Clinical, Technical, and MRI Features Associated with Patients' Outcome at 3 Months and 2 Years following Prostate Artery Embolization: Is There an Added Value of Radiomics?

Our aim was to investigate which features were associated with clinical successes at short- and mid-terms following prostate artery embolization (PAE) for symptomatic benign prostate hypertrophy (BPH). All adults treated by PAE for BPH at our referral center between January 2017 and March 2021, with pre-treatment MRI, technical success, and follow-up at 3 months and 2 years were included in this single-center retrospective study. Radiologists reviewed the prostatic protrusion index (PPI), adenomatous dominant BPH (adBPH), and Wasserman classification on pre-treatment MRI. Radiomics analysis was achieved on the transitional zone on pre-treatment T2-weighted imaging (WI) and ADC, and comprised reproducibility assessment, unsupervised classifications, and supervised radiomics scores obtained with cross-validated Elasticnet regressions. Eighty-eight patients were included (median age: 65 years), with 81.8% clinical successes at 3 months and 60.2% at 2 years. No feature was associated with success at 3 months, except the radiomics score trained on T2-WI and ADC (AUROC = 0.694). Regarding success at 2 years, no radiomics approaches provided significant performances; however, Wasserman type-1 and change in international prostate symptom score (IPSS) at 3 months ≤ -35% were associated with success in multivariable analysis (OR = 5.82, p = 0.0296, and OR = 9.04, p = 0.0002). Thus, while radiomics provided limited interest, Wasserman classification and early IPSS changes appeared predictive of mid-term outcomes.

Prostatic artery embolisation versus medical treatment in patients with benign prostatic hyperplasia (PARTEM): a randomised, multicentre, open-label, phase 3, superiority trial.

Background: Prostatic artery embolisation (PAE) is a minimally invasive treatment of symptomatic benign prostatic hyperplasia (BPH). Our aim was to compare patient's symptoms improvement after PAE and medical treatment. Methods: A randomised, open-label, superiority trial was set in 10 French hospitals. Patients with bothersome lower urinary tract symptoms (LUTS) defined by International Prostatic Symptom Score (IPSS) > 11 and quality of life (QoL) > 3, and BPH ≥50 ml resistant to alpha-blocker monotherapy were randomly assigned (1:1) to PAE or Combined Therapy ([CT], oral dutasteride 0.5 mg/tamsulosin hydrochloride 0.4 mg per day). Randomisation was stratified by centre, IPSS and prostate volume with a minimisation procedure. The primary outcome was the 9-month IPSS change. Primary and safety analysis were done according to the intention-to-treat (ITT) principle among patients with an evaluable primary outcome. ClinicalTrials.gov Identifier: NCT02869971. Findings: Ninety patients were randomised from September 2016 to February 2020, and 44 and 43 patients assessed for primary endpoint in PAE and CT groups, respectively. The 9-month change of IPSS was -10.0 (95% confidence interval [CI]: -11.8 to -8.3) and -5.7 (95% CI: -7.5 to -3.8) in the PAE and CT groups, respectively. This reduction was significantly greater in the PAE group than in the CT group (-4.4 [95% CI: -6.9 to -1.9], p = 0.0008). The IIEF-15 score change was 8.2 (95% CI: 2.9-13.5) and -2.8 (95% CI: -8.4 to 2.8) in the PAE and CT groups, respectively. No treatment-related AE or hospitalisation was noticed. After 9 months, 5 and 18 patients had invasive prostate re-treatment in the PAE and CT group, respectively. Interpretation: In patients with BPH ≥50 ml and bothersome LUTS resistant to alpha-blocker monotherapy, PAE provides more urinary and sexual symptoms benefit than CT up to 24 months. Funding: French Ministry of Health and a complementary grant from Merit Medical.

Prostatic Artery Embolization for Benign Prostatic Obstruction: Single-Centre Retrospective Study Comparing Microspheres Versus n-Butyl Cyanoacrylate.

