RPS 1909 - IR in the management of benign and malignant disease in male patients

Author Block: L. Engelage¹, N. Behnel¹, P. Doerwald², L. Steinmeister¹, R. Muschter¹, A. Lumiani¹; ¹Berlin/DE, ²Hamburg/DE
Purpose: The objective of this study was to report a retrospective clinical service evaluation of TULSA for patients with organ-confined primary prostate cancer treated at a single centre.
Methods or Background: 300 men with primary localised PCa visible on MRI and confirmed by biopsy were treated under clinical routine. Based on patients’ preferences and disease characteristics, 163 men received whole-gland treatments and 137 focal TULSA. Adverse events (AEs), prostate-specific antigen (PSA), and functional and oncological outcomes were assessed using mp-MRI and biopsy, if necessary.
Results or Findings: Baseline characteristics include median [IQR] age 66 [60-73], PSA 6.85 ng/ml [4.64-9.5], overall cancer length 7.6 mm [4.35-10], prostate volume 49.2 cc [min 11–max 180], baseline risk stratifications include ISUP 1 (52/300), 2 (191/300), 3 (46/300), 4 (9/300), and 5 (2/300). 57 patients experienced Grade 1 and 2 complications, mostly resolving within 4 weeks through prolonged catheterisation and antibiotics. Grade 3 adverse events occurred in seven patients, resolving within 3 months. No grade 4 or higher AEs and no bowel-related complications were observed. Median [IQR] IIEF score of 24 [14-29] at baseline remained stable at the 48-mo follow-up with a value of 25 [13-30]. IPSS score immediately post-treatment increased from its baseline value of 8 [4-15] to 12 [5-19] and improved to 8 [2.5-10.5] by 12 months and further improved to 48-mo with 6.5 [3.5-8]. To the last follow-up, 26 men experienced biochemical failure (Phoenix≥2); MRI findings showed suspicion of residual cancer in 26 men, 54% (14/26) of which were confirmed by positive biopsy. 15 patients received salvage therapy (3 surgery, 12 other), 18 patients remained under active surveillance, and 13 patients underwent a single repeat TULSA.
Conclusion: TULSA offers promising safety, functional, and oncological results for the treatment of organ-confined prostate cancer.
Limitations: No systematic follow-up protocol limits this study.
Funding for this study: Study is a clinical service evaluation and so no funding was obtained for this study.
Has your study been approved by an ethics committee? Not applicable
Ethics committee - additional information: No ethical approval was sought for this study.

Author Block: M. Anttinen¹, P. Mäkelä¹, P. Doerwald², P. Nurminen¹, T. Sainio¹, H. E. Pärssinen¹, R. Blanco Sequeiros¹, P. J. Boström¹; ¹Turku/FI, ²Hamburg/DE
Purpose: The purpose of this study was to report the 12-month safety and oncological outcomes of salvage TULSA (sTULSA) for men with localised radio-recurrent PCa.
Methods or Background: Men with biopsy-proven localised PCa recurrence after RT were enrolled. mp-MRI and 18-F-PSMA-PET-CT were used to confirm organ-confined disease. Patients were followed every three months for adverse events (AEs, Clavien-Dindo), functional status, and PSA. Disease control was evaluated at 12-month by mpMRI, PSMA PET-CT, and prostate biopsy targeting the treatment area plus areas suspicious in imaging.
Results or Findings: Forty-one men underwent sTULSA (25 whole-gland and 16 focal ablation); one patient withdrew from the study due to frequent follow-up protocol three months after his treatment with undetectable PSA (<0.006 ng/ml). Baseline characteristics included median [IQR] age 73 [69-77], PSA 3.3 ng/ml [2.3-7], and an interval of 11 years [8-13] between RT and sTULSA. 12-month follow-ups are available for 31 men. AEs included two grade 3 events and 17 grade 2 events. One patient with castration-resistant PCa experienced a pubo-prostatic fistula and osteitis after sTULSA, treated with prolonged suprapubic catheterization and oral antibiotics. Median PSA at 12-month was 0.19 ng/ml (IQR 0.07–0.57) and was undetectable (<0.1) in 13 patients. Two patients were diagnosed with biochemical recurrence (PSA≥nadir+2) at 12-month follow-up, correlating with the extraprostatic disease on imaging. At 12-month MRI and PSMA PET-CT, 28/31 (90%) men had no visible cancer in the prostate, and four patients had seminal vesicle invasion. Biopsy outcomes at one year revealed that 26/30 (87%) were free of any PCa in the treatment region, while four patients had positive out-of-field biopsies.
Conclusion: Salvage therapy options for men with radio-recurrent PCa are limited. Twelve-month clinical outcomes of sTULSA show remarkable oncological outcomes with a favorable safety profile for treating localised radio-recurrent PCa.
Limitations: Small population
Funding for this study: This study was investigator-initiated so funding was received for it.
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: Ethics committee approval was granted and informed consent was obtained from all study participants.

