Next Article in Journal
MicroRNA-133a and MicroRNA-145 May Be Involved in the Development of Hypertension-Mediated Organ Damage in Children with Primary Hypertension—A Preliminary Study
Next Article in Special Issue
All You Need to Know About TACE: A Comprehensive Review of Indications, Techniques, Efficacy, Limits, and Technical Advancement
Previous Article in Journal
Comparative Study of Exchange Nailing and Augmentative Plating for Treating Aseptic Nonunion of Femoral Shafts Post Intramedullary Nailing: A Single-Blind, Multicentric Randomized Clinical Trial
Previous Article in Special Issue
Human-in-the-Loop—A Deep Learning Strategy in Combination with a Patient-Specific Gaussian Mixture Model Leads to the Fast Characterization of Volumetric Ground-Glass Opacity and Consolidation in the Computed Tomography Scans of COVID-19 Patients
 
 
Search for Articles:
Title / Keyword
Author / Affiliation / Email
Journal
Article Type
 
 
Advanced Search
 
Section
Special Issue
Volume
Issue
Number
Page
 
Journals
JCM
Volume 13
Issue 22
10.3390/jcm13226930
jcm-logo
Submit to this Journal Review for this Journal Propose a Special Issue
► Article Menu

Article Menu

share Share announcement Help format_quote Cite question_answer Discuss in SciProfiles
first_page
settings
Order Article Reprints
Font Type:
Arial Georgia Verdana
Font Size:
Aa Aa Aa
Line Spacing:
Column Width:
Background:
Article

Combination Prostatic Artery Embolization Prior to Water-Jet Ablation (Aquablation) for Benign Prostatic Hypertrophy: A Propensity Score Analysis

by
Sandeep Bagla
1,
Inderjit Singh
2,
Abin Sajan
3,*,
Antony Sare
4,
Alex Pavidapha
1,
Tej Mehta
5,
John Klein
2,
Shawn Marhamati
2 and
Lori Lerner
6
1
IR Centers USA, 2755 Hartland Road, Falls Church, VA 22043, USA
2
Potomac Urology, 1800 N. Beauregard Street, Alexandria, VA 22311, USA
3
Department of Radiology, Columbia University Irving Medical Center, 622 W 168th St, New York, NY 10032, USA
4
Department of Radiology & Biomedical Imaging, Yale University School of Medicine, P.O. Box 208042, New Haven, CT 06520-8042, USA
5
Department of Radiology, Johns Hopkins Hospital, 1800 Orleans St, Baltimore, MD 21287, USA
6
Department of Surgery, Boston University Chobanian & Avedisian School of Medicine, 72 East Concord Street, Boston, MA 02118, USA
*
Author to whom correspondence should be addressed.
J. Clin. Med. 2024, 13(22), 6930; https://doi.org/10.3390/jcm13226930
Submission received: 9 October 2024 / Revised: 11 November 2024 / Accepted: 13 November 2024 / Published: 18 November 2024
(This article belongs to the Special Issue Technological Advancements and Clinical Innovations in Diagnostic and Interventional Radiology)
Browse Figures
Versions Notes

Abstract

:
Objectives: To compare post-operative bleeding measures in patients who underwent prostatic artery embolization (PAE) prior to water-jet ablation (aquablation) vs. water-jet ablation alone. Methods: A retrospective review identified 145 patients treated with water-jet ablation for benign prostatic hyperplasia from December 2018 to June 2021. Patients were divided into two groups: water-jet ablation alone (n = 56) vs. pre-operative PAE and water-jet ablation (n = 89). Patient demographics, pertinent laboratory values, operative reports, and hospital courses were reviewed. Results: PAE was technically successful in all patients (n = 89), and all 89 patients underwent successful water-jet ablation within a median time of 2 days. Compared to water-jet ablation alone, pre-operative PAE resulted in a significant reduction in post-operative bleeding as measured via lower rates of continuous bladder irrigation, hemostatic measures, and hematuria. Pre-operative PAE was also associated with lower rates of post-operative urinary retention (odds ratio 17, p = 0.02) and less likely to require reoperation 30 days after the procedure (p = 0.003). There were no major PAE-related adverse events reported in the combination arm. Conclusions: Compared to water-jet ablation alone, pre-operative PAE resulted in fewer bleeding-related complications and urinary retention.

