Case Conference

Nelly Tan

Resident

Case

63 yo AA, BPH s/p Urolift

IPSS score = 32/35 (severe)

Incomplete emptying: 5

Frequency: 4

Intermittency: 4

Urgency: 5

Weak Stream: 5

Straining: 4

Nocturia: 5

QOL: 6 (Terrible)

IIEF: 7 (severe ED)

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Urolift

• 3 year study: 88% improvement in IPSS score vs sham
• 15/140 (10.7%) in intervention arm required post-tx surgical treatment

Can J Urol. 2015 Jun;22(3):7772-82.

Left Pre and Post Embo

Right Pre- & Post- Embo

BPH

• In 2000, 4.5 million with primary dx of BPH
• 87,000 prostatectomy done for BPH
• $1.1 billion/ yr US
• Olmstead county study: prevalence of moderate to severe LUTS was 26%, 33%, 41%, and 46% of men in 5th, 6th, 7th, 8th
• Moderate to severe LUTS in 40% of AA

J.T. Wei, E. Calhoun, S.J. Jacobsen Urologic diseases in America project: benign prostatic hyperplasia J Urol, 173 (2005), pp. 1256–1261

BPH

Benign prostatic hyperplasia (BPH): proliferation of smooth muscle and epithelial cells within central gland

Cause lower urinary tract symptoms (LUTS) via

•Direct bladder outlet obstruction (BOO)

•Increased smooth muscle tone and resistance within the enlarged gland

Can cause acute urinary retention (AUR) and poor quality of life due to urinary frequency

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AUA 2010 Guidelines

AUA Symptom Score

Quantify severity by AUA Symptom Score Index

Divided into overactive bladder symptoms (urgency, frequency, ect) and obstructive (weak stream, straining, ect)

50% men with moderate to severe LUTS by 8^th decade

Not life threatening, but impact of QoL

BPH Treatment

•Watchful waiting: Mild symptoms or not bothersome

•Medical (moderate to severe symptoms)

–α adrenergic blockers, 5 alpha reductase inhibitor (5-ARI), Anti-cholinergics

–Combination therapy

•α blockers + 5 ARI

•α blockers + anti-cholinergics

•Minimally invasive therapy

–Transurethral resection of the prostate (TURP): 80% → 30%

–Laser vaporization: increasing

Improves IPSS score ~ 70-80%

(Urolift, Embolization)

•Prostatectomy (rare)

AUA BPH Guidelines 2010; Urology. 2015 Oct;86(4):676-81. doi: 10.1016/j.urology.2015.05.011. Epub 2015 Jul 31.

PAE

• First case 2000 done for acute urinary retention
• Largest study 255 pts (Pisco): time =73 min; technical success 98%; Sexual function score improves 48%
• Prostate volume reduction by 30-50%
• RCT: TURP vs PAE (Gao), n=114
• Moderate to severe LUTS
• At 2 yrs, similar IPSS and sexual function
• Clinical (9.4 vs 3.9%) and technical (5.3 vs 0%) failure higher in PAE.
• Post embolization 11%; Acute retention 26% PAE vs 6% TURP
• Hematuria 7% TURP

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J Vasc Interv Radiol, 11 (2000), pp. 767–770; J.M.

Pisco, H.R. Tinto, L.C. Pinheiro, et al. Eur Radiol, 23 (2013), pp. 2561–2572

D. Kurbatov, G.I. Russo, A. Lepetukhin, et al. Urology, 84 (2014), pp. 400–404

Y.A. Gao, Y. Huang, R. Zhang, et al. Radiology, 270 (2014), pp. 920–928

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Angiographic Anatomy

AJR Am J Roentgenol. 2014 Oct;203(4):W373-82. doi: 10.2214/AJR.13.11687. Bilhim T1, Pereira JA, Fernandes L, Rio Tinto H, Pisco JM.

Type A (60-80%)

Superior glut (posterior)

Anterior glut & pudental (anterior)

Type B (15-30%)

Common gluteal (posterior)

Internal pudental (anterior)

Type C (5-7%)

Trifurcation: superior, inferior glut, pudental

Type D (0.2%)

Superior glut + pudental (anterior)

Inferior glut (posterior)

AJR Am J Roentgenol. 2014 Oct;203(4):W373-82. doi: 10.2214/AJR.13.11687. Bilhim T1, Pereira JA, Fernandes L, Rio Tinto H, Pisco JM.

S Glut (P)

Inf Pud

Inf Glut (A)

Sf Glut

Int Pud (A)

Int Pud (A)

Int Pud

S Glut (P)

Inf Glut (P)

S Glut

Inf Glut

Inf Glut (P)

Int Pud (A)

Conventional Type A

SIR Position Statement

• Safe and effective based on short-term results
• Subspecialist best suited given technically challenging, requires use of microcatheter
• Supports high quality research

J Vasc Interv Radiol. 2014 Sep;25(9):1349-51. doi: 10.1016/j.jvir.2014.05.005. Epub 2014 Jun 30.