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Free Paper Session Embolisation
Date:
Mon, Sep 9, 2019
Time:
16:15 - 17:15
Room:
Room 113

2206.1 - A CT protocol for 4D angiography and perfusion imaging of the prostate for embolization planning: proof of concept study

Abstract

Purpose

To evaluate the visibility of the prostatic artery (PA) prior to prostate artery embolization (PAE) in benign prostatic hyperplasia using a novel CT protocol providing 4D-CT angiography (4D-CTA) and quantitative perfusion information.

Material and methods

22 consecutive patients (mean age 67±7 years) underwent a dynamic CT scan of the pelvis (scan range: 22.4cm, cycle time: 1.5s, scan time: 44s, 25 scan cycles, 70kVp, 100mAs, 70ml iodinated contrast media, flow rate 6ml/s, 10s delay). Image post-processing consisted of noise reduction, motion correction, and fusion of multiple arterial time points resulting in time-resolved 4D-CTA. Intraprocedural cone-beam CT was performed with microcatheter in the PA. In both modalities the CNR of the right internal iliac artery and PA were calculated. Visibility of the PA was scored using a Likert scale (score 1=not seen, score 4= intraprostatic PA branches seen).

Results

The average CTDIvol and DLP of CT was 35.7±6.8mGy and 737.4±146.3mGycm, respectively. CNR in 4D-CTA and cone-beam CT were 45±19 and 69±27, respectively (p<0.01). The mean visibility score of the PA was 3.6±0.6 for 4D-CTA and 3.97±0.2 for cone-beam CT (p<0.001). The PA was visualized in 100% of 4D-CTA examinations, with one PA being visible only proximally. Prostate CT perfusion analysis showed blood flow, blood volume, mean transit time and flow extraction product values of 27.9±12.5ml/100ml/min, 2.0±0.8ml/100ml, 4.5±0.5s, 12.6±5.4ml/100ml/min, respectively.

Conclusion

We introduced a CT protocol for PAE planning providing excellent visualization of the PA at reasonable dose and low contrast volume. The additionally available quantitative perfusion information might potentially be useful for outcome prediction after embolization.

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2206.2 - Prostatic artery embolization with HydroPearls: safety and efficacy

Abstract

Purpose

Prostatic artery embolization (PAE) has been described as a new, effective and safe procedure for the treatment of patients with lower urinary tract symptoms (LUTS), secondary to benign prostatic hyperplasia (BPH). To date, several studies have reported outcomes of PAE with different bland embolic agents, but the safety and efficacy of new bland embolic microspheres, HydroPearl, has not been reported. Our aim was to study the outcome of patents with BPH treated with HydroPearl.

Material and methods

174 patients (mean age 69.7 years) with BPH treated with 200 μm HydroPearls for PAE in a single German institution were assessed. Preinterventional and follow-up imaging was carried out in MRI and US. Clinical follow-up included post-void residual volume (PVR), prostatic volume (PV), International Prostate Symptom Score (IPSS), quality of life (QoL) and peak urinary flow (Qmax) recorded at 2, 6 and 12 months.

Results

Clinical and imaging follow-up revealed a significant improvement at any time point after PAE. No major complications were reported.

prae PAE 2 month 6 month 12 month
PV (ml) 131.7 82.4 78.1 75.3
PVR (ml) 176.7 68.5 52.2 53.7
Qmax (ml/s) 6.7 11.8 12.3 12.1
IPSS 21.3 9.6 7.8 8
QoL 4.7 1.5 1.3 1.3

Conclusion

PAE with HydroPearls is an effective, safe and well-tolerated alternative for the treatment of BPH. Final results will be reported at the time of Congress.

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2206.3 - Prostatic artery embolization for benign prostatic hyperplasia: anatomical, technical and radiation exposure considerations in 168 cases

Abstract

Purpose

Prostatic artery embolization (PAE) has been established as a safe and effective treatment option for benign prostatic hyperplasia. We aim to provide important anatomical and technical considerations extracted from our case series of 168 patients who underwent PAE.