Author Block: S. H. Lee, D. Shim, J. Yoo, B. Park, C. S. Park, S. K. Kim, J. W. Lee; Incheon/KR
Purpose: This study aims to analyse the origins of prostatic arteries (PAs) in Korean population with LUTS or malignant hematuria and to compare with literatures. Prostatic artery embolisation (PAE) is a safe and effective treatment for lower urinary tract symptoms (LUTS) and hematuria from malignancy. Nevertheless, PAE remains challenging due to numerous anatomic variations.
Methods or Background: From April 2018 to August 2023, 73 patients (mean age=68.9 ± 9.6) with LUTS (n=69) or malignant hematuria (n=4) underwent PAE. CTA and transcatheter angiography images were retrospectively reviewed for arterial anatomy evaluation. The branching pattern of internal iliac artery (IIA) and the origin of PA were categorised, and the incidence of each type was recorded.
Results or Findings: PAE was successfully implemented in 143 of 146 pelvic sidewalls. PA cannulation failed in three sidewalls due to total IIA occlusion. Most common IIA was A type (dividing into superior gluteal and gluteal-pudendal trunk, 72%). Eleven of 143 sidewalls exhibited dual PAs. A total of 154 PA origin was investigated. Internal pudendal artery origin (IPA, type IV) was most common, 40%, followed by superior vesical artery origin (type I, 25%) and obturator origin (type III) in 19%. Less commonly, anterior division of IIA origin (type II) was 7%. Type V (uncommon origins) was 8% including three distal IPA, two inferior gluteal, two medial femoral circumflex, and two rectal arteries and two quadfurcation and one trifurcation patterns.
Conclusion: In Korean population, the most common IIA pattern and PA origin was type A and IV, respectively, which aligns with previous reports.
Limitations: The limitations of the study include its retrospective nature, small sample size, and single centre study.
Funding for this study: No funding was received for this study.
Has your study been approved by an ethics committee? Not applicable
Ethics committee - additional information: This study is a retrospective study hence no ethical approval was required.

Author Block: L. S. Alizadeh, C. Booz, I. Yel, D. Radek, T. Vogl; Frankfurt a. Main/DE
Purpose: The objective of this study was to evaluate the efficacy, safety, and outcomes of prostatic artery embolisation (PAE) in patients with benign prostatic hyperplasia (BPH) over a six-year period at a single centre and to discern its impact on clinical symptoms, prostate volume, and procedural specifics.
Methods or Background: A single-centre retrospective study was conducted, analysing 551 PAE interventions performed by a single interventional radiologist from January 2017 to July 2023. The study reviewed technical specifics, changes in prostate volume, PSA levels, International Prostate Symptom Score (IPSS), Quality of Life (QoL) scores, International Index of Erectile Function (IIEF), and procedural radiological metrics.
Results or Findings: The average age of patients was 68.81 years. A significant majority underwent bilateral embolisations in a single session (435 out of 551) with particles predominantly sized 100-300 μm (441 out of 551). Post-intervention, there was a notable reduction in prostatic volume (mean decrease of 9.66 ml) and PSA levels (mean decrease of 0.32 ng/ml). Symptomatic relief was evident with a substantial drop in IPSS (mean decrease of 9.17) and improved QoL scores (mean decrease of 1.74). IIEF scores showed a slight increase post-procedure. The average fluoroscopy time was 25.23 minutes, with an average dose area product (DAP) of 25452.08 μGym².
Conclusion: PAE emerges as a potent therapeutic intervention for BPH patients, offering symptomatic relief, reduction in prostate volume, and a favorable safety profile. We reported increasing patient numbers since the implementation of the technique. This single-center experience provides a comprehensive insight into the real-world applicability and efficacy of PAE.
Limitations: Single centre retrospective trial limits the scope of this study.
Funding for this study: No funding was obtained for this study.
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: The ethical approval was received from the Institutional ethics committee with a waiver for informed consent.

