Positionspapier der Deutschen Gesellschaft für Interventionsradiologie (DeGIR) zur Prostataarterienembolisation

Zusammenfassung

Hintergrund Mit der Prostataarterienembolisation (PAE) steht seit einigen Jahren ein klinisch etabliertes minimalinvasives endovaskuläres Verfahren zur Behandlung des benignen Prostatasyndroms (BPS) zur Verfügung.

Methoden In diesem von der Lenkungsgruppe Wissenschaft und Forschung der Deutschen Gesellschaft für Interventionelle Radiologie initiierten interdisziplinären Positionspapier wird die Methode der PAE dargestellt und im Kontext der aktuellen Datenlage diskutiert.

Ergebnisse Die PAE ist ein sicheres interventionell-radiologisches Verfahren zur Behandlung des BPS. In Bezug auf die Beschwerdesymptomatik, gemessen mit dem IPSS (International Prostate Symptom Score), hat die PAE im Vergleich zu dem historischen Goldstandard der transurethralen Resektion (TUR) der Prostata einen vergleichbaren Effekt. Im Hinblick auf die subvesikale Desobstruktion ist die PAE der TUR unterlegen, sie behindert allerdings eine spätere chirurgische Therapie nicht. Aufgrund der bereits vorhandenen Evidenz wird die PAE vom britischen National Institute for Health and Care Excellence als Therapiealternative empfohlen. Die Durchführbarkeit in Lokalanästhesie und der Erhalt der Sexualfunktion sind für die Patienten wichtige Argumente für die interventionelle Therapie. Patientenauswahl und Therapiekonzept erfordern eine enge interdisziplinäre Zusammenarbeit zwischen Urologen und Radiologen.

Schlussfolgerung Effektivität und Sicherheit der PAE zur Behandlung des BPS sind nachgewiesen. In weiteren randomisierten Studien sollten Langzeitergebnisse generiert und die am besten geeigneten Indikationen für die PAE bei BPS definiert werden.

Kernaussagen: 

• Die PAE als endovaskuläres Verfahren ist eine patientenfreundliche minimalinvasive alternative Therapieoption des BPS.

• Die PAE kann die Beschwerden des unteren Harntraktes (LUTS), vergleichbar der transurethralen Resektion (TUR), reduzieren. Das desobstruktive bzw. volumenreduzierende Potenzial der PAE ist dem der TUR unterlegen.

• Die wichtigsten Vorteile der PAE sind Durchführbarkeit in Lokalanästhesie (ohne Narkose), kurze Ausfallzeiten des Patienten und Erhalt der sexuellen Funktion, inklusive der antegraden Ejakulation.

• Die PAE ist aufgrund der bisher vorliegenden Evidenz im therapeutischen Algorithmus zwischen der konservativen, medikamentösen Therapie und der TUR zu positionieren. Der Stellenwert der PAE im Kontext anderer minimalinvasiver Verfahren (MIST) bedarf noch weiterer Evaluation, setzt aber einen grundsätzlich offenen Umgang mit der PAE voraus.

• Die PAE wird zumeist auf Zuweisung von Urologen von interventionellen Radiologen durchgeführt und erfordert eine enge interdisziplinäre Zusammenarbeit.

Zitierweise

• Kovacs A, Bücker A, Grimm M et al. Position Paper of the German Society for Interventional Radiology (DeGIR) on Prostatic Artery Embolization. Fortschr Röntgenstr 2020; 192: 835 – 846

Key words

prostate - interventional procedures - benign prostate syndrome - lower urinary tract symptoms - prostate artery embolization

