Value of magnetic resonance angiography before prostatic artery embolization for intervention planning.

Knowledge about anatomical details seems to facilitate the procedure and planning of prostatic artery embolization (PAE) in patients with symptomatic benign prostatic hyperplasia (BPS). The aim of our study was the pre-interventional visualization of the prostatic artery (PA) with MRA and the correlation of iliac elongation and bifurcation angles with technical success of PAE and technical parameters. MRA data of patients with PAE were analysed retrospectively regarding PA visibility, PA type, vessel elongation, and defined angles were correlated with intervention time, fluoroscopy time, dose area product (DAP), cumulative air kerma (CAK), contrast media (CM) dose and technical success of embolization. T-test, ANOVA, Pearson correlation, and Kruskal-Wallis test was applied for statistical analysis. Between April 2018 and March 2021, a total of 78 patients were included. MRA identified the PA origin in 126 of 147 cases (accuracy 86%). Vessel elongation affected time for catheterization of right PA (p = 0.02), fluoroscopy time (p = 0.05), and CM dose (p = 0.02) significantly. Moderate correlation was observed for iliac bifurcation angles with DAP (r = 0.30 left; r = 0.34 right; p = 0.01) and CAK (r = 0.32 left; r = 0.36 right; p = 0.01) on both sides. Comparing the first half and second half of patients, median intervention time (125 vs. 105 min.) and number of iliac CBCT could be reduced (p < 0.001). We conclude that MRA could depict exact pelvic artery configuration, identify PA origin, and might obviate iliac CBCT. Vessel elongation of pelvic arteries increased intervention time and contrast media dose while the PA origin had no significant influence on intervention time and/or technical success.

Effect of continuity nursing based on the theory of Knowledge-Attitude-Practice on quality of life, self-efficacy, and treatment compliance in elderly patients with benign prostatic hyperplasia.

OBJECTIVE: The purpose of this study was to analyze the impact of continuity nursing based on the theory of Knowledge-Attitude-Practice (KAP) on the quality of life, self-efficacy, and treatment compliance in elderly patients with benign prostatic hyperplasia (BPH). METHODS: In this single-center, randomized controlled study, a total of 232 elderly BPH patients who received treatment at our hospital from June 2020 to June 2022 were selected as the research subjects. They were randomly divided into the research group (n = 116) and the control group (n = 116). The control group received conventional interventions, while the research group received continuity nursing based on the theory of KAP on the basis of control group. Anxiety, depression, self-care agency, quality of life, self-efficacy, treatment compliance, and nursing satisfaction were compared between these 2 groups. RESULTS: Before nursing intervention, both groups showed a decrease in SAS and SDS scores after the intervention. Furthermore, self-care ability, self-care responsibility, self-concept, health knowledge level, role function, emotional function, somatic function, cognitive function, social function, and General Self-Efficacy Scale scores increased. Additionally, the research group demonstrated lower/higher levels than the control group (P < .05). The research group exhibited higher treatment compliance (P = .002) and greater nursing satisfaction compared to the control group (P = .014). CONCLUSION: Continuity nursing based on the theory of KAP can improve negative emotions in elderly BPH patients, enhance their self-efficacy and treatment compliance, and achieve better clinical outcomes.

Multicenter Quantification of Radiation Exposure and Associated Risks for Prostatic Artery Embolization in 1476 Patients.

