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Clinical Evaluation Course Embolisation
Date:
Sat, Sep 7, 2019
Time:
16:15 - 17:15
Room:
Room 112
Learning Objectives:
1. What is the current role of embolisation and what are the alternatives?
2. To give a quick overview of the technique with tips and tricks
3. To discuss the results and complications
4. What does the literature say and what trials are lacking?

605.1 - Underlying pathology and work-up

Abstract

Abstract Content

Lower urinary tract symptoms (LUTS) are common and can be caused by a multitude of conditions and therefore symptoms need to be evaluated carefully. LUTS can be divided into storage, voiding and post-micturition symptoms, they cause bother and can significantly impair QoL.

The underlying pathology is likely to be benign prostatic hyperplasia that is causing LUTS, but it is usually thought that it is the relief of benign prostatic obstruction (BPO) that is the principal goal of surgical intervention.

It is a common perception that surgical rather than medical treatment becomes appropriate in patients with bothersome LUTS due to benign prostatic obstruction (BPO), who are unwilling to try medical therapies, or in cases where medical therapies are ineffective or not well tolerated, and especially in patients with complicated LUTS, such as recurrent retention or bladder stones. However, with the advent of more minimally invasive treatments the threshold for surgical intervention has become much lower.

Patients need a thorough assessment of their symptoms, which is usually achieved with the help of an International Prostate Symptom Score (IPSS) and a frequency volume chart. Preservation of erectile and ejaculatory function is often one of the reasons why patients select minimally invasive treatments (MITs) and therefore the use of an erectile and ejaculatory score can also be valuable (e.g. IIEF and MSHQ-EjD). Renal function blood tests and a full blood count are routinely measured, and a PSA test is usually included, partly as a ‘screening’ test for prostate cancer risk and also as a useful additional marker of prostate volume and risk of progression of LUTS/BPO. Flow rate and post-void residual volumes should be measured before surgical intervention and formal pressure flow urodynamic studies should be considered in borderline cases. It is usually considered that patients considered for surgical intervention will have at least moderate LUTS with an IPSS >8/35 (but often considerably higher) and a flow rate of less than 12-15mL/sec.

Traditionally prostate volume assessment was not carried out before surgery however, with the advent of newer modalities of treatment this has become more widely adopted, usually by trans-rectal ultrasound although this is usually achieved at least as well my pre-treatment MRI scanning in patients being considered for PAE. Pre-treatment imaging will be discussed in the next presentation.

Patient choice for surgical intervention is important, and it is important to bear in mind, that patients’ and clinicians’ expectations of outcomes from treatment may differ. For instance, patients may prefer treatment options that are less effective if they result in a smaller risk of complications or a faster return to normal activities, rather than a dramatic improvement in flow rate. There is little doubt that there is a desire from patients for MITs.

Once MITs become more widely available, special care is needed when the relatively strict entry criteria for RCTs are relaxed in general clinical practice and a broader group of patients are treated with the newer treatments like PAE.

References

1. Gravas S, Cornu JN, Drake MJ, et al. Guidelines on the management of non-neurogenic male lower urinary tract symptoms (LUTS), incl. benign prostatic obstruction (BPO) Presented at the EAU Annual Congress Copenhagen 2018. Arnhem, The Netherlands: EAU Guide-lines Office; 2018.978-94-92671-01-1 In: http://uroweb.org/ guideline/treatment-of-non-neurogenic-male-luts/

2. Hashim H & Abrams P. Transurethral resection of the prostate for benign prostatic obstruction: will it remain the gold standard. Eur Urol 2015; 67: 1097-1098

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605.2 - Imaging

Abstract

Abstract Content

Bladder ultrasound (US) may be useful to exclude bladder cancer, stone, or diverticulum and to evaluate the bladder wall thickness (that increases with long-standing bladder outlet obstruction - BOO due to hypertrophy). Bladder US is considered first-line approach as a screening tool in men with lower urinary tract symptoms to measure the post-void residual volume (PVR) and thus exclude severe BOO.

Renal US may be useful to exclude renal cancer or obstruction due to BPH.

Transrectal US (TRUS) of the prostate is the most reliable and less expensive technique to determine the prostate volume (transverse diameter × anteroposterior diameter × length × 0.52) and should be performed before surgery or minimally-invasive therapies (MIST) to help choose the best treatment option. The anteroposterior diameter (AP) is most accurately measured in the sagittal plane to avoid the “salami” distortion of measurements in the axial plane. TRUS also allows exploring the zonal anatomy and BPH patterns and identifying and measuring the protrusion index of the median lobe into the bladder base that may be associated with poorer outcomes after MIST procedures. Total prostate volume, proportion of central gland/total prostate volume, presence of one or more adenomas with more than 1 cm in the central-gland and lobar distributions have potential for the subtyping of BPH for effects on outcome.

