Prostate artery embolization as an effective treatment for clinically significant prostate cancer‑related hemorrhage:...

A 79-year old Caucasian male with metastatic hormone refractory prostate cancer and bilateral nephrostomy was admitted to the emergency department due to 4-day bloody urethral discharge, weakness and dizziness. The patient was treated with the luteinizing hormone-releasing hormone-antagonist and abiraterone acetate plus prednisone, dabigatran 150 mg bid (for atrial fibrillation and coronary heart disease) and 5-aminosalicylic acid for the management of mild ulcerative colitis. Imaging revealed bladder overdistention and blood analysis low levels of hematocrit (HCT) and hemoglobin (HGB) (HCT, 22%; HGB, 7.1 gr/dl). A 22F, 3-way urethral catheter was placed, and blood clots were removed with a syringe. Continuous normal saline irrigation was initiated, and the dabigatran was withdrawn; however, no evidence of control of blood loss was shown. Computed tomography and urography revealed a large prostate lesion invading the bladder neck, a pelvic lymph-node block and lack of blood extravasation. Diagnostic urethrocystoscopy revealed diffuse hematuria from the prostate lesion and bladder neck. Bipolar coagulation was performed in the absence of any significant improvement. Upon withdrawal of intravesical irrigation, the oral consumption of a large water volume (a useful measure to control hematuria and avoid clot formation) could not be applied to the patient due to urine storage and normal voiding being not feasible. Subsequently, the patient was informed on the option of superselective arterial embolization (SAE). Following signing of the relevant consent form, the patient underwent bilateral SAE of prostatic and inferior cystic arteries, while he was in heparin delivery. Dabigatran was re-administered on the 5th postprocedural day and the catheter was removed following 5 days. Following a 4-month follow-up, the patient's condition was stable with no traceable hematuria. In conclusion, the minimal invasiveness of SAE is an attractive option, notably in patients with cardiovascular comorbidities. It appears to be a safe alternative with an acceptable rate of minor complications. The encouraging results and the survival outcomes warrant further evaluation with comparative prospective multicenter studies.