Author Block: A. Viitala¹, M. Anttinen¹, P. Mäkelä¹, P. Doerwald², P. Nurminen¹, H. E. Pärssinen¹, T. Sainio¹, R. Blanco Sequeiros¹, P. J. Boström¹; ¹Turku/FI, ²Hamburg/DE
Purpose: The aim of this study was to assess clinical outcomes of MRI-guided transurethral ultrasound ablation (TULSA) in treating benign prostatic hyperplasia (BPH).
Methods or Background: Men with BPH scheduled for TURP were enrolled. EPIC-26, IPSS, IIEF-5, uroflowmetry, PSA, MRI, and complications in Clavien-Dindo were recorded.
Results or Findings: Thirty patients received TULSA, with a median follow-up of 16-mo (max 48-mo). At baseline, median [IQR] age was 67 years [64–72], PSA 3.1 ug/l [2.2–6.9], prostate volume 51.5 ml [min 29-max 107], average flow rate 4.1 ml/s [3.4–7], maximum flow rate 11 ml/s [8–15], voided volume 211 ml [139–336], and post-void residual(PVR) 71 ml [40–247]. Median sonication, hospitalization, and catheterization times were 39 min, 24 h, and 16 d, respectively. Complications included one grade 1, 8 grade 2, and one grade 3 events, all resolving within three-months. 24/30 patients have completed their 12-month follow-up with two men dropping off due to cancer diagnosis. Between baseline and 12 months, median values for measured parameters changed as follows: prostate volume, PSA, PVR reduced from 51.5 to 31 ml, 3.1 to 1.5 ug/l, and 71 to 41.5 ml, respectively. Average flow rate, Qmax, and voided volume increased from 4.1 to 8.7 ml/s, 11 to 18 ml/s, 211 to 301 ml, respectively. IPSS, IPSS QoL, IIEF-5 scores improved from 16.5 to 4, 4 to 1, and 15 to 19, respectively. EPIC-26 urinary incontinence, irritative/obstructive, bowel, sexual, and hormonal domains improved from 85.5 to 100, 65.6 to 94, 87.5 to 100, 54 to 67, and 95 to 100, respectively. Results of uroflowmetry, functional, and QOL questionnaires all improved at 12-month despite discontinuation of LUTS medication in 26/30 patients.
Conclusion: 12-mo clinical-outcomes demonstrate safety and efficacy of TULSA for treating BPH.
Limitations: Small population
Funding for this study: Study was funded by Profound Medical.
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: Ethics committee approval was granted and informed consent was obtained from all study participants.

Author Block: A. Mininni, L. Tomasino, E. Lanza, G. Ferrillo, D. Poretti, M. Francone, V. Pedicini; Milan/IT
Purpose: Male varicocele is characterised by high prevalence in young individuals, diminished fertility rates and adverse impact on the quality of life. The aim of this study is to evaluate the recurrence rate of varicocele in patients who had undergone endovascular treatment using N-butyl 2 cyanoacrylate plus methacryloxy sulfolane (NBCA-MS, Glubran2) glue.
Methods or Background: A retrospective analysis of varicocele embolisation procedures completed between January 2016 and December 2022 was performed. A total of 102 patients were recruited (mean age 27.7 years) through phone interview. Before the procedure 10.8% patients had stage two disease severity; 61.8% had stage three and 27.5% had stage four. All patients manifested typical varicocele symptoms such as testicular heaviness, pain or spermiogram abnormalities. Improvement in spermiogram, recurrence rate of disease and need for new treatment were evaluated.
Results or Findings: Spermiogram improvement was observed in 81.3% of patients (49 patients underwent semen analysis 6-8 months after the procedure). Recurrence rate of disease was 10.8% (11 patients) and among those, patients requiring new treatment were 45.5% (three patients needed new endovascular embolisation treatment using NBCA-MS, and two patients needed classic surgery). No significant post-procedural complications were reported.
Conclusion: Endovascular embolisation using NBCA-MS glue is an effective treatment for male varicocele, offering very low recurrence rates and negligible complications.
Limitations: The single-centre and retrospective nature of the study were identified limitations.
Funding for this study: No funding was received for this study.
Has your study been approved by an ethics committee? Not applicable
Ethics committee - additional information: IRB approval was waived considering the retrospective non-interventional study design.

