Prostate Artery Embolization: Challenges, Tips, Tricks, and Perspectives
Abstract
:1. Introduction
2. Tips and Tricks to Perform Prostate Artery Embolization (PAE)
2.1. Perform an Arterial Mapping: Preoperative Computerized Tomography (CT) Angiogram or Intraoperative Cone-Beam CT (CBCT)
2.2. Manage Aortoiliac Anatomy
- Tortuous common iliac arteries (Figure 1);
- Aortic or iliac bifurcation forming a very acute angle.
2.3. Identify the Origin of the Prostatic Artery
2.4. Manage the Prostatic Artery Catheterism
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- Atheroma and sinuous arteries (increasing with age);
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- Type 1 prostatic artery, with tight angulation between the anterior trunk of the internal iliac and the inferior bladder artery (this situation also sometimes occurs with the internal pudendal artery on type 4).
2.4.1. When the Internal Iliac Arteries Are Tortuous or When the Catheter Is Unstable
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- with the use of a longer sheath (45 centimeters for example), when a femoral approach is intended;
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- with the “buddy-wire technic” [9]: the use of an increased sheath caliber (7 french) and the positioning of a guidewire parallel to the catheter, to increase the stability of this one;
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- and with a radial approach [10], which can be considered to overcome the loss of stability inherent in the cross-over.
2.4.2. When the Prostatic Artery Arises with a Very Acute Angulation
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- Use a rigid torque catheter with a tight distal curve to directly catheterize the artery without a microcatheter. This type of catheter should be handled with care, as it is very rigid and can easily lead to dissection of the prostatic artery.
2.5. Know the Intra-Prostatic Anatomy, Detect and Protect the Shunt and Collaterals
2.5.1. Middle Rectal and Inferior Vesical Collaterals
2.5.2. Internal Pudendal Artery Collateral
- -
- The post-capsular collaterals, which are usually found at the apex, are opacified during DSA with a flow rate usually superior to 0.5 cc/s. These collaterals disappear with the decrease in the injection rate. In these cases, embolization can be performed without risk but must be performed at a low flow rate;
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- The pre-capsular collaterals, which are true intra-prostatic arterial connections (usually described as the “accessory pudendal artery” (aPA)). In some extreme situations, there is no real prostatic artery, and the prostate is vascularized by several small branches along the latero-prostatic course of the aPA, which then gives the penile vascularization. As soon as the connections with the internal pudendal artery are of a certain size (we can consider that the visibility of a true course in angiography is a good cut-off) there is a significant risk of non-target embolization, including with low-flow embolization. These connections must, therefore, be protected prior to embolization.
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- First case: the central prostatic branches can be supraselectively catheterized. In this case, a very careful embolization can be performed. Most attention must be paid to avoid reflux into the aPA.
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- Second case: a supraselective catheterization is impossible. It is then necessary to occlude the accessory pudendal artery in its post-prostatic portion to be able to embolize upstream “by collaterality” of the prostatic branches. Nevertheless, the consequences of the occlusion of the aPA on penile vascularization must be taken into account. A recent study found no difference between a patient who received embolization of penile collateral in terms of erectile function [14]. These are still debated, despite numerous studies on the subject in the context of radical prostate surgeries for prostate cancer. These anatomical studies classified penile vascularization according to three categories [15] depending on whether the vascularization is performed only by the internal pudendal (type I, 61.9%), by the internal and accessory pudendal (type II, 32.8%), or only via the accessory pudendal arteries (type III, 5.4%). Put another way, this means that when an aPA is founded, it is the only supply to the penile in 14% of the case (type III/(type II + III)). By cross-referencing these data with MacLean [14], who reported around 12% of penile/aPA protection coiling during PAE, we arrived at a number of 1.7% (12% × 14%) of patients who are potentially at risk of protective occlusion of a type III vascularization. We, therefore, recommend before occluding an aPA to ensure that it is not the only artery supplying the penis, in which case the risk of post-occlusion impotence seems real to us. In our experience, the presence of selectively non-catheterizable prostatic branches in the context of type III penile vascularization in young subjects wishing to preserve their sexual activity is the only situation contraindicating embolization.