1. Introduction

Water-jet ablation has emerged as an alternative to transurethral resection of the prostate to treat bladder outlet obstruction (BOO) in the setting of benign prostatic hyperplasia (BPH) [1]. The system utilizes ultrasound guidance and robotic technology to precisely ablate prostate tissue with a high-pressure water jet. The major advantages of this procedure are the ability to treat prostates of various sizes, even those in the large and very large category, quickly and efficiently; reduced sexual side effects compared to other procedures for larger glands; and a shorter learning curve than many resection techniques [2]. However, a known disadvantage of water-jet ablation is the potential for bleeding complications largely, if not completely, attributable to the non-thermal nature of the procedure. Transfusion rates as high as 6–10% were reported in early clinical trials [3,4]. More recent approaches to minimize bleeding complications include post-operative cautery using monopolar, bipolar, or laser energy [5]. This may extend the length of the surgery and increase the risk for delayed bleeding, especially in patients with risk factors such as larger prostate sizes and those on anticoagulants.
Prostatic artery embolization (PAE) is a proven treatment for hematuria of prostatic origin that can be performed with very low risk of serious complications in an outpatient setting with moderate sedation or local anesthesia [6,7,8]. Therefore, performing a PAE prior to water-jet ablation may be a reasonable adjunct procedure if the combination reduces bleeding complications, both early and delayed. Multiple retrospective and prospective studies have identified that PAE is also effective in reducing prostate volume in patients with BPH [7,8,9,10,11,12,13]. It is similar in effectiveness to other minimally invasive surgical treatment options such as Rezum and Urolift [14,15,16]. The purpose of this analysis was to quantify the effect of pre-operative PAE in reducing post-procedural bleeding and the need for bleeding-related therapeutic measures.

2. Materials and Methods

2.1. Study Population and Experimental Design

This retrospective study was approved by an Institutional Review Board (Sterling IRB), and study activities were performed with HIPAA compliance. Records were reviewed from 145 consecutive patients who underwent water-jet ablation by a single operator from December 2018 to June 2021 for severe lower urinary tract symptoms (LUTS) secondary to benign prostatic hypertrophy.
Data collected included baseline age, pre-operative prostate volume (transrectal US), urological surgical history, pre- and post-operative assessments/medications (International Prostatic Symptom Score (IPSS), Qmax, Post-Void Residual (PVR), prostate specific antigen (PSA), quality of life (QoL), and International Index of Erectile Function (IIEF)), information related to water-jet ablation surgery, hospitalization (technical reports, operative time, duration of stay, and complications), and post-operative events (re-admission, re-intervention, etc.). If the patient received a combination treatment with pre-operative PAE, information pertaining to the PAE procedure was obtained (technical reports, technical success, complications). Prostatic volumes from standard of care transrectal ultrasound were also recorded. Adverse events were assessed according to the Society of Interventional Radiology (SIR) Classification System [17]. Operative complications were assessed according to the Clavien–Dindo Scale [18].

2.2. Patient Selection

The patients were selected to undergo pre-operative PAE based on the preference of the operating surgeon. The selection criteria included prostate gland size, patient comorbidities, and presence of anticoagulation.

2.3. Procedure

Water-jet ablation: Water-jet ablation was performed using the AquaBeam Robotic System (PROCEPT BioRobotics, Redwood Shores, Redwood, CA, USA). After administering general anesthesia, the patients were positioned in the lithotomy position. Biplanar BK transrectal ultrasound was inserted and appropriately positioned in the rectum before locking into place on the robotic arm. Using a freehand approach, the cystoscope and jet apparatus were then advanced and locked into place. The ultrasound was adjusted to visualize the prostate in the sagittal plane. The depth of treatment start, bladder neck, mid-prostate, verumontanum, and distal extent of treatment were mapped. Once appropriately adjusted, water-jet ablation was performed according to the mapped plan (Figure 1). Additional passes, usually 1–3, were performed as necessary. After water-jet ablation was complete, hemostasis was achieved with a combination of loop electrode cautery and/or Foley catheter traction, as required. The use of the above hemostatic measures was compared between the two groups. All patients were then started on continuous bladder irrigation.
Prostatic artery embolization: PAE was performed in a similar fashion as previously described [7] (Figure 2). Cone beam CT was not performed for any intra-procedural planning. If aberrant anastomoses were identified on digital subtraction angiography, coil embolization or selective prostatic artery catheterization was performed to prevent non-target embolization. Embolization was performed using small-caliber microspheres, 100–300 microns (Embozene, Boston Scientific, Marlborough, MA, USA, or Hydropearl, Terumo Medical, Somerset, NJ, USA) and gel–foam slurry, until complete stasis was achieved (Figure 3 and Figure 4). The selection between Embozene and Hydropearl microspheres was based on operator preference, and outcomes differences between the two groups were not collected.
To compare differences in baseline patient characteristics and outcomes between the two groups, Pearson’s chi-square or Fisher’s exact test were used to analyze categorical variables, and Mann–Whitney U-test or Student’s t-test were used for continuous variables.
Propensity score matching was performed to minimize the effects of hidden, non-random confounding variables and selection biases. The 1:1 nearest neighbor propensity score matching without replacement was first attempted with a propensity score estimated using logistic regression of the treatment on the covariates. This matching yielded poor balance, leading to the full matching on the propensity score, which yielded adequate balance. The propensity score was estimated using a probit regression of the treatment on the covariates, which yielded better balance than did a logistic regression. A standardized mean difference was used to evaluate the balance of the covariate distribution between the 2 groups. After matching, the marginal odds ratio was used to analyze categorical variables, while the Wilcoxon signed-rank test or paired t test were employed to compare continuous variables.
A 2-tailed p value of <0.05 was considered statistically significant. All statistical analyses were performed using R (version 4.04; R Foundation for Statistical Computing, Vienna, Austria). The R package MatchIt was used for propensity score matching.

