Stesura Seveso Archivio Italiano di Urologia e Andrologia 2024; 96(2):12306 1 CASE SERIES parameters has yet to be described. This case series pres- ents three patients of high medical risk with intractable hematuria of prostatic origin, where PAE was performed and resulted in the resolution of prostatic hemorrhage. CASE PRESENTATION Case 1 A 91-year-old man presented with a 48-hour history of painless gross hematuria. Previous medical history included BPH with voiding LUTS, atrial fibrillation on Edoxaban, left cortical stroke, dyslipidemia, hypertension and right-sided heart failure with ascites. Hemoglobin was 111 g/L at arrival, while pre-procedure hemoglobin was 89 g/L (baseline 120 g/L). Anticoagulation was held at arrival and daily subcutaneous thromboprophylaxis was prescribed. The prostate gland volume was 200cc on computed tomography (CT) (Figure 1). Cystoscopy con- firmed the prostate gland was the origin of the hematuria. Continuous bladder irrigation (CBI) was performed for 10 days, with no resolution of symptoms. Given the multiple medical comorbidities, this patient was not a candidate for surgery and was offered PAE, which he accepted. The patient was on CBI for 5 days post-PAE before the reso- lution of the gross hematuria and passed the trial of void on day 6. Anticoagulation therapy was resumed on day 7 post-PAE. At 6-month follow-up, the patient was voiding well and had no recurrence of hematuria. Case 2 An 85-year-old man presented with recurrent gross hematuria for one month with clots, complicated by uri- nary retention and infection. Previous medical history included BPH, atrial flutter on Apixaban, sick sinus syn- drome with pacemaker, coronary artery bypass surgery, type 2 diabetes mellitus and hypertension. At presenta- tion, hemoglobin was 84 g/L (baseline 115 g/L) and required transfusion of 2 units of packed red blood cells (PRBC). The prostate gland volume was 120cc on CT Introduction: Benign prostatic hyperplasia is a prevalent disease that could be responsible of severe intractable hematuria requiring invasive surgical man- agement. Case presentation: We report three high-risk cases presented with intractable hematuria of prostatic origin with high medical co-morbidities treated safely and effectively by prostatic artery embolization with favorable outcomes. Conclusions: In non-surgical, anticoagulated patients, prostatic artery embolization represents a safe and effective intervention for the treatment of intractable hematuria related to benign pro- static hyperplasia. KEY WORDS: Benign prostatic hyperplasia; Gross hematuria; Angioembolization; Coagulation disorders. Submitted 24 February 2024; Accepted 9 February 2024 INTRODUCTION Benign prostatic hyperplasia (BPH) is a prevalent disease, affecting up to 50% of men over the age of 50, usually associated with lower urinary tract symptoms (LUTS) (1). Intractable hematuria represents a severe complication of BPH, which often requires invasive management (2). While transurethral resection of the prostate (TURP) remains the mainstay therapy for BPH, laser enucleation techniques represent the standard of care for the surgical treatment of larger prostates or in anticoagulated patients (3, 4). However, elderly or co-morbid patients may be at high medical risk for the prolonged anesthesia-time asso- ciated with laser TURP. In these cases, non-surgical treat- ment for BPH, such as prostatic artery embolization (PAE), may be considered. PAE consists of embolization of selected prostatic arteries to produce ischemic necrosis and shrinkage of the prostate gland (5, 6). Arterial embolization has previously been described for treatment of intractable hematuria due to prostate and bladder pathologies (7, 8). However, to the best of our knowl- edge, PAE for the treatment of intractable hematuria in co-morbid BPH patients with unregulated coagulation Prostatic artery embolization for intractable hematuria in patients with unregulated coagulation parameters: Three case reports Manuel Belmonte 1, Abdulghani Khogeer 2*, Ghizlane Moussaoui 3, Rafael Melo 4, Louis-Martin Boucher 4, Tatiana Villalpando-Cabrera 4, Serge Carrier 1, Mélanie Aubé-Peterkin 1 1 Department of Surgery, Division of Urology, McGill University Health Center, Montreal, Canada; 2 Department of Surgery, Faculty of Medicine, Rabigh, King Abdulaziz University, Jeddah, Saudi Arabia; 3 Department of Urological Sciences, University of British Columbia, Vancouver, Canada; 4 Department of Radiology, McGill University, Montreal, Canada. * Co-First Author. DOI: 10.4081/aiua.2024.12306 