J Korean Soc Radiol JKSR Journal of the Korean Society of Radiology 1738-2637 2288-2928 The Korean Society of Radiology 10.3348/jksr.2019.80.4.656 Urologic Intervention Review Article Prostate Artery Embolization: Treatment of Symptomatic Benign Prostatic Hyperplasia https://orcid.org/0000-0002-6493-9215 Hwang Jin Ho MD https://orcid.org/0000-0003-2155-8188 Park Sang Woo MD Department of Radiology, Konkuk University School of Medicine, Seoul, Korea. Corresponding author: Sang Woo Park, MD. Department of Radiology, Konkuk University School of Medicine, 120-1 Neungdong-ro, Gwangjin-gu, Seoul 05030, Korea. Tel 82-2-2030-5487, Fax 82-2-2030-5549, psw0224@kuh.ac.kr 07 2019 30 07 2019 80 4 656 666 04 03 2019 25 03 2019 27 03 2019 Copyrights © 2019 The Korean Society of Radiology 2019 The Korean Society of Radiology This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Prostatic artery embolization (PAE) is an emerging treatment option for lower urinary tract symptoms (LUTS) caused by benign prostatic hyperplasia (BPH). PAE is a minimally invasive technique and provides good results in BPH patients with moderate-to-severe LUTS. Most patients with BPH are old and have atherosclerosis. PAE can be technically challenging in these patients because of the tortuosity and small diameters of prostatic arteries. Therefore, patient selection is essential for successful results. To perform a safe procedure with no non-target embolization, precise knowledge of the prostatic arterial anatomy and meticulous techniques are important. A multidisciplinary approach by interventional radiologists and urologists is essential to achieve better outcomes.

 Embolization, Therapeutic Arteries Prostate Prostatic Hyperplasia Benign Prostatic Hyperplasia

The authors have no potential conflicts of interest to disclose.

 McWilliams JP Kuo MD Rose SC Bagla S Caplin DM Cohen EI Society of Interventional Radiology position statement: prostate artery embolization for treatment of benign disease of the prostate J Vasc Interv Radiol 2014 25 1349 1351 McVary KT Roehrborn CG Avins AL Barry MJ Bruskewitz RC Donnell RF Update on AUA guideline on the management of benign prostatic hyperplasia J Urol 2011 185 1793 1803 Carnevale FC Antunes AA Prostatic artery embolization for enlarged prostates due to benign prostatic hyperplasia. How I do it Cardiovasc Intervent Radiol 2013 36 1452 1463 Mebust WK Holtgrewe HL Cockett AT Peters PC Transurethral prostatectomy: immediate and postoperative complications. a cooperative study of 13 participating institutions evaluating 3,885 patients. 1989 J Urol 2002 167 999 1003 discussion 1004 Westenberg A Gilling P Kennett K Frampton C Fraundorfer M Holmium laser resection of the prostate versus transurethral resection of the prostate: results of a randomized trial with 4-year minimum long-term followup J Urol 2004 172 616 619 Rastinehad AR Caplin DM Ost MC VanderBrink BA Lobko I Badlani GH Selective arterial prostatic embolization (SAPE) for refractory hematuria of prostatic origin Urology 2008 71 181 184 DeMeritt JS Elmasri FF Esposito MP Rosenberg GS Relief of benign prostatic hyperplasia-related bladder outlet obstruction after transarterial polyvinyl alcohol prostate embolization J Vasc Interv Radiol 2000 11 767 770 Sun F Sánchez FM Crisóstomo V Lima JR Luis L García-Martínez V Benign prostatic hyperplasia: transcatheter arterial embolization as potential treatment--preliminary study in pigs Radiology 2008 246 783 789 Jeon GS Won JH Lee BM Kim JH Ahn HS Lee EJ The effect of transarterial prostate embolization in hormone-induced benign prostatic hyperplasia in dogs: a pilot study J Vasc Interv Radiol 2009 20 384 390 Carnevale FC Antunes AA Da Motta Leal Filho JM De Oliveira Cerri LM Baroni RH Marcelino AS Prostatic artery embolization as a primary treatment for benign prostatic hyperplasia: preliminary results in two patients Cardiovasc Intervent Radiol 2010 33 355 361 Bagla S Martin CP Van Breda A Sheridan MJ Sterling KM Papadouris D Early results from a United States trial of prostatic artery embolization in the treatment of benign prostatic hyperplasia J Vasc Interv Radiol 2014 25 47 52 Carnevale FC Da Motta-Leal-Filho JM Antunes AA Baroni RH Marcelino AS Cerri LM Quality of life and clinical symptom improvement support prostatic artery embolization for patients with acute urinary retention caused by benign prostatic hyperplasia J Vasc Interv Radiol 2013 24 535 542 Gao YA Huang Y Zhang R Yang YD Zhang Q Hou M Benign prostatic hyperplasia: prostatic arterial embolization versus transurethral resection of the prostate--a prospective, randomized, and controlled clinical trial Radiology 2014 270 920 928 De Assis AM Moreira AM De Paula Rodrigues VC Yoshinaga EM Antunes AA Harward SH Prostatic artery embolization for treatment of benign prostatic hyperplasia in patients with prostates > 90 g: a prospective single-center study J Vasc Interv Radiol 2015 26 87 93 Kurbatov D Russo GI Lepetukhin A Dubsky S Sitkin I Morgia G Prostatic artery embolization for prostate volume greater than 80 cm3: results from a single-center prospective study Urology 2014 84 400 404 Bilhim T Pisco JM Rio Tinto H Fernandes L Pinheiro LC Furtado A Prostatic arterial supply: anatomic and imaging findings relevant for selective arterial embolization J Vasc Interv Radiol 2012 23 1403 1415 Sun F Crisóstomo V Báez-Díaz C Sánchez FM Prostatic artery embolization (PAE) for symptomatic benign prostatic hyperplasia (BPH): part 2, insights into the technical rationale Cardiovasc Intervent Radiol 2016 39 161 169 Jones P Rai BP Nair R Somani BK Current status of prostate artery embolization for lower urinary tract symptoms: review of world literature Urology 2015 86 676 681 Bilhim T Tinto HR Fernandes L Martins Pisco J Radiological anatomy of prostatic arteries Tech Vasc Interv Radiol 2012 15 276 285 Martins Pisco J J Pereira J Rio Tinto H Fernandes L Bilhim T How to perform prostatic arterial embolization Tech Vasc Interv Radiol 2012 15 286 289 Fernandes L Rio Tinto H Pereira J Duarte M Bilhim T Martins Pisco J Prostatic arterial embolization: postprocedural follow-up Tech Vasc Interv Radiol 2012 15 294 299 A Pereira J Bilhim T Duarte M Rio Tinto H Fernandes L Martins Pisco J Patient selection and counseling before prostatic arterial embolization Tech Vasc Interv Radiol 2012 15 270 275 Pisco JM Rio Tinto H Campos Pinheiro L Bilhim T Duarte M Fernandes L Embolisation of prostatic arteries as treatment of moderate to severe lower urinary symptoms (LUTS) secondary to benign hyperplasia: results of short- and mid-term follow-up Eur Radiol 2013 23 2561 2572 Bhatia S Harward SH Sinha VK Narayanan G Prostate artery embolization via transradial or transulnar versus transfemoral arterial access: technical results J Vasc Interv Radiol 2017 28 898 905 Bagla S Rholl KS Sterling KM Van Breda A Papadouris D Cooper JM Utility of cone-beam CT imaging in prostatic artery embolization J Vasc Interv Radiol 2013 24 1603 1607 Pisco J Campos Pinheiro L Bilhim T Duarte M Rio Tinto H Fernandes L Prostatic arterial embolization for benign prostatic hyperplasia: short- and intermediate-term results Radiology 2013 266 668 677 Bilhim T Pisco J Campos Pinheiro L Rio Tinto H Fernandes L Pereira JA Does polyvinyl alcohol particle size change the outcome of prostatic arterial embolization for benign prostatic hyperplasia? Results from a single-center randomized prospective study J Vasc Interv Radiol 2013 24 1595 1602.e1 Laurent A Microspheres and nonspherical particles for embolization Tech Vasc Interv Radiol 2007 10 248 256 Hwang JH Park SW Chang IS Jung SI Jeon HJ Lho YS Comparison of nonspherical polyvinyl alcohol particles and microspheres for prostatic arterial embolization in patients with benign prostatic hyperplasia Biomed Res Int 2017 2017 8732351 Bhatia S Sinha V Bordegaray M Kably I Harward S Narayanan G Role of coil embolization during prostatic artery embolization: incidence, indications, and safety profile☆ J Vasc Interv Radiol 2017 28 656 664.e3 Pisco JM Pinheiro LC Bilhim T Duarte M Mendes JR Oliveira AG Prostatic arterial embolization to treat benign prostatic hyperplasia J Vasc Interv Radiol 2011 22 11 19 quiz 20 Bilhim T Pisco J Rio Tinto H Fernandes L Campos Pinheiro L Duarte M Unilateral versus bilateral prostatic arterial embolization for lower urinary tract symptoms in patients with prostate enlargement Cardiovasc Intervent Radiol 2013 36 403 411 Henry BM Pekala PA Vikse J Sanna B Skinningsrud B Saganiak K Variations in the arterial blood supply to the penis and the accessory pudendal artery: a meta-analysis and review of implications in radical prostatectomy J Urol 2017 198 345 353 An ipsilateral oblique view of the right internal iliac arteriogram demonstrates the anterior and posterior branches.