PURPOSE: To compare the safety and efficacy of n-butyl cyanoacrylate glue (NBCA) versus microspheres for prostatic artery embolization (PAE) in patients with benign prostatic obstruction (BPO). MATERIALS AND METHODS: This institutional review board-approved, single-centre, retrospective study included consecutive patients undergoing PAE from September 2017 to July 2020. Age, medical history, previous treatment, pre- and post-PAE prostatic volumes and International Prostate Symptom Scores (IPSSs) were systematically analysed. Procedural duration, dosimetry, immediate and delayed complications were recorded. Patients at the beginning of the study were treated with microspheres and patients at the end of the study with NBCA. The main outcome measures were the absolute and relative changes in IPSS at 3 months. Statistical analyses comprised unpaired t-tests, Wilcoxon tests, Chi-2 tests, uni- and multivariate linear regressions. RESULTS: Sixty-two patients were included (median age: 65.9 years). Thirty-two patients were treated with microspheres and 30 with NBCA. There were no significant baseline differences between the two groups except for the baseline PSA (P = 0.0251). Average procedural and fluoroscopy times, and radiation exposure were significantly lower in the NBCA group versus the microspheres group (80.7 ± 22.5 versus 112 ± 42.1 min [P = 0.0011], 24.2 ± 9.6 min versus 42.1 ± 20.2 min [P = 0.0001], 12,004.6 ± 6702 uGy.m2 versus 25,614.9 ± 15,749.2 uGy.m2 [P = 0.0001], respectively). Immediate complications were all minor, and there were no significant differences between the two groups (4/32 [12.5%] with microspheres versus 7/30 [23.3%] with NBCA, P = 0.4335), nor for delayed complications (P = 1). No association was found between the PAE techniques and the absolute change in IPSS at 3 months (-10.2 ± 7.9 with microspheres versus -9.5 ± 7.6 with NBCA, P = 0.7157). CONCLUSION: PAE using NBCA was safe and effective for symptomatic BPO, with faster procedures, lower radiation exposure and similar safety and efficacy compared to microspheres. Operator learning curve could have biased the procedural times and radiation exposure between groups favouring NBCA.

Local recurrence and other oncologic outcomes after percutaneous image-guided tumor ablations on stageT1b renal cell carcinoma: a systematic review and network meta-analysis.

OBJECTIVE: A systematic review of clinical trials on thermal ablation of T1b RCC was conducted to assess oncologic outcomes of those procedures. The primary endpoint was the rate of local recurrence. Secondary endpoints included technical efficacy, progression to metastatic disease, cancer-specific mortality, complications and renal function decrease. METHODS: PubMed (MEDLINE) and Embase databases were searched in June 2020 for eligible trials following the PRISMA selection process. Prevalence of local recurrence and per procedural major adverse effects were calculated using double arcsine transformation and a random-effects model. RESULTS: Nine clinical trials (all retrospective) involving 288 patients with T1b renal clear cell carcinoma treated with either percutaneous microwave ablation, cryoablation or radiofrequency ablation were analyzed. Using a random-effects model, the overall prevalence of local recurrence following percutaneous ablation was 0.08 (0.04-0.14; p = 0.05). Primary technical efficacy was 226/263 (86%) patients and secondary technical efficacy was 247/263 (94%). Overall, 10/176 (6%) patients presented metastatic locations following the ablation. Major adverse effects prevalence was 0.09 (0.06-0.14; p = 0.05). CONCLUSIONS: Thermal ablations are feasible, safe, and effective to treat T1b renal clear cell carcinoma. More trials are necessary to determine the rate of the evidence of the benefit.HighlightsThermal ablations are feasible and safe to treat T1b renal clear cell carcinoma.Oncologic outcomes appear to be very good on both local control and distant progression.Due to small number and heterogeneity of studies more trials are necessary to determine the rate of the evidence of the benefit.

Prostate Artery Embolization Using N-Butyl Cyanoacrylate Glue for Urinary Tract Symptoms Due to Benign Prostatic Hyperplasia: A Valid Alternative to Microparticles?

Our goal was to evaluate the feasibility, safety, and short-term outcomes of prostate artery embolization (PAE) with N-butyl cyanoacrylate (NBCA) glue as the only embolic agent in patients with benign prostatic hyperplasia (BPH)-related lower urinary tract symptoms (LUTSs). A two-center retrospective study of 50 patients (mean age, 67.6 ± 7.4 years; range, 54-85 years) treated with NBCA between 2017 and 2020 was conducted. PAE was performed using a mixture of Glubran 2 glue and Lipiodol in a 1:8 ratio, under local anesthesia, on an outpatient basis, after cone-beam computed tomography vascular mapping. Mean total injected NBCA/Lipiodol volume was 0.9 ± 0.3 mL, total injection time was 21.9 ± 7.8 s, and total radiation dose was 18,458 ± 16,397 mGy·cm. Statistically significant improvements over time occurred for the International Prostate Symptoms Score (9.9 ± 6.8 versus 20.5 ± 6.7, p = 0.0001), quality-of-life score (2.2 ± 1.5 versus 4.9 ± 1.0, p = 0.0001), prostate-specific antigen level (4.6 ± 3.0 versus 6.4 ± 3.7, p = 0.0001), and prostate volume (77.3 ± 30.5 versus 98.3 ± 40.2, p = 0.0001) at a median of 3 months versus baseline. Minor adverse events developed in 11/50 (22%) patients, but no major complications occurred. The International Index of Erectile Function did not change significantly. PAE with NBCA is feasible, safe, fast, and effective for patients with BPH-related LUTSs. Prospective comparative studies with longer follow-ups are warranted.