Publication History

Received: 09 March 2020

Accepted: 11 May 2020

Article published online:
02 July 2020

• References

• 1 Vuichoud C, Loughlin KR. Benign prostatic hyperplasia: epidemiology, economics and evaluation. The Canadian journal of urology 2015; 22 (Suppl. 01) 1-6
• 2 Bschleipfer T, Bach T, Berges R. et al S2e guideline of the German urologists: Instrumental treatment of benign prostatic hyperplasia. Der Urologe Ausg A 2016; 55: 195-207 . doi:10.1007/s00120-015-3983-0
• 3 Li M, Qiu J, Hou Q. et al Endoscopic enucleation versus open prostatectomy for treating large benign prostatic hyperplasia: a meta-analysis of randomized controlled trials. PloS one 2015; 10: e0121265 . doi:10.1371/journal.pone.0121265
• 4 Kuntz RM, Lehrich K, Ahyai SA. Holmium laser enucleation of the prostate versus open prostatectomy for prostates greater than 100 grams: 5-year follow-up results of a randomised clinical trial. Eur Urol 2008; 53: 160-166 . doi:10.1016/j.eururo.2007.08.036
• 5 Naspro R, Suardi N, Salonia A. et al Holmium laser enucleation of the prostate versus open prostatectomy for prostates >70g: 24-month follow-up. Eur Urol 2006; 50: 563-568 . doi:10.1016/j.eururo.2006.04.003
• 6 Briganti A, Naspro R, Gallina A. et al Impact on sexual function of holmium laser enucleation versus transurethral resection of the prostate: results of a prospective, 2-center, randomized trial. J Urol 2006; 175: 1817-1821 . doi:10.1016/s0022-5347(05)00983-3
• 7 Skolarikos A, Papachristou C, Athanasiadis G. et al Eighteen-month results of a randomized prospective study comparing transurethral photoselective vaporization with transvesical open enucleation for prostatic adenomas greater than 80 cc. Journal of endourology 2008; 22: 2333-2340 . doi:10.1089/end.2008.9709
• 8 Bischoff W, Goerttler U. Successful intra-arterial embolization of bleeding carcinoma of the prostate (author's transl). Der Urologe Ausg A 1977; 16: 99-102
• 9 DeMeritt JS, Elmasri FF, Esposito MP. et al Relief of benign prostatic hyperplasia-related bladder outlet obstruction after transarterial polyvinyl alcohol prostate embolization. J Vasc Interv Radiol 2000; 11: 767-770
• 10 Carnevale FC, Antunes AA, da Motta Leal Filho JM. et al Prostatic artery embolization as a primary treatment for benign prostatic hyperplasia: preliminary results in two patients. Cardiovasc Intervent Radiol 2010; 33: 355-361 . doi:10.1007/s00270-009-9727-z
• 11 Li P, Wang C, Cao Q. et al Prostatic Arterial Embolization Followed by Holmium Laser Enucleation of the Prostate as a Planned Combined Approach for Extremely Enlarged Benign Prostate Hyperplasia. Urologia internationalis 2017; 99: 422-428 . doi:10.1159/000478788
• 12 Nejmark AI, Nejmark BA, Tachalov MA. et al SUPERSELECTIVE PROSTATIC ARTERY EMBOLIZATION AS A PREPARATORY STEP BEFORE TURP IN THE TREATMENT OF BENIGN PROSTATIC HYPERPLASIA IN PATIENTS WITH LARGE PROSTATES]. Urologiia (Moscow, Russia: 1999) 2015; 60-62, 64
• 13 Oelke M, Bschleipfer T, Hofner K. Fake News BPH – what is really true!. Der Urologe Ausg A 2019; 58: 271-283 . doi:10.1007/s00120-019-0885-6
• 14 Rosier PF, de la Rosette JJ. Is there a correlation between prostate size and bladder-outlet obstruction?. World J Urol 1995; 13: 9-13
• 15 Eckhardt MD, van Venrooij GE, van Melick HH. et al Prevalence and bothersomeness of lower urinary tract symptoms in benign prostatic hyperplasia and their impact on well-being. J Urol 2001; 166: 563-568
