Treatment of Benign Prostatic Hyperplasia by Occlusion of the Impaired Urogenital Venous System – First Experience

Abstract

Purpose: To effect regression of benign prostatic hyperplasia (BPH), Gat et al. (Andrologia 2008) proposed to occlude incompetent spermatic veins to reduce increased hydrostatic pressure on the prostatic venous plexus and prevent reflux with androgen rich blood from the testicles. Our aim was to implement this treatment strategy in clinical practice and to report about first results. Methods: Embolization of the spermatic veins was performed in 30 patients with BPH. In 16 patients, we obtained follow-up data from at least 6 months. The sonographic transabdominal prostatic volume, prostate-specific antigen (PSA) and peripheral total testosterone levels were determined before and 6 months after the intervention. Subjective symptomatology was assessed using standardized questionnaires (International Prostate Symptom Score [IPSS] and Quality of Life score [QoL]) before and 6 months after the procedure. Results: The age of all treated patients was 46???77 years. The age of the 16 patients who received follow-up was 51???77 years. IPSS (median 18 [IQR 20.75???14.50] vs. 9 [IQR 11.00???7.25], p?<?0.0001) and QoL score (4 [IQR 5???3] vs. 2 [IQR 3???1], p?<?0.001) were significantly decreased 6 months after the intervention. The subjective improvement of symptoms did not correspond with prostatic volumes, which did not change significantly (54.31???30.90 vs. 50.50???29.26?ml, p?=?n.?s.). 4/16 patients had a measurable post-void urine volume, which decreased in two patients 6 months after the procedure, remained unchanged in one patient, and was no longer detectable in one patient. 4 of the 11 had a sonographically detectable varicocele before the intervention, and one patient had a trabeculated bladder. Both the peripheral total testosterone levels (4.55???1.27 vs. 3.93???1.00?ng/ml; p?=?n.?s.) and PSA levels (3.74???2.83 vs. 4.06???3.34?ng/ml; p?=?n.?s.) showed no significant differences. Conclusion: Interventional occlusion of the spermatic veins in patients with BPH is a feasible outpatient procedure with a low complication rate. Intermediate results are satisfactory. Mid- and long-term results and pathophysiologic mechanisms need to be further elucidated. Key Points: ??Venous embolization in patients with BPH is a feasible outpatient procedure. ??It shows satisfactory intermediate result with good symptom relief. ??Medium and long-term results need to be further evaluated. Citation Format: ??Strunk H, Meier M, Schild HH et?al. Treatment of Benign Prostatic Hyperplasia by Occlusion of the Impaired Urogenital Venous System ? First Experience. Fortschr R?ntgenstr 2015; 187: 180???186

Varicocele is the root cause ofBPH: Destruction of the valves in the spermatic veins produces elevated pressure which diverts undiluted testosterone directly from the testes to the prostate

“…These patients had not been previously diagnosed with varicocele on clinical studies and all were found to have bilateral ISV valvular insufficiency at venography. (Rauch & Strunk, 2017;Strunk, Meier, Schild, & Rauch, 2015) Our observations give new life to the pioneering work of Huggins and Hodges over 70 years ago. In 1940, they had made the observation that long exposure of the prostate to high testosterone concentration leads to BPH (Huggins & Stevens, 1940).…”

“…These patients had not been previously diagnosed with varicocele on clinical studies and all were found to have bilateral ISV valvular insufficiency at venography. (Rauch & Strunk, ; Strunk, Meier, Schild, & Rauch, )…”

Reply to Letter

“…We would like to impress upon the authors that our paper described a proposed theory to explain the clinical findings. Other authors have proposed different methods for reducing benign prostatic hyperplasia by embolising venous pathways in the pelvis, and indeed, the mechanism of action is complex [2]. In this case, resolution was firstly described by the patient as resolution of symptoms in \ 24 h; this was subsequently confirmed on ultrasound imaging.…”

Benign Prostatic Hyperplasia: Long-term follow-up of prostate volume reduction after sclerotherapy of the internal spermatic veins

“…Strunk et al. () conducted a randomised study of 30 patients recently published, who were treated for BPH using this technique. They also demonstrated reversal of flow direction in the prostatic venous drainage system in their patients.…”

“…This free testosterone‐rich blood arrives directly to the prostate before it has undergone full volumetric dilution (Gat, Joshua & Gornish, ; Gat et al., ; Jarow, Chen, Trentacoste, & Zirkin, 2001; Strunk, Meier, Schild, & Rauch, ). Extremely high concentration of free testosterone, more than 100 times the systemic serum concentration, flows directly into the prostate, via this previously unknown route as we have directly demonstrated in venographic images obtained during the interventional radiology procedure (Figure ).…”