Patient Selection and Counseling before Prostatic Arterial Embolization

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Prostatic arterial embolization (PAE) for relief of lower urinary tract symptoms (LUTS) in patients with prostate enlargement or benign prostatic hyperplasia (PE or BPH) is an experimental procedure with promising preliminary results. Patient evaluation and selection before PAE is paramount to improve technical and clinical results. Our inclusion criteria for PAE include: male patients, age>40 years, prostate volume>30 cm3 and diagnosis of PE or BPH with moderate to severe LUTS refractory to medical treatment for at least 6 months (International Prostate Symptom Score [IPSS]>18, or quality of life [QoL]>3, or both) or with acute urinary retention refractory to medical therapy. Exclusion criteria include: malignancy (based on pre-embolization digital rectal and transrectal ultrasound [TRUS] examinations and prostate specific antigen [PSA] measurements with positive biopsy), large bladder diverticula, large bladder stones, chronic renal failure, tortuosity and advanced atherosclerosis of a) iliac or b) prostatic arteries on pre-procedural computed tomographic angiography (CTA), active urinary tract infection and unregulated coagulation parameters. Approximately one-third of the patients seen initially on consultation satisfy the criteria to be selected for PAE after undergoing the pre-procedural patient evaluation workflow. In the pre-procedural consultation patients are informed of all possible therapeutic options for LUTS with the investigational nature of the procedure being strongly reinforced. The major advantage of PAE relies on the minimally-invasive nature of the technique with minimal morbidity and rapid recovery,and it being performed as an outpatient procedure. However, the experimental nature and uncertain clinical outcome should also be weighed before opting for PAE. All these considerations should be explained to the patient and discussed during the informed consent before PAE.

Section snippets

Clinical Evaluation: International Prostate Symptom Score (IPSS), Quality of Life (QoL), and International Index of Erectile Function (IIEF)

Lower urinary tract symptoms (LUTS) are frequently associated with prostate enlargement or benign prostatic hyperplasia (PE or BPH). LUTS are broadly categorized as involving problems of either bladder emptying (voiding and postmicturation) or bladder storage. Emptying problems include hesitancy in initiation of voiding, weak stream, dribbling, diminished stream caliber, stop-start urination, and urinary retention, usually ascribed to the mechanical impact of an enlarged prostatic transitional

Prostatic Medication

Medical therapy is a first-line treatment option and surgery is usually performed to improve symptoms and decrease progression of the disease in patients who develop complications or who have inadequately controlled symptoms on medical treatment.7

It is suggested that patients with mild symptoms of BPH (IPSS≤7) and others with moderate or severe symptoms (IPSS≥8) who are not bothered by their symptoms (i.e., they do not interfere with daily activities of living) should be managed using a

Prostate Volume Assessment, PSA Evaluation, and Cancer Screening

Prostate volume assessment by digital rectal examination (DRE) and transrectal ultrasound (TRUS) is routinely performed . As a general guideline, an enlarged prostate (prostate volume >30 mL) is indicated by a more than 2 finger width diameter at DRE.8 In addition, DRE may also detect concomitant cancer.9 However, in men with larger prostates, accurate assessment of size and volume is challenging,10 therefore TRUS is also performed as it allows a more accurate measurement.

The serum PSA test is

Uroflow Studies

For patients who indicate that their symptoms are especially troublesome, or in whom pharmacological management has produced suboptimal results, uroflowmetry may be warranted. This test measures the maximum flow rate (Qmax) and the post-void residual volume (PVR). The Qmax and PVR give useful information on micturation, and the results can be used to assess severity of obstruction, predict the likelihood of disease progression and response to treatment. The normal Qmax in a young healthy adult

Inclusion and Exclusion Criteria and Pre-procedural Patient Evaluation Workflow

We don't treat patients without clinical indication and strictly respect the inclusion and exclusion criteria. It is ensured that medical therapy has been attempted without success for at least 6 months. We work with our referring urologists and discuss the different treatment options in complex cases. Treatment is planned before entering the angio suite with computed tomographic angiography (CTA) and procedures which do not suit the arterial anatomy are not accepted.

Inclusion criteria for PAE

Informed Consent and Patient Counseling

In the preprocedural consultation patients are informed of all the possible therapeutical options for LUTS, and the investigational nature of the procedure is strongly reinforced. It is explained to the patients that because of the experimental nature of the procedure tight clinical evaluation will be performed before and after PAE. Before and after PAE (1 month, 6 months, 12 months, 18 months, 2 years and 3 years) patients are evaluated with IPSS, QoL, IIEF, Qmax, PVR, prostate volume on TRUS

Conclusions

Preprocedural clinical evaluation and patient selection for PAE are paramount to improve technical and clinical results. Knowledge of all the most relevant clinical parameters, exams, patient management, and prostatic medications are important in patient evaluation and selection before PAE. Rigorous inclusion and exclusion criteria are very important. When counseling patients before PAE the experimental nature of the procedure should be clearly explained and all possible therapeutic options

Acknowledgments

This work reflects in part the work from Bilhim T. Embolizaão das artérias prostáticas no tratamento da hiperplasia benigna da próstata. PhD thesis, Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisbon, Portugal, May 2011. The corresponding author confirms that he has full access to all the data in this study and has final responsibility for the decision to submit it for publication.

The author had full access to all of the data in the study and takes responsibility for the

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