Prostatic and scrotal necrosis following prostate artery embolization: a rare complication with a successful long-term outcome

Abstract

Background

This case report highlights a rare but severe complication of prostate artery embolization (PAE)—prostate necrosis. Once successfully managed, it resulted in an optimal long-term clinical outcome.

Case presentation

A 70-year-old male was diagnosed with benign prostatic hyperplasia (BPH) and presented with severe lower urinary tract symptoms (LUTS), requiring a permanent urethral catheter. One month after PAE, the patient developed extensive prostate necrosis, which was associated with scrotal cutaneous necrosis, confirmed through imaging and clinical evaluation. The patient was treated with intensive medical therapy and scrotal surgical debridement, leading to clinical improvement. The patient was discharged after one month following clinical improvements and was instructed to continue antibiotic therapy. An outpatient visit was scheduled for 6 months, where full recovery was observed, allowing for the removal of his urinary catheter. The patient was assessed at 18 months with a significant reduction in prostate volume (20 cc) and in the International Prostatic Symptoms Score (IPSS), dropping to 6.

Conclusion

Prostate necrosis is an extremely rare complication of PAE. While life-threatening, if managed promptly, it can lead to an excellent long-term clinical improvement in LUTS, due to a substantial reduction in prostate volume.

Background

Prostatic artery embolization (PAE) is an increasingly recognized minimally invasive procedure for the treatment of benign prostatic hyperplasia (BPH) in moderate-severe lower urinary tract symptoms (LUTS) [1]. PAE involves the super-selective embolization of the prostatic arteries using embolic agents to induce ischemia, leading to prostate volume reduction and symptomatic relief of LUTS associated with BPH. The procedure has gained popularity for its comparable effectiveness to traditional surgical options while offering fewer adverse effects, particularly the preservation of erectile, sexual, and ejaculatory function [2, 3].

Despite being a minimally invasive procedure, PAE is associated with a range of potential complications, some of which may be serious, associated with non-target embolization [1, 3]. The reported complications include damage to the bladder, rectum, penis, seminal vesicles, pelvic organs, bones, skin and urinary tract infections [4, 5]. Other complications are intrinsic to the embolization of the prostate itself. In a subset of patients, post-embolization syndrome, characterized by pelvic pain, fever, haematuria and dysuria, may occur because of ischemic injury to the prostate and surrounding tissues, which according to a systematic review of 2116 patients, can occur in up to 25% [6].

This case report describes a patient who developed extensive prostate necrosis following PAE, a very uncommon complication. Given the rarity of prostate necrosis post-PAE, further research is needed to establish the precise prevalence rates and identify potential risk factors.

Case presentation

Medical history

A 70-year-old male, diagnosed with BPH, presented with severe LUTS and high-pressure chronic urinary retention, which necessitated the placement of a permanent urinary catheter.

Before coming to our attention, the patient had been taking tamsulosin hydrochloride 0.4 mg for approximately 7 years, with a progressive increase in the IPSS score up to 35, its maximum, when it was decided to place the bladder catheter. A preliminary ultrasound examination was performed, revealing a prostatic volume of 90 cc. Together with the urologist, a decision to proceed for endovascular treatment through PAE was made, based on the prostatic volume and the associated symptomatology.

Procedure

The procedure was performed via right retrograde femoral access with a 5Fr introducer sheath. Using a cross-over technique, the left internal iliac artery was catheterized and a selective angiogram was performed. Super-selective angiogram with a Progreat microcatheter 1.9Fr in the left main prostatic artery, before the origin of the central prostatic and peripheral prostatic artery, was performed (Fig. 1b). Cone-beam CT was carried out to confirm the correct localisation and exclude any collateral arteries. Calibrated embolizing particles (250 microns, Embozene; Boston Scientific) were deployed, resulting in a satisfactory angiographic outcome on the left side (Fig. 1d). The same wire and catheter manipulation technique was performed on the right side (Fig. 1a). Angiographic evaluation of the right prostatic artery revealed an anastomosis with a penile arterial branch. To prevent non-target embolization, a pushable coil was deployed at this site, which resulted in immediate reduction in flow through the anastomotic branch. Super-selective angiogram and then cone-beam CT were performed. After confirmation of correct positioning, 250-micron embolizing particles were injected, resulting in a successful angiographic outcome (Fig. 1c). A single dose of ciprofloxacin 500 mg was administered to the patient on the day of the procedure. As per institutional protocol, a trial without catheter was recommended 2–3 weeks following the procedure.

Fig. 1.

a and b diagnostic angiograms of the right and left prostatic artery respectively before embolization; c and d diagnostic angiograms of the right and left prostatic arteries respectively after embolization

Outcome

The patient was discharged the following day with only mild abdominal discomfort, which did not require analgesia medications. One month later, the patient presented to the emergency department with abdominal pain, fever, and raised inflammatory biomarkers (18WBC; 150CRP). A CT scan revealed massive prostate necrosis with an internally liquefied appearance (Fig. 2a), along with right hemiscrotal skin necrosis and ulceration (Fig. 2b). Additionally, the CT scan documented the presence of cirrhosis of the liver and partial superior mesenteric vein thrombosis.

Fig. 2.

a CT scan of massive prostatic necrosis with liquefied appearance and airy prostate content; b CT scan of scrotal necrosis

The patient started antibiotic therapy with aminoglycosides, macrolides and metronidazole and underwent surgical debridement of the scrotal wound.

