Tive conhecimento há pouco tempo atrás que a técnica de Radiologia de Intervenção - embolização prostática no tratamento da hiperplasia benigna da próstata, teria sido alvo de criticas e contestação no seio da Ordem dos Médicos. por outras especialidades que não a Radiologia

Alves, Filipe Caseiro

English

Acta Radiológica Portuguesa

ACTA RADIOLÓGICA PORTUGUESA
Janeiro-Abril 2016   nº 107  Volume XXVIII   7-8
EDITORIAL
7
Filipe Caseiro Alves
I learned not long ago that the Interventional Radiology 
technique - prostatic embolization in the treatment of  benign 
prostatic hyperplasia, might have been subject to criticism 
and contestation within the Medical Association by other 
than the radiology specialties. If  this is true, and I believe 
that there are no serious doubts, it is a bizarre situation which 
has no similar precedent in Modern Medicine. Whether you 
like this technique more or less, medical knowledge cannot 
and should not be based on personal impressions or on the 
generalization of  separate cases that perhaps presented some 
kind of  complication. Knowledge is spread through the 
publication of  results after undergoing scientific arbitration 
and after the technique reproduction by other researchers 
with similar results. As with any other kind of  treatment, 
the expected effectiveness cannot be 100%, nor can the 
complication rate have unbearable values. It turns out that 
the prostate embolization in cases of  BPH has satisfied these 
two conditions to such extent that there is now a considerable 
body of  opinion that validates it and is being accepted as an 
alternative therapy by the scientific community.
As in other cases, the introduction of  new paradigms in 
Medicine is always a slow process and is seen initially with 
reluctance while the strength of  the available scientific data 
does not allow that change more or less radical.
In the opinion article of  this ARP issue we have chosen 
to reproduce in full the position of  the Scientific Society 
perhaps more entitled to do so in this particular field - CIRSE 
(Cardiovascular and Interventional Radiological Society of  
Europe) and that is precisely in order to clarify the current 
situation of  the technique, the knowledge that was produced 
and what remains to be achieved. It is a rigorous document, 
scientifically comprehensive and honest, worth reading 
before forming an opinion.
Medicine, an exact science (or semi-exact in many situations), 
lives precisely from the opposite of  dogmatism. Research, 
curiosity and scientific confrontation are the key elements 
to the progress of  medical science. Thus knowledge is 
generated.
Tive conhecimento há pouco tempo atrás que a técnica 
de Radiologia de Intervenção - embolização prostática no 
tratamento da hiperplasia benigna da próstata, teria sido alvo 
de criticas e contestação no seio da Ordem dos Médicos. por 
outras especialidades que não a Radiologia. A ser verdade, 
e estou em crer que não restam grandes dúvidas, é uma 
situação bizarra que não encontra precedentes similares na 
Medicina Moderna. Goste-se mais ou menos da técnica, o 
conhecimento em Medicina não pode nem deve ser feito 
com base em impressões pessoais ou na generalização 
de casos avulso que porventura apresentaram algum 
tipo de complicações. O conhecimento faz-se através da 
publicação de resultados depois de submetidos a arbitragem 
cientifica e pela posterior reprodução da técnica por outros 
investigadores com resultados similares. Como qualquer 
outro tipo de tratamento, a eficácia esperada não pode 
ser de 100%, nem a taxa de complicações possuir valores 
incomportáveis. Acontece que a embolização prostática nas 
situações de HBP tem satisfeito estas duas condições de tal 
forma que existe hoje um considerável corpo de opinião que 
a valida e a faz ser aceite como alternativa terapêutica pela 
comunidade cientifica.
Como noutros casos, a introdução de novos paradigmas 
em Medicina é sempre um processo moroso e que é visto 
inicialmente com relutância enquanto a solidez dos dados 
cientificos disponíveis não permite essa mudança mais ou 
menos radical.
No artigo de opinião deste numero da ARP optámos por 
reproduzir na íntegra a posição da Sociedade Cientifica 
porventura mais habilitada para o fazer neste dominio 
particular - o CIRSE (Cardiovascular and Interventional 
Radiological Society of  Europe) e que o faz precisamente 
no sentido de explicitar a situação actual da técnica, o 
conhecimento que foi produzido e o que falta alcançar. É um 
documento rigoroso, cientificamente abrangente e honesto 
que vale a pena ler antes de formar qualquer opinião.
A Medicina, ciência exacta (ou semi-exacta em muitas 
situações) vive precisamente do oposto do dogmatismo. A 
investigação, a curiosidade e a confrontação cientifica são 
os elementos chave para o progresso das ciências médicas. 
Assim se faz o conhecimento.
Artigo de opinião / Opinion article
Upon your request, we are writing to express the Cardiovascular 
and Interventional Society of  Europe’s (CIRSE) opinion on 
the procedure of  prostatic artery embolisation.
Since prostatic artery embolisation was first performed in 
2008, this therapy has met with substantial clinical success 
