Interventional radiology/Original

Prostate embolization: a new field of Interventional Radiology

Prostate embolization:
a new field of Interventional Radiology
N. Kisilevzkya,*, R. Garca Mnacoa, O. Paraltaa, M. Rabelinoa, R. Rosales Arrobaa, P. Rodrgueza,
J. Ocantosb, P.F. Martnezc y O. Damiac

a Imaging Diagnosis Department, Section of Angiography and Endovascular Therapy, Hospital Italiano de Buenos Aires,
Ciudad Autnoma de Buenos Aires, Argentina.
b Imaging Diagnosis Department, Section of Urological Imaging, Hospital Italiano de Buenos Aires,
Ciudad Autnoma de Buenos Aires, Argentina
c Urology Department, Hospital Italiano de Buenos Aires, Ciudad Autnoma de Buenos Aires, Argentina

Abstract
Purpose: To report our initial experience with prostate embolization as an alternative treatment for benign prostatic
hyperplasia (BPH) from a technical perspective and determine the contribution of imaging diagnosis.
Materials and methods: Sixteen patients with lower urinary tract symptoms due to benign prostatic hyperplasia un-
derwent prostate embolization. All patients were evaluated with specific questionnaires to determine the severity of
symptoms, the impact on quality of life and erectile function, and underwent pelvic ultrasound and MRI, uroflowmetry
and PSA before and 30 days after the procedure.
Results: Embolization was successful in all patients; in 10 cases the procedure was performed bilaterally and in six, only
one side was embolized. The average time for completion of the procedure was 82 minutes and the average fluoros-
copy time was 38.5 minutes. All procedures were performed on an out patient basis with an average hospital stay of
6.4 hours. The mean contrast medium used was 175 ml. At 30 days there was a mean reduction of prostate volume of
21%. Clinical improvement was characterized by a mean 8-point improvement on IPSS, 2 points on QOL and 4 points
on IIEF. The uroflowmetry improved by 39% and PSA dropped by 26%. No major complications implying unscheduled
hospitalization or additional surgical procedures were observed. Minor adverse events were documented in 9 patients.
Conclusion: The initial results of prostate embolization as an alternative treatment for BPH indicate that it is a safe and
effective procedure to be consolidated as a new field of action of interventional radiology.
2013 Sociedad Argentina de Radiologa. Published by Elsevier Espaa, S.L. All rights reserved.

Keywords: Benign prostatic hyperplasia; Prostatic adenoma; Arterial embolization; Interventional radiology.

Introduction or patients with urinary obstruction complications5.

Benign prostatic hyperplasia (BPH) has a high prevalence rate
in men from the age of 50, and further increases with age1,2.
BHP is a condition often associated with lower urinary tract
symptoms (particularly decrease urine flow rates, frequent
urination and urinary urgency), with an impact on the pa-
tients quality of life3,4.
Depending on the severity of symptoms and the clinical prog-
ress of BPH, there are a number of options for the manage-
ment of this condition, ranging from observation to medica-
tion or surgical intervention.
The efficacy demonstrated by drugs such as alpha-blockers
and five-alpha reductase inhibitors has reduced indications
for surgery. However, surgical management, either by trans-
urethral resection or by open prostatectomy, is considered
the treatment of choice in drug treatment-resistant patients
Surgery is not exempt from risks, and associated complica-
tions may include: urinary tract infection, stenosis, postoper-
ative pain, urinary retention or incontinence, sexual dysfunc-
tion and hemorrhages6.
For this reason, less invasive treatments have been developed
with the aim of reducing the risk of morbidity related to stan-
dard surgical procedures7,8. New therapeutic options include,
but are not limited to: transurethral microwave thermothera-
py, transurethral needle ablation, Holmium laser enucleation
or resection, photoselective (green light laser) vaporization
of the prostate, transurethral resection of the prostate us-
ing bipolar energy and transurethral incision of the prostate8.
However, it should be noted that these options have still not
shown major efficacy in the management of symptoms of
patients with BPH8,9. Furthermore, these techniques are not
widely available and are generally highly costly.

