Advanced image guidance for prostatic artery embolization – a multicenter technical note

Abstract

Background Prostatic artery embolization (PAE) is associated with patients’ quality of life improvements and limited side effects compared to surgery. However, this procedure remains technically challenging due to complex vasculature, anatomical variations and small arteries, inducing long procedure times and high radiation exposure levels both to patients and medical staff. Moreover, the risk of non-target embolization can lead to relevant complications. In this context, advanced imaging can constitute a solid ally to address these challenges and deliver good clinical outcomes at acceptable radiation levels. Main text This technical note aims to share the consolidated experience of four institutions detailing their optimized workflow using advanced image guidance, discussing variants, and sharing their best practices to reach a consensus standardized imaging workflow for PAE procedure, as well as pre and post-operative imaging. Conclusions This technical note puts forth a consensus optimized imaging workflow and best practices, with the hope of helping drive adoption of the procedure, deliver good clinical outcomes, and minimize radiation dose levels and contrast media injections while making PAE procedures shorter and safer.

Prostate artery embolization on lower urinary tract symptoms related to benign prostatic hyperplasia: A systematic review and meta-analysis

“…In the UK Register of Prostate Embolization study, PAE had a reoperation rate of 19.9% within 2 years, whereas only 5% of men who had undergone an initial TURP procedure needed repeat surgery[ 32 ]. Furthermore, patients with suboptimal outcomes after PAE were more likely to receive escalation, such as resective techniques, whereas patients were more likely to receive pharmacological treatment after TURP[ 33 ]. PAE may fill a therapeutic gap between pharmacological and surgical treatment in the treatment pathway of patients with LUTS/BPH or even replace pharmacological treatment in selected patients.…”

Prostatic Artery Embolization: Technical Pearls

“…The following injection parameters are typically used: 22 to 26 mL of pure contrast, injected at 2 mL/second, with an X-ray delay of 6 to 8 seconds. 29 Distal CBCT is performed with the microcatheter tip in PA. The protocol for this CBCT includes injection of 2 to 4 mL of contrast into the PA based on the size of the gland, immediately followed by 5-or 6-second spin.…”

“…The following injection parameters are typically used: 22 to 26 mL of pure contrast, injected at 2 mL/second, with an X-ray delay of 6 to 8 seconds. 29…”

Controversies in Prostate Artery Embolization: Future Best Practice

“…There is considerable variability among men in prostatic artery origins, and even more so in collateral blood supply both to the prostate and to neighboring organs. 27 However, efficacy and safety depend on thorough identification of pelvic arterial anatomy such that all blood supply to the prostate is occluded while preventing any nontarget embolization. Using digital subtraction angiography (DSA) only at predefined angulations can lead to incomplete identification of prostatic supply, and high levels of radiation exposure.…”

“…Using digital subtraction angiography (DSA) only at predefined angulations can lead to incomplete identification of prostatic supply, and high levels of radiation exposure. 27 Thus, to better identify soft tissues, target vessels, and anastomoses, both preprocedural MRI or CTA and intraoperative conebeam computed tomography (CBCT) are utilized. 27 However, as mentioned previously, preoperative imaging is not part of routine BPH workup.…”