Author Block: E. Karapinar, C. C. Ercan, M. S. Çakır, A. B. Aydin; Istanbul/TR
Purpose: High-flow priapism is a persistent penile tumescence, which is relatively uncommon compared to low-flow priapism. It is typically associated with a history of trauma leading to lacerations in the cavernosal arteries within the corpora cavernosa. Super-selective arterial embolisation is a well-established therapeutic technique; however, conservative management is usually the initial approach in paediatric population. As a tertiary medical centre, we are compelled to provide treatment to those who do not respond to conservative measures.
Methods or Background: We observed a total of four paediatric patients with high-flow priapism between 2020-2022. Three of these patients had documented trauma histories, while the cause in one patient remained uncertain due to their mental status. All patients underwent conservative treatment for up to two weeks, with no observed response. Initially, we conducted Doppler ultrasound examinations to assess arterial waveforms and identify fistula tracts in the corpora cavernosa. Subsequently, we performed conventional angiography and proceeded with an embolisation plan.
Results or Findings: Among the patients, three exhibited angiographic evidence of arteriocavernosal fistulas. Super-selective embolisation with gel-foam was successfully completed in all patients, and post-procedural angiography revealed the absence of residual pathological flow. In long-term follow-up, all of these patients exhibited recovery with no reported complications overtime. Early postoperative and subsequent intermittent follow-up Doppler studies have consistently demonstrated normal flow. The fourth patient, who had an uncertain history of trauma, exhibited normal angiographic features and was deemed ineligible for embolisation.
Conclusion: Super-selective embolisation emerges as a promising technique for managing high-flow priapism not only in adults but also in paediatric patients.
Limitations: Given the rarity of this condition, our study was limited by the small number of patients.
Funding for this study: No funding was received for this study.
Has your study been approved by an ethics committee? Not applicable
Ethics committee - additional information: We adapted a treatment modality with proven successful outcomes in the literature to our own patients under the most suitable conditions. We did not employ any additional medications or medical interventions beyond the methods documented in the literature.

Author Block: Y. Wimper, L. te Molder, M. Sedelaar, J. Bomers, C. G. Overduin, J. Fütterer; Nijmegen/NL
Purpose: The aim of this study was to investigate the feasibility and safety of an integrated system for MRI-guided FLA in localized PCa. Current active treatment of localised prostate cancer (PCa) is directed towards whole-gland radical treatment. MRI-guided focal laser ablation (FLA) presents a minimally invasive treatment alternative for selected patients offering targeted tumour treatment at reduced morbidity. It relies on a laser applicator combined with real-time MR thermometry feedback for accurate ablation control. However, in current systems these are often non-integrated. Our study will enable a more precise tissue ablation without damaging vital adjacent structures.
Methods or Background: Between April 2022 and May 2023, 10 patients (mean age: 66±7.2 years) with low- and intermediate risk PCa were prospectively included and treated with MRI-guided FLA using an integrated FLA system (Tranberg,CLS). Primary endpoints were technical success, procedure-related adverse events (AEs) and tumour response on MRI at 6 months. Secondary endpoints were prostate-specific antigen (PSA) levels, sexual and urinary function response at 6 months.
Results or Findings: Technical success was achieved in 10/10 (100%) patients. Two AEs were observed, acute urinary retention (classification D, n=1) and urinary tract infection (classification B, n=1). Six-month follow-up was available in 6/10 patients. In all six patients, follow-up MRI indicated no evidence of residual tumor. At six months, mean PSA level was reduced (5.9 vs. 3.4 ng/mL; p=0.59), urinary function scores (10.0 vs. 7.8; p=0.37) and sexual function scores improved (10.3 vs. 15.4; p=0.47) compared to baseline, all being non-statistically significant.
Conclusion: Our study demonstrates feasibility and safety of an integrated MRI-guided FLA system in patients with low-to-intermediate risk PCa. Initial experience indicates good oncological response and potential improvement in urinary and sexual function.
Limitations: This feasibility study is limited by a small, single-institution cohort and short-term follow-up.
Funding for this study: Clinical Laserthermia Systems has provided funding for this study.
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: The ethical approval was obtained by the Institutional Review Board.