102 Rev. Argent. Radiol. 2014;78(2): 102-113

 N. Kisilevzky et al.

It has been recently suggested that prostate embolization
(PE) for the treatment of BPH in men may be as effective as
uterine embolization for the treatment of uterine fibroids in
women10. Preclinical experimental studies have demonstrat-
ed that PE is safe, does not cause erectile dysfunction and
may reduce the prostate volume11-13. The first clinical case
was reported by DeMeritt et al14, who used embolization to
manage a case of hematuria caused by percutaneous biopsy
in a patient with BPH. These authors did not only achieve he-
mostasis but also observed a significant clinical improvement
in symptoms associated with BPH14. Later, other authors also
established that PE appeared to be safe and effective for the
management of symptoms in patients with BPH15,16.
In this paper we report our initial experience with PE for the
management of BPH from a technical perspective and deter-
mine the contribution of imaging diagnosis.
patients with a mean age of 72 years (range: 52-87) under-
went PE as management for BPH. All cases were refractory to
medical therapy and had an indication for surgery.
Patients were evaluated with specific questionnaires for grad-
ing lower urinary tract symptoms and their impact on the
quality of life and erectile function. We used the International
Prostatic Symptoms Score (IPSS) for grading symptoms, the
Quality of Life Questionnaire (QOL) and the International In-
dex of Erectile Function (IIEF), shown in Annex 1.
In all cases, prostate specific antigen (PSA) serum levels were
measured, the maximum urinary flow rate (Qmax) was deter-
mined by uroflowmetry, post-void residual (PVR) volume was
estimated by ultrasound and magnetic resonance imaging
(MRI) was performed to determine the volume and anatomi-
cal features of the prostate.

Pre- and post-embolization

Materials and methods
This study was approved by the Institutional Ethics Commit-
tee for research protocols and all patients enrolled signed an
informed consent. Between August 2012 and July 2013, 16
prostatic magnetic resonance
imaging protocol
Pre-embolization MRI was performed within 7 to 10 days
prior to the procedure, while the post-embolization follow-

a b

a d

Figure 1 Pre-embolization prostatic magnetic resonance imaging, T2-weighted TSE images, (a) axial and (b) sagittal slices clearly
show the hypointense band delimiting the true prostate capsule and multiple hyperplastic nodules of heterogeneous signal
deforming the gland and compressing the peripheral zone, represented by a band in the posterior aspect of the gland. (c)
Coronal slice showing the prostate gland replaced and deformed by multiple nodules. (d) Calculation of prostate gland volume.

Rev. Argent. Radiol. 2014;78(2): 102-113 103

Prostate embolization: a new field of Interventional Radiology

up was performed after 30 days. Angiography and

The scans were performed on a 1.5 Tesla scanner (Magnetom
Avanto; Siemens Medical Solutions, Erlangen, Germany),
using a body phased array surface coil, and the posterior sur-
face of the prostate was taken as reference for orientation
of sequences. Axial and coronal sequences were oriented
perpendicular and parallel to the prostate posterior surface,
respectively. The protocol included non-contrast sequences:
T1-weighted turbo spin echo (TSE) images in the axial plane
and T2-weighted TSE images in the axial, sagittal and coronal
planes, as well as diffusion/apparent diffusion coefficient in
the axial plane (b value: 50, 400 and 1000 s/mm2). Addition-
ally, dynamic sequences were used (3D Flash VIBE transverse)
following the intravenous administration of gadolinium
(gadoterate meglumine at a dose of 0.1 mmol/kg at a rate
of 3 ml/s, followed by a 20-ml flush of saline solution inject-
ed at a similar rate), with consecutive acquisitions for 5 min
(after contrast administration), and delayed sequences at 7
min with TSE images in the axial, coronal and sagittal planes.
Prostate volumes were estimated by adding sections, which
were assessed by a radiologist with a 15-year experience in
urological imaging (fig. 1).
embolization protocol
Prostate embolization was performed on an outpatient basis
in all cases using a digital subtraction angiography unit (Ar-
tis Zeego; Siemens Medical Solutions, Erlangen, Germany),
located in the hybrid operating room of the Angiography
and Endovascular Therapy Section. All patients had a blad-
der catheter placed and a dose of 400 mg ciprofloxacin was
administered intravenously prior to the procedure. Interven-
tion was performed under local anesthesia by percutaneous
puncture and catheterization of the right common femoral
artery. An aortic angiography was performed followed by se-
lective angiography of both internal iliac arteries to assess the
vascular anatomy of the pelvis, mainly focusing on the origin
of prostate arteries (fig. 2).
Once arteries where identified,they were selectively charac-
terized with a microcatheter (Pro Great 2.7, Terumo, USA,
or Maestro 2.4, Merit Medical, South Jordan, USA) ad-
vanced coaxially through a 5-F angiographic catheter.
At the operators discretion, in doubtful cases, angiographic im-
ages were obtained by cone-beam computed tomography (CT)17

a b c

Figure 2 Pelvic angiography for identification of prostate arteries. (a) Digital subtraction arterial angiography with the catheter
placed on the left internal iliac artery. Left anterior oblique projection. Note the following branches: superior gluteal artery
(GS), inferior gluteal artery (GI), internal pudendal artery (PI), obturator artery (O), prostatic-vesical trunk (VP), vesical artery (V),
prostate artery (P) and hemorrhoidal artery (H). (b) Selective angiography of the prostatic-vesical trunk performed with micro-
catheter. (c) Angiography performed by superselective catheterization of the left prostate artery using a microcatheter. Note
contrast retention by the gland (arrow).