Magnetic resonance imaging (MRI) in BPH patients is used to exclude cancer when high clinical suspicion and negative biopsy are present. MRI also depicts the zonal anatomy and the protrusion index of the median lobe that may be predictors of treatment response. Multiparametric MRI with perfusion imaging is able to quantify the vascularity of the prostate and detect ischemia after embolization that may be important prognostic factors after prostate artery embolization (PAE). Diffusion imaging before and after PAE is another potential predictor of outcome after PAE. MR angiography (MRA) to depict the anatomy of the prostatic arteries and help plan/guide the embolization has shown promising results.

CT Angiography (CTA) is a valuable pre-procedural tool to help plan the procedure and study the vascular anatomy of the male pelvic arteries. Also allows to measure prostate volume. The use of high concentrations and volumes of iodine (100–120 mL at a concentration of 350–370 mg/mL iodine) is an important feature to obtain enough opacification of the PAs. We also give the patient a vasodilator before the acquisition (Nitromint 0.5 mg, sublingual) to help identify the PAs. With this protocol the threshold for acquisition can be placed as high as 200 HU. With 16-row CT scanners, the acquisition time for the pelvis is approximately 13 s (scan range of around 30 cm). When using 64 or higher multirow detector CT scanners, it is important to adjust the pitch to have a scan time that is not too fast (below 10 seconds) because it may not give enough time to allow correct PA opacification.

Cone-beam CT (CBCT) is an essential tool for PAE. When no pre-procedural CTA is present, CBCT can be used to map the arterial anatomy of the pelvis with injections from the aorta or internal iliac arteries. CBCT should also be used after reaching the prostatic arteries to certify correct catheter placement and to identify anastomoses that may lead to non-target embolization. We always use power-injection for CBCT with the following protocols: aorta - 35 mL; 3 mL/s; arrival time 3 seconds; internal iliac artery - 20 mL; 2 mL/s; arrival time 2 seconds; selective in the prostatic arteries - 6 mL; 0.5mL/s; arrival time 1.5 seconds. We use non-diluted contrast 350 mg I/mL; 10-second rotational scan of 180º at 18º rotation per second; Image acquisition every 0.5º; Source power of 125 kVp; 316 matrix images (512x512 voxels). Computer assisted identification of the prostatic arteries and embolization guidance using dedicated softwares may also help during PAE. Overlay from CBCT images to 2D-fluoroscopy images can guide interventionalists into the prostatic arteries without the need for further injections of contrast media. We limit the use of DSA runs for PAE and have replaced them largely with CBCT because CBCT has much lower radiation exposure. We use roadmap or overlay guidance to reach the prostatic arteries.

References

Wasserman NF. Benign prostatic hyperplasia: a review and ultrasound classification. Radiol Clin North Am. 2006;44:689–710.

Barentsz JO, Richenberg J, Clements R, et al. ESUR prostate MR guidelines 2012. Eur Radiol. 2012;22:746–57.

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;200:612-9.

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;64:118–40.

Bilhim T, Pisco JM, Rio Tinto H, et al. Prostatic arterial supply: anatomic and imaging findings relevant for selective arterial embolization. J Vasc Interv Radiol. 2012;23:1403–15.

Bagla S, Rholl KS, Sterling KM, et al. Utility of cone-beam CT imaging in prostatic artery embolization. J Vasc Interv Radiol. 2013;24:1603–7.

Chiaradia M, Radaelli A, Campeggi A, Bouanane M, De La Taille A, Kobeiter H. Automatic three-dimensional detection of prostatic arteries using cone-beam CT during prostatic arterial embolization.J Vasc Interv Radiol. 2015;26:413-7.

Bilhim T, Pisco J, Pereira JA, et al. Predictors of Clinical Outcome after Prostate Artery Embolization with Spherical and Nonspherical Polyvinyl Alcohol Particles in Patients with Benign Prostatic Hyperplasia. Radiology. 2016 Oct;281(1):289-300.

Abt D, Müllhaupt G, Mordasini L, Güsewell S, Markart S, Zumstein V, Kessler TM, Schmid HP, Engeler DS, Hechelhammer L. Outcome prediction of prostatic artery embolization: post hoc analysis of a randomized, open-label, non-inferiority trial. BJU Int. 2018 Nov 30. doi: 10.1111/bju.14632.

de Assis AM, Maciel MS, Moreira AM, et al. Prostate Zonal Volumetry as a Predictor of Clinical Outcomes for Prostate Artery Embolization. Cardiovasc Intervent Radiol. 2017 Feb;40(2):245-251.

Little MW, Boardman P, Macdonald AC, et al. Adenomatous-Dominant Benign Prostatic Hyperplasia (AdBPH) as a Predictor for Clinical Success Following Prostate Artery Embolization: An Age-Matched Case-Control Study. Cardiovasc Intervent Radiol. 2017 May;40(5):682-689.