3. Results

Baseline Characteristics

56 patients received water-jet ablation alone, and 89 patients received pre-operative PAE. In the combined group, patients underwent water-jet ablation within 7 days of PAE. There were significant differences in baseline age and prostate gland size between the two groups (Table 1). The mean age for the water-jet ablation group was 62.2 ± 8.6 (SD) years, and the combination group was 69.6 years ± 8.9 (p < 0.001). Mean prostate gland size among the water-jet ablation group was 52.6 ± 24.8 mL and among the combination group was 79.0 ± 27.3 mL (p < 0.001). After propensity score matching, these variables were adequately balanced (Table 2). Pre-treatment variables, including PSA, Qmax, PVR, IPSS, QOL, and IIEF, were not significantly different between groups with both pre- and post-propensity score matching analyses.
There were no significant differences in length of hospital stay after propensity score matching.
In the immediate post-operative period, patients in the water-jet ablation group were 7.6 (OR) times more likely to require continuous bladder irrigation > 2 h post-operation (n = 43 vs. 30, p < 0.001) (Table 3). The water-jet ablation-only treatment group was also 14.7 times more likely to require hemostatic measures during their hospital stay (n = 57 vs. 45, p < 0.001). There was no difference in use of additional manual bladder irrigation of the Foley catheter between the water-jet ablation and combination treatment groups during their hospital stay (p = 0.15).
During the follow-up period (mean = 4.1 ± 3.1 months, range 0–33 months), patients that received water-jet ablation alone were 3.0 times more likely to experience prolonged hematuria (>6 weeks post-op) (n = 22 vs. 16, p = 0.01). Similarly significant differences were also recorded for post-operative urinary retention (n = 7 vs. 3, p = 0.02). There was no difference in rates of post-operative dysuria between groups.
Patients in the water-jet ablation group were 13 times more likely to return to the OR due to a procedural complication after 30 days (n = 6 vs. 3, p = 0.003). No significant differences were demonstrated when comparing long-term Foley catheter requirements and return to OR within 30 days.

