than 12 and symptoms of BPH have been refractory to medical treatment for 6 months, then the patient is a candidate for PAE.

Table 49.1

International Prostate Symptom Score ^a

In the Past Month:	Not at All	Less Than 1 in 5 Times	Less Than Half the Time	About Half the Time	More Than Half the Time	Almost Always
Incomplete Emptying: How often have you had the sensation of not emptying your bladder?	0	1	2	3	4	5
Frequency: How often have you had to urinate less than every 2 hours?	0	1	2	3	4	5
Intermittency: How often have you found you stopped and started again several times when you urinated?	0	1	2	3	4	5
Urgency: How often have you found it difficult to postpone urination?	0	1	2	3	4	5
Weak Stream: How often have you had a weak urinary stream?	0	1	2	3	4	5
Straining: How often have you had to strain to start urination?	0	1	2	3	4	5
	None	1 Time	2 Times	3 Times	4 Times	5 Times
Nocturia: How many times did you typically get up at night to urinate?	0	1	2	3	4	5

a Scores: 0–7 (mild), 8–19 (moderate), 20–35 (severe).

Postvoid residual testing is an assessment of bladder emptying. An elevated PVR indicates a problem with emptying. A PVR greater than 50 mL is considered a large amount of residual urine; PVR greater than 300 mL is considered chronic retention.
Urodynamic studies can reproduce patient symptoms and help make an accurate diagnosis of the primary cause of LUTS. Uroflowmetry is a test performed by urologists that requires a device for catching and measuring urine. A graph is created that shows changes in flow rate. Less than 10 mL/s is predictive of bladder outlet obstruction.
Prostate volume greater than 50 g.
Negative screening for prostate cancer.
Negative screening for LUTS secondary to other causes such as renal failure, bladder calculi or diverticula, suspected prostate cancer, urethral stenosis, or neurogenic bladder disorders.

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