3. Perspective, Evolution, and Discussion about PAE
3.1. PAE Safety and Complications
3.2. PAE Limitations
3.3. Embolization Agent
3.4. Particle Size
3.5. Peripheral vs. Central Prostate
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
References
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Study | Pisco, 2019 [19] | Insauti, 2020 [18] | Abt, 2018 [16] | Carnevale, 2015 [17] | Russo, 2015 [21] | Ray, 2018 [20] | Salem, 2018 [22] |
---|---|---|---|---|---|---|---|
Patient Number | n = 78 | n = 23 | n = 48 | n = 15 | n = 80 | n = 199 | n = 45 |
Design | RCT, PAE vs. Sham | RCT, PAE vs. TURP | RCT, PAE vs. TURP | RCT, PAE vs. TURP | RCT, PAE vs. prostatectomy | Registry-based study | Prospective, PAE only |
Total adverse event, n (%) | 25 (32.0) | 15 (65.2) | 36 (75) | 4 (46.7) | 7 (8.7) | 136 (68.3) | 26 (57.8) |
Clavien Dindo grade | |||||||
grade I | 21 (26.9) | 4 (17.3) | 54% | 6 (7.5) | 134 (67.3) | 24 (53.3) | |
grade II | 3 (3.8) | 11 (47.8) | 17% | 1 (1.3) | 2 (1) | 2 (4.4) | |
grade III | 1 (1.3) | 0 | 4.30% | 0 | 0 | ||
grade IV | 0 | 0 | 0 | 0 | |||
grade V | 0 | 0 | 0 | 0 | |||
Description (number, %) | |||||||
Urinary frequency and urgency | 3 (6.6) | ||||||
Burning perineal pain | 1 (1.3) | 1 (4.3) | 15 (31.3) | ||||
Burning urethral pain | 3 (3.8) | 4 (17.3) | |||||
Dysuria | 3 (3.8) | 5 (6.3) | 13 (28.9) | ||||
Ecchymosis | 2 (2.6) | ||||||
Haematospermia | 7 (9.0) | 1 (6.7) | 1 (1.3) | 25 (12.6) | 2 (4.4) | ||
Haematuria | 5 (6.4) | 1 (4.3) | 4 (8.3) | 2 (13.3) | 37 (18.6) | 6 (13.3) | |
Inguinal haematoma | 4 (5.1) | 4 (2) | |||||
Penile ulcer | 2 (1) | ||||||
Artery dissection | 4 (2.0) | ||||||
Acute urinary retention | 5 (21.7) | 1 (2.1) | 2 (4.4) | ||||
Radiodermitis | 1 (4.3) | ||||||
Erectile dysfunction | 1 (4.3) | ||||||
Change in ejaculation volume | 1 (4.3) | 2 (13.3) | 48 (24.1) | ||||
Incontinence | 2 (1) | ||||||
Prostate fragment expelled | 1 (1.3) | ||||||
Rectorrhagia/rectal ischemia | 2 (2.6) | 1 (4.3) | 1 (6.7) | ||||
Urinary tract infection | 1 (1.3) | 10 (20.1) | 1 (1.3) | 14 (7.0) | |||
Other | 6 (12.5) | 1 (6.7) |
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Moulin, B.; Di Primio, M.; Vignaux, O.; Sarrazin, J.L.; Angelopoulos, G.; Hakime, A. Prostate Artery Embolization: Challenges, Tips, Tricks, and Perspectives. J. Pers. Med. 2023, 13, 87. https://doi.org/10.3390/jpm13010087
Moulin B, Di Primio M, Vignaux O, Sarrazin JL, Angelopoulos G, Hakime A. Prostate Artery Embolization: Challenges, Tips, Tricks, and Perspectives. Journal of Personalized Medicine. 2023; 13(1):87. https://doi.org/10.3390/jpm13010087
Chicago/Turabian StyleMoulin, Benjamin, Massimiliano Di Primio, Olivier Vignaux, Jean Luc Sarrazin, Georgios Angelopoulos, and Antoine Hakime. 2023. "Prostate Artery Embolization: Challenges, Tips, Tricks, and Perspectives" Journal of Personalized Medicine 13, no. 1: 87. https://doi.org/10.3390/jpm13010087