104 Rev. Argent. Radiol. 2014;78(2): 102-113


With the microcatheter appropriately positioned, free-flow em-
bolization was performed with trisacryl microspheres (Embos-
phere , Biosphere Medical, South Jordan, USA) until the arterial
flow to the prostate was occluded. After angiographic post-
embolization follow-up, the catheter was removed and manual
compression was performed at the puncture site. Patients were
discharged 6 hours after the procedure, with no bladder cath-
eter in place and with prescription of oral antibiotic therapy (cip-
rofloxacin 1 g QD) for 8 days and no steroidal anti-inflammatory
drugs. All patients were contacted by telephone during the first
week and symptoms or complications were recorded and clas-
sified according to the classification proposed by the American
Society of Interventional Radiology18.
After 30 days embolization, a prostate MRI follow-up, uro-
flowmetry, PVR by ultrasound and PSA measurements were
performed. Patients completed again the IPSS, QOL and IIEF
questionnaires.
As this is a preliminary report with a limited number of pa-
tients and a short-term follow-up, no strict statistical analysis
was performed. Categorical variables were expressed as per-
centage (%) and continuous variables were expressed with
mean standard deviation.
Results
Embolization was bilateral in 10/16 (62.5%) patients and uni-
lateral in 6/16 (27.5%). Unilateral embolization (3 cases) was
a b c
Figure 3 Selective angiography of the left prostate artery before and after embolization. (a) The left anterior oblique projection
permits identification of the arterial vessels of the left half of the gland. (b) Image in neutral position (anteroposterior). (c) Post-
embolization follow-up angiography showing interruption of flow through the left prostate artery.
N. Kisilevzky et al.
performed because of the impossibility of catheterizing one of
the prostate arteries due to abundant arteriosclerotic changes.
In the remaining 3 cases, the existence of anastomosis be-
tween the prostate artery and other vessels (middle rectal ar-
tery, differential artery and cavernous artery) was document-
ed, which precluded safe selective embolization.
The mean procedure time was 82 min (range: 50-138) and
the mean fluoroscopy time was 38.5 min (range: 21-83). No
clinical complications were seen during the procedure. Mean
iodinated contrast consumption was 175 ml (range: 100-350).
The left prostate artery (PA) was found to arise from the
inferior vesical artery in 8 cases (forming a common trunk:
prostatic-vesical trunk), from the internal pudendal artery in
4 cases, from the obturator artery in 1 case and directly from
the anterior division of the internal iliac artery in 3 cases.
The right PA arose from the inferior vesical artery (forming a
common trunk: prostatic-vesical trunk) in 7 cases, from the in-
ternal pudendal artery in 2 cases, from the obturator artery in 2
cases, with the middle rectal artery in 1 case and directly from
the anterior division of the internal iliac artery in 3 cases (fig. 3).
In one case, there were 2 prostate arteries on the right side:
one prostatic-vesical artery arising from the internal iliac ar-
tery and the other from the internal pudendal artery. In 9 cas-
es, flat-panel detector cone-beam CT images were acquired
for a safe identification of the prostatic arterial supply.
Clinical outcomes of treatment at 30 days are summarized
in Table 1. There was no need to continue with specific pros-
tatic medication in none of the patients during the 30-day
Rev. Argent. Radiol. 2014;78(2): 102-113 105
Prostate embolization: a new field of Interventional Radiology

Table 1: Evolution of parameters investigated. Averages from values obtained are shown with their standard deviation.

Parameter Pre-PE Post-PE Interpretation

IPSS 17 points 5.5 9 points 4.8 Clinical improvement by 8 points

QOL 4 points 0.7 2 points 1.2 Improvement in quality of life by 2 points
IIEF 16 points 8.7 20 points 10.6 Improvement in erectile function by 4 points
PSA 4.3 ng/dL 7.3 3.2 ng/dL 5 Serum decrease of 1 ng/dL
Qmax 9 ml/s 4.9 12.5 ml/s 2.7 Improvement in urinary flow of 3 ml/s
PVR volume 88 ml 83 48 ml 34 Improvement in post-void urinary retention
Prostate volume 109 cc 51 87 cc 34 Prostate volume reduction of 21%

