T. Bilhim

CHULC, Saint Louis Hospital Interventional Radiology

Author of 2 Presentations

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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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.

Hide

Presenter of 2 Presentations

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.

Hide

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.

Hide