• 16 Everaert K, Anderson P, Wood R. et al Nocturia is more bothersome than daytime LUTS: Results from an Observational, Real-life Practice Database including 8659 European and American LUTS patients. International journal of clinical practice 2018; 72: e13091 . doi:10.1111/ijcp.13091
• 17 Everaert K, Herve F, Bosch R. et al International Continence Society consensus on the diagnosis and treatment of nocturia. Neurourology and urodynamics 2019; 38: 478-498 . doi:10.1002/nau.23939
• 18 Everaert K, Herve F, Bower W. et al How can we develop a more clinically useful and robust algorithm for diagnosing and treating nocturia? ICI-RS 2017. Neurourology and urodynamics 2018; 37: S46-S59 . doi:10.1002/nau.23569
• 19 Bonekamp D, Salomon G. Imaging for initial diagnosis of localized prostate cancer. Der Urologe Ausg A 2019; 58: 494-503 . doi:10.1007/s00120-019-0901-x
• 20 Sapoval M, Dariane C, Pellerin O. et al Prostatic artery embolisation for symptomatic BPH. Presse Med 2019; 48: 447-453 . doi:10.1016/j.lpm.2019.03.009
• 21 Pisco J, Bilhim T, Costa NV. et al Safety and Efficacy of Prostatic Artery Chemoembolization for Prostate Cancer-Initial Experience. J Vasc Interv Radiol 2018; 29: 298-305 . doi:10.1016/j.jvir.2017.10.013
• 22 Bilhim T, Pisco J, Pereira JA. et al Predictors of Clinical Outcome after Prostate Artery Embolization with Spherical and Nonspherical Polyvinyl Alcohol Particles in Patients with Benign Prostatic Hyperplasia. Radiology 2016; 281: 289-300 . doi:10.1148/radiol.2016152292
• 23 Carnevale FC, da Motta-Leal-Filho JM, Antunes AA. et al 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: 535-542 . doi:10.1016/j.jvir.2012.12.019
• 24 Wang MQ, Guo LP, Zhang GD. et al 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 . doi:10.1186/s12894-015-0026-5
• 25 Abt D, Mullhaupt G, Mordasini L. et al Outcome prediction of prostatic artery embolization: post hoc analysis of a randomized, open-label, non-inferiority trial. BJU Int 2019; 124: 134-144 . doi:10.1111/bju.14632
• 26 Little MW, Boardman P, Macdonald AC. et al Adenomatous-Dominant Benign Prostatic Hyperplasia (AdBPH) as a Predictor for Clinical Success Following Prostate Artery Embolization: An Age-Matched Case-Control Study. Cardiovasc Intervent Radiol 2017; 40: 682-689 . doi:10.1007/s00270-017-1602-8
• 27 Bagla S, Rholl KS, Sterling KM. et al Utility of cone-beam CT imaging in prostatic artery embolization. J Vasc Interv Radiol 2013; 24: 1603-1607 . doi:10.1016/j.jvir.2013.06.024
• 28 Werncke T, von Falck C, Luepke M. et al Collimation and Image Quality of C-Arm Computed Tomography: Potential of Radiation Dose Reduction While Maintaining Equal Image Quality. Investigative radiology 2015; 50: 514-521 . doi:10.1097/rli.0000000000000158
• 29 Uflacker A, Haskal ZJ, Bilhim T. et al Meta-Analysis of Prostatic Artery Embolization for Benign Prostatic Hyperplasia. J Vasc Interv Radiol 2016; 27: 1686-1697 .e1688. doi:10.1016/j.jvir.2016.08.004
• 30 Isaacson AJ, Fischman AM, Burke CT. Technical Feasibility of Prostatic Artery Embolization From a Transradial Approach. American journal of roentgenology 2016; 206: 442-444 . doi:10.2214/ajr.15.15146
• 31 Bhatia S, Harward SH, Sinha VK. et al Prostate Artery Embolization via Transradial or Transulnar versus Transfemoral Arterial Access: Technical Results. J Vasc Interv Radiol 2017; 28: 898-905 . doi:10.1016/j.jvir.2017.02.029