Background Prostatic artery embolization (PAE) is a safe, minimally invasive angiographic procedure that effectively treats benign prostatic hyperplasia; however, PAE-related patient radiation exposure and associated risks are not completely understood. Purpose To quantify radiation dose and assess radiation-related adverse events in patients who underwent PAE at multiple centers. Materials and Methods This retrospective study included patients undergoing PAE for any indication performed by experienced operators at 10 high-volume international centers from January 2014 to May 2021. Patient characteristics, procedural and radiation dose data, and radiation-related adverse events were collected. Procedural radiation effective doses were calculated by multiplying kerma-area product values by an established conversion factor for abdominopelvic fluoroscopy-guided procedures. Relationships between cumulative air kerma (CAK) or effective dose and patient body mass index (BMI), fluoroscopy time, or radiation field area were assessed with linear regression. Differences in radiation dose stemming from radiopaque prostheses or fluoroscopy unit type were assessed using two-sample t tests and Wilcoxon rank sum tests. Results A total of 1476 patients (mean age, 69.9 years ± 9.0 [SD]) were included, of whom 1345 (91.1%) and 131 (8.9%) underwent the procedure with fixed interventional or mobile fluoroscopy units, respectively. Median procedure effective dose was 17.8 mSv for fixed interventional units and 12.3 mSv for mobile units. CAK and effective dose both correlated positively with BMI (R2 = 0.15 and 0.17; P < .001) and fluoroscopy time (R2 = 0.16 and 0.08; P < .001). No radiation-related 90-day adverse events were reported. Patients with radiopaque implants versus those without implants had higher median CAK (1452 mGy [range, 900-2685 mGy] vs 1177 mGy [range, 700-1959 mGy], respectively; P = .01). Median effective dose was lower for mobile than for fixed interventional systems (12.3 mSv [range, 8.5-22.0 mSv] vs 20.4 mSv [range, 13.8-30.6 mSv], respectively; P < .001). Conclusion Patients who underwent PAE performed with fixed interventional or mobile fluoroscopy units were exposed to a median effective radiation dose of 17.8 mSv or 12.3 mSv, respectively. No radiation-related adverse events at 90 days were reported. © RSNA, 2024 See also the editorial by Mahesh in this issue.

Prostatic Artery Embolization in Patients with Refractory Lower Urinary Tract Symptoms after a Prior Minimally Invasive Surgical Treatment.

The purpose of this study was to report on prostatic artery embolization (PAE) outcomes in patients with refractory or recurrent lower urinary tract symptoms (LUTSs) due to benign prostatic hyperplasia (BPH) who had previously undergone a minimally invasive surgical technique (MIST). A single-center retrospective study identified 16 eligible patients. Baseline prostate volume at the time of PAE was 112.9 mL (SD ± 52.7). There were no adverse events throughout the follow-up period. There was significant improvement in International Prostate Symptom Score and quality of life from baseline of 23.5 (SD ± 5.1) and 4.9 (SD ± 0.9), respectively, to the last follow-up of 11.6 (SD ± 7.2) and 2 (SD ± 1.6), respectively. There was nonsignificant improvement in sexual function after PAE compared with baseline after MIST. PAE can be a safe and effective treatment in patients who have undergone prior MIST without negatively impacting erectile or ejaculatory function.

Cardiovascular Comorbidities Do Not Impact Prostate Artery Embolisation (PAE) Outcomes: Retrospective Analysis of the National UK-ROPE Registry.

PURPOSE: Prostate artery embolisation (PAE) is a key treatment for the management of symptomatic benign prostatic hyperplasia (BPH). Common cardiovascular risk factors might be associated with suboptimal outcomes and thus influence patient treatment selection. The aim of the study was to evaluate whether cardiovascular comorbidities affect PAE outcomes. METHODS: Retrospective subset analysis of the UK Registry of Prostate Artery Embolisation (UK-ROPE) database was performed with patients who had a full documented past medical histories including hypertension, diabetes, coronary artery disease (CAD), diabetes and smoking status as well as international prostate symptom score (IPSS) at baseline and at 12 months. Multiple regression was performed to assess for any significant predictors. RESULTS: Comorbidity data were available for 100/216 patients (mean age 65.8 ± 6.4 years), baseline IPSS 20.9 ± 7.0). Regression analysis revealed that the presence of hypertension (53.7% IPSS reduction vs. absence 51.4%, p = 0.94), diabetes (52.6% vs. absence 52.1%, p = 0.6), CAD (59.2% vs. absence 51.4%, p = 0.95), no comorbidities (49.8% vs. any comorbidity present 55.3%, p = 0.66), smoking status (non-smoker, 52.6%, current smoker, 61.5%, ex-smoker, 49.8%, p > 0.05), age (p = 0.52) and baseline Qmax (p = 0.41) did not significantly impact IPSS reduction at 12 months post-PAE. Baseline prostate volume significantly influenced IPSS reduction (≥ 80 cc prostates, 58.9% vs. < 80 cc prostates 43.2%, p < 0.05). CONCLUSION: The presence of cardiovascular comorbidities/smoking history does not appear to significantly impact PAE symptom score outcomes at 12 months post procedure. Our findings suggest that if the prostatic artery can be accessed, then clinical success is comparable to those without cardiovascular comorbidities.

