Prostate Artery Embolization

Transcription

1 Prostate Artery Embolization in the office interventional suite Robert J. Kennedy, M.D. Interventional & Vascular Center Melbourne, Florida

2 The speaker has no financial conflicts of interest to disclose.

3 Benign Prostatic Hyperplasia Age-associated enlargement of the prostate Prevalence 14 million cases in United States 50% of men over 50 80% of men over 80

4 Lower Urinary Tract Symptoms (LUTS) Feeling of incomplete bladder emptying Frequency Intermittency Urgency Weak stream Straining Nocturia Quality of Life (QOL) International Prostate Symptom Score (IPSS)

5 Treatment of BPH Medical: Alpha-adrenergic blockers 5-alpha reductase inhibitors Phosphodiesterase-5 enzyme inhibitors

6 Treatment of BPH Surgical: Transurethral Transurethral resection of the prostate (TURP) Transurethral microwave therapy (TUMT) Transurethral incision of the prostate (TUIP) Transurethral needle ablation (TUNA) Green light photoselective vaporization (PVP) UroLift Open (Prostatectomy)

7 Prostate Artery Embolization Emerging endovascular treatment for LUTS/BPH First case report of PAE for BPH in 2000 DeMeritt JS, et al J Vasc Interv Radiol, 2000;11: Early experience in Brazil and Portugal within last 10 years Retrospective cohort and prospective single-arm studies

8 Prostate Artery Embolization RCT published by in 2014 comparing PAE v. TURP 114 patients Yuan-an Gao, et al Radiology 2014; 270: Improved symptoms in both groups Higher reported complications in PAE group PAE group: technical/clinical failures were labeled complications TURP group: bleeding requiring transfusion, retrograde ejaculation, impotence, incontinence not complications

9 CLINICAL STUDY Meta-Analysis of Prostatic Artery Embolization for Benign Prostatic Hyperplasia Andre Uflacker, MD, Ziv J Haskal, MD, Tiago Bilhim, MD, James Patrie, MS, Timothy Huber, MD, and João Martins Pisco, MD ABSTRACT Purpose: To perform meta-analysis of available data on prostatic artery embolization (PAE). Materials and Methods: Meta-analysis was conducted on articles published between November 2009 and December Peer-reviewed studies with 4 5 patients and standard deviations and/or individual-level data on one or more of the following outcomes were included: prostate volume (PV), peak flow rate (Qmax), postvoid residual (PVR), International Prostate Symptom Score (IPSS), quality of life (QOL) score, International Index of Erectile Function (IIEF) score, and prostate-specific antigen (PSA) level. A random-effects meta-analysis was performed on the outcomes at 1, 3, 6, and 12 months after PAE compared with baseline values, with a P o.05 decision rule as the null hypothesis rejection criterion. Results: Nineteen of 268 studies were included in data collection, with 6 included in the meta-analysis. At 12 months, PV decreased by cm 3 (P o.001), PSA remained unchanged (P ¼.248), PVR decreased by ml (P o.001), Qmax increased by 5.39 ml/s (P o.001), IPSS improved by points (P o.001), QOL score improved by 2.49 points (P o.001), and IIEF was unchanged (P ¼ 1.0). There were a total of 218 adverse events (AEs) among 662 patients (32.93%), with 216 being Society of Interventional Radiology class A/B (99%). The most common complications were rectalgia/dysuria (n ¼ 60; 9.0%) and acute urinary retention (n ¼ 52; 7.8%). No class D/E complications were reported. Conclusions: PAE provided improvement in Qmax, PVR, IPSS, and QOL endpoints at 12 months, with a low incidence of serious AEs (0.3%), although minor AEs were common (32.93%). There was no adverse effect on erectile function.

10 Meta-analysis 12-mo outcomes PV decreased by g PSA unchanged PVR decreased by ml Qmax increased by 5.39 ml/s IPSS decreased by points QOL score improved by 2.49 points No class D/E complications Uflacker A, et al J Vasc Interv Radiol 2016;27:

11 Limitations of PAE Data Limited long-term data Consistent definitions of outcomes lacking Most published studies retrospective Redundant data/overlapping patients RCTs small sample size, questions about adverse event reporting

12 Candidate Evaluation Moderate-severe LUTS from BPH IPSS Not related to bladder dysfunction, chronic prostatitis, prostate cancer, etc. Large prostate (greater than 60 g) Patient goals Symptom improvement/resolution Discontinuation of medications

13 Technique How I Do It Place Foley Femoral access (also can be done transradial) Internal iliac arteriogram (30-45 degree ipsilateral anterior oblique) Identify prostatic artery

14 Technique Identify Prostatic Artery Posterior to bladder vessel (Superior Vesical Artery) Anterior to Internal Pudendal Artery Tortuous, S-shaped Perfusion to midline (below Foley balloon) Corkscrew intraparenchymal branches Hemiglandular staining

15 Technique Identify Prostatic Artery Posterior to bladder vessel (Superior Vesical Artery) Anterior to Internal Pudendal Artery Tortuous, S-shaped Perfusion to midline (below Foley balloon) Corkscrew intraparenchymal branches Hemiglandular staining

16 SV P IP

17 Technique Identify Prostatic Artery Posterior to bladder vessel (Superior Vesical Artery) Anterior to Internal Pudendal Artery Tortuous, S-shaped Perfusion to midline (below Foley balloon) Corkscrew intraparenchymal branches Hemiglandular staining

18 SV P IG O IP

19 Technique Identify Prostatic Artery Posterior to bladder vessel (Superior Vesical Artery) Anterior to Internal Pudendal Artery Tortuous, S-shaped Perfusion to midline (below Foley balloon) Corkscrew intraparenchymal branches Hemiglandular staining

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22 Technique Identify Prostatic Artery Posterior to bladder vessel (Superior Vesical Artery) Anterior to Internal Pudendal Artery Tortuous, S-shaped Perfusion to midline (below Foley balloon) Corkscrew intraparenchymal branches Hemiglandular staining

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24 Technique Identify Prostatic Artery Posterior to bladder vessel (Superior Vesical Artery) Anterior to Internal Pudendal Artery Tortuous, S-shaped Perfusion to midline (below Foley balloon) Corkscrew intraparenchymal branches Hemiglandular staining

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26 Technique What You Need Base catheter (Cobra-2) Microcatheter (2.0F to 2.7F) Guidewire with flexible tip (0.014-in. or inch) Trisacryl gelatin micospheres ( micron size)

27 Technique Embolization Dilute embolics (avoid clumping, premature stasis) Mix 2 ml spheres in 10 ml normal saline, 10 ml contrast Administer NTG into prostatic artery through microcatheter Embolize very slowly, until stasis PErFecTED? Repeat on contralateral side

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30 Technical Challenge: Atherosclerosis

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33 P IP

34 Postoperative Management Methylprednisolone dose pack NSAIDS Pyridium Vesicare Ciprofloxacin x 5 days Colace RTC 2 weeks

35 Complications Non-target embolization: Bladder, rectum, penis, seminal vesicles PES UTI Prostatitis Hematuria Hemospermia Radiation injury NOT SEXUAL DYSFUNCTION

36 Getting Started Hematuria Urinary retention Very large prostates

37 Case Study: 66-year-old male with hematuria, acute urinary retention, and 192-g prostate.

38 O P IP

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41 Post-op Day 1

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44 Summary Prostate artery embolization is safe Early results are encouraging Feasible in the outpatient setting More high quality data to determine role for PAE as first line treatment