Treatment of Benign Prostatic Hyperplasia by Occlusion of the Impaired Urogenital Venous System – First Experience

 

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Abstract

Purpose: To effect regression of benign prostatic hyperplasia (BPH), Gat et al. (Andrologia 2008) proposed to occlude incompetent spermatic veins to reduce increased hydrostatic pressure on the prostatic venous plexus and prevent reflux with androgen rich blood from the testicles. Our aim was to implement this treatment strategy in clinical practice and to report about first results.

Methods: Embolization of the spermatic veins was performed in 30 patients with BPH. In 16 patients, we obtained follow-up data from at least 6 months. The sonographic transabdominal prostatic volume, prostate-specific antigen (PSA) and peripheral total testosterone levels were determined before and 6 months after the intervention. Subjective symptomatology was assessed using standardized questionnaires (International Prostate Symptom Score [IPSS] and Quality of Life score [QoL]) before and 6 months after the procedure.

Results: The age of all treated patients was 46 – 77 years. The age of the 16 patients who received follow-up was 51 – 77 years. IPSS (median 18 [IQR 20.75 – 14.50] vs. 9 [IQR 11.00 – 7.25], p < 0.0001) and QoL score (4 [IQR 5 – 3] vs. 2 [IQR 3 – 1], p < 0.001) were significantly decreased 6 months after the intervention. The subjective improvement of symptoms did not correspond with prostatic volumes, which did not change significantly (54.31 ± 30.90 vs. 50.50 ± 29.26 ml, p = n. s.). 4/16 patients had a measurable post-void urine volume, which decreased in two patients 6 months after the procedure, remained unchanged in one patient, and was no longer detectable in one patient. 4 of the 11 had a sonographically detectable varicocele before the intervention, and one patient had a trabeculated bladder. Both the peripheral total testosterone levels (4.55 ± 1.27 vs. 3.93 ± 1.00 ng/ml; p = n. s.) and PSA levels (3.74 ± 2.83 vs. 4.06 ± 3.34 ng/ml; p = n. s.) showed no significant differences.

Conclusion: Interventional occlusion of the spermatic veins in patients with BPH is a feasible outpatient procedure with a low complication rate. Intermediate results are satisfactory. Mid- and long-term results and pathophysiologic mechanisms need to be further elucidated.

Key Points:

• Venous embolization in patients with BPH is a feasible outpatient procedure.

• It shows satisfactory intermediate result with good symptom relief.

• Medium and long-term results need to be further evaluated.

Citation Format:

• Strunk H, Meier M, Schild HH et al. Treatment of Benign Prostatic Hyperplasia by Occlusion of the Impaired Urogenital Venous System – First Experience. Fortschr Röntgenstr 2015; 187: 180 – 186

Zusammenfassung

Ziel: Nach dem von Gat et al. (Andrologia 2008) vorgeschlagenen Prinzip soll eine Embolisation der insuffizienten Testikularvenen bei Patienten mit benigner Prostatahyperplasie (BPH) einen erhöhten hydrostatischen Druck im prostatischen Venenplexus senken und eine Überflutung der Prostata mit androgenreichem Blut aus dem Hoden verhindern, sodass eine Regression der BPH resultiert. Dieses neue Therapieprinzip sollte im Rahmen der klinischen Routine eingesetzt und über erste Ergebnisse berichtet werden.

Methoden: Bei 30 Patienten mit BPH wurde eine Embolisation der Testikularvenen durchgeführt. Bei 16 Patienten lagen zum Stichtag Nachsorgedaten von wenigstens 6 Monaten vor. Sonografisches transabdominelles Prostatavolumen, prostataspezifisches Antigen (PSA) und peripheres Gesamttestosteron wurden vor und 6 Monate nach dem Eingriff bestimmt. Die subjektive Beschwerdesymptomatik wurde mittels internationalem Prostata Symptom Score (IPSS) und Quality of Life Index (QoL) vor und 6 Monate nach dem Eingriff bestimmt.

Ergebnisse: Das Patientenalter betrug beim Eingriff 46 – 77 Jahren, das der 16 verlaufskontrollierten Patienten 51 – 77 Jahre. IPSS (Median 18 [IQR 20,75 – 14,50] vs. 9 [IQR 11,00 – 7,25], p < 0,0001) und QoL-Score (4 [IQR 5 – 3] vs. 2 [IQR 3 – 1], p < 0,001) waren 6 Monate nach dem Eingriff signifikant erniedrigt. Die subjektive Beschwerdebesserung fand in der Messung des Prostatavolumens kein Korrelat, welches mit 54,31 ± 30,90 vs. 50,50 ± 29,26 ml (p = n. s.) nicht signifikant verändert war. Bei 4 der 16 behandelten Patienten ließ sich ein Restharnvolumen nachweisen, welches bei zwei Patienten 6 Monate nach dem Eingriff unverändert, bei einem Patient rückläufig war, bei einem Patient war kein Restharn mehr nachweisbar. Bei 4/16 Patienten war vor dem Eingriff auch sonografisch eine Varikozele nachweisbar, bei einem Patienten eine Balkenblase. Bei den peripheren Gesamttestosteronwerten (4,55 ± 1,27 vs. 3,93 ± 1,00 ng/ml; p = n. s.) und den PSA-Werten (3,74 ± 2,83 vs. 4,06 ± 3,34 ng/ml; p = n. s.) konnten im Verlauf keine signifikanten Unterschiede festgestellt werden.

Schlussfolgerung: Die venöse Embolisationsbehandlung der BPH ist ein ambulant durchführbarer Eingriff mit geringer Komplikationsrate. Es zeigt sich ein zufriedenstellendes Zwischenergebnis. Mittel- und längerfristige Ergebnisse sowie pathophysiologische Mechanismen des Eingriffs sind weiter zu evaluieren.

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