4. Discussion

As a newer technique to treat bladder outlet obstruction secondary to BPH, water-jet ablation has been proven to achieve a similar reduction in urinary symptoms with a lower rate of ejaculatory dysfunction when compared to TURP [19]. Unlike other minimally invasive treatments such as Rezum (Boston Scientific, Marlborough, MA, USA) and Urolift (Teleflex, Pleasanton, CA, USA), water-jet ablation can effectively treat large prostates greater than 80 mL [20]. However, one disadvantage with larger prostates is the incidence of bleeding complications compared to other surgical modalities, with post-procedural transfusion rates as high as 10% [3]. There remains some degree of uncertainty regarding how bleeding should be managed during the procedure, but a combination of both electrocautery and traction techniques has been reported to yield the best results [21].
PAE has been shown to be a successful stand-alone therapy in reducing lower urinary symptoms secondary to BPH in prostate glands of all sizes [22]. The use of pre-operative embolization to reduce intraoperative blood loss is a well-established practice, most performed prior to hypervascular tumor resection, such as renal cell carcinoma [23]. More recently, the benefit of embolization before simple prostatectomy to treat BPH has been described [24]. Pre-operative embolization has also evolved outside of urology to include practices such as head and neck tumors, fibroids, musculoskeletal lesions, and hepatic oncology [25].
The concept of utilizing pre-operative PAE has a similar rationale given the rate of bleeding complications. Potential non-target embolization remains the main disadvantage of performing PAE before water-jet ablation. However, given that PAE is associated with very few severe adverse events (less than 0.3%), the combined approach to BPH offers a potential solution to prevent bleeding-related complications [26]. The benefits are likely higher in patients with increased vascularity, such as larger glands with or without indwelling catheters, and those with recurring infections. These benefits need to be weighed against the cost and risk of two procedures, both for the patient and the healthcare system. The medical and financial implications of two procedures are balanced with potentially improved patient factors such as same-day discharge, lower rates of bleeding-related complications, faster recovery time, and quicker return to pre-procedural activities.
The two comparative groups in this report contain large sample sizes compared to other PAE and water-jet ablation analyses, lending strength to the conclusions. The difference in prostate volume between the two groups merits discussion. Patients with risk factors for bleeding, such as larger gland sizes, were referred for PAE based on the operator’s judgment. Given the known higher rate of bleeding complications after water-jet ablation in prostates greater than 80 mg, this group would likely stand to benefit from pre-operative PAE more than those with smaller prostate glands. However, propensity score matching was utilized to adjust for this difference. After this adjustment, the data demonstrated improved outcomes with combination therapy, with a lower incidence of prolonged hematuria, urinary retention, and a reduced need for post-surgical procedures to manage the hematuria.
Fassia et al. reported a similar study recently looking at 11 patients that underwent pre-aquablation PAE [27]. Unlike the current study, the prostate sizes were larger, measuring with a mean volume of 189.9 mL. This feasibility study did not have a comparison group but reported indicators of bleeding such as hemoglobin and platelet levels. Although the mean post-procedure change was 1.4 g/dL, there were no cases of bleeding complications requiring blood products.
Combination therapy for BPH is increasingly common, especially involving PAE, as the American Urologic Association guidelines on BPH recently included PAE as a possible treatment option [28,29]. Babore et al. reported on 17 patients that underwent PAE approximately 48.4 months following Urolift [30]. The degree of symptom relief was similar to a treatment-naive PAE control group at follow-up. Varadhan et al. also reported on salvage PAE in a group of 16 patients with BPH [31]. Prior minimally invasive surgical treatments included Urolift (n = 6), Rezum (n = 5), GreenLight (n = 3), transurethral needle ablation (n = 1), and transurethral microwave thermotherapy (n = 1). PAE was performed approximately 3.3 years after the initial treatment. PAE was technically feasible in all patients, and significant improvements in IPSS and QoL were reported in all patients.
The main limitations of this analysis were the retrospective nature of data collection, the lack of randomization between the comparative groups, and the differences in prostate sizes. If the data were collected prospectively in a randomized fashion, there likely would not have been a difference in prostate volume between the two groups. Additionally, there would likely be a significant difference in length of stay if the data were more homogenous. Instead, this represents a “real world” dataset in which patients with larger prostates were more likely to undergo combination therapy due to greater concern for bleeding complications. Although additional data are necessary, combination therapy in smaller glands is less efficacious, as PAE is technically challenging with increased risk and cost to the patient and to the healthcare system. Pre-operative PAE is most appropriate in larger glands and those with medical comorbidities increasing the risk of bleeding, such as those on anticoagulation. Prospective studies are necessary to confirm these benefits and identify the select patients that will benefit from this approach.

5. Conclusions

Water-jet ablation has emerged as an effective treatment for BPH with its respective technology similar to TURP. Pre-operative PAE can reduce bleeding-related complications associated with water-jet ablation alone in select patients.

Author Contributions

Conceptualization, L.L.; Formal analysis, T.M.; Resources, J.K.; Data curation, A.S. (Antony Sare); Writing—original draft, A.S. (Abin Sajan); Writing—review & editing, A.P. and S.M.; Supervision, S.B.; Project administration, I.S. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

The study was conducted in accordance with the Declaration of Helsinki, and approved by the Institutional Review Board Sterling IRB (10033-AIsaacson) for studies involving humans.

Informed Consent Statement

Informed consent was obtained from all subjects involved in the study.

Data Availability Statement

The original contributions presented in the study are included in the article, further inquiries can be directed to the corresponding author/s.

Conflicts of Interest

Dr. Bagla is a consultant for Boston Scientific, Varian Medical Systems, Medtronic, Embolx, IMBiotechnologies, and Phillips Medical System. Dr. Singh and Dr. Marhamati are consultants for Procept Biorobotics. Dr. Lerner is a consultant for Janssen Pharmaceuticals.