Summary Archivio Italiano di Urologia e Andrologia 2024; 96(2):12306 M. Belmonte, A. Khogeer, G. Moussaoui, et al. 2 scan. Cystoscopy confirmed the prostate as the source of the bleeding. Symptoms did not resolve after 7 days of CBI. Given the multiple cardiac comorbidities and mini- mal LUTS prior to presentation, PAE was preferred by the patient. The anticoagulation was held 24 hours prior to the intervention. The patient had no reoccurrence of hematuria and passed trial of void at day 1 post PAE intervention; anticoagulation therapy was resumed then, and he was discharged from hospital on post-intervention day 2. At 1-month follow-up, he reported an improve- ment in LUTS and no recurrence of hematuria; he was subsequently lost to follow-up. Case 3 A 78-year-old man was transferred to our center in the context of an intractable prostatic hemorrhage non- resolving after 30 days of CBI. Patient was previously known for atrial fibrillation on Warfarin, hypertension, type 2 diabetes mellitus, morbid obesity, and chronic uri- nary retention secondary to BPH. The prostate volume was 150cc measured on CT. On arrival, hemoglobin level was 78 g/L (baselines 121 g/L) and raised to 96 g/L after receiving 2 units of PRBC transfusion. The cystoscopy confirmed the bleeding originated from the prostate. Surgery did not represent a safe treatment option for this patient given the significant medical comorbidities and associated anesthetic risk. As such, PAE was offered and accepted by the patient. Anticoagulation therapy was held 24 hours prior to the intervention. The patient had reso- lution of gross hematuria on post-procedure day 1. He resumed anticoagulation therapy day 1 post-intervention. At 6-month follow-up, he had no reoccurrence of gross hematuria and LUTS had also improved. Prostatic artery embolization technique description Technically, PAE was achieved under local anesthetic (Xylocaine) at the arterial femoral puncture site. Ultrasound was performed prior to the puncture to assess for the presence of femoral arterial pathology. Subsequently, the right common femoral artery was punctured, permitting the insertion of a 5-French regular vascular sheath. A 5-French Cobra (Cook, Bloomington, IN, USA) catheter was used for the internal iliac artery catheterizations and a 2-French ProGreat microcatheter (Terumo, Somerset, NJ, USA) and Fathom™ 0.016 inch wire (Boston Scientific, Marlborough, MA, USA) were used for the catheterization of the prostatic arteries. The micro- catheter was advanced in the prostatic arteries beyond any significant side branches supplying the bladder, rec- tum or penis and its placement was confirmed using cone-beam CT. The PErFecTED technique (Proximal Embolization First, Then Embolize Distal) was per- formed. This technique, when possible, has been associ- ated with greater degree of prostatic ischemia and infarc- Figure 1. Prostate gland measurements pre-angioembolization for patient described in Case 1 (axial and sagittal views). Figure 2a. Angiogram of prostatic arteries right lobe of the prostate pre and post angioembolization, respectively (patient in case 1). Note the absence of the prostatic parenchymal blush (arrow) post embolization. Archivio Italiano di Urologia e Andrologia 2024; 96(2):12306 3 Prostatic artery embolization for intractable hematuria tion, thus leading to better clinical outcomes (13). Embolization was performed using Embospheres 300- 500 um (Merit Medical, South Jordan, UT, USA) diluted in 20 mL 1:1 ratio of contrast to saline injected in 1 ml aliquots followed by 3 ml normal saline flush between aliquots until complete stasis was obtained (Figure 2a). A similar technique was performed on both sides, always making sure to avoid non-targeted embolization via col- laterals to other critical arterial structures such as the penile arteries (Figures 2b, 3). DISCUSSION Prostate hemorrhage represents a severe complication of BPH, and rapid control of the bleeding is necessary to avoid morbidity associated with intractable gross hema- turia. Medical therapies, such as 5-alpha reductase inhibitors, have previously been proposed as treatment avenues in BPH-related gross hematuria (9). However, time to response, particularly in patients with larger prostates, has been reported to be on average 10 days or longer (9). When conservative management fails, surgical procedures such as TURP or Holmium laser enucleation of the prostate often represent the best treatment option for patients. While regional anesthesia is preferred for these interventions, it may be