Perioperative Blood Loss after Preoperative Prostatic Artery Embolization in Patients Undergoing Simple Prostatectomy: A Propensity Score‒Matched Study

Clinical question
Is preoperative prostatic artery embolization (PAE) safe and effective at reducing intraoperative blood loss?

Take-away point
Preoperative bilateral PAE safely and effectively reduces intraoperative bleeding and operative time.

Reference
Sare A, Kothari P, Cieslak JA, et al. Perioperative blood loss after preoperative prostatic artery embolization in patients undergoing simple prostatectomy: a propensity score‒matched study. Journal of Vascular and Interventional Radiology. 2021;32(8):1113-1118.

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Study design
Retrospective cohort study

Funding source
Self-funded or unfunded

Setting
Single institution, Rutgers – New Jersey Medical School, Newark, NJ

Figure




Figure. (a) Mean estimated blood loss (mL) with standard deviations during prostatectomy in the group with embolization before surgery versus control group. (b) Mean operative time (minutes) of prostatectomy in the group with embolization before surgery versus control group. PAE = prostate artery embolization.

Summary

Benign prostatic hyperplasia (BPH) is a common cause of lower urinary tract symptoms, affecting most men over the age of 60 years of age and >80% of men at or above the age of 70. First-line treatment has historically involved lifestyle modifications and pharmacotherapy with 5-a-reductase inhibitors, a-blockers, and phosphodiesterase inhibitors, with surgery being recommended if these measures fail to provide adequate relief. Surgical options include TURP and prostatectomy, with complication rates increasing with increased prostate size. The most common complication is bleeding requiring transfusion, which has been shown to occur in 11.9% of patients undergoing open prostate resection, which is generally performed for patients with larger prostates. Preoperative embolization has been shown to be a safe and effective method of reducing operative estimated blood loss (EBL), transfusions, and hospital length of stay (LOS) for resection of a variety of hypervascular tumors, but has not yet been evaluated in patients undergoing prostatectomy.

In this retrospective case series, 63 patients with prostatic hypertrophy with severe lower urinary tract symptoms (LUTS) were analyzed. All patients had prostates with mass > 80 grams and subsequently underwent prostatectomy. Patients either underwent bilateral PAE or no embolization prior to the procedure; patients undergoing unilateral PAE were excluded. Data collected included demographics, comorbidities, preoperative prostate volume (by transrectal ultrasound), method of prostatectomy, PAE technical details, pre- and post-operative hematologic labs, EBL, operative time, transfusion, and duration of post-operative continuous bladder irrigation (CBI). In patients who underwent embolization, bilateral PAE was performed using 250-μm hydrogel microspheres until cessation of anterograde flow, followed by gelfoam slurry injection. Patients then underwent either robotic prostatectomy or open suprapubic prostatectomy within 2 weeks of PAE.

60 patients were analyzed in this study, including 16 patients undergoing bilateral PAE and 44 patients in the non-embolization arm. 32 of the non-embolization patients were used from the 44 for 2:1 propensity score-matching. In the embolization group, 11 patients underwent robotic prostatectomy while 5 underwent open suprapubic prostatectomy compared to 10 and 22 patients respectively in the non-embolization group. Demographics and baseline characteristics between groups were not significantly different. Median time between PAE and prostatectomy was 6 days (4-18 days). Mean EBL was 303 ± 219.7 ml in the PAE arm compared to 545 ± 380 ml in the non-embolization arm (p < 0.01). Mean operative time was 140.5 ± 35.4 minutes in the PAE arm versus 180.5 ± 56.6 minutes in the non-embolization arm (p < 0.01). Change in hemoglobin during surgery was 2.16 g/dl in the PAE group and 3.50 g/dl in the non-embolization group (p = 0.020). 6% of patients in the PAE group underwent transfusion compared to 19% in the non-embolization group, but with a mean of 0.19 units per patient in the PAE group versus 0.44 in the non-embolization group, which was not significantly different (p = 0.334). LOS did not significantly differ between groups, and no major or minor complications occurred.

Commentary

The AUA recommends surgery as standard of care for BPH; however, large prostates can be challenging to treat and have higher rates of bleeding complications. Prostate artery embolization has been shown to be safe and effective for treating both prostate related hematuria and LUTS. This study demonstrated a decrease in operative blood loss and mean operative time in patients undergoing preoperative PAE before prostatectomy for prostates of large size (>80 g). It did not, however, demonstrate a statistically-significant reduction in LOS or transfusion. The lack of difference in transfusions may be due to low sample size in combination with variability in transfusion thresholds between Urologists. The only prior study similar to the one summarized here found decreased LOS and intraoperative blood loss, but only used change in hematologic lab studies and did not assess EBL. This does suggest that lack of significant difference in LOS in this study may be due to its small sample size. This is an acknowledged limitation of the study in addition to its retrospective nature. One challenge in standardization posited by the authors is the relatively large range of time between PAE and prostatectomy, which may have resulted in differences in the development of collateral circulation prior to surgery, resulting in clinically-significant differences in blood loss. Future investigations should focus on randomized trials involving multiple high-volume centers as well as research into the timeline of collateral generation in the prostatic vasculature. Finally, it would be interesting to evaluate the effectiveness of unilateral dominant PAE for the purpose of operative blood loss reduction.

Post Author
Jared Edwards, MD
General Medical Officer
Medical Readiness Division
Naval Surface Forces Pacific, San Diego, CA
@JaredRayEdwards

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