References

  1. Gilling, P.J.; Barber, N.; Bidair, M.; Anderson, P.; Sutton, M.; Aho, T.; Kramolowsky, E.; Thomas, A.; Kaufman, R.P.; Badlani, G.; et al. Five-year outcomes for Aquablation therapy compared to TURP: Results from a double-blind, randomized trial in men with LUTS due to BPH. Can. J. Urol. 2022, 29, 10960–10968. [Google Scholar]
  2. Taktak, S.; Jones, P.; Haq, A.; Rai, B.P.; Somani, B.K. Aquablation: A novel and minimally invasive surgery for benign prostate enlargement. Ther. Adv. Urol. 2018, 10, 183–188. [Google Scholar] [CrossRef]
  3. Desai, M.; Bidair, M.; Bhojani, N.; Trainer, A.; Arther, A.; Kramolowsky, E.; Doumanian, L.; Elterman, D.; Kaufman, R.P.; Lingeman, J.; et al. WATER II (80–150 mL) procedural outcomes. BJU Int. 2019, 123, 106–112. [Google Scholar] [CrossRef]
  4. Gilling, P.; Barber, N.; Bidair, M.; Anderson, P.; Sutton, M.; Aho, T.; Kramolowsky, E.; Thomas, A.; Cowan, B.; Kaufman, R.P., Jr.; et al. WATER: A Double-Blind, Randomized, Controlled Trial of Aquablation(®) vs Transurethral Resection of the Prostate in Benign Prostatic Hyperplasia. J. Urol. 2018, 199, 1252–1261. [Google Scholar] [CrossRef]
  5. Menon, A.; Gilling, P.J. Aquablation and question of hemostasis. Can. J. Urol. 2021, 28, 10691. [Google Scholar]
  6. Kably, I.; Acharya, V.; Richardson, A.J.; Bhatia, S. Prostatic Artery Embolization in Refractory Hematuria of Prostatic Origin. Tech. Vasc. Interv. Radiol. 2020, 23, 100694. [Google Scholar] [CrossRef]
  7. Picel, A.C.; Hsieh, T.C.; Shapiro, R.M.; Vezeridis, A.M.; Isaacson, A.J. Prostatic Artery Embolization for Benign Prostatic Hyperplasia: Patient Evaluation, Anatomy, and Technique for Successful Treatment. Radiographics 2019, 39, 1526–1548. [Google Scholar] [CrossRef]
  8. Pisco, J.; Bilhim, T.; Ribeiro, M.; Fernandes, L.; Costa, N.; Oliveira, A. Short-, medium-, and long-term outcome of prostate artery embolization for patients with benign prostatic hyperplasia: 1000 patients. J. Vasc. Interv. Radiol. 2017, 28, S3. [Google Scholar] [CrossRef]
  9. Sapoval, M.; Thiounn, N.; Descazeaud, A.; Déan, C.; Ruffion, A.; Pagnoux, G.; Duarte, R.C.; Robert, G.; Petitpierre, F.; Karsenty, G. Prostatic artery embolisation versus medical treatment in patients with benign prostatic hyperplasia (PARTEM): A randomised, multicentre, open-label, phase 3, superiority trial. Lancet Reg. Health Eur. 2023, 31, 100672. [Google Scholar] [CrossRef]
  10. Abt, D.; Hechelhammer, L.; Müllhaupt, G.; Markart, S.; Güsewell, S.; Kessler, T.M.; Schmid, H.-P.; Engeler, D.S.; Mordasini, L. Comparison of prostatic artery embolisation (PAE) versus transurethral resection of the prostate (TURP) for benign prostatic hyperplasia: Randomised, open label, non-inferiority trial. BMJ 2018, 361, k2338. [Google Scholar] [CrossRef]
  11. Abt, D.; Müllhaupt, G.; Hechelhammer, L.; Markart, S.; Güsewell, S.; Schmid, H.-P.; Mordasini, L.; Engeler, D.S. Prostatic Artery Embolisation Versus Transurethral Resection of the Prostate for Benign Prostatic Hyperplasia: 2-yr Outcomes of a Randomised, Open-label, Single-centre Trial. Eur. Urol. 2021, 80, 34–42. [Google Scholar] [CrossRef]
  12. Pisco, J.M.; Bilhim, T.; Costa, N.V.; Torres, D.; Pisco, J.; Pinheiro, L.C.; Oliveira, A.G. Randomised Clinical Trial of Prostatic Artery Embolisation Versus a Sham Procedure for Benign Prostatic Hyperplasia. Eur. Urol. 2020, 77, 354–362. [Google Scholar] [CrossRef]
  13. Insausti, I.; de Ocáriz, A.S.; Galbete, A.; Capdevila, F.; Solchaga, S.; Giral, P.; Bilhim, T.; Isaacson, A.; Urtasun, F.; Napal, S. Randomized Comparison of Prostatic Artery Embolization versus Transurethral Resection of the Prostate for Treatment of Benign Prostatic Hyperplasia. J. Vasc. Interv. Radiol. 2020, 31, 882–890. [Google Scholar] [CrossRef]
  14. Tanneru, K.; Jazayeri, S.B.; Alam, M.U.; Kumar, J.; Bazargani, S.; Kuntz, G.; Ganapathi, H.P.; Bandyk, M.; Marino, R.; Koochekpour, S. An Indirect Comparison of Newer Minimally Invasive Treatments for Benign Prostatic Hyperplasia: A Network Meta-Analysis Model. J. Endourol. 2021, 35, 409–416. [Google Scholar] [CrossRef]
  15. Sajan, A.; Mehta, T.; Desai, P.; Isaacson, A.; Bagla, S. Minimally Invasive Treatments for Benign Prostatic Hyperplasia: Systematic Review and Network Meta-Analysis. J. Vasc. Interv. Radiol. 2022, 33, 359–367.e8. [Google Scholar] [CrossRef]