GPT = gluteal-pudendal trunk, IGA = inferior gluteal artery, IPA = internal pudendal artery, OA = obturator artery, PA = prostatic artery, SGA = superior gluteal artery

 A 76-year-old man with benign prostatic hyperplasia and lower urinary tract symptoms treated with PAE.

A. An ipsilateral oblique view of the left internal iliac angiogram shows the prostatic artery (white arrows) originating from the anterior division of the internal iliac artery (black arrow).

B. The left prostatic artery (white arrow) originating from the common trunk (black dotted arrow) of the internal pudendal artery (black arrow) and inferior gluteal artery (white dotted arrow).

C. The right prostatic artery (white arrow) originating from the internal pudendal artery (black arrow).

D, E. Selective angiography of both prostatic arteries (arrows) on anterior-posterior projection shows staining of the prostate gland (asterisks) with increased vascularity. A PAE with a microsphere (300–500 µm) was performed.

PAE = prostatic artery embolization

F, G. Trans-rectal ultrasound before (F) and after (G) PAE shows the prostatic volumes of 213.1 cc and 112.5 cc, respectively (a reduction of 47.2% after PAE).

 A 58-year-old man with benign prostatic hyperplasia and lower urinary tract symptoms treated with prostatic artery embolization.

A. Selective angiography of the right accessory pudendal artery (white arrows) on anterior-posterior projection shows parenchymal staining of both prostate lobes (white asterisks) supplied by fine prostatic branches (white dotted arrows). The tip of the microcatheter (black arrow) is positioned in the accessory pudendal artery just proximal to the origin of the inferior vesical artery (black dotted arrows). Arterial supply (black asterisk) to the penis is observed.

B. After embolization, arterial supply to the penis and prostate gland was absent. Temporary erectile dysfunction had occurred, which improved 3 weeks later without any specific treatment.

 International Prostate Symptom Score