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Treatment of Benign Prostatic Hyperplasia by Occlusion of The 180 Interventional Radiology Treatment of Benign Prostatic Hyperplasia by Occlusion of the Impaired Urogenital Venous System – First Experience Behandlung der benignen Prostatahyperplasie durch Embolisation des insuffizienten urogenitalen Venensystems – eine Zwischenbilanz Authors H. Strunk, M. Meier, H. H. Schild, M. Rauch Affiliation Department of Radiology, University Bonn, Germany Key words Abstract culated bladder. Both the peripheral total tes- " ● abdomen ! tosterone levels (4.55 ± 1.27 vs. 3.93 ± 1.00 ng/ ●" prostate Purpose: To effect regression of benign pro- ml; p = n. s.) and PSA levels (3.74 ± 2.83 vs. ●" blood vessels static hyperplasia (BPH), Gat et al. (Andrologia 4.06 ± 3.34 ng/ml; p = n. s.) showed no signifi- ●" genital/reproductive 2008) proposed to occlude incompetent sper- cant differences. matic veins to reduce increased hydrostatic Conclusion: Interventional occlusion of the pressure on the prostatic venous plexus and spermatic veins in patients with BPH is a prevent reflux with androgen rich blood feasible outpatient procedure with a low com- from the testicles. Our aim was to implement plication rate. Intermediate results are satis- this treatment strategy in clinical practice factory. Mid- and long-term results and patho- and to report about first results. physiologic mechanisms need to be further Methods: Embolization of the spermatic elucidated. veins was performed in 30 patients with Key Points: BPH. In 16 patients, we obtained follow-up ▶ Venous embolization in patients with BPH data from at least 6 months. The sonographic is a feasible outpatient procedure. transabdominal prostatic volume, prostate- ▶ It shows satisfactory intermediate result specific antigen (PSA) and peripheral total with good symptom relief. testosterone levels were determined before ▶ Medium and long-term results need to be and 6 months after the intervention. Subjec- further evaluated. tive symptomatology was assessed using Citation Format: standardized questionnaires (International ▶ Strunk H, Meier M, Schild HH et al. Treat- received 16.4.2014 Prostate Symptom Score [IPSS] and Quality of ment of Benign Prostatic Hyperplasia by accepted 8.9.2014 Life score [QoL]) before and 6 months after Occlusion of the Impaired Urogenital Ve- the procedure. nous System – First Experience. Fortschr Bibliography Results: The age of all treated patients was Röntgenstr 2015; 187: 180–186 DOI http://dx.doi.org/ 46 – 77 years. The age of the 16 patients who 10.1055/s-0034-1385353 – This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. Published online: 12.11.2014 received follow-up was 51 77 years. IPSS Fortschr Röntgenstr 2015; 187: (median 18 [IQR 20.75 – 14.50] vs. 9 [IQR Zusammenfassung 180–186 © Georg Thieme 11.00 – 7.25], p < 0.0001) and QoL score (4 ! Verlag KG Stuttgart · New York · [IQR 5 – 3] vs. 2 [IQR 3 – 1], p < 0.001) were Ziel: Nach dem von Gat et al. (Andrologia 2008) ISSN 1438-9029 significantly decreased 6 months after the in- vorgeschlagenen Prinzip soll eine Embolisation tervention. The subjective improvement of der insuffizienten Testikularvenen bei Patienten Correspondence symptoms did not correspond with prostatic mit benigner Prostatahyperplasie (BPH) einen er- Dr. Maximilian Rauch volumes, which did not change significantly höhten hydrostatischen Druck im prostatischen Dep. of Radiology, (54.31 ± 30.90 vs. 50.50 ± 29.26 ml, p = n. s.). Venenplexus senken und eine Überflutung der University Bonn 4/16 patients had a measurable post-void ur- Prostata mit androgenreichem Blut aus dem Ho- Sigmund-Freud-Str. 25 ine volume, which decreased in two patients den verhindern, sodass eine Regression der BPH 53105 Bonn 6 months after the procedure, remained un- resultiert. Dieses neue Therapieprinzip sollte im Germany changed in one patient, and was no longer de- Rahmen der klinischen Routine eingesetzt und Tel.: ++ 49/2 28/28 71 50 91 Fax: ++ 49/2 28/28 71 11 66 tectable in one patient. 4 of the 11 had a so- über erste Ergebnisse berichtet werden. maximilian.rauch@ nographically detectable varicocele before Methoden: Bei 30 Patienten mit BPH wurde eine ukb.uni-bonn.de the intervention, and one patient had a trabe- Embolisation der Testikularvenen durchgeführt. Strunk H et al. Treatment of Benign … Fortschr Röntgenstr 2015; 187: 180–186 Interventional Radiology 181 Bei 16 Patienten lagen zum Stichtag Nachsorgedaten von wenig- Patients and Methods stens 6 Monaten vor. Sonografisches transabdominelles Prostata- ! volumen, prostataspezifisches Antigen (PSA) und peripheres Ge- The following evaluation was based on 30 consecutive pa- samttestosteron wurden vor und 6 Monate nach dem Eingriff tients treated by intervention for benign prostate