• 32 Li Q, Duan F, Wang MQ. et al Prostatic Arterial Embolization with Small Sized Particles for the Treatment of Lower Urinary Tract Symptoms Due to Large Benign Prostatic Hyperplasia: Preliminary Results. Chinese medical journal 2015; 128: 2072-2077 . doi:10.4103/0366-6999.161370
• 33 Goncalves OM, Carnevale FC, Moreira AM. et al Comparative Study Using 100–300 Versus 300–500 mum Microspheres for Symptomatic Patients Due to Enlarged-BPH Prostates. Cardiovasc Intervent Radiol 2016; 39: 1372-1378 . doi:10.1007/s00270-016-1443-x
• 34 Torres D, Costa NV, Pisco J. et al Prostatic Artery Embolization for Benign Prostatic Hyperplasia: Prospective Randomized Trial of 100–300 mum versus 300–500 mum versus 100- to 300-mum + 300- to 500-mum Embospheres. J Vasc Interv Radiol 2019; 30: 638-644 . doi:10.1016/j.jvir.2019.02.014
• 35 Moreira AM, de Assis AM, Carnevale FC. et al A Review of Adverse Events Related to Prostatic Artery Embolization for Treatment of Bladder Outlet Obstruction Due to BPH. Cardiovasc Intervent Radiol 2017; 40: 1490-1500 . doi:10.1007/s00270-017-1765-3
• 36 Carnevale FC, Moreira AM, Antunes AA. The "PErFecTED technique": proximal embolization first, then embolize distal for benign prostatic hyperplasia. Cardiovasc Intervent Radiol 2014; 37: 1602-1605 . doi:10.1007/s00270-014-0908-z
• 37 Carnevale FC, Moreira AM, Harward SH. et al Recurrence of Lower Urinary Tract Symptoms Following Prostate Artery Embolization for Benign Hyperplasia: Single Center Experience Comparing Two Techniques. Cardiovasc Intervent Radiol 2017; 40: 366-374 . doi:10.1007/s00270-017-1569-5
• 38 Isaacson AJ, Hartman TS, Bagla S. et al Initial Experience with Balloon-Occlusion Prostatic Artery Embolization. J Vasc Interv Radiol 2018; 29: 85-89 . doi:10.1016/j.jvir.2017.09.015
• 39 Christidis D, Clarebrough E, Ly V. et al Prostatic artery embolization for benign prostatic obstruction: assessment of safety and efficacy. World J Urol 2018; 36: 575-584 . doi:10.1007/s00345-018-2220-z
• 40 Salem R, Hairston J, Hohlastos E. et al Prostate Artery Embolization for Lower Urinary Tract Symptoms Secondary to Benign Prostatic Hyperplasia: Results From a Prospective FDA-Approved Investigational Device Exemption Study. Urology 2018; 120: 205-210 . doi:10.1016/j.urology.2018.07.012
• 41 Lebdai S, Delongchamps NB, Sapoval M. et al Early results and complications of prostatic arterial embolization for benign prostatic hyperplasia. World J Urol 2016; 34: 625-632 . doi:10.1007/s00345-015-1665-6
• 42 Roehrborn CG, Siami P, Barkin J. et al The effects of combination therapy with dutasteride and tamsulosin on clinical outcomes in men with symptomatic benign prostatic hyperplasia: 4-year results from the CombAT study. Eur Urol 2010; 57: 123-131 . doi:10.1016/j.eururo.2009.09.035
• 43 Serati M, Andersson KE, Dmochowski R. et al Systematic Review of Combination Drug Therapy for Non-neurogenic Lower Urinary Tract Symptoms. Eur Urol 2019; 75: 129-168 . doi:10.1016/j.eururo.2018.09.029
• 44 Gravas S, Cornu JN, Gacci M. et al EAU guidelines. Presented at the EAU Annual Congress Barcelona 2019. ISBN 978-94-92671-04-2
• 45 Magistro G, Stief CG, Gratzke C. Novel minimally invasive treatment options for male lower urinary tract symptom. Der Urologe Ausg A 2019; 58: 254-262 . doi:10.1007/s00120-019-0876-7
