Is Prostatic Artery Embolization Similar to Uterine Artery Embolization?

Abstract

Recently, arterial embolization has been proposed as a safe and effective treatment for benign prostatic hyperplasia (BPH) [1]. Nonetheless, prostatic arterial embolization (PAE) is not a new procedure; it has been used for almost 40 years to control prostatic bleeding [2]. In 2000, De Merritt et al. [3] reported a case of embolization to treat hematuria after prostate biopsy in a patient with BPH. Interestingly, embolization not only stopped the bleeding, but also reduced the size of the gland and led to improvement in lower urinary tract symptoms. This observation sparked interest in a potential new application for embolotherapy. Early proponents of this new application noticed some similarities between prostatic artery embolization (PAE) and the well-established uterine artery embolization (UAE) procedure. UAE for treatment of symptomatic fibroids is now considered an excellent alternative to hysterectomy based on level I scientific evidence [4]. But what is the relationship between embolization for uterine fibroids and BPH? There are indeed some similarities. Both diseases are the most common benign tumors of the female and male pelvis, respectively. Both diseases have a tissue structure characterized by the presence of stromal and smooth muscle components, which are intrinsically hormone-dependent for their development and growth—estrogen and testosterone, respectively. Although considered benign tumors, both illnesses cause symptoms that produce a deep impact on quality of life, and usually are treated with conventional medical and surgical therapies, intrinsically associated with risks and morbidity, including sexual dysfunction. In contrast, embolization is a minimally invasive alternative that delivers embolic agents with the aim of causing targeted and controlled tissue ischemia and necrosis of the offending tumors. However, aside from these similarities, there are also many differences, which should be kept in mind for those who have experience in UFE and intend to explore the PAE field. Uterine fibroids affect premenopausal, therefore young, women up to the fifth decade of life, whereas BPH affects men starting from the fifth decade of life, with most symptomatic patients requiring treatment when they are even older. As a consequence, many BPH patients have significant atherosclerotic changes in their vessels, which make endovascular procedures more difficult and challenging. Uterine arteries in women with fibroids have a fairly constant anatomic location, distribution, and course, and their diameter grows proportionally to the size of the leiomyomatous uterus. In contrast, prostatic arteries are subject to numerous anatomic variations in terms of their origin and distribution, while remaining quite small in diameter, even when the prostate reaches fairly large volumes. It is also not uncommon to find more than one prostatic artery on each side [5]. In an anatomic description published recently, two main arterial pedicles to the prostate have been identified: the superior and inferior prostatic pedicles [5]. The former provides the main arterial supply of the prostate, in addition to both the inferior bladder and N. Kisilevzky (&) Interventional Radiologist at Endovascular Center, Rua Guararapes 682, City Lapa, SP CEP 05077051, Brazil e-mail: dr.nestor@embolution.com.br