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Prostatic Artery Embolization (PAE) for Symptomatic Benign Prostatic Hyperplasia (BPH): Part 2, Insights into the Technical Rationale

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Abstract

Rationale of prostatic artery embolization (PAE) in the treatment of symptomatic benign prostatic hyperplasia is conventionally believed to include two parts: shrinkage of the enlarged prostate gland as a result of PAE-induced ischemic infarction and potential effects to relax the increased prostatic smooth muscle tone by reducing the number and density of α1-adrenergic receptor in the prostate stroma. This review describes new insights into the likely mechanisms behind PAE, such as ischemia-induced apoptosis, apoptosis enhanced by blockage of androgens circulation to the embolized prostate, secondary denervation following PAE, and potential effect of nitric oxide pathway immediately after embolization. Studies on therapeutic mechanisms in PAE may shed light on potentially new treatment strategies and development of novel techniques.

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References

  1. Smith JC Jr, Kerr WS, Athanasoulis CA, Waltman AC, Ring EJ, Baum S. Angiographic management of bleeding secondary to genitourinary tract surgery. J Urol. 1975;113(1):89–92.

    PubMed  Google Scholar 

  2. Mitchell ME, Waltman AC, Athanasoulis CA, Kerr WS Jr, Dretler SP. Control of massive prostatic bleeding with angiographic techniques. J Urol. 1976;115(6):692–5.

    CAS  PubMed  Google Scholar 

  3. Hare WS, Holland CJ. Paresis following internal iliac artery embolization. Radiology. 1983;146(1):47–51.

    Article  CAS  PubMed  Google Scholar 

  4. Appleton DS, Sibley GN, Doyle PT. Internal iliac artery embolisation for the control of severe bladder and prostate haemorrhage. Br J Urol. 1988;61(1):45–7.

    Article  CAS  PubMed  Google Scholar 

  5. Pisco JM, Martins JM, Correia MG. Internal iliac artery: embolization to control hemorrhage from pelvic neoplasms. Radiology. 1989;172(2):337–9.

    Article  CAS  PubMed  Google Scholar 

  6. Delgal A, Cercueil JP, Koutlidis N, Michel F, Kermarrec I, Mourey E, Cormier L, Krausé D, Loffroy R. Outcome of transcatheter arterial embolization for bladder and prostate hemorrhage. J Urol. 2010;183(5):1947–53.

    Article  PubMed  Google Scholar 

  7. Loffroy R, Pottecher P, Cherblanc V, Favelier S, Estivalet L, Koutlidis N, Moulin M, Cercueil JP, Cormier L, Krausé D. Current role of transcatheter arterial embolization for bladder and prostate hemorrhage. Diagn Interv Imaging. 2014;95(11):1027–34.

    Article  CAS  PubMed  Google Scholar 

  8. Jander HP, Russinovich NA. Transcatheter gelfoam embolization in abdominal, retroperitoneal, and pelvic hemorrhage. Radiology. 1980;136(2):337–44.

    Article  CAS  PubMed  Google Scholar 

  9. DeMeritt JS, Elmasri FF, Esposito MP, Rosenberg GS. Relief of benign prostatic hyperplasia-related bladder outlet obstruction after transarterial polyvinyl alcohol prostate embolization. J Vasc Interv Radiol. 2000;11(6):767–70.

    Article  CAS  PubMed  Google Scholar 

  10. Sun F, Sánchez FM, Crisóstomo V, Lima JR, Luis L, García-Martínez V, López-Sánchez C, Usón J, Maynar M. Benign prostatic hyperplasia: transcatheter arterial embolization as potential treatment-preliminary study in pigs. Radiology. 2008;246(3):783–9.

    Article  PubMed  Google Scholar 

  11. Mauro MA. Can hyperplastic prostate follow uterine fibroids and be managed with transcatheter arterial embolization? Radiology. 2008;246(3):657–8.

    Article  PubMed  Google Scholar 

  12. Faintuch S, Mostafa EM, Carnevale FC, Ganguli S, Rabkin DJ, Goldberg SN. Prostatic artery embolization as a primary treatment for benign prostatic hyperplasia in a canine model (abstract). J Vasc Interv Radiol. 2008;19(2):S1–210.

    Article  Google Scholar 

  13. Carnevale FC, Antunes AA, da Motta Leal Filho JM, de Oliveira Cerri LM, Baroni RH, Marcelino AS, Freire GC, Moreira AM, Srougi M, Cerri GG. Prostatic artery embolization as a primary treatment for benign prostatic hyperplasia: preliminary results in two patients. Cardiovasc Intervent Radiol. 2010;33(2):355–61.