  16. Shin, B.N.H.; Qu, L.; Rhee, H.; Chung, E. Systematic review and network meta-analysis of re-intervention rates of new surgical interventions for benign prostatic hyperplasia. BJU Int. 2024, 134, 155–165. [Google Scholar] [CrossRef]
  17. Baerlocher, M.O.; Nikolic, B.; Sze, D.Y. Adverse Event Classification: Clarification and Validation of the Society of Interventional Radiology Specialty-Specific System. J. Vasc. Interv. Radiol. 2023, 34, 1–3. [Google Scholar] [CrossRef]
  18. Clavien, P.A.; Barkun, J.; de Oliveira, M.L.; Vauthey, J.N.; Dindo, D.; Schulick, R.D.; de Santibañes, E.; Pekolj, J.; Slankamenac, K.; Bassi, C.; et al. The Clavien-Dindo classification of surgical complications: Five-year experience. Ann. Surg. 2009, 250, 187–196. [Google Scholar] [CrossRef]
  19. Nguyen, D.D.; Barber, N.; Bidair, M.; Gilling, P.; Anderson, P.; Zorn, K.C.; Badlani, G.; Humphreys, M.; Kaplan, S.; Kaufman, R.; et al. WATER versus WATER II 2-Year Update: Comparing Aquablation Therapy for Benign Prostatic Hyperplasia in 30–80-cm3 and 80–150-cm3 Prostates. Eur. Urol. Open Sci. 2021, 25, 21–28. [Google Scholar] [CrossRef]
  20. Assad, A.; Nguyen, D.D.; Barber, N.; Bidair, M.; Gilling, P.; Anderson, P.; Badlani, G.; Humphreys, M.; Kaplan, S.; Kaufman, R.; et al. WATER vs WATER II 3-Year Update: Comparing Aquablation Therapy for Benign Prostatic Hyperplasia in 30–80 cc and 80–150 cc Prostates. Urology 2022, 165, 268–274. [Google Scholar] [CrossRef]
  21. Elterman, D.; Bach, T.; Rijo, E.; Misrai, V.; Anderson, P.; Zorn, K.C.; Bhojani, N.; El Hajj, A.; Chughtai, B.; Desai, M. Transfusion rates after 800 Aquablation procedures using various haemostasis methods. BJU Int. 2020, 125, 568–572. [Google Scholar] [CrossRef]
  22. Wang, M.; Guo, L.; Duan, F.; Yuan, K.; Zhang, G.; Li, K.; Yan, J.; Wang, Y.; Kang, H. Prostatic arterial embolization for the treatment of lower urinary tract symptoms caused by benign prostatic hyperplasia: A comparative study of medium- and large-volume prostates. BJU Int. 2016, 117, 155–164. [Google Scholar] [CrossRef]
  23. Jaganjac, S.; Schefe, L.; Avdagić, E.; Spahović, H.; Hiros, M. Preoperative kidney tumor embolization as procedure for therapy of advanced kidney cancer. Acta Inf. Med. 2014, 22, 302–305. [Google Scholar] [CrossRef]
  24. Sare, A.; Kothari, P.; Cieslak, J.A., 3rd; Gantz, O.; Aly, S.; Kumar, A.; Patel, N.; Shukla, P.A. Perioperative Blood Loss after Preoperative Prostatic Artery Embolization in Patients Undergoing Simple Prostatectomy: A Propensity Score–Matched Study. J. Vasc. Interv. Radiol. 2021, 32, 1113–1118. [Google Scholar] [CrossRef]
  25. Rilling, W.S.; Chen, G.W. Preoperative embolization. Semin. Interv. Radiol. 2004, 21, 3–9. [Google Scholar] [CrossRef]
  26. Moreira, A.M.; de Assis, A.M.; Carnevale, F.C.; Antunes, A.A.; Srougi, M.; Cerri, G.G. A Review of Adverse Events Related to Prostatic Artery Embolization for Treatment of Bladder Outlet Obstruction Due to BPH. Cardiovasc. Interv. Radiol. 2017, 40, 1490–1500. [Google Scholar] [CrossRef]
  27. Fassia, M.; Balasubramanian, A.; Basourakos, S.; Fassia, M.; Balasubramanian, A.; Basourakos, S.; Lewicki, P.; Fainberg, J.; Currie, B.; Te, A.; et al. Abstract No. 509 Prostate artery embolization is associated with a reduced rate of post-Aquablation bleeding. J. Vasc. Interv. Radiol. 2022, 33, S187–S188. [Google Scholar] [CrossRef]
  28. Sandhu, J.S.; Bixler, B.R.; Dahm, P.; Goueli, R.; Kirkby, E.; Stoffel, J.T.; Wilt, T.J. Management of Lower Urinary Tract Symptoms Attributed to Benign Prostatic Hyperplasia (BPH): AUA Guideline Amendment 2023. J. Urol. 2024, 211, 11–19. [Google Scholar] [CrossRef]
  29. Bilhim, T.; McWilliams, J.P.; Bagla, S. Updated American Urological Association Guidelines for the Management of Benign Prostatic Hyperplasia: Prostatic Artery Embolization Made it into the Guidelines! CardioVascular Interv. Radiol. 2024, 47, 150–153. [Google Scholar] [CrossRef]
  30. Babore, Y.; Moorthy, G.; Li, X.; Vance, A.; Clark, T. Abstract No. 98 Outcomes of Prostate Artery Embolization Following Failure of Prostatic Urethral Lift (UroLift): A Case-Control Study. J. Vasc. Interv. Radiol. 2024, 35, S44. [Google Scholar] [CrossRef]