IIEF: International Index of Erectile Function; IPSS: International Prostatic Symptoms Score; PSA: Prostate Specific Antigen;
Qmax: maximum urinary flow; QOL: quality of life; PVR: post-void residual

follow-up period. In 2/5 patients with acute urinary retention
and indwelling bladder catheter prior to the procedure, the
catheter could be definitely removed.
In all patients, pre-embolization MRI showed an increase in
prostate size at the expense of the central gland, with compres-
sion and thinning of the peripheral gland. T2-weighted images
showed glandular and stromal hyperplasia in all cases (fig. 4).
Post-embolization MRI showed in all patients prostate vol-
ume reduction (average 21%) and a decrease in signal inten-
sity of the gland on T2-weighted TSE images. Follow-up MRIs
showed areas of decreased or no vascularitation, which was
more evident in 11 cases. In these latter cases, MRI depicted
diffuse a vascular areas in the central gland in 9 patients, a
vascular areas with multiple nodules in 1 patient and avascu-
larity in almost the whole central gland with heterogeneous
hyperintense signal on T1-weighted images, a finding that

a b c

d e f

Figure 4 Pre- and postembolization prostatic MRI. When comparing (a) pre-embolization T2-weighted TSE images with (b) post-
embolization T2-weighted TSE images, we can see prostate volume reduction, absence of the bladder catheter and multiple
nodules with a decreased signal (arrows) in the central gland. Comparing (c) pre-embolization T1-weighted TSE images with (d)
post-embolization T1-weighted TSE images, focal hypointense areas on T2-weighted images appear as hyperintense areas on
T1-weighted images (arrows), a finding that is consistent with a hemorrhagic component (hemorrhagic necrosis). Comparison
of intravenous contrast-enhanced images in (e) pre-embolization contrast-enhanced T1-weighted TSE images and (f) post-embo-
lization T1-weighed TSE images shows no contrast uptake, which can be attributed to post-embolization avascularity (arrows).

106 Rev. Argent. Radiol. 2014;78(2): 102-113


Table 2: Adverse events observed in the postoperative period
Event Frequency
Urinary tract infection 3 19%
Urinary retention 1 6%
Hematospermia 5 31%
Burning during urination 4 25%
Rectal bleeding 1 6%
was interpreted as hemorrhagic component associated with
avascularity.
Of the 5 remaining patients, 2 showed signs of avascularity
involving the central and peripheral gland, 2 showed avascu-
larity predominantly on the left half of the gland and 1 had
bilateral avascularity.
Only 9/16 patients experienced minor complications or ad-
verse effects, all of them being grade B according to the
classification proposed by the American Society of Interven-
tional Radiology (table 2). There were three cases of urinary
infection (rapidly resolved with antibiotic therapy) and one
patient developed acute urinary retention (requiring transient
bladder catheter for 25 days). Adverse side effects included
burning during urination in 4 patients, which resolved with
oral corticosteroids, a single event of rectal bleeding in one
patient and transient hematospermia in 5 cases.
Discussion
Embolization is an interventional radiology technique that
has been used in medicine for almost 40 years and that has
a b c d
Figure 5 Variations in the origin of the prostate artery (P). (a) Independent origin in the anterior division of the internal iliac
artery (AH). (b) Origin from the common trunk with the hemorrhoidal artery (H). (c) Independent origin in the internal pudendal
artery (PI). (d) Origin in the obturator artery (O).
N. Kisilevzky et al.
proven to be very useful for resolving various conditions in
different parts of the human body. Specifically in urology, this
method is used to control hemorrhage caused by trauma,
tumors or vascular disorders, as well as for the treatment of
varicocele19.23.
In the last decades, embolization became established as treat-
ment of uterine fibroids based on level A scientific evidence,
as highlighted by the American College of Obstetricians and
Gynecologists 24 Curiously enough, uterine fibroids share
some similarities with prostate adenoma: apart from being
related to hormonal dependency, both are highly prevalent
genital conditions, characterized by the presence of smooth
muscle and stroma. For this reason, it is not surprising that
the following hypothesis should have arisen: if embolization
is effective for treating uterine fibroids, will it be equally ef-
fective for treating prostate adenoma?
The observation by DeMeritt et al 14 led to the development
of specific research on this issue. Several studies have been
recently published that conclude that embolization appears
to be a safe and effective technique for BPH symptoms man-
agement25. The study having the largest number of cases
(over 250 cases) and the longest follow-up demonstrated
control of symptoms in 72% of patients at 36 months26.
This study is only a preliminary report on the immediate ef-
fects of PE in patients with BPH, but our results show, from
the clinical improvement achieved, that embolization is a re-
producible and promising method. All objective assessments,
such as IPSS, quality of life and erectile function scores, PSA
and uroflowmetry improved significantly after PE.
Pisco et al27, in their original article about the first 15 pa-
tients treated with PE report a mean prostate volume de-
crease of 26.5% at 30 days. In a later study conducted in a
Rev. Argent. Radiol. 2014;78(2): 102-113 107
Prostate embolization: a new field of Interventional Radiology