contraindicated due to patients’ anticoagulation status. Consequently, prolonged general anesthesia is used, which increases the risk for perioperative complications in anticoagulated patients with cardiac or metabolic comorbidities (10). PAE repre- sents a minimally invasive procedure performed under local anesthesia. Embolization of the prostatic arteries was previously shown to improve LUTS and preserve sex- ual function scores in patients with BPH (11). A previous study, where patients with unregulated coagulation parameters were excluded, has reported on the use of PAE for the treatment of BPH related gross hematuria and found the intervention to be safe for non-surgical candi- dates (7). In this case series, we presented three non-sur- gical candidates on anticoagulation therapy who success- fully underwent PAE. In all 3 cases, no immediate com- plications occurred. None of the patients developed infection, and groin pain was not a complaint our partic- ipants reported. Complete resolution of the intractable hematuria was seen in all cases, with no reoccurrence at a minimum of 6-months’ follow-up. While PAE represents a non-inferi- or alternative to TURP, it is not void of limitations (12). The access to this procedure in the community is limited and anatomical variants or severe atherosclerotic disease render the procedure difficult and sometimes impossible. The follow-up times for the patients in our series is short, limiting the assessment of the durability of the hemostat- ic effect of PAE. CONCLUSIONS PAE represents a safe and effective intervention for the treatment of BPH-related intractable hematuria in non- surgical and anticoagulated patients. Our experience with PAE in high-risk patients has been favourable and war- rants further investigation with a larger cohort and longer follow-up. REFERENCES 1. Berry SJ, Coffey DS, Walsh PC, Ewing LL. The development of human benign prostatic hyperplasia with age. J Urol. 1984; 132:474-9. Figure 2b. Angiogram of the left lobe of the prostate pre and post angioembolization, respectively (patient in case 1). Figure 3. Visualization of the penile arteries (arrows) prior to angioembolization of the left prostatic artery (block arrow). Archivio Italiano di Urologia e Andrologia 2024; 96(2):12306 M. Belmonte, A. Khogeer, G. Moussaoui, et al. 4 2. Ramyil VM, Dakum NK, Liman HU, Udeh EI. The management of prostatic haematuria. Niger J Med. 2008; 17:439-42. 3. Elzayat EA, Elhilali MM. Holmium laser enucleation of the prostate (HoLEP): the endourologic alternative to open prostatecto- my. Eur Urol. 2006; 49:87-91. 4. Elzayat E, Habib E, Elhilali M. Holmium laser enucleation of the prostate in patients on anticoagulant therapy or with bleeding disor- ders. J Urol. 2006; 175:1428-32. 5. DeMeritt JS, Elmasri FF, Esposito MP, Rosenberg GS. Relief of benign prostatic hyperplasia-related bladder outlet obstruction after transarterial polyvinyl alcohol prostate embolization. J Vasc Interv Radiol. 2000; 11:767-70. 6. Kuang M, Vu A, Athreya S. 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Prostatic Arterial Embolization Treating Moderate-to-Severe Lower Urinary Tract Symptoms Related to Benign Prostate Hyperplasia: A Meta-Analysis. Cardiovasc Intervent Radiol. 2017; 40:22-32. 12. Abt D, Hechelhammer L, Müllhaupt G, et al. Comparison of pro- static artery embolisation (PAE) versus transurethral resection of the prostate (TURP) for benign prostatic hyperplasia: randomised, open label, non-inferiority trial. BMJ. 2018; 361:k2338. 13. Carnevale FC, Moreira AM, Antunes AA. The "PErFecTED tech- nique": proximal embolization first, then embolize distal for benign prostatic hyperplasia. Cardiovasc Intervent Radiol. 2014; 37:1602-5. Correspondence Manuel Belmonte, MD manuel.belmontecg@gmail.com Mélanie Aubé-Peterkin, MD, FRCSC (Corresponding Author) melanie.aube-peterkin@muhc.mcgill.ca Carrier Serge, MD serge.carrier@mcgill.ca McGill University Health Centre 1001 Décarie Blvd, Montreal, Quebec H4A 3J1, Canada Abdulghani Khogeer, MD dr-abdulghani@hotmail.com Department of Surgery, Faculty of Medicine, Rabigh, King Abdulaziz University, Jeddah, Saudi Arabia Ghizlane Moussaoui, MD ghizlane.moussaoui@mail.mcgill.ca Department of Urological Sciences, University of British Columbia, Vancouver, Canada Rafael Melo, MD rcardosodemelo@gmail.com Louis-Martin Boucher, MD lmboucher@yahoo.com Tatiana Villalpando-Cabrera, MD tacaal@hotmail.com Department of Radiology, McGill University, Montreal, Canada Conflict of interest: The authors declare no potential conflict of interest.