  31. Goyal, P.; Varadhan, A.K.; Jenkins, K.; Hohlastos, E.; Salem, R.; Mouli, S.K. Prostatic Artery Embolization in Patients with Refractory Lower Urinary Tract Symptoms after a Prior Minimally Invasive Surgical Treatment. J. Vasc. Interv. Radiol. 2024, 35, 744–750. [Google Scholar] [CrossRef] [PubMed]
Jcm 13 06930 g001
Figure 1. Schematic diagram demonstrating water-jet ablation of prostatic tissue.
Figure 1. Schematic diagram demonstrating water-jet ablation of prostatic tissue.
Jcm 13 06930 g001
Jcm 13 06930 g002
Figure 2. Schematic diagram with a large hypervascular prostate resulting in bladder outlet syndrome. A catheter is placed into prostatic arteries, and particles are released to decrease blood flow.
Figure 2. Schematic diagram with a large hypervascular prostate resulting in bladder outlet syndrome. A catheter is placed into prostatic arteries, and particles are released to decrease blood flow.
Jcm 13 06930 g002
Jcm 13 06930 g003
Figure 3. Angiogram of the internal illiac artery demonstrating the relevant prostate artery embolization anatomy. SG: superior gluteal. IG: inferior gluteal. IP: internal pudendal. OA: obturator artery.
Figure 3. Angiogram of the internal illiac artery demonstrating the relevant prostate artery embolization anatomy. SG: superior gluteal. IG: inferior gluteal. IP: internal pudendal. OA: obturator artery.
Jcm 13 06930 g003
Jcm 13 06930 g004
Figure 4. Angiogram of the distal prostatic arteries demonstrating the size and intensity of the periurethral vasculature.
Figure 4. Angiogram of the distal prostatic arteries demonstrating the size and intensity of the periurethral vasculature.
Jcm 13 06930 g004
Table 1. Summary of patient demographics and treatment variables before propensity score matching.
Table 1. Summary of patient demographics and treatment variables before propensity score matching.
Before Propensity Score Matching
AquaPAE + Aqua
(n = 56)(n = 89)p Value
Age, mean (SD)62.2 (8.6)69.6 (8.9)<0.001
PRE-TREATMENT VARIABLES
PSA, mean (SD)3.1 (5.3)4.2 (3.1)0.292
Qmax (mL), mean (SD)10.1 (5.3)9.5 (6.3)0.624
PVR (mL), mean (SD)113.2 (111.2)140.7 (125.5)0.241
IPSS, mean (SD)18.1 (7.4)16.0 (8.8)0.247
QOL, mean (SD)3.6 (1.4)3.8 (4.1)0.802
IIEF, mean (SD)16.1 (6.9)15.9 (6.8)0.901
Urocuff Peak Flow, mean (SD)10.6 (8.7)9.5 (4.6)0.549
Urocuff Detrusor Pressure, mean (SD)120.4 (46.9)142.5 (50.8)0.102
Prostate Gland Size (mL), mean (SD)52.6 (24.8)79.0 (27.3)<0.001
INTRA-/PERI-TREATMENT VARIABLES
Number of Passes Required for Treatment, mean (SD)1.8 (0.5)2.0 (0.2)<0.001
Case Length (minutes), mean (SD)58.7 (22.7)57.4 (16.7)0.722
Hospital Length of Stay (hours), mean (SD)35.2 (24.1)18.3 (19.1)<0.001
Table 2. Summary of patient demographics and treatment variables after propensity score matching.
Table 2. Summary of patient demographics and treatment variables after propensity score matching.
After Propensity Score Matching
AquaPAE + Aqua
(n = 56)(n = 89)p Value
Age, mean (SD)62.2 (8.6)60.5 (109.6)0.912
PRE-TREATMENT VARIABLES
PSA, mean (SD)3.2 (5.5)3.6 (13.8)0.877
Qmax (mL), mean (SD)10.1 (5.4)13.4 (33.4)0.519
PVR (mL), mean (SD)116.8 (112.7)144.5 (339.3)0.613
IPSS, mean (SD)18.00 (7.5)14.6 (24.7)0.446
QOL, mean (SD)3.6 (1.4)3.2 (5.1)0.704
IIEF, mean (SD)15.8 (6.8)19.7 (47.7)0.685
Urocuff Peak Flow, mean (SD)10.7 (8.8)14.7 (41.1)0.631
Urocuff Detrusor Pressure, mean (SD)118.1 (46.4)200.0 (498.8)0.429
Prostate Gland Size (mL), mean (SD)52.3 (24.7)55.6 (96.7)0.803
INTRA-/PERI-TREATMENT VARIABLES
Number of Passes Required for Treatment, mean (SD)1.8 (0.5)2.1 (4.2)0.631
Case Length (minutes), mean (SD)58.2 (22.7)53.9 (109.6)0.789
Hospital Length of Stay (hours), mean (SD)34.4 (23.5)24.7 (75.3)0.347
Table 3. Odds ratio analysis of adverse events. * Aquablation alone: PAE + aquablation.
Table 3. Odds ratio analysis of adverse events. * Aquablation alone: PAE + aquablation.
After Propensity Score Matching
Odds Ratio *p Value
Discharged with a Foley catheter0.30.004
Continuous Bladder Irrigation Required > 2 h7.6<0.001
Hemostatic Measures Required14.7<0.001
Hematuria3.00.013
Urinary Retention17.10.021
Dysuria2.80.227
Bladder Irrigation Required2.70.146
Required reoperation within 30 days1.80.361
Required reoperation after 30 days13.00.003
Required Foley catheter for greater than 30 days8.70.233
Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content.