much larger number of patients the same authors28 reported
a mean prostate volume decrease of 20% (a similar result to
that obtained from our series). However, a direct relationship
between prostate volume decrease and clinical improvement
could not be demonstrated: Pisco et al16 reported 33 pa-
tients with no clinical improvement despite a prostate volume
decrease of over 15%, while in the same paper they reported
12 cases of prostate volume increase after treatment, with
clinical improvement.
The use of MRI for pre- and post-procedure assessment also
results from the knowledge gained in the treatment of uter-
ine fibroids29. It is well known that MRI is an imaging method
that provides high tissue contrast and shows more detailed
prostate anatomy and changes in vascularity, in addition to
allowing measurement of the prostate gland volume. The use
of the same imaging protocol for pre- and post-embolization
assessment reduces variability in comparison. T2-weighted
sequences are the most useful to show prostatic anatomy
and identify signal changes in the glandular and stromal com-
ponent before and after treatment30. The use of T1-weight-
ed TSE sequences, with and without intravenous contrast, al-
lowed identification of both avascular areas and hemorrhagic
changes secondary to necrosis resulting from embolization.
Even if bilateral embolization is advisable for the treatment of
the entire gland involved, a good response may be observed
even with unilateral embolization. In effect, Bilhim et al31 re-
ported symptom relief in almost half the patients who under-
went unilateral embolization. In our series, effects were sat-
isfactory in patients treated with unilateral embolization and
those undergoing bilateral embolization, but the absence of
negative results may be due to the limited sample size.
The origin of prostatic-vesical arteries is variable. In the elderly,
arteries may be tortuous and elongated, and may also have
atheromatous stenotic/occlusive lesions31,32. Accurately
identifying the origin of prostate arteries, navigating within
an arterial network with accentuated curves and localized
narrow segments and performing super selective catheteriza-
tion of very fine arteries is the specific technical challenge of
this procedure. In our study, the presence of atherosclerotic
vessels precluded bilateral selective catheterization and thus,
bilateral embolization in 3 patients (fig. 5).
Comprehension of the functional arterial anatomy is crucial
to perform a correct procedure and avoid complications32.
The prostate artery is in close relationship with bladder, rec-
tal and ejaculatory system vessels32. Furthermore, there are
various anastomoses with the rectal and internal pudendal
artery31,32, which may pose a potential risk for the passage
of particles through these communications, with the result-
ing ischemia of non-prostatic tissues. In our initial series, this
situation was seen in 3 cases and we decided to avoid embo-
lization for fear of causing undesired ischemic complications.
Thus, recognition of the prostate artery in the angiographic
procedure is crucial for an effective and safe treatment31,32
(figs. 6 and 7).

a b c

d e f

Figure 6 Vascular abnormalities commonly observed in patients with arteriosclerosis impairing intravascular maneuvers during
prostate embolization. (a) marked tortuosity of the left iliac artery. (b) stenosis in the origin of the right internal iliac artery (ar-
row). (c) occlusion of the left internal iliac artery (arrow). (d) Stenosis in the origin of the left prostate artery (arrow). (e) stenosis
in the origin of the right prostatic-vesical trunk (arrow). (f) stenosis in the origin of the anterior division of the right internal iliac
artery (arrow).

