Intentionally unilateral prostatic artery embolization: Patient selection, technique and potential benefits

Prostatic artery embolization (PAE) is a promising but also technically demanding interventional radiologic treatment for symptomatic benign prostatic hyperplasia. Many technical challenges in PAE are associated with the complex anatomy of prostatic arteries (PAs) and with the systematic attempts to catheterize the PAs of both pelvic sides. Long procedure times and high radiation doses are often the result of these attempts and are considered significant disadvantages of PAE. The authors hypothesized that, in selected patients, these disadvantages could be mitigated by intentionally embolizing PAs of only one pelvic side.

To describe the authors' approach for intentionally unilateral PAE (IU-PAE) and its potential benefits.

This was a single-center retrospective study of patients treated with IU-PAE during a period of 2 years. IU-PAE was applied in patients with opacification of more than half of the contralateral prostatic lobe after angiography of the ipsilateral PA (subgroup A), or with markedly asymmetric prostatic enlargement, with the dominant prostatic lobe occupying at least two thirds of the entire gland (subgroup B). All patients treated with IU-PAE also fulfilled at least one of the following criteria: Severe tortuosity or severe atheromatosis of the pelvic arteries, non-visualization, or visualization of a tiny (< 1 mm) contralateral PA on preprocedural computed tomographic angiography. Intraprocedural contrast-enhanced ultrasonography (iCEUS) was applied to monitor prostatic infarction. IU-PAE patients were compared to a control group treated with bilateral PAE.

IU-PAE was performed in a total 13 patients (subgroup A, n = 7; subgroup B, n = 6). Dose-area product, fluoroscopy time and operation time in the IU-PAE group (9767.8 μGy∙m², 30.3 minutes, 64.0 minutes, respectively) were significantly shorter (45.4%, 35.9%, 45.8% respectively, P < 0.01) compared to the control group. Clinical and imaging outcomes did not differ significantly between the IU-PAE group and the control group. In the 2 clinical failures of IU-PAE (both in subgroup A), the extent of prostatic infarction (demonstrated by iCEUS) was significantly smaller compared to the rest of the IU-PAE group.

In selected patients, IU-PAE is associated with comparable outcomes, but with lower radiation exposure and a shorter procedure compared to bilateral PAE. iCEUS could facilitate patient selection for IU-PAE.