Prostate Artery Embolisation of Megaprostate Causing External Iliac Vein Compression

An 84-year-old fit and well male farmer presented to the emergency department with acute urinary clot retention. A 3-way indwelling catheter for continuous bladder irrigation was inserted. Vital signs and blood tests were unremarkable. Digital-rectal examination revealed a grossly enlarged benign prostate. Prostate specific antigen (PSA) was elevated at 25.6 ng/mL, but PSA density was normal at 0.038 ng/mL². CT demonstrated prostatomegaly, with the prostate measuring 117 mm × 92 mm × 127 mm, extending superiorly beyond the true pelvis (Figure 1). There was no associated hydroureteronephrosis. Gland volume was calculated at 665 mL.

Forty-eight hours into his admission, the patient experienced a syncopal episode associated with rapid atrial fibrillation, tachypnoea, and a troponin leak. CT pulmonary angiogram (CTPA) revealed extensive bilateral, non-occlusive PE extending distally from the main pulmonary arteries. Lower limb Doppler ultrasonography confirmed left below knee deep vein thrombosis (DVT).

The patient subsequently underwent catheter-directed thrombolysis. Significant extrinsic compression of the left iliac veins was noted between the megaprostate and the external and internal iliac arteries. Alteplase was infused at 1 mg/hour via each infusion catheter (total 2 mg/hour) for 24 hours, resulting in complete resolution of the bilateral PE down to the segmental level. However, this resulted in transfusion-dependent haematuria.

Multidisciplinary consensus supported prostate artery embolisation (PAE) for the management of intractable haematuria in the context of therapeutic anticoagulation and to alleviate iliac venous compression through organ atrophy in the longer term. Transarterial particle embolisation of the prostate using the PErFecTED technique was performed via left conventional radial access (Figure 2). Macrohaematuria resolved within 24 hours of embolisation with a successful trial-of-void 14 days post procedure.