    Article  PubMed Central  PubMed  Google Scholar 

  14. Pisco JM, Pinheiro LC, Bilhim T, Duarte M, Mendes JR, Oliveira AG. Prostatic arterial embolization to treat benign prostatic hyperplasia. J Vasc Interv Radiol. 2011;22(1):11–9.

    Article  PubMed  Google Scholar 

  15. McWilliams JP, Kuo MD, Rose SC, Bagla S, Caplin DM, Cohen EI, Faintuch S, Spies JB, Saad WE, Nikolic B. Society of interventional radiology position statement: prostate artery embolization for treatment of benign disease of the prostate. J Vasc Interv Radiol. 2014;25(9):1349–51.

    Article  PubMed  Google Scholar 

  16. Stokes LS, Wallace MJ, Godwin RB, Kundu S, Cardella JF, Society of Interventional Radiology Standards of Practice Committee. Quality improvement guidelines for uterine artery embolization for symptomatic leiomyomas. J Vasc Interv Radiol. 2010;21(8):1153–63.

    Article  PubMed  Google Scholar 

  17. Drooz AT, Lewis CA, Allen TE, Citron SJ, Cole PE, Freeman NJ, Husted JW, Malloy PC, Martin LG, Van Moore A, Neithamer CD, Roberts AC, Sacks D, Sanchez O, Venbrux AC, Bakal CW, Society of Interventional Radiology Standards of Practice Committee. Quality improvement guidelines for percutaneous transcatheter embolization. J Vasc Interv Radiol. 2003;14(9):S237–42.

    PubMed  Google Scholar 

  18. Camara-Lopes G, Mattedi R, Antunes AA, Carnevale FC, Cerri GG, Srougi M, Alves VA, Leite KR. The histology of prostate tissue following prostatic artery embolization for the treatment of benign prostatic hyperplasia. Int Braz J Urol. 2013;39(2):222–7.

    PubMed  Google Scholar 

  19. Pisco J, Campos Pinheiro L, Bilhim T, Duarte M, Rio Tinto H, Fernandes L, Vaz Santos V, Oliveira AG. Prostatic arterial embolization for benign prostatic hyperplasia: short- and intermediate-term results. Radiology. 2013;266(2):668–77.

    Article  PubMed  Google Scholar 

  20. Carnevale FC, da Motta-Leal-Filho JM, Antunes AA, Baroni RH, Marcelino AS, Cerri LM, Yoshinaga EM, Cerri GG, Srougi M. Quality of life and clinical symptom improvement support prostatic artery embolization for patients with acute urinary retention caused by benign prostatic hyperplasia. J Vasc Interv Radiol. 2013;24(4):535–42.

    Article  PubMed  Google Scholar 

  21. Bagla S, Martin CP, van Breda A, Sheridan MJ, Sterling KM, Papadouris D, Rholl KS, Smirniotopoulos JB, van Breda A. Early results from a United States trial of prostatic artery embolization in the treatment of benign prostatic hyperplasia. J Vasc Interv Radiol. 2014;25(1):47–52.

    Article  PubMed  Google Scholar 

  22. Brook OR, Faintuch S, Brook A, Goldberg SN, Rofsky NM, Lenkinski RE. Embolization therapy for benign prostatic hyperplasia: influence of embolization particle size on gland perfusion. J Magn Reson Imaging. 2013;38(2):380–7.

    Article  PubMed  Google Scholar 

  23. Bilhim T, Pisco J, Pinheiro LC, Tinto HR, Fernandes L, Pereira JA, Duarte M, Oliveira AG. Does polyvinyl alcohol particle size change the outcome of prostatic arterial embolization for benign prostatic hyperplasia? Results from a single-center randomized prospective study. J Vasc Interv Radiol. 2013;24(11):1595–602.

    Article  PubMed  Google Scholar 

  24. Wang MQ, Guo LP, Zhang GD, Yuan K, Li K, Duan F, Yan JY, Wang Y, Kang HY, Wang ZJ. Prostatic arterial embolization for the treatment of lower urinary tract symptoms due to large (>80 mL) benign prostatic hyperplasia: results of midterm follow-up from Chinese population. BMC Urol. 2015;15:33.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  25. Kurbatov D, Russo GI, Lepetukhin A, Dubsky S, Sitkin I, Morgia G, Rozhivanov R, Cimino S, Sansalone S. Prostatic artery embolization for prostate volume greater than 80 cm3: results from a single-center prospective study. Urology. 2014;84(2):400–4.

