Patient Selection and Counseling before Prostatic Arterial Embolization
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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2017, Canadian Association of Radiologists JournalCitation Excerpt :Although PAE promises to be a viable therapeutic alternative for BPH, current evidence remains limited, and PAE for the treatment of BPH should, at present, be considered only in patients who have failed medical therapy and either refuse surgery or are contraindicated for surgery. It is also important to recognize that LUTS has a multitude of causes apart from BPH, including neurologic disease, bladder dysfunction, urinary tract infection, stone disease, and urethral stricture, among others; these conditions should be excluded prior to treatment, as PAE would be unlikely to be helpful for these conditions [32]. Further research is needed to define clear indications and contraindications for PAE.