Material and methods

We performed PAE for 168 consecutive patients from January 2013 to January 2019. Most commonly used tools were cobra-head 5-French angiographic catheter and 2.7-French microcatheter. Preoperative CT angiography and intraoperative cone-beam CT were not utilized. Anatomy, radiation dose and procedure duration were recorded and analyzed.

Results

In the 168 patients, 331 prostatic arteries (PAs) were angiographically identified. Median procedure duration was 69 minutes. Mean radiation dose was 562 mGy. In 3 patients (2%), only unilateral PA was identified; while the rest had bilateral supply. 9 patients (5%) had 3 PAs. No PAs could be identified in 2 patients (1%). The frequencies of origins of PAs were found to be as follows: 132 (40%) from superior vesical artery, 97 (29%) from internal pudendal artery, 70 (21%) from obturator artery, 29 (9%) originated directly from anterior division of internal iliac artery and only 3 (1%) originated from inferior gluteal artery. PA origins were symmetrical in 46% of bilateral cases. Intraprostatic anastomosis between contralateral PAs was observed in 31 patients (18%). Penile, rectal or vesical anastomoses were angiographically identified with 59 PAs (18%).

Conclusion

Thorough anatomical and technical knowledge is essential to guarantee successful PAE, avoid potential complications of non-target embolization and optimize radiation exposure.

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2206.4 - PAE provides a proportionately greater change in storage symptoms compared with surgery: multivariate analysis of the UK-ROPE database

Abstract

Purpose

Studies have shown storage symptoms are a particularly bothersome subset of lower urinary tract symptoms (LUTS) and are commonly a patient’s most severe complaint. PAE is known to reduce storage symptoms effectively, but no comparative studies against surgery have examined the International Prostate Symptom Score (IPSS) breakdown. We aimed to identify which procedure reduced storage symptoms to a greater extent relative to the overall IPSS score.

Material and methods

Analysis of the UK-ROPE database identified 146 patients (121 PAE, 25 TURP/ HoLEP) with the IPSS breakdown score recorded at baseline and 12 months (mean age 66.2, mean prostate volume 102 mls, mean Qmax 9.9 ml/s). Analysis of Variance (ANOVA) and t-test was performed to assess for differences in reduction of voiding symptoms, storage symptoms and the ratio between the two.

Results

No significant difference was seen in overall IPSS reduction between the two groups, although there was a trend towards a greater reduction in the surgery cohort vs PAE (13.4 vs 10.9, p=0.13). Surgery reduced voiding symptoms to a greater extent although this was not significant compared with PAE (8.4 vs 6.7, p=0.1). The reduction in storage symptoms was similar between the treatments (4.9 vs 4.2 , p=0.34), but the proportionate change in storage symptoms relative to overall IPSS reduction was significantly greater in PAE group (-0.1) vs surgery (-0.3, p<0.001).

Conclusion

PAE is a good option for patients with bothersome storage symptoms as it forms a larger proportion of total IPSS reduction compared with surgery. This suggests a different mechanism of symptom relief to surgery.

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2206.5 - Correlation between peri-procedural prostate enhancement and the number of prostatic arterial targets during prostate artery embolisation

Abstract

Purpose

To assess whether the degree of hemi-prostatic parenchymal enhancement on cone-beam CT (CBCT) predicts the number of prostatic arteries (PAs) for potential targeting during prostate artery embolisation (PAE).

Material and methods

During PAE, CBCT was performed prior to embolisation to confirm correct catheter placement, using the same contrast injection parameters. The degree of parenchymal enhancement of each hemi-prostate on CBCT was scored, where 0 was no enhancement, 1 was partial and 2 was complete. The number of PAs supplying each hemi-prostate was assessed on a pre-procedural CT angiogram and also during embolisation. Differences between groups were analysed using Fisher’s exact test.