hyperpla- bestimmt. Die subjektive Beschwerdesymptomatik wurde mit- sia (BPH) at our clinic by February 2014. Follow-up data tels internationalem Prostata Symptom Score (IPSS) und Quality from at least 6 months was available for 16 of these patients of Life Index (QoL) vor und 6 Monate nach dem Eingriff bestimmt. by the cut-off date. Ergebnisse: Das Patientenalter betrug beim Eingriff 46 – 77 Jah- The inclusion criteria were an age of > 40 years, confirmed ren, das der 16 verlaufskontrollierten Patienten 51 – 77 Jahre. BPH, no obstructive uropathy, no acute urinary retention, IPSS (Median 18 [IQR 20,75 – 14,50] vs. 9 [IQR 11,00 – 7,25], failure of treatment with medication for at least 6 months p < 0,0001) und QoL-Score (4 [IQR 5 – 3] vs. 2 [IQR 3 – 1], or rejection of treatment with medication as well as rejec- p < 0,001) waren 6 Monate nach dem Eingriff signifikant ernie- tion of surgery by the patient. The exclusion criteria were drigt. Die subjektive Beschwerdebesserung fand in der Messung acute urinary retention, obstructive uropathy, confirmed des Prostatavolumens kein Korrelat, welches mit 54,31 ± 30,90 prostate carcinoma and contraindications for intervention, vs. 50,50 ± 29,26 ml (p = n. s.) nicht signifikant verändert war. Bei such as coagulation defect, renal insufficiency. 4 der 16 behandelten Patienten ließ sich ein Restharnvolumen All patients contacted the clinic on their own because they nachweisen, welches bei zwei Patienten 6 Monate nach dem Ein- had heard or read about the vein occlusion treatment con- griff unverändert, bei einem Patient rückläufig war, bei einem cept used by Gat et al. [4]. Patient war kein Restharn mehr nachweisbar. Bei 4/16 Patienten All patients were informed of possible complications, such as war vor dem Eingriff auch sonografisch eine Varikozele nach- contrast medium reactions, infections, bleeding and other weisbar, bei einem Patienten eine Balkenblase. Bei den periphe- vascular complications, orchitis, epididymitis, and possible ren Gesamttestosteronwerten (4,55 ± 1,27 vs. 3,93 ± 1,00 ng/ml; treatment failure, prior to intervention (●" Table 1). p = n. s.) und den PSA-Werten (3,74 ± 2,83 vs. 4,06 ± 3,34 ng/ml; Patients were also informed of other available BPH treat- p = n. s.) konnten im Verlauf keine signifikanten Unterschiede ment options during the preoperation discussion. At this festgestellt werden. time Schlussfolgerung: Die venöse Embolisationsbehandlung der BPH ▶ The patient history including prior treatments, interven- ist ein ambulant durchführbarer Eingriff mit geringer Komplika- tions, secondary diagnoses, and medication history were tionsrate. Es zeigt sich ein zufriedenstellendes Zwischenergebnis. recorded. Mittel- und längerfristige Ergebnisse sowie pathophysiologische ▶ Ultrasound of both kidneys, the bladder (before and after Mechanismen des Eingriffs sind weiter zu evaluieren. urination), the prostate (transabdominal), and both testi- cles (to sonographically detect a varicocele) was per- formed and documented. The prostate volume was calcu- Introduction lated with the ellipsoid formula. ! ▶ Patients were asked to complete a standardized ques- Although testosterone promotes cell proliferation in the tionnaire regarding quality of life [QOL]) and another prostate [1], a low serum testosterone level is seen in pa- questionnaire (International Prostate Symptom Score tients with benign prostate hyperplasia (BPH) [2]. Interest- [IPSS]), which were used to classify the severity of the ingly, it was nonetheless able to be shown that the adminis- voiding disorder and the associated level of suffering [5] tration of antiandrogenic medications can have a reductive (●" Table 2, 3). effect on BPH [3]. ▶ The following laboratory values were determined: PSA, Based on this paradox, Gat et al. 2008 formulated the hy- peripheral total testosterone, creatinine, TSH, clotting. pothesis that venous valve insufficiency of the spermatic The intervention was performed in 26/30 patients comple- veins may be responsible for the development of BPH [4]: tely via a right cubital vein access (cephalic vein or basilic On the one hand, the valve insufficiency results in reflux vein, 5F introducer) and in 1/30 patients via the right femo- via venous collaterals into the prostatic plexus which can ral vein (5F introducer) due to the lack of a suitable cubital cause an increase in the volume of the organ. On the other puncture point. The left spermatic vein was probed most ef- hand, the backed-up blood contains significant quantities of fectively with a 5F vertebral catheter and the right spermat- This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. free, unbound, i. e., active, testosterone. This hormone load ic vein with a 5F headhunter 1 catheter. causes accelerated
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