Virtual Injection Software Reduces Radiation Exposure and Procedural Time of Prostatic Artery Embolization Performed with Cone-Beam CT.

PURPOSE: To evaluate the impact of virtual injection software (VIS) use during cone-beam computed tomography (CT)-guided prostatic artery embolization (PAE) on both patient radiation exposure and procedural time. MATERIALS AND METHODS: This institutional review board (IRB)-approved comparative retrospective study analyzed the treatment at a single institution of 131 consecutive patients from January 2020 to May 2022. Cone-beam CT was used with (Group 1, 77/131; 58.8%) or without VIS (Group 2, 54/131, 41.2%). Radiation exposure (number of digital subtraction angiography [DSA] procedures), dose area product (DAP), total air kerma (AK), peak skin dose (PSD), fluoroscopy time (FT), and procedure time (PT) were recorded. The influences of age, body mass index, radial access, and use of VIS were assessed. RESULTS: In bivariate analysis, VIS use (Group 1) showed reduction in the number of DSA procedures (8.6 ± 3.7 vs 16.8 ± 4.3; P < .001), DAP (110.4 Gy·cm2 ± 46.8 vs 140.5 Gy·cm2 ± 61; P < .01), AK (642 mGy ± 451 vs 1,150 mGy ± 637; P = .01), PSD (358 mGy ± 251 vs 860 mGy ± 510; P = .001), FT (35.6 minutes ± 15.4 vs 46.6 minutes ± 20; P = .001), and PT (94.6 minutes ± 41.3 vs 115.2 minutes ± 39.6, P = .005) compared to those in Group 2. In multivariate analysis, AK, PSD, FT, and PT reductions were associated with VIS use (P < .001, P < .001, P = .001, and P = .006, respectively). CONCLUSIONS: The use of VIS during PAE performed under cone-beam CT guidance led to significant reduction in patient radiation exposure and procedural time.

A correlation study between prostate necrosis rate calculated by 3D Slicer software and clinical efficacy of prostatic artery embolization, along with an analysis of predictors of clinical success after prostatic artery embolization.

PURPOSE: To analyze the correlation between the prostate necrosis rate at 1-month after prostatic artery embolization (PAE) and the clinical efficacy at 1-year after PAE, and to explore potential predictors of clinical success after PAE for the treatment of lower urinary tract symptoms secondary to benign prostatic hyperplasia (BPH). METHODS: The prostate magnetic resonance imaging data at 1-month after PAE were imported into 3D Slicer software for calculating the prostate necrosis rate and thus analyzing the relationship between the prostate necrosis rate at 1-month after PAE and the efficacy score ratio at 1-year after PAE. The 151 patients with PAE technical success were divided into a clinical success group (n = 126) and a clinical failure group (n = 25). Independent predictors of clinical success after PAE were analyzed by multifactorial logistic regression, and the predictive performance of each factor was evaluated by applying the receiver operating characteristic curve and the area under the curve (AUC). RESULTS: There was a linear negative correlation between the prostate necrosis rate at 1-month after PAE and the efficacy score ratio at 1-year after surgery (P < 0.001). In the clinical success group, both the initial prostate volume (PV) and the prostate necrosis rate at 1-month after PAE were significantly higher than in the clinical failure group (P < 0.001), and acute urinary retention (AUR) and adenomatous-dominant BPH were also associated with clinical success (P < 0.05). Multifactorial logistic regression analysis revealed that larger initial PV, a higher prostate necrosis rate at 1-month after surgery, and AUR were independent predictors of clinical success after PAE. The AUC values for these three indicators and their combination were 0.720, 0.928, 0.599, and 0.951, respectively, in which the prostate necrosis rate at 1-month after PAE demonstrating a high predictive value. CONCLUSION: The higher the prostate necrosis rate at 1-month after PAE, the better the clinical efficacy at 1-year after PAE is likely to be, and the prostate necrosis rate at 1-month after PAE is expected to become a predictor of clinical success after PAE.

Management of Lower Urinary Tract Symptoms Attributed to Benign Prostatic Hyperplasia (BPH): AUA Guideline Amendment 2023.