108 Rev. Argent. Radiol. 2014;78(2): 102-113

 N. Kisilevzky et al.

Pisco et al26 suggest using multidetector CT angiography as
routine testing during screening for prior identification of ana-
tomic variants and establishing the procedures degree of tech-
nical difficulty. Even if this may provide further anatomical data,
this method has not been globally validated yet, and therefore
this test has not been performed in any of our patients.
Another potentially useful tool in selected cases is the cone-
beam CT, as it allows the acquisition of CT angiograms in
various planes from a rotational angiography17. Cone-beam
CT is advanced technology that uses C-arm flat-panel fluo-
roscopy systems to acquire and display three-dimensional
(3D) images. As it provides high- and low-contrast soft tis-
sue (CT-like) images in multiple viewing planes, it constitutes
a substantial improvement over conventional single-planar
digital subtraction angiography and fluoroscopy17. This re-
source (available at our department) enabled us to identify
extra prostatic vessels in doubtful cases, thus avoiding poten-
tial complications (fig. 8).
PE causes minimal side effects and it is virtually painless. In
our series, it was rarely necessary to prescribe potent analge-
sics and all patients asked to be discharged after a few hours
at rest. This excellent tolerance to treatment offers a further
advantage for patients and also has a beneficial impact on
hospital bed occupancy.
When adverse effects or complications of PE occurred in our
study, they were minor and of little concern, as they did not
require hospitalization or additional procedures, except for
one case in which the patient developed acute urinary reten-
tion and required a transient bladder catheter for 25 days.
This complication was also reported by other authors and is
related to the inflammation caused by ischemia of the pros-
tate gland tissue26.
Limitations of our study include: the small number of pa-
tients, the short-term follow-up and the lack of comparison
of PE with other treatments. Nonetheless, our objective was
to show the safety and efficacy of this new therapeutic al-
ternative and its potential benefits in a preliminary series of
cases treated at our institution.
Undoubtedly, further studies are needed in a larger number
of patients with longer follow-up to assess the true appli-
cability of this technique within the battery of therapeutic
options available for BPH. In addition, a large number of clini-
cal issues remain to be investigated, including identification
of subsets of patients in relation to prostate volume, degree
of occlusion, severity of symptoms, as well as efficacy and
durability of treatment for a better therapeutic management.
Other technical aspects, such as the type and size of particles
that should be used and/or the need for unilateral or bilat-
eral embolization, also remain to be defined. These issues will
surely be addressed in future research.

a b c

Figure 7 Anastomosis of the prostate artery with other pelvic branches. (a) Communication of the vesical-prostatic trunk with
the right (D) deferential artery. (b) Communication with the left cavernous artery (C). (c) Communication with the superior
hemorrhoidal artery, tributary of the inferior mesenteric artery (MI).

Rev. Argent. Radiol. 2014;78(2): 102-113 109

Prostate embolization: a new field of Interventional Radiology

a b

c d

Figure 8 Images acquired by cone-beam CT. (a) Selective angiography performed with the micro catheter placed inside a branch
arising from the left internal pudendal artery (PI), with features generating some doubts about the irrigated tissue. (b) The CT
image acquired by digital angiography shows contrast retention on the left prostatic bed (arrow). (c) Selective angiography per-
formed with the micro catheter placed inside a branch arising from the right internal pudendal artery, with features generating
doubts about the irrigated tissue. (d) The CT image obtained by digital angiography shows contrast retention on the rectal wall
(arrow), allowing identification of the hemorrhoidal artery and avoiding embolization.

Conclusion Conflicts of interest

The authors declare no conflicts of interest.
In this preliminary institutional study, prostate embolization
proved to be a feasible and safe procedure, with good con-
trol of symptoms in the short term, as prostate volume re-
duction was achieved with no erectile dysfunction or other
major complications, as already reported in the worldwide
literature.

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 N. Kisilevzky et al.

Annex 1

International Prostate Symptom Score (IPSS) Questionnaire

Less than once

Almost always
More than half
Less than half

Half the time

Not at all

the time

the time
Over the past month

Score
Incomplete emptying
How often have you had a sensation of not emptying
your bladder completely after you finish urinating? 0 1 2 3 4 5 ----
Frequency
How often have you had to urinate again less than
two hours after you finished urinating? 0 1 2 3 4 5 ----
Intermittency
How often have you found you stopped and started
again several times when you urinated? 0 1 2 3 4 5 ----
Urgency
How difficult have you found it to postpone urination? 0 1 2 3 4 5 ----
Weak stream
How often have you had a weak urinary stream? 0 1 2 3 4 5 ----
Straining
How often have you had to push or strain
to begin urination 0 1 2 3 4 5 ----

or more
2 times

3 times

4 times

5 times
1 time
None

Score
Nocturia
How many times did you most typically get up to
urinate from the time you went to bed until the time
you got up in the morning? 0 1 2 3 4 5 ----

Total IPSS score.

Interpretation of total IPSS score: 0-7 = mildly symptomatic; 8-19 = moderately symptomatic; 20-35 = severely symptomatic.

Quality of life due to urinary symptoms

dissatisfied
dissatisfied
Delighted

Unhappy
satisfied /
Pleased

satisfied

Terrible
equally
Mostly

Mostly
Mixed

If you were to spend the rest of your

life with your urinary condition the

way it is now, how would you feel
about that) (choose one option) 0 1 2 3 4 5 ----

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Prostate embolization: a new field of Interventional Radiology

International Index of Erectile Function (IIEF)

Please, be sure that you select one response for each question. Tick the option that best describes your sexual experience
over the last month. The survey must be completed by the patient and returned to the patients treating physician.