    Article  PubMed  Google Scholar 

  26. de Assis AM, Moreira AM, de Paula Rodrigues VC, Yoshinaga EM, Antunes AA, Harward SH, Srougi M, Carnevale FC. Prostatic artery embolization for treatment of benign prostatic hyperplasia in patients with prostates >90 g: a prospective single-center study. J Vasc Interv Radiol. 2015;26(1):87–93.

    Article  PubMed  Google Scholar 

  27. Golzarian J, Weng L. Particle embolization: factors affecting arterial distribution. J Vasc Interv Radiol. 2014;25(11):1773–4.

    Article  PubMed  Google Scholar 

  28. Ofjord ES, Clausen G. Intrarenal flow of microspheres and red blood cells: skimming in slit and tube models. Am J Physiol. 1983;245(3):H429–36.

    CAS  PubMed  Google Scholar 

  29. Bilhim T, Pisco JM, Tinto HR, Fernandes L, Pinheiro LC, Furtado A, Casal D, Duarte M, Pereira J, Oliveira AG, O’Neill JE. Prostatic arterial supply: anatomic and imaging findings relevant for selective arterial embolization. J Vasc Interv Radiol. 2012;23(11):1403–15.

    Article  PubMed  Google Scholar 

  30. Carnevale FC, Moreira AM, Antunes AA. The “PErFecTED technique”: proximal embolization first, then embolize distal for benign prostatic hyperplasia. Cardiovasc Intervent Radiol. 2014;37(6):1602–5.

    Article  PubMed  Google Scholar 

  31. Pareek G, Shevchuk M, Armenakas NA, Vasjovic L, Hochberg DA, Basillote JB, Fracchia JA. The effect of finasteride on the expression of vascular endothelial growth factor and microvessel density: a possible mechanism for decreased prostatic bleeding in treated patients. J Urol. 2003;169(1):20–3.

    Article  CAS  PubMed  Google Scholar 

  32. Monti S, Sciarra F, Adamo MV, Toscano V, Trotta MC, Martini C, Lanzara S, Silverio FD. Prevalent decrease of the EGF content in the periurethral zone of BPH tissue induced by treatment with finasteride or flutamide. J Androl. 1997;18(5):488–94.

    CAS  PubMed  Google Scholar 

  33. Bilhim T. Response to “does polyvinyl alcohol particle size change the outcome of prostatic arterial embolization for benign prostatic hyperplasia? Results from a single-center randomized prospective study”. J Vasc Interv Radiol. 2014;25(4):659–60.

    Article  PubMed  Google Scholar 

  34. Kerr JF, Wyllie AH, Currie AR. Apoptosis: a basic biological phenomenon with wide-ranging implications in tissue kinetics. Br J Cancer. 1972;26(4):239–57.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  35. Haanen C, Vermes I. Apoptosis and inflammation. Mediat Inflamm. 1995;4(1):5–15.

    Article  CAS  Google Scholar 

  36. Lekås E, Engstrand C, Bergh A, Damber JE. Transient ischemia induces apoptosis in the ventral prostate of the rat. Urol Res. 1999;27(3):174–9.

    Article  PubMed  Google Scholar 

  37. Lekås E, Johansson M, Widmark A, Bergh A, Damber JE. Decrement of blood flow precedes the involution of the ventral prostate in the rat after castration. Urol Res. 1997;25(5):309–14.

    Article  PubMed  Google Scholar 

  38. Shabsigh A, Chang DT, Heitjan DF, Kiss A, Olsson CA, Puchner PJ, Buttyan R. Rapid reduction in blood flow to the rat ventral prostate gland after castration: preliminary evidence that androgens influence prostate size by regulating blood flow to the prostate gland and prostatic endothelial cell survival. Prostate. 1998;36(3):201–6.

    Article  CAS  PubMed  Google Scholar 

  39. Franck-Lissbrant I, Häggström S, Damber JE, Bergh A. Testosterone stimulates angiogenesis and vascular regrowth in the ventral prostate in castrated adult rats. Endocrinology. 1998;139(2):451–6.

    CAS  PubMed  Google Scholar 

  40. Sun F, Sánchez FM, Crisóstomo V, Díaz-Güemes I, López-Sánchez C, Usón J, Maynar M. Transarterial prostatic embolization: initial experience in a canine model. Am J Roentgenol. 2011;197(2):495–501.

