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World J Radiol. Aug 28, 2020; 12(8): 172-183
Published online Aug 28, 2020. doi: 10.4329/wjr.v12.i8.172
Sonographic evaluation of prostatic artery embolization: Far beyond size measurements
Hippocrates Moschouris, Andreas Dimakis, Anastasia Anagnostopoulou, Konstantinos Stamatiou, Katerina Malagari
Hippocrates Moschouris, Andreas Dimakis, Anastasia Anagnostopoulou, Radiology Department, General Hospital “Tzanio”, Piraeus 18536, Greece
Konstantinos Stamatiou, Urology Department, General Hospital “Tzanio”, Piraeus 18536, Greece
Katerina Malagari, Second Department of Radiology, University of Athens, “Attikon” Hospital, Athens 12462, Greece
Author contributions: Moschouris H wrote the paper; Moschouris H, Dimakis A and Anagnostopoulou A performed the imaging studies and collected the data; Moschouris H, Dimakis A and Malagari K performed the PAE procedures; Stamatiou K and Malagari K supervised and coordinated the work.
Conflict-of-interest statement: There is no conflict of interest associated with any of the authors of this manuscript.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Hippocrates Moschouris, MD, MSc, PhD, Doctor, Interventional Radiologist, Radiology Department, General Hospital “Tzanio”, Zanni and Afentouli 1 Str., Piraeus 18536, Greece. hipmosch@gmail.com
Received: March 22, 2020
Peer-review started: March 22, 2020
First decision: April 29, 2020
Revised: May 2, 2020
Accepted: July 1, 2020
Article in press: July 1, 2020
Published online: August 28, 2020
Abstract

Prostatic artery embolization (PAE) has gained acceptance as a minimally invasive, safe and effective treatment of symptomatic benign prostatic hyperplasia. Radiologic imaging is an indispensable part of post-interventional evaluation of PAE and serves both clinical and investigational purposes. In this context, ultrasonography (US) has a central and multifaceted role. Gray-scale US is routinely utilized for measurement of significant outcome parameters (prostatic volume, intra-vesical prostatic protrusion and post-void residual volume) before and after PAE. Improvement of these parameters may become more obvious one-month post-PAE, or later. Contrast-enhanced US (CEUS) with intravenous administration of a second-generation echo-enhancer can demonstrate prostatic infarcts (as enhancement defects) immediately post-PAE and monitor their resolution over time. The volume of prostatic infarcts can also be measured and compared to prostatic volume. Prostatic infarction is a definite sign of the local efficacy of PAE and a predictor of prostate shrinkage and (at least in some patients) of clinical success. CEUS can also be performed intraoperatively in the angio-suite, for on-site evaluation of the ischemic effect; a variation of this technique, with intraarterial (instead of intravenous) administration of diluted echo enhancer, can also be applied intraoperatively, to map the embolized territory and to prevent non-target embolization. Initial experience with US-elastographic techniques (shear-wave and strain elastography) has shown that they can detect and quantify the improvement of tissue elasticity post-PAE, thus providing new insights into the therapeutic mechanisms of this treatment. With utilization of high-end equipment, experience and standardized imaging protocols, US could be the primary modality for imaging evaluation of PAE.

Keywords: Prostatic artery embolization, Benign prostatic hyperplasia, Ultrasound, Contrast-enhanced ultrasound, Infarction, Strain elastography, Shear-wave elastography

Core tip: Ultrasonography is a practical and affordable modality for imaging evaluation of the efficacy of prostatic artery embolization (PAE). This evaluation includes, but is not limited to, standard measurements of prostatic volume, intravesical prostatic protrusion and post-void residual volume. With contrast-enhanced ultrasound, prostatic infarcts can be easily detected shortly after PAE, and their extent appears to have clinical and prognostic value. Strain- and shear-wave elastography can depict the changes in prostatic consistency caused by PAE. A comprehensive description of all these applications is attempted in the following review.