Prostate artery embolization: increasing self-referrals and awareness of treatment options,CVIR Endovascular

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Prostate artery embolization: increasing self-referrals and awareness of treatment options
CVIR Endovascular Pub Date : 2021-08-23 , DOI: 10.1186/s42155-021-00251-5
Himanshu Sharma ₁ , Samuel Z Maron ₁ , Ardeshir R Rastinehad ₂ , Aaron M Fischman ₁

Affiliation

Prostatic artery embolization (PAE) is a minimally invasive therapy performed as an elective outpatient procedure for lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH). Multiple studies have demonstrated the efficacy of PAE in reducing LUTS over the medium and long term (Pisco et al. 2016; Carnevale et al. 2020). PAE is transitioning from the research setting to implementation as a routine clinical procedure (Young and Golzarian 2019). The number of patients treated with PAE has grown in recent years, but the current literature has not well characterized awareness of PAE as a treatment option among patients. As PAE becomes more widespread, patients may not want to wait for a referral from a urologist or primary care physician, and instead self-refer to interventional radiology (IR) directly. IR practices in turn may need to engage with the patient community more directly and increase their online presence.

PAE cases from