1) Over the past 4 weeks, how often were you able to get 5) During sexual intercourse, how difficult was it to main-
an erection during sexual activity? tain your erection?
o 0. No sexual activity o 0. No sexual activity
o 1. Never o 1. Never
o 2. A few times (less than 50%) o 2. A few times (less than 50%)
o 3. Sometimes (50%) o 3. Sometimes (50%)
o 4. Most times (more than 50%) o 4. Most times (more than 50%)
o 5. Always o 5. Always

4) How often were you able to maintain your erection after 3) When you attempted intercourse, how often were you
you had penetrated your partner? able to penetrate your partner?
o 0. No sexual activity o 0. No sexual activity
o 1. Never o 1. Never
o 2. A few times (less than 50%) o 2. A few times (less than 50%)
o 3. Sometimes (50%) o 3. Sometimes (50%)
o 4. Most times (more than 50%) o 4. Most times (more than 50%)
o 5. Always o 5. Always

2) Over the past 4 weeks, how often were your erections 6) How do you rate your confidence that you could get
hard enough for penetration? and keep an erection?
o 0. No sexual activity o 0. No sexual activity
o 1. Never o 1. Never
o 2. A few times (less than 50%) o 2. A few times (less than 50%)
o 3. Sometimes (50%) o 3. Sometimes (50%)
o 4. Most times (more than 50%) o 4. Most times (more than 50%)
o 5. Always o 5. Always

Result: normal = 26-36; mild = 22-25; mild to moderate = 17-21; moderate = 11-16; serious = 1-10.

References laser prostatectomy and electrovaporization in men with benign prostatic

1. Garraway WM, Collins GN, Lee RJ. High prevalence of benign prostatic
hypertrophy in the community. Lancet. 1991;338: 469-71.
2. Kassabian VS. Sexual function in patients treated for benign prostatic hy-
perplasia. Lancet 2003;361:60-2.
3. Rosen RC, Giuliano F, Carson CC. Sexual dysfunction and lower urinary
tract symptoms (LUTS) associated with benign prostatic hyperplasia (BPH).
Eur Urol. 2005;47:824-37.
4. Eckhardt MD, van Venrooij GE, van Melick HH, Boon TA. Prevalence and
bothersomeness of lower urinary tract symptoms in benign prostatic hy-
perplasia and their impact on well-being. J Urol. 2001;166:563-8.
5. Patel AK, Chapple CR. Benign prostatic hyperplasia: treatment in primary
care. BMJ. 2006;333:535-9.
6. Varkarakis J, Bartsch G, Horninger W. Long-term morbidity and mor-
tality of transurethral prostatectomy: a 10-year follow-up. Prostate.
2004;58:248-51.
7. Van Melick HH, van Venrooij GE, Eckhardt MD, Boon TA. A randomized
controlled trial comparing transurethral resection of the prostate, contact
hyperplasia: analysis of subjective changes, morbidity and mortality. J Urol.
2003;169:1411-6.
8. Lourenco T, Pickard R, Vale L, Grant A, Fraser C, MacLennan G, et al.
Minimally invasive treatments for benign prostatic enlargement: system-
atic review of randomized controlled trials. BMJ. 2008;337:1662.
9. Baazeem A, Elhilali MM. Surgical management of benign prostatic hyper-
plasia: current evidence. Nat Clin Pract Urol. 2008; 5:540-9.
10. Mauro MA. Can hyperplastic prostate follow uterine fi broids and be man-
aged with transcatheter arterial embolization? Radiology. 2008;246:657-8.
11. Faintuch S, Mostafa EM, Carnevale FC, Ganguli S, Rabkin DJ, Goldberg
SN. Prostatic artery embolization as a primary treatment for benign pros-
tatic hyperplasia in a canine model [abstract]. J Vasc Interv Radiol. 2008;19
Suppl:S7.
12. Sun F, Snchez FM, Crisstomo V, Lima JR, Luis L, Garca- Martnez V, et al.
Benign prostatic hyperplasia: transcatheter arterial embolization as poten-
tial treatment: preliminary study in pigs. Radiology. 2008;246:783-9.
13. Jeon GS, Won JH, Lee BM, Kim JH, Ahn HS, Lee EJ, et al. The effect of
transarterial prostate embolization in hormone-induced benign prostatic
hyperplasia in dogs: a pilot study. J Vasc Interv Radiol. 2009;20:384-90.
14. DeMeritt JS, Elmasri FF, Esposito MP, Rosenberg GS. Relief of benign pros-