Results

Results are shown in Table 1. Complete hemi-prostatic enhancement predicts the absence of further PAs (p=0.02). Where enhancement was incomplete, but only a single PA was identified, extra-prostatic branching was demonstrated in 5 of 15 patients (33%).

Table 1: Hemi-prostatic enhancement vs number of PAs

Enhancement score

1

2

Number of prostatic arteries

1

15

20

2

6

0

Conclusion

Complete enhancement of a hemi-prostate negates the need to search for further embolic targets. However, where hemi-prostatic enhancement is incomplete, the presence of proximal segmental branches or additional PAs should be considered. This may be particularly of significance when pre-procedural imaging of the prostatic arterial supply is unavailable or inadequate to determine whether multiple vessels should be targeted during PAE.

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2206.6 - Outcome of prostatic artery embolization for benign prostatic hyperplasia: 1550 patients follow up to 10 years

Abstract

Purpose

To evaluate the outcome of prostatic artery embolization (PAE) for symptomatic benign prostatic hyperplasia (BPH) patients with moderate to severe lower urinary tract symptoms (LUTS).

Material and methods

Between March 2009 and February 2019, 1550 patients with symptomatic BPH and severe LUTS underwent PAE.The prostate was larger than 100 cm³ in 312 patients and 156 patients were in acute urinary retention (AUR).

Results

There was a statistically significant (P< 0.001) change from baseline to observed value in the evaluated parameters. The cumulative clinical success rates at short, medium and long term follow up were 88.1% (95% CI, 77.6% - 92.4%), 85.1% (95% CI, 71.3% - 93.1%), and 76.8% (95% CI, 69.1 – 84.6%), respectively. From the 156 patients in AUR, 140 (89.7%) had the bladder catheter removed between 2 days and 3 months; 10 had repeated successful PAE and 6 had surgery. From the 312 patients with prostate larger than 100 were there was clinical success in 252 (80.7%) (95% CI 78.2% - 93.1%) at short term, in 242- 77.6% (95% CI, 74.8% - 84.9%) at medium and in 235 (75.3%) (95% CI, 72.4% - 82%) at long term. There were 3 major complications, a bladder wall ischemia, a perineal pain for 3 months without sequela and a patient had expelled prostate fragments and AUR treated by TURP without sequela.

Conclusion

Due to the good clinical results of PAE for symptomatic BPH patients with moderate to severe LUTS at short, mid and long term follow up, PAE may become the standard procedure for BPH.

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2206.7 - The proSTatic aRtery EmbolizAtion for the treatMent of benign prostatic hyperplasia (STREAM) study: two-year results from a prospective cohort

Abstract

Purpose

The STREAM study was initiated to assess the safety and efficacy of prostate artery embolisation in the short to medium term. Pre and post-operative imaging with multi-parametric MRI was concurrently performed.

Material and methods

Patients were referred from a benign prostatic hyperplasia clinic for consideration of PAE based on factors including personal preference for minimally invasive treatment or contraindications to surgery.

International prostate symptom score (IPSS), International Index for Erectile Function (IIEF), and a quality of life assessment (EQ-5D) were recorded along with MRI pre-PAE, at three months, one year and two years.

Embolisation was performed at a single centre via a femoral approach using 300-500um particles and the assistance of cone beam CT in all cases.

Results

A total of 50 patients were recruited. Mean gland volume was 63mls (21-171) and mean age 68 (56-91). There were two technical failures.

Overall, the good outcomes seen at one year were maintained into the second year of follow up with only a two-point reduction in the cohort average IPSS from year one to year two.

MRI appearances continued to correlate with clinical outcomes at two years and may provide some insights into identifying those who will respond well to PAE.

Conclusion

Prostate Artery Embolisation remains an effective and durable treatment at two-year follow up. MRI has provided useful correlates between physiological/radiological features and symptomatic relief.

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