• 46 Christidis D, McGrath S, Perera M. et al Minimally invasive surgical therapies for benign prostatic hypertrophy: The rise in minimally invasive surgical therapies. Prostate international 2017; 5: 41-46 . doi:10.1016/j.prnil.2017.01.007
• 47 Lebdai S, Chevrot A, Doizi S. et al Do patients have to choose between ejaculation and miction? A systematic review about ejaculation preservation technics for benign prostatic obstruction surgical treatment. World J Urol 2019; 37: 299-308 . doi:10.1007/s00345-018-2368-6
• 48 Abt D, Hechelhammer L, Mullhaupt G. et al Comparison of prostatic artery embolisation (PAE) versus transurethral resection of the prostate (TURP) for benign prostatic hyperplasia: randomised, open label, non-inferiority trial. BMJ (Clinical research ed) 2018; 361: k2338 . doi:10.1136/bmj.k2338
• 49 Abt D, Mordasini L, Hechelhammer L. et al Prostatic artery embolization versus conventional TUR-P in the treatment of benign prostatic hyperplasia: protocol for a prospective randomized non-inferiority trial. BMC Urol 2014; 14: 94 . doi:10.1186/1471-2490-14-94
• 50 Hofner K, Bach T, Berges R. et al S2e guideline of the German urologists: Conservative and pharmacologic treatment of benign prostatic hyperplasia. Der Urologe Ausg A 2016; 55: 184-194 . doi:10.1007/s00120-015-3984-z
• 51 Gao YA, Huang Y, Zhang R. et al Benign prostatic hyperplasia: prostatic arterial embolization versus transurethral resection of the prostate--a prospective, randomized, and controlled clinical trial. Radiology 2014; 270: 920-928 . doi:10.1148/radiol.13122803
• 52 Pisco JM, Pinheiro LC, Bilhim T. et al Prostatic arterial embolization to treat benign prostatic hyperplasia. J Vasc Interv Radiol 2011; 22: 11-19 ; quiz 20. doi:10.1016/j.jvir.2010.09.030
• 53 Carnevale FC, Iscaife A, Yoshinaga EM. et al Transurethral Resection of the Prostate (TURP) Versus Original and PErFecTED Prostate Artery Embolization (PAE) Due to Benign Prostatic Hyperplasia (BPH): Preliminary Results of a Single Center, Prospective, Urodynamic-Controlled Analysis. Cardiovasc Intervent Radiol 2016; 39: 44-52 . doi:10.1007/s00270-015-1202-4
• 54 Zumstein V, Betschart P, Vetterlein MW. et al Prostatic Artery Embolization versus Standard Surgical Treatment for Lower Urinary Tract Symptoms Secondary to Benign Prostatic Hyperplasia: A Systematic Review and Meta-analysis. Eur Urol Focus 2018; DOI: 10.1016/j.euf.2018.09.005.
• 55 Russo GI, Kurbatov D, Sansalone S. et al Prostatic Arterial Embolization vs Open Prostatectomy: A 1-Year Matched-pair Analysis of Functional Outcomes and Morbidities. Urology 2015; 86: 343-348 . doi:10.1016/j.urology.2015.04.037
• 56 Ray AF, Powell J, Speakman MJ. et al Efficacy and safety of prostate artery embolization for benign prostatic hyperplasia: an observational study and propensity-matched comparison with transurethral resection of the prostate (the UK-ROPE study). BJU Int 2018; 122: 270-282 . doi:10.1111/bju.14249
• 57 Pisco JM, Rio Tinto H, Campos Pinheiro L. et al 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: 2561-2572 . doi:10.1007/s00330-012-2714-9
• 58 Bagla S, Smirniotopoulos JB, Orlando JC. et al Comparative Analysis of Prostate Volume as a Predictor of Outcome in Prostate Artery Embolization. J Vasc Interv Radiol 2015; 26: 1832-1838 . doi:10.1016/j.jvir.2015.08.018
• 59 Kurbatov D, Russo GI, Lepetukhin A. et al Prostatic artery embolization for prostate volume greater than 80 cm3: results from a single-center prospective study. Urology 2014; 84: 400-404 . doi:10.1016/j.urology.2014.04.028