112 Rev. Argent. Radiol. 2014;78(2): 102-113


tatic hyperplasia-related bladder outlet obstruction after transarterial poly-
vinyl alcohol prostate embolization. J Vasc Interv Radiol. 2000;11:767-70.
15. Carnevale FC, Antunes AA, da Motta Leal Filho JM, de Oliveira Cerri LM,
Baroni RH, Marcelino AS, et al. Prostatic artery embolization as a primary
treatment for benign prostatic hyperplasia: preliminary results in two pa-
tients. Cardiovasc Intervent Radiol. 2010;33:355-61.
16. Pisco J, Campos Pinheiro L, Bilhim T, Duarte M, Rio Tinto H, Fernandes
L, et al. Prostatic arterial embolization for benign prostatic hyperplasia:
short- and intermediate-term results. Radiology. 2013;266:668-77.
17. Bagla S, Rholl KS, Sterling KM, van Breda A, Papadouris D, Cooper JM, et
al. Utility of cone-beam CT imaging in prostatic artery embolization. J Vasc
Interv Radiol. 2013;24:1603-7.
18. Leoni CJ, Potter JE, Rosen MP, Brophy DP, Lang EV. Classifying complica-
tions of interventional procedures: a survey of practicing radiologists. J
Vasc Interv Radiol. 2001;12:55-9.
19. Fiorelli RL, Koolpe HA, Klaus RL. Use of polyvinyl alcohol in treatment of
bladder and prostatic hemangioma. Urology. 1991; 38:480-2.
20. Michel F, Dubruille T, Cercueil JP, Paparel P, Cognet F, Krause D. Arterial
embolization for massive hematuria following transurethral prostatec-
tomy. J Urol. 2002;168:2550-1.
21. Barbieri A, Simonazzi N, Marcato C, Larini P, Barbagallo M, Frattini A, et al.
Massive hematuria after transurethral resection of the prostate: manage-
ment by intra-arterial embolization. Urol Int. 2002;69:318-20.
22. Garca Mnaco R, Martnez P, Peralta O, Giudice C, Damia O. Compli-
caciones hemorrgicas del intervencionismo renal: utilidad de la emboli-
zacin. Rev Argent Radiol. 1998;62:283-7.
23. Martnez P, Giudice C, Garca Mnaco R, Damia O, Schiapapietra C. Hem-
orragias secundarias a procedimientos percutneos renales: su tratamien-
to por embolizacin arterial. Rev Arg Urol.1999;64:94-9.
24. American College of Obstetricians and Gynecologists. ACOG practice bul-
N. Kisilevzky et al.
letin. Alternatives to hysterectomy in the management of leiomyomas.
Obstet Gynecol. 2008;112: 387-400.
25. Carnevale FC, Antunes AA. Prostatic artery embolization for enlarged
prostates due to benign prostatic hyperplasia. How I do it. Cardiovasc
Intervent Radiol. 2013;36:1452-63.
26. Pisco JM, Rio Tinto H, Campos Pinheiro L, Bilhim T, Duarte M, Fernandes 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;23:2561-72.
27. Pisco JM, Campos Pinheiro L, Bilhim T, Duarte M, Mendes JR, Oliveira AG.
Prostatic arterial embolization to treat benign prostatic hyperplasia. J Vasc
Interv Radiol. 2011;22:11-9.
28. Bilhim T, Pisco JM, Rio Tinto H, Fernandes L, Campos Pinheiro L, Duarte
M, et al. Unilateral versus bilateral prostatic arterial embolization for lower
urinary tract symptoms in patients with prostate enlargement. Cardiovasc
Intervent Radiol. 2013;36: 403-11.
29. Kroencke TJ, Scheurig C, Poellinger A, Gronewold M, Hamm B. Uterine
artery embolization for leiomyomas: percentage of infarction predicts
clinical outcome. Radiology. 2010;255: 834-41.
30. Villeirs GM, L Verstraete K, De Neve WJ, De Meerleer GO. Magnetic reso-
nance imaging anatomy of the prostate and periprostatic area: a guide for
radiotherapists. Radiother Oncol. 2005;76:99-106.
31. Bilhim T, Pisco JM, Rio Tinto H, Fernandes L, Pinheiro LC, Furtado A, et
al. Prostatic arterial supply: anatomic and imaging fi ndings relevant for
selective arterial embolization. J Vasc Interv Radiol. 2012;23:1403-15.
32. Garca Mnaco R, Garategui L, Kizilevsky N, Peralta O, Rodriguez P, Pala-
cios-Jaraquemada J. Human cadaveric specimen study of the prostatic ar-
terial anatomy: implications for arterial embolization. J Vasc Interv Radiol.
2014;25:315-22.
Rev. Argent. Radiol. 2014;78(2): 102-113 113