PURPOSE: The purpose of this American Urological Association (AUA) Guideline amendment is to provide a useful reference on the effective evidence-based management of male lower urinary tract symptoms secondary/attributed to BPH (LUTS/BPH). MATERIALS AND METHODS: The Minnesota Evidence Review Team searched Ovid MEDLINE, the Cochrane Library, and the Agency for Healthcare Research and Quality (AHRQ) database to identify studies relevant to the management of BPH. The guideline was updated in 2023 to capture eligible literature published between September 2020 and October 2022. When sufficient evidence existed, the body of evidence was assigned a strength rating of A (high), B (moderate), or C (low) for support of Strong, Moderate, or Conditional Recommendations. In the absence of sufficient evidence, additional information is provided as Clinical Principles and Expert Opinions. RESULTS: The BPH amendment resulted in changes to statements/supporting text on combination therapy, photoselective vaporization of the prostate (PVP), water vapor thermal therapy (WVTT), laser enucleation, and prostate artery embolization (PAE). A new statement on temporary implanted prostatic devices (TIPD) was added. In addition, statements on transurethral needle ablation (TUNA) and transurethral microwave thermotherapy (TUMT) were removed and information regarding these legacy technologies was added to the background section. References and the accompanying treatment algorithms were updated to align with the updated text. CONCLUSION: This guideline seeks to improve clinicians' ability to evaluate and treat patients with BPH/LUTS based on currently available evidence. Future studies will be essential to further support these statements to improve patient care.

Prostate artery embolization using n-butyl cyanoacrylate glue for symptomatic benign prostatic hyperplasia: A six-month outcome analysis in 103 patients.

PURPOSE: The purpose of this study was to assess the feasibility, safety, and 6-month outcomes of prostate artery embolization (PAE) using N-butyl-cyanoacrylate (NBCA) glue as the only embolic agent in patients with benign prostatic hyperplasia (BPH)-related lower urinary tract symptoms. MATERIALS AND METHODS: Patients with BPH-related lower urinary tract symptoms who were treated by PAE using methacryloxysulfolane-NBCA mixed with ethiodized oil (1:8 ratio) between September 2018 and January 2023 were retrospectively included. Vascular mapping was made using cone-beam computed tomography angiography. PAEs were performed as an outpatient procedure, under local anaesthesia. Outcomes were assessed at six months using the International Prostate Symptoms Score (IPSS) and associated quality-of-life score (IPSS-QoL), prostate-specific antigen (PSA) level, prostate volume, and International Index of Erectile Function form 5 (IIEF5). RESULTS: A total of 103 men with a mean age of 68.4 ± 6 (standard deviation [SD]) years were included. Technical success rate was 100%. The mean fluoroscopy time was 26.4 ± 12.5 (SD) min and the median radiation dose was 23 980 mGy·cm (Q1, Q3: 16 770, 38 450). Compared to baseline, statistically significant improvements were observed at six months for the IPSS (8.9 ± 6.2 [SD] vs. 20.2 ± 6.5 [SD]; P = 0.01), IPSS-QoL (2.1 ± 1.4 [SD] vs. 5.1 ± 0.9 [SD]; P = 0.01), PSA level (3.6 ± 3.2 [SD] ng/mL vs. 4.8 ± 4.2 [SD] ng/mL; P = 0.0001), and prostate volume (78.6 ± 43.5 [SD] mL vs. 119.1 ± 65.7 [SD] mL; P = 0.01). Minor adverse events developed in 19/103 (18.4%) patients. No major complications occurred. Compared to baseline, the IIEF5 did not change significantly at six months (15.3 ± 6.8 [SD] vs. 15.8 ± 6.8 [SD]; P = 0.078). CONCLUSION: PAE with NBCA is a feasible and safe method that provides good outcomes at six months in patients with BPH-related lower urinary tract symptoms. This method deserves further evaluation in randomized trials with longer follow-up.

Safety of Prostatic Artery Embolization via Transradial Access versus Transfemoral Access.