Subsequently, he was referred to the Hepatology department for the management of previously undiagnosed cirrhosis. Anticoagulant therapy for the venous thrombosis was given together with the antibiotic therapy.

A follow-up CT scan performed one week later demonstrated resolution of the scrotal necrotic changes. A control MRI, also performed one week later, confirmed diffuse prostatic necrosis (Fig. 3). The patient clinically improved, became asymptomatic, and showed normalization of WBC. He was discharged one month later with instructions to continue home antibiotic therapy with Amoxicillin and Clavulanic Acid for 10 days.

Fig. 3.

T1-weighted MR after gadolinium and T2 mri sequences showing massive prostate necrosis

At the 6-month follow-up, the patient presented for an outpatient visit and reported significant clinical improvement. The urinary catheter was removed, and the patient noted a marked reduction in lower urinary tract symptoms.

Due to the delay in scheduled follow-up caused by patient-related factors, the subsequent clinical and imaging assessment was performed at 18 months, in which the patient reported an International Prostatic Symptoms Score (IPSS) score of 6 and underwent a follow-up ultrasound, which demonstrated a significant reduction in prostatic volume, now measuring approximately 20 cc, compared to 90 cc prior to the procedure (Fig. 4).

Fig. 4.

18 months follow-up ultrasound showing reduction in prostate volume to 20 cc

Discussion and conclusions

While the majority of PAE complications are minor [4], the present case highlights an unusual and severe adverse event—extensive prostate necrosis leading to significant morbidity before ultimate clinical recovery and significant long-term improvement. Less severe complications may occur if necrotic tissue sloughs into the urethra, leading to urinary retention and recurrent catheter blockages [7]. However, one case described acute urinary retention as a consequence of expelled prostatic tissue [8]. On the other end of the spectrum, necrosis can lead to life-threatening complications, primarily due to the risk of urosepsis and septic shock [9].

A possible way to mitigate the risk of non-target embolization, is through cone-beam CT [1], or with a control-reflux catheter [10]. Although careful procedural planning was implemented to mitigate the risk of microembolic infarcts from non-target embolization, as evidenced by protective coil embolization of an anastomotic penile branch [11], the patient still developed scrotal and prostatic necrosis. Other factors unrelated to the procedure could have contributed to such complication, such as the presence of previously undiagnosed liver cirrhosis and mesenteric vein thrombosis.

Furthermore, the patient’s pre-existing need for a urinary catheter prior to the procedure could have compounded the risk, as prolonged catheterization has been associated with chronic inflammation and altered prostatic perfusion, which could have exacerbated and augmented post-embolization tissue damage [12]. Medical management, including antibiotic therapy and anticoagulation, facilitated recovery. Surgical debridement of the scrotal necrosis was necessary but did not compromise long-term functional outcomes.

The small size of the microspheres (100 μm) used in this case may have contributed to the observed necrotic effect due to their deeper penetration and enhanced ischemic effect into the prostatic tissue, compared to larger particles. Smaller particles (< 100 μm) have been associated with large prostate size reduction [13] and lower PSA levels, despite non-significant differences in functional outcomes [14]. On the other hand, 100–300 μm microspheres have been associated with increased risk of minor complications, mainly dysuria [14]. According to CIRSE guidelines, microspheres measuring 300–500 μm or PVA particles in the 100–300 μm range are recommended to reduce the risk of adverse effects, including non-target embolization [15]. PAE technique remains heterogeneous, particularly in terms of embolic agent selection and particle sizing.

At 18 months, the patient exhibited significant improvement in urinary symptoms, as reflected by an IPSS score of 6 and a remarkable reduction in prostatic volume, from 90 cc to 20 cc. This aligns with prior research indicating that prostate infarcts post-PAE correlate with significant prostate shrinkage and improved clinical outcomes. Volume reduction of the prostate after embolization can be significant (averaging 32.0% after 12–18 months; p < 0.001) only in patients with infarcts present in the central gland [16]. A higher prostate necrosis rate at 1 month after PAE has been correlated with better clinical outcomes at 1 year, making the 1-month necrosis rate a potential predictor of long-term success following PAE [17].

In conclusion, prostate necrosis is an exceedingly rare complication following PAE, potentially aggravated by pre-existing urinary catheters or underlying comorbidities. While this is a potentially life-threatening complication, if appropriately managed and treated, it can correlate with an excellent clinical outcome, potentially better than the standard prognosis of 9.2 IPSS improvement [18]. This is likely associated to the substantial degree of prostatic necrosis, leading to an extensive reduction in prostatic volume and, consequently, improvement in LUTS.

Abbreviations

PAE

Prostate Artery Embolization

BPH

Benign Prostatic Hyperplasia

LUTS

lower urinary tract symptoms

IPSS

International Prostatic Symptoms Score

Authors’ contributions

All authors made substantial contributions in conception and design of the case report, drafting of and final approval of the version to be published. MAT, EM, AZ were responsible for conceptualization. EM, AZ, MAT were responsible for writing-original draft. EM, AZ, MAT, NU were responsible for writing—review & editing. AZ, MAT, TR, MK, FS, RL were responsible for supervision.

Funding

Not applicable.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

Formal ethical approval from Sapienza University was not required for this case report.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.