Share and Cite

MDPI and ACS Style

Bagla, S.; Singh, I.; Sajan, A.; Sare, A.; Pavidapha, A.; Mehta, T.; Klein, J.; Marhamati, S.; Lerner, L. Combination Prostatic Artery Embolization Prior to Water-Jet Ablation (Aquablation) for Benign Prostatic Hypertrophy: A Propensity Score Analysis. J. Clin. Med. 2024, 13, 6930. https://doi.org/10.3390/jcm13226930

AMA Style

Bagla S, Singh I, Sajan A, Sare A, Pavidapha A, Mehta T, Klein J, Marhamati S, Lerner L. Combination Prostatic Artery Embolization Prior to Water-Jet Ablation (Aquablation) for Benign Prostatic Hypertrophy: A Propensity Score Analysis. Journal of Clinical Medicine. 2024; 13(22):6930. https://doi.org/10.3390/jcm13226930

Chicago/Turabian Style

Bagla, Sandeep, Inderjit Singh, Abin Sajan, Antony Sare, Alex Pavidapha, Tej Mehta, John Klein, Shawn Marhamati, and Lori Lerner. 2024. "Combination Prostatic Artery Embolization Prior to Water-Jet Ablation (Aquablation) for Benign Prostatic Hypertrophy: A Propensity Score Analysis" Journal of Clinical Medicine 13, no. 22: 6930. https://doi.org/10.3390/jcm13226930

APA Style

Bagla, S., Singh, I., Sajan, A., Sare, A., Pavidapha, A., Mehta, T., Klein, J., Marhamati, S., & Lerner, L. (2024). Combination Prostatic Artery Embolization Prior to Water-Jet Ablation (Aquablation) for Benign Prostatic Hypertrophy: A Propensity Score Analysis. Journal of Clinical Medicine, 13(22), 6930. https://doi.org/10.3390/jcm13226930

Note that from the first issue of 2016, this journal uses article numbers instead of page numbers. See further details here.

Article Metrics

Back to TopTop