Prostate Artery Embolization: Single Center Experience
Prostate Artery Embolization: Single Center Experience
Benign prostatic hyperplasia (BPH) is an enlarged prostate gland from smooth muscle and
 glandular hyperplasia seen in the aging population with a prevalence of upto 90% in patients
 in the ninth decade. Lower urinary tract symptoms (LUTS) and bladder outlet obstruction (BOO)
 are the most common presenting symptoms of BPH. Patients are initially evaluated with a
 complete history and physical exam to rule out other causes of LUTS and assess the severity
 of LUTS with scoring systems such as the American Urologic Association Symptom Index (AUASI)
 or the International Prostate Symptom Score (IPSS). Patients with mild or no symptoms are
 treated with watchful waiting. Surgical procedure such as transurethral resection of the
 prostate and minimally invasive procedures such as microwave ablation and prostate artery
 embolization are performed in patients with failed medical management or patients who are not
 able to tolerate the side effects of the medications. Prostate artery embolization is a safe
 minimally invasive procedure shown to improve IPSS and quality of life with none or potential
 risk of minor complications shown in short, intermediate, and long term follow up.
Benign prostatic hyperplasia (BPH) is an enlarged prostate from smooth muscle and glandular
 hyperplasia that results in lower urinary tract symptoms due to bladder outlet obstruction.
 It is seen in 8% of men in the fourth decade with increased prevalence to up to 90% of men in
 the ninth decade (1). Patients typically present with groups of symptoms referred to as lower
 urinary tract symptoms (LUTS) of which may include urgency, frequency, nocturia, incomplete
 bladder emptying, and weak urinary stream (2). LUTS is mainly categorized into irritative,
 obstructive, and mixed types. This has a variable impact on patients' quality of life by
 interfering with sleep, activities of daily living, anxiety, mobility, leisure, and effect on
 sexual activities (3). The risk factors for developing BPH include African American race,
 obesity, type 2 diabetes mellitus, high levels of alcohol consumption, and physical
 inactivity (4).

 Patients with LUTs are evaluated with a complete history and physical to rule out causes
 other than BPH and bladder dysfunction such as excess fluid and caffeine intake, and use of
 medications including diuretics and antihistamine. Patients are further evaluated with
 screening tools such as the American Urologic Association Symptom Index (AUASI) or the
 International Prostate Symptom Score (IPSS) to determine the severity of LUTS secondary to
 BPH. IPSS is an 8 question screening tool that assesses the quality of life in addition to 7
 questions in AUASI (4). Each question is scored from 0 to 5 and a minimum change of 3 points
 is considered a clinically important difference (5). Patients with AUASI score of less than 8
 are considered to have mild or no symptoms and are managed with watchful waiting (6).
 Moderate or severe symptoms are considered in patients with AUASI score of 8 or greater than
 8 and are managed with pharmacologic treatment including alpha-adrenergic receptor blockers,
 5 alpha-reductase inhibitors, antimuscarinic agents, and phosphodiesterase 5 inhibitors.
 Additionally, international index of erectile function (IIEF) is used to further assess
 quality of life. For patients who have failed medical management, experience side effects
 from medications, or not interested in medical therapy are offered minimally invasive
 surgical treatment such as microwave ablation, surgical treatment including open
 prostatectomy and transurethral resection of the prostate (TURP) and interventional radiology
 procedure, prostate artery embolization.

 Prostate artery embolization (PAE) is a safe and effective minimally invasive interventional
 radiology procedure in which intraprostatic vessels are embolized to shrink the size of the
 prostate gland. Preprocedural assessment includes IPSS, the international index of erectile
 function (IIEF-5) to asses pre-existing erectile dysfunction (7), postvoid residual (PVR) to
 objectively assess the degree of bladder outlet obstruction, cross-sectional imaging of the
 prostate gland, and screening for prostate cancer (8). The current indication for PAE is
 patients with moderate or severe LUTS from BPH who have not responded to medications or find
 medication side effects to be intolerable. Patients are excluded from the procedure in other
 causes of LUTS such as prostate cancer, neurogenic bladder prostatitis, urethral strictures.
 Clinical trials are underway that demonstrate the efficacy of the procedure and define
 indications and contraindications. Meta-analysis showed a statistically significant decrease
 in IPSS of 12.9, 15, 15, and 20.4 points from baseline at 1, 3, 6, 12 months, respectively
 (9). Additionally, statistically significant improvement in the quality of life and PVR were
 noted at 1, 3, 6, 12 months. An overall incidence of a compilation was 32.9% (9), the
 majority of which were classified as minor per SIR guidelines. Rectalgia, dysuria, and
 transient urinary retention were the most frequent minor complications of PAE. A few major
 complications related to PAE were severe urinary tract infection and bladder ischemia
Inclusion Criteria:

 -  Anyone with international prostate symptom score greater than or equal to 8 (moderate
 to severe lower urinary tract symptoms)

 -  Quality of life assessment greater than 3

 -  Prostate volume greater than 40 cm3

 -  Men >45 years old

 -  Indwelling urinary catheter secondary to benign prostatic hyperplasia or
 moderate-severe lower urinary tract symptoms

 Exclusion Criteria:

 -  Evidence of tortuous or severe atherosclerotic vessels on CT

 -  Neurogenic bladder

 -  <8 international prostate symptoms score

 -  Prostate volume less than 40cm3

 -  History of prostate cancer