• 60 Rampoldi A, Barbosa F, Secco S. et al Prostatic Artery Embolization as an Alternative to Indwelling Bladder Catheterization to Manage Benign Prostatic Hyperplasia in Poor Surgical Candidates. Cardiovasc Intervent Radiol 2017; 40: 530-536 . doi:10.1007/s00270-017-1582-8
• 61 Wang MQ, Duan F, Yuan K. et al Benign Prostatic Hyperplasia: Cone-Beam CT in Conjunction with DSA for Identifying Prostatic Arterial Anatomy. Radiology 2017; 282: 271-280 . doi:10.1148/radiol.2016152415
• 62 Franiel T, Aschenbach R, Trupp S. et al Prostatic Artery Embolization with 250-mum Spherical Polyzene-Coated Hydrogel Microspheres for Lower Urinary Tract Symptoms with Follow-up MR Imaging. J Vasc Interv Radiol 2018; 29: 1127-1137 . doi:10.1016/j.jvir.2018.03.014
• 63 Malling B, Roder MA, Brasso K. et al Prostate artery embolisation for benign prostatic hyperplasia: a systematic review and meta-analysis. Eur Radiol 2019; 29: 287-298 . doi:10.1007/s00330-018-5564-2
• 64 Pisco JM, Bilhim T, Pinheiro LC. et al Medium- and Long-Term Outcome of Prostate Artery Embolization for Patients with Benign Prostatic Hyperplasia: Results in 630 Patients. J Vasc Interv Radiol 2016; 27: 1115-1122 . doi:10.1016/j.jvir.2016.04.001
• 65 Hawlik K, Vreugdenburg T. Prostate artery embolisation for benign prostatic hyperplasia – Systematic Review. Health Technology Assessment (Ludwig Bolzmann Institut) 2017
• 66 Mankowski C, Ikenwilo D, Heidenreich S. et al Men's preferences for the treatment of lower urinary tract symptoms associated with benign prostatic hyperplasia: a discrete choice experiment. Patient preference and adherence 2016; 10: 2407-2417 . doi:10.2147/ppa.S112161
• 67 Gilling P, Barber N, Bidair M. et al WATER: A Double-Blind, Randomized, Controlled Trial of Aquablation((R)) vs Transurethral Resection of the Prostate in Benign Prostatic Hyperplasia. J Urol 2018; 199: 1252-1261 . doi:10.1016/j.juro.2017.12.065
• 68 Gilling P, Barber N, Bidair M. et al Two-Year Outcomes After Aquablation Compared to TURP: Efficacy and Ejaculatory Improvements Sustained. Adv Ther 2019; 36: 1326-1336 . doi:10.1007/s12325-019-00952-3
• 69 Zheng X, Qiu Y, Qiu S. et al Photoselective vaporization has comparative efficacy and safety among high-risk benign prostate hyperplasia patients on or off systematic anticoagulation: a meta-analysis. World J Urol 2018; DOI: 10.1007/s00345-018-2530-1.
• 70 Naspro R, Gomez Sancha F, Manica M. et al From “gold standard” resection to reproducible “future standard” endoscopic enucleation of the prostate: what we know about anatomical enucleation. Minerva Urol Nefrol 2017; 69: 446-458 . doi:10.23736/S0393-2249.17.02834-X
• 71 Cornu JN, Ahyai S, Bachmann A. et al A Systematic Review and Meta-analysis of Functional Outcomes and Complications Following Transurethral Procedures for Lower Urinary Tract Symptoms Resulting from Benign Prostatic Obstruction: An Update. Eur Urol 2015; 67: 1066-1096 . doi:10.1016/j.eururo.2014.06.017
• 72 Mayor S. NICE recommends prostate artery embolisation as a treatment option for BPH symptoms. BMJ (Clinical research ed) 2018; 361: k1879 . doi:10.1136/bmj.k1879
• 73 Abt D, Mullhaupt G, Mordasini L. et al Outcome prediction of prostatic artery embolization: post hoc analysis of a randomized, open-label, non-inferiority trial. BJU Int 2018; DOI: 10.1111/bju.14632.