    Article  Google Scholar 

  41. Frenk NE, Baroni RH, Carnevale FC, Gonçalves OM, Antunes AA, Srougi M, Cerri GG. MRI findings after prostatic artery embolization for treatment of benign hyperplasia. Am J Roentgenol. 2014;203(4):813–21.

    Article  Google Scholar 

  42. Carson C 3rd, Rittmaster R. The role of dihydrotestosterone in benign prostatic hyperplasia. Urology. 2003;61(4 Suppl 1):2–7.

    Article  PubMed  Google Scholar 

  43. Span PN, Völler MC, Smals AG, Sweep FG, Schalken JA, Feneley MR, Kirby RS. Selectivity of finasteride as an in vivo inhibitor of 5alpha-reductase isozyme enzymatic activity in the human prostate. J Urol. 1999;161(1):332–7.

    Article  CAS  PubMed  Google Scholar 

  44. Steers WD. 5alpha-reductase activity in the prostate. Urology. 2001;58(6):17–24.

    Article  CAS  PubMed  Google Scholar 

  45. Uygur MC, Arik AI, Altuğ U, Erol D. Effects of the 5 alpha-reductase inhibitor finasteride on serum levels of gonadal, adrenal, and hypophyseal hormones and its clinical significance: a prospective clinical study. Steroids. 1998;63(4):208–13.

    Article  CAS  PubMed  Google Scholar 

  46. Pisco JM, Tinto HR, Pinheiro LC, Bilhim T, Duarte M, Fernandes L, Pereira J, Oliveira AG. Embolisation of prostatic arteries as treatment of moderate to severe lower urinary symptoms (LUTS) secondary to benign hyperplasia: results of short- and mid-term follow-up. Eur Radiol. 2013;23(9):2561.

    Article  PubMed  Google Scholar 

  47. Antunes AA, Carnevale FC, da Motta Leal Filho JM, Yoshinaga EM, Cerri LM, Baroni RH, Marcelino AS, Cerri GG, Srougi M. Clinical, laboratorial, and urodynamic findings of prostatic artery embolization for the treatment of urinary retention related to benign prostatic hyperplasia. A prospective single-center pilot study. Cardiovasc Intervent Radiol. 2013;36(4):978–86.

    Article  PubMed  Google Scholar 

  48. Gormley GJ, Stoner E, Bruskewitz RC, Imperato-McGinley J, Walsh PC, McConnell JD, Andriole GL, Geller J, Bracken BR, Tenover JS, et al. The effect of finasteride in men with benign prostatic hyperplasia. The Finasteride Study Group. N Engl J Med. 1992;327(17):1185–91.

    Article  CAS  PubMed  Google Scholar 

  49. Smith AB, Carson CC. Finasteride in the treatment of patients with benign prostatic hyperplasia: a review. Ther Clin Risk Manag. 2009;5(3):535–45.

    PubMed Central  CAS  PubMed  Google Scholar 

  50. Din KE, Kiemeney LALM, de Wildt MJ, Debruyne FM, de la Rosette JJ. Correlation between uroflowmetry, prostate volume, postvoid residue, and lower urinary tract symptoms as measured by the International Prostate Symptom Score. Urology. 1996;48(3):393–7.

    Article  Google Scholar 

  51. Barry MJ, Cockett AT, Holtgrewe HL, McConnell JD, Sihelnik SA, Winfield HN. Relationship of symptoms of prostatism to commonly used physiological and anatomical measures of the severity of benign prostatic hyperplasia. J Urol. 1993;150(2 Pt 1):351–8.

    CAS  PubMed  Google Scholar 

  52. Kobayashi S, Tang R, Shapiro E, Lepor H. Characterization and localization of prostatic alpha 1 adrenoceptors using radioligand receptor binding on slide-mounted tissue section. J Urol. 1993;150(6):2002–6.

    CAS  PubMed  Google Scholar 

  53. Nasu K, Moriyama N, Kawabe K, Tsujimoto G, Murai M, Tanaka T, Yano J. Quantification and distribution of alpha 1-adrenoceptor subtype mRNAs in human prostate: comparison of benign hypertrophied tissue and non-hypertrophied tissue. Br J Pharmacol. 1996;119(5):797–803.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  54. Furuya S, Kumamoto Y, Yokoyama E, Tsukamoto T, Izumi T, Abiko Y. Alpha-adrenergic activity and urethral pressure in prostatic zone in benign prostatic hypertrophy. J Urol. 1982;128(4):836–9.