in patients. Studies continue to demonstrate the benefits this 
procedure has for patients suffering from benign prostatic 
hyperplasia (BPH), and many trials have proved the significant 
positive changes in patients’ urodynamic characteristics, 
including the International Prostate Symptom Score (IPSS), 
the maximal flow rate (Qmax), the International Index of  
Erectile Dysfunction (IIEF) and prostate volume (PV).
One such fundamental study was Prof. F. Carnevale’s 2015 
prospective, randomised trial of  30 patients, comparing 
transurethral resection of  the prostate (TURP) with original 
and PErFecTED PAE. While both TURP and PErFecTED 
PAE were determined to yield similar symptom improvement, 
TURP achieved slightly better urodynamic results, but was 
also associated with more adverse events than PAE (1).
This PErFecTED technique was used in Dr. G. Amouyal’s 
2013-2015 study of  32 patients that showed this PAE 
technique to be safe and efficient in treating lower urinary 
tract symptoms (LUTS) related to BPH, as outcomes revealed 
100% technical success, and 78% overall clinical success (2).
In the first large series study published by Prof. J. Pisco in 
2013, PAE was performed in 89 patients with a short-term 
clinical success rate of  78% at 6-month follow-up, and an 
average IPSS decrease of  13.1 points by 12-month follow-
up, along with no loss of  sexual function in patients (3). 
In the most recent publication by Prof. Pisco of  a single-
centre retrospective cohort study of  patients with moderate 
to severe LUTS, PAE was performed in 152 patients with 
a clinical success rate of  77.8% at 18 months and 72.4% 
thereafter to 66 months (4).
The ongoing UK-Registry of  Prostate Embolisation 
(ROPE), which is analysing the efficacy and safety of  PAE, 
also promises satisfactory results. As of  September 2015, the 
registry had recruited 187 patients, out of  which 128 received 
PAE with positive effects. The results from the University 
Hospital Southampton, showed an average decrease of  12 
points in IPSS at three-month follow-up of  PAE patients (5).
These are just a few of  the many studies which have been 
conducted on PAE and have been published or anticipate 
optimistic outcomes. More research in the form of  registries 
or clinical trials is needed to gather further data on this 
procedure, but, the overwhelming positive results so far 
indicate that PAE should continue to be performed with 
multidisciplinary collaboration within trials and registries to 
further define the role of  PAE in patients with BPH.
It is essential that multidisciplinary collaboration be 
embraced between urologists, diagnostic radiologists and 
interventional radiologists in order to determine the most 
appropriate indications for this procedure and to achieve the 
best results. Although this procedure is unlikely to replace 
medical therapy, many urologists believe that it is a beneficial 
option for select patients. Brazilian urologist Dr. A. Antunes 
stated that advantages of  PAE include: 1.) It is an outpatient 
procedure, 2.) It is performed under local anaesthesia, 3.) 
It has a low complication rate, and 4.) It does not produce 
retrograde ejaculation or early urinary incontinence (6). 
Interdisciplinary cooperation is necessary to ensure patients 
receive the ideal treatment for their specific circumstances.
We hope this will assist in the effort to clarify the validity 
and value of  the prostatic artery embolisation procedure and 
ensure that all perspectives be carefully and fully considered 
in the discussion surrounding its continuation in Portugal.
If  questions remain that we may be of  any assistance in 
answering, we would be happy to offer further support on 
this matter.
Elias Brountzos, MD PhD
CIRSE President
References
1. Carnevale F, Iscaife A, Yoshinaga E, Moreira A, Antunes A, Srougi 
M. Transurethral resection of  the prostate (TURP) versus original and 
PErFecTED prostate artery embolization (PAE) due to benign prostatic 
hyperplasica (BPH): preliminary results of  a single center, prospective, 
urodynamic-controlled analysis. Cardiovasc Intervent Radiol. 2016;39(1):44-
52.
2. Amouyal G, Thiounn N, Pellerin O, Yen-Ting L, Del Giudice C, Dean 
C, et al. Clinical results after prostatic artery embolization using the 
PErFecTED technique: a single-center study. Cardiovasc Intervent Radiol. 
2016;39(3):367–75.
3. Pisco JM, Rio Tinto H, Pinheiro LC, Bilhim T, Duarte M, Fernandes L, 
et al. Embolisation of  prostatic arteries as treatment of  moderate to severe 
lower urinary symptoms (LUTS) secondary to benign hyperplasia: results of  
short- and mid-term follow-up. Eur Radiol. 2013;23(9):2561–72.
4. Pisco JM, Bilhim T, Pinheiro LC, Fernandes L, Pereira J, Costa NV, Duarte 
M, et al. Prostate embolization as an alternative to open surgery in patients 
with large prostate and moderate to severe lower urinary tract symptoms. J 
Vasc Interv Radiol. 2016;27(5):700-8.
5. Hacking N. (2015, Sept. 29). Current evidence on prostate artery 
embolisation [Webcast]. CIRSE 2015. Retrieved from www.esir.org.
6. Antunes A. (2013, Sept. 15). PAE: the urologist’s perspective [Webcast]. 
CIRSE 2013. Retrieved from www.esir.org.
by Prof. Carnevale.


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