PURPOSE: To compare prostatic artery embolization (PAE) via transradial access (TRA-PAE) versus transfemoral access (TFA-PAE) to assist access selection. MATERIAL AND METHODS: Procedural outcomes and adverse events were evaluated in 998 patients who underwent PAE at a single center from April 2014 to August 2022; 821 (82%) underwent TRA-PAE (Group R) and 177 (18%) underwent TFA-PAE (Group F). Mean age and prostate size of Groups R and F were 69.2 years (SD ± 8.4) and 117.4 g (SD ± 63.1) and 75.2 years (SD ± 12.1) and 127.2 g (SD ± 83.6), respectively (P < .01 and P = .16; postpropensity matching: P = .38 and P = .35, respectively). Indications for PAE included lower urinary tract symptoms, acute or chronic urinary retention, and hematuria. Procedural and patient-specific metrics were reviewed. Technical success was defined as bilateral PAE. Adverse events were recorded according to the Society of Interventional Radiology (SIR) adverse events classification. Statistical significance was defined as P < .05. RESULTS: Technical success was achieved in 798 (97.2%) patients in Group R and 165 (93.2%) patients in Group F. Mean procedural time, single- and continuous-rotation fluoroscopy time, dose area product, and air kerma were significantly lower in Group R than in Group F (P < .001). Moreover, 6 (0.7%) patients in Group R and 9 (5.5%) patients in Group F had access site ecchymoses, whereas 5 (0.6%) patients in Group R and 6 (3.6%) in Group F had access site hematomas. Two patients experienced transient ischemic attacks (TIAs) after TRA-PAE and recovered without intervention. Two occult radial artery occlusions were noted, but no patient experienced hand ischemia. CONCLUSIONS: In a large single interventional radiologist cohort, TRA-PAE demonstrated similar technical success to that of TFA-PAE with lower access site hemorrhagic complications and radiation requirements; however, TIA and occult radial artery occlusions remain a concern.

Is Artificial Intelligence the Key to Revolutionizing Benign Prostatic Hyperplasia Diagnosis and Management?

Benign prostatic hyperplasia (BPH) is a prevalent condition among older men that is characterized by the enlargement of the prostate gland and compression of the urethra, which often results in lower urinary tract symptoms, such as frequent urination, difficulty in starting urination, and incomplete bladder emptying. The development of BPH is thought to be primarily due to an imbalance between cell proliferation and apoptosis, underlying inflammation, epithelial-to-mesenchymal transition, and local paracrine and autocrine growth factors, although the exact molecular mechanisms are not yet fully understood. Anatomical structures considered natural and benign observations can occasionally present multi-parametric magnetic resonance imaging appearances that resemble prostate cancer (PCa), posing a risk of misinterpretation and generating false-positive outcomes and subsequently, unnecessary interventions. To aid in the diagnosis of BPH, distinguish it from PCa, and assist with treatment and outcome prediction, various Artificial Intelligence (AI)-based algorithms have been proposed to assist clinicians in the medical practice. Here, we explore the results of these new technological advances and discuss their potential to enhance clinicians' cognitive abilities and expertise. There is no doubt that AI holds extensive medical potential, but the cornerstone for secure, efficient, and ethical integration into diverse medical fields still remains well-structured clinical trials.

Terapia termal con vapor de agua: variaciones técnicas entre hospitales universitarios españoles y eficacia a 2 años de seguimiento / Water vapor thermal therapy: technical variations among spanish hospitals and efficacy at 2-year follow-up

Objetivo El objetivo de este trabajo es conocer experiencia inicial con la terapia térmica con vapor de agua (TTVA) para hiperplasia benigna de próstata (HBP) en los hospitales universitarios españoles, así como describir las diferencias en cuanto a técnica y seguimiento observadas entre los centros. Materiales y métodos Este estudio multicéntrico observacional retrospectivo recogió características basales, datos quirúrgicos, posoperatorios y seguimiento a los uno, tres, seis, 12 y 24 meses, incluyendo cuestionarios validados, variaciones flujométricas, complicaciones y la necesidad de tratamiento farmacológico y quirúrgico tras el procedimiento. También se analizaron los posibles desencadenantes de retención aguda de orina (RAO) en el posoperatorio. Resultados Se incluyeron un total de 105 pacientes. No se observaron diferencias entre los grupos con y sin RAO con respecto a tiempo de sondaje (cinco y 4,3 días respectivamente, p = 0,178), ni volumen prostático (47,9 y 41,4 g, respectivamente, p = 0,147). La mejoría media a los tres, seis, 12 y 24 meses en cuanto de flujo máximo fue de 5,3, 5,2, 4,2 y 3,8 mL/s, respectivamente. En cuanto a la eyaculación, se observa una mejoría en la misma a partir de los tres meses de seguimiento que se mantiene en el tiempo. Conclusiones El tratamiento mínimamente invasivo de HBP con TTVA presenta buenos resultados funcionales a 24 meses de seguimiento, sin afectación significativa de la función sexual y con una baja incidencia de complicaciones. Existen pequeñas variaciones principalmente en cuanto al posoperatorio inmediato entre los hospitales participantes en el estudio. (AU)

