V5-05: Prostate Artery Embolization prior to robotic simple prostatectomy in a patient with high bleeding risk
Prostate artery embolization (PAE) is an alternative to surgery for patients with lower urinary tract symptoms (LUTS) associated with benign prostatic hyperplasia (BPH) who are poor surgical candidates. We describe a novel use of PAE as a preoperative measure to reduce perioperative bleeding risk in a high-risk patient undergoing robotic simple prostatectomy.
A 61 year-old man presented with LUTS refractory to medication that progressed to hematuria and urinary retention. Cystoscopy and CT urogram demonstrated a markedly enlarged prostate >110gm. The patient elected for robotic-assisted simple prostatectomy. However, he was a Jehovah&[prime]s Witness on chronic anticoagulation and refusing blood transfusions. The decision was made to perform PAE preoperative to reduce bleeding risk. PAE was performed the day prior to surgery. A catheter was inserted into femoral artery to the external iliac artery to the internal iliac artery. Digital Subtraction angiography was used to identify the prostatic arteries, which were embolized with 100-300 and 300-500 µm Tris-acryl Gelatin Microspheres (Embosphere; Merit Medical Systems Inc, South Jordan, Utah, USA), until there was no appreciable flow to the prostate from either artery. Intraprocedural cone beam CT was performed, which yielded detailed vascular anatomy and confirmed targeted embolization. The following day, the patient underwent robotic-assisted simple prostatectomy. _x000D_
The prostate enucleation planes were noticeably avascular, allowing for minimal blood loss and good visualization. Console time was 189 minutes with an estimated blood loss of 100mL and no postoperative hematuria. Whole-mount pathology demonstrated mild ischemic changes and confirmed presence of microspheres within prostatic tissue, indicative of successful PAE. The patient had an uneventful postoperative course and was discharged on postoperative day 2 with no complications. He successfully passed a trial of void and reported resolution of urinary symptoms.
We describe a novel multidisciplinary approach using PAE prior to prostate surgery for BPH as a means of preoperative risk reduction in a high-risk patient. Preoperative PAE could potentially be used for risk reduction in other high-risk patients requiring complex surgery for BPH and could be combined with the surgical approach preferred by the surgeon.