Franiel T, Aschenbach R, Trupp S, et al. Prostatic Artery Embolization with 250-μm Spherical Polyzene-Coated Hydrogel Microspheres for Lower Urinary Tract Symptoms with Follow-up MR Imaging. J Vasc Interv Radiol. 2018 Aug;29(8):1127-1137.

Interventional Urology. Chapter 15. Selective Arterial Prostatic Embolization (SAPE): BPH Embolization. Tiago Bilhim, João Pisco. Springer 2016.

Zhang JL, Wang MQ, Shen YG, et al. Effectiveness of Contrast-enhanced MR Angiography for Visualization of the Prostatic Artery prior to Prostatic Arterial Embolization. Radiology. 2019 Feb 26:181524. doi: 10.1148/radiol.2019181524.

Kim AY, Field DH, DeMulder D, Spies J, Krishnan P. Utility of MR Angiography in the Identification of Prostatic Artery Origin Prior to Prostatic Artery Embolization. J Vasc Interv Radiol. 2018 Mar;29(3):307-310.e1.

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605.3 - Patient selection for PAE: good and bad candidates

605.6 - The surgeon's view

Abstract

Abstract Content

The role of surgery in the treatment of male lower urinary tract symptoms (LUTS) due to benign prostatic obstruction (BPO) is reserved to patients, fit to surgery, who have not obtained adequate relief from LUTS using conservative or medical treatments and in those with recurrent or refractory urinary retention, overflow incontinence, recurrent UTIs, bladder stones or diverticula and dilatation of the upper urinary tract due to BPO, with or without renal insufficiency (defined as absolute indications to surgery). Although in last decade several treatments have been proposed for the treatment of moderate to severe LUTS secondary to BPO, transurethral resection of the prostate (TURP) still represents the standard of treatment in men with the prostate size of 30-80 mL and can be performed both as bipolar and monopolar resection. Transurethral incision of the prostate (TUIP), instead, is recommended in case of prostate size <30mL without a middle lobe. In case of larger prostates (80-100 mL), open prostatectomy represents an effective procedure with acceptable and durable functional outcomes while endoscopic enucleation techniques (such as holmium laser enucleation -HoLEP-, Tm:YAG laser assisted anatomical enucleation -ThuLEP- are emerging as safe and minimally-invasive alternatives together with laser vaporisation techniques (also known as “GreenLight” laser vaporisation of the prostate) especially in patients receiving anticoagulant or antiplatelet therapy. Minimally invasive prostatectomy (performed as laparoscopic simpleprostatectomy and robot-assisted simple prostatectomy) has been proposed as an alternative to open prostatectomy. Perioperative outcomes and functional results are acceptable, although long term series and randomized clinical trials are not available. Conversely, in men unfit to surgery, the placement of prostatic stents has been proposed as an alternative to an indwelling catheter but they actually have a limited role due to an high frequency of local side effects including the migration of the stent itself. The placement of prostatic urethral lift (commonly known as UroLift) represents a novel technique that allows to obtain an opening of prostatic urethra by retracting the obstructing lateral lobes. Their use is primarily indicated in patients interested in preserving ejaculatory function, with prostates < 70 mL and no middle lobe. Other treatments for BPO are represented by Transurethral microwave therapy (TUMT) and Transurethral needle ablation of the prostate (TUNA). Compared to TURP, these procedures show a decrease morbidity but a lower efficacy and durability with a higher re-treatment rate.

In the recent years, several minimally invasive treatments for lower urinary tract symptoms secondary to BPO have been proposed and in this scenario prostate artery embolization (PAE) is emerging as a viable, minimally invasive alternative to surgery. In the first instance, PAE can be indicated in patients unfit for surgery and severe LUTS. Indeed, this technique can have a role in those patients intended to preserve their fertility, often compromised by surgical approaches, or in patients with large median lobe that does not allow other minimally invasive treatment such as UroLift.

Moreover, transurethral prostate convective water vapor thermal energy (Rezum system) has been proposed as a minimally invasive procedure that can be performed under local anesthesia in an office setting with a good safety profile and with reported favorable 4-year outcomes. However, large comparative series with longer follow-up are awaited.

Finally, Aquablation represents a novel minimally invasive water ablation therapy which combines image guidance and robotics (PROCEPT BioRobotics) for the removal of prostatic tissue. The procedure is usually performed under general anesthesia and is mostly automated. When compared to TURP, Aquablation seems to provide non-inferior symptom relief and a lower risk of sexual dysfunction (in particular, anejaculation) for the treatment of both small and large (up to 150mL) prostates. However, larger series and longer follow-up are available.

In conclusion, the surgical therapy for BPO is an extended and constantly updated field. To date, several techniques have been proposed. In this scenario, strong evidences are needed to draw conclusions on safety and long-term outcomes of the different techniques. Meanwhile, the choice should be driven by surgeon’s experience/preference, patient’s wishes and expectations and patient’s features that may make a technique more appropriate than others.

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