    CAS  PubMed  Google Scholar 

  55. Djavan B, Chapple C, Milani S, Marberger M. State of the art on the efficacy and tolerability of alpha1-adrenoceptor antagonists in patients with lower urinary tract symptoms suggestive of benign prostatic hyperplasia. Urology. 2004;64(6):1081–8.

    Article  PubMed  Google Scholar 

  56. Hennenberg M, Stief CG, Gratzke C. Prostatic α1-adrenoceptors: new concepts of function, regulation, and intracellular signaling. Neurourol Urodyn. 2014;33(7):1074–85.

    Article  CAS  PubMed  Google Scholar 

  57. Resnick MI, Roehrborn CG. Rapid onset of action with alfuzosin 10 mg once daily in men with benign prostatic hyperplasia: a randomized, placebo-controlled trial. Prostate Cancer Prostatic Dis. 2007;10(2):155–9.

    Article  CAS  PubMed  Google Scholar 

  58. Brehmer M, Hilliges M, Kinn AC. Denervation of periurethral prostatic tissue by transurethral microwave thermotherapy. Scand J Urol Nephrol. 2000;34(1):42–5.

    Article  CAS  PubMed  Google Scholar 

  59. Bdesha AS, Schachter M, Sever P, Witherow RO. Radioligand-binding analysis of human prostatic alpha-1 adrenoreceptor density following transurethral microwave therapy. Br J Urol. 1996;78(6):886–92.

    Article  CAS  PubMed  Google Scholar 

  60. Zlotta AR, Raviv G, Peny MO, Noel JC, Haot J, Schulman CC. Possible mechanisms of action of transurethral needle ablation of the prostate on benign prostatic hyperplasia symptoms: a neurohistochemical study. J Urol. 1997;157(3):894–9.

    Article  CAS  PubMed  Google Scholar 

  61. Hedlund P. Nitric oxide/cGMP-mediated effects in the outflow region of the lower urinary tract—is there a basis for pharmacological targeting of cGMP? World J Urol. 2005;23(6):362–7.

    Article  CAS  PubMed  Google Scholar 

  62. Andersson KE. LUTS treatment: future treatment options. Neurourol Urodyn. 2007;26(6 Suppl):934–47.

    Article  CAS  PubMed  Google Scholar 

  63. Kedia GT, Uckert S, Jonas U, Kuczyk MA, Burchardt M. The nitric oxide pathway in the human prostate: clinical implications in men with lower urinary tract symptoms. World J Urol. 2008;26(6):603–9.

    Article  CAS  PubMed  Google Scholar 

  64. Depré C, Fiérain L, Hue L. Activation of nitric oxide synthase by ischaemia in the perfused heart. Cardiovasc Res. 1997;33(1):82–7.

    Article  PubMed  Google Scholar 

  65. Malinski T, Bailey F, Zhang ZG, Chopp M. Nitric oxide measured by a porphyrinic microsensor in rat brain after transient middle cerebral artery occlusion. J Cereb Blood Flow Metab. 1993;13(3):355–8.

    Article  CAS  PubMed  Google Scholar 

  66. Iadecola C. Bright and dark sides of nitric oxide in ischemic brain injury. Trends Neurosci. 1997;20(3):132–9.

    Article  CAS  PubMed  Google Scholar 

  67. Eliasson MJ, Huang Z, Ferrante RJ, Sasamata M, Molliver ME, Snyder SH, Moskowitz MA. Neuronal nitric oxide synthase activation and peroxynitrite formation in ischemic stroke linked to neural damage. J Neurosci. 1999;19(14):5910–8.

    CAS  PubMed  Google Scholar 

  68. Yalçinkaya FR, Davarci M, Akçin S, Gökçe A, Güven EO, İnci M, Balbay MD. Urodynamic evaluation of acute effects of sildenafil on voiding among males with erectile dysfunction and symptomatic benign prostate. Turk J Med Sci. 2012;42(6):951–6.

    Google Scholar 

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  1. Jesús Usón Minimally Invasive Surgery Centre, Carretera N-521, km. 41.8, 10071, Cáceres, Spain

    Fei Sun, Verónica Crisóstomo, Claudia Báez-Díaz & Francisco M. Sánchez

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  1. Fei Sun
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  2. Verónica Crisóstomo
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Sun, F., Crisóstomo, V., Báez-Díaz, C. et al. Prostatic Artery Embolization (PAE) for Symptomatic Benign Prostatic Hyperplasia (BPH): Part 2, Insights into the Technical Rationale. Cardiovasc Intervent Radiol 39, 161–169 (2016). https://doi.org/10.1007/s00270-015-1238-5

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