Unilateral nephrectomy versus renal arterial embolization and technique survival in peritoneal dialysis patients with autosomal dominant polycystic kidney disease.

BACKGROUND: Autosomal dominant polycystic kidney disease (ADPKD) is a common genetic disorder associated with progressive enlargement of the kidneys and liver. ADPKD patients may require renal volume reduction, especially before renal transplantation. The standard treatment is unilateral nephrectomy. However, surgery incurs a risk of blood transfusion and alloimmunization. Furthermore, when patients are treated with peritoneal dialysis (PD), surgery is associated with an increased risk of temporary or definitive switch to haemodialysis (HD). Unilateral renal arterial embolization can be used as an alternative approach to nephrectomy. METHODS: We performed a multicentre retrospective study to compare the technique of survival of PD after transcatheter renal artery embolization with that of nephrectomy in an ADPKD population. We included ADPKD patients treated with PD submitted to renal volume reduction by either surgery or arterial embolization. Secondary objectives were to compare the frequency and duration of a temporary switch to HD in both groups and the impact of the procedure on PD adequacy parameters. RESULTS: More than 700 patient files from 12 centres were screened. Only 37 patients met the inclusion criteria (i.e. treated with PD at the time of renal volume reduction) and were included in the study (21 embolized and 16 nephrectomized). Permanent switch to HD was observed in 6 embolized patients (28.6%) versus 11 nephrectomized patients (68.8%) (P = 0.0001). Renal artery embolization was associated with better technique survival: subdistribution hazard ratio (SHR) 0.29 [95% confidence interval (CI) 0.12-0.75; P = 0.01]. By multivariate analysis, renal volume reduction by embolization and male gender were associated with a decreased risk of switching to HD. After embolization, a decrease in PD adequacy parameters was observed but no embolized patients required temporary HD; the duration of hospitalization was significantly lower [5 days [interquartile range (IQR) 4.0-6.0] in the embolization group versus 8.5 days (IQR 6.0-11.0) in the surgery group. CONCLUSIONS: Transcatheter renal artery embolization yields better technique survival of PD in ADPKD patients requiring renal volume reduction.

Percutaneous low-pressure bone stenting to control cement deposition in extensive lytic lesions.

OBJECTIVE: To evaluate low-pressure bone stenting combined with cementoplasty in extensive lytic lesions. METHODS: A single-centre study involving four consecutive patients (four women) with extensive lytic tumours was performed. The average age was 65 years. Surgical treatment was not indicated or not wished for by the patients. Institutional review board approval and informed consent were obtained. Percutaneous consolidation was performed by an interventional radiologist under fluoroscopy guidance. Follow-up was assessed using the visual analogue scale (VAS). RESULTS: Under general (n = 2) or local (n = 2) anaesthesia, five 11-gauge bone biopsy needles were advanced in four lesions. Five auto-expandable uncovered stents (10-14 mm diameter and 40-60 mm long) were inserted. In all cases, bone cement was successfully placed into the tumours. The volume of cement that was injected through the cannulas into the stents was 5-10 mL. Using VAS, pain decreased from more than 9/10 preoperatively to less than 2/10 after the procedure for all patients (p < 0.05). No complications occurred during the follow-up (8-19 months). CONCLUSION: This study suggests that cementoplasty combined with low-pressure bone stenting could allow effective bone stabilization resulting in pain relief. KEY POINTS: • Low-pressure bone stenting is possible. • This technique improves cement injection control. • The procedure allows effective bone stabilization resulting in pain relief.

Renal embolization.

Recent developments in endovascular radiological techniques and devices make embolization as a major therapeutic option in many renal vascular or neoplastic diseases, before surgery. These techniques show a very good efficacy with a low morbidity and a better renal tolerance. Indications of embolization in nephrology are post-biopsy arteriovenous fistulas, renal graft intolerance, functional exclusion and polycystic kidney disease before transplantation. Others are at the interface between nephrology and urology as angiomyolipomas (mostly in tuberous sclerosis context), arterial aneurysms and arteriovenous malformations.