Aim The aim of this work is to evaluate the initial experience with water vapor thermal therapy (WVTT) for benign prostatic hyperplasia (BPH) in Spanish university hospitals, as well as to describe the differences in technique and follow-up between centers. Materials and Methods This retrospective observational multicenter study collected baseline characteristics, surgical, postoperative and follow-up data at 1, 3, 6, 12 and 24 months, including validated questionnaires, flowmetric variations, complications, and the need for pharmacological or surgical treatment following the procedure. Possible triggers for postoperative acute urinary retention (AUR) were also analyzed. Results A total of 105 patients were included. No differences were observed between the groups with and without AUR with respect to catheterization time (5 and 4.3 days respectively, p = 0.178), or prostate volume (47.9 gr and 41.4 gr respectively, p = 0.147). The mean improvement at 3, 6, 12 and 24 months in terms of peak flow was 5.3, 5.2, 4.2 and 3.8 ml/s, respectively. As for ejaculation, an improvement was observed after 3 months of follow-up and was maintained over time. Conclusions Minimally invasive treatment for BPH with WVTT shows good functional outcomes at 24 months follow-up, without significant impairment of sexual function and a low incidence of complications. There are minor inter-hospital variations, mainly in the immediate postoperative period. (AU)

Prostatic Artery Origin Variability: Five Steps to Improve Identification during Percutaneous Embolization.

Background and Objectives: The purpose of the current paper is to present our study on the variability in the prostatic artery origin, discuss the less frequent origins, and present the challenges of the prostatic artery embolization (PAE) procedure, thus aiding young interventional radiologists. Materials and Methods: We studied the origins of the prostatic artery on digital subtraction angiography (DSA) examinations from PAE procedures on 35 male pelvises (70 hemi-pelvises). Results: Our study has demonstrated that the most frequent origin of the prostatic artery (PA) is the internal pudendal artery (IPA), 37.1%, followed by the anterior gluteal trunk, 27.1%, and the superior vesical artery (SVA), 21.4%. Less frequent origins are the obturator artery (OBT), 11.4%, and the inferior gluteal artery (IGA), 2.8%. Conclusions: Compared to other studies, we notice some differences in the statistical results, but the most frequent origins remain the same. What is more important for young interventional radiologists is to be aware of all the possible origins of the PA in order to be able to offer a proper treatment to their patients. The important aspect that will ensure the success of the procedure without post-procedural complications is represented by the successful embolization of the targeted prostatic parenchyma.

Is Artificial Intelligence the Key to Revolutionizing Benign Prostatic Hyperplasia Diagnosis and Management?

Benign prostatic hyperplasia (BPH) is a prevalent condition among older men that is characterized by the enlargement of the prostate gland and compression of the urethra, which often results in lower urinary tract symptoms, such as frequent urination, difficulty in starting urination, and incomplete bladder emptying. The development of BPH is thought to be primarily due to an imbalance between cell proliferation and apoptosis, underlying inflammation, epithelial-to-mesenchymal transition, and local paracrine and autocrine growth factors, although the exact molecular mechanisms are not yet fully understood. Anatomical structures considered natural and benign observations can occasionally present multi-parametric magnetic resonance imaging appearances that resemble prostate cancer (PCa), posing a risk of misinterpretation and generating false-positive outcomes and subsequently, unnecessary interventions. To aid in the diagnosis of BPH, distinguish it from PCa, and assist with treatment and outcome prediction, various Artificial Intelligence (AI)-based algorithms have been proposed to assist clinicians in the medical practice. Here, we explore the results of these new technological advances and discuss their potential to enhance clinicians’ cognitive abilities and expertise. There is no doubt that AI holds extensive medical potential, but the cornerstone for secure, efficient, and ethical integration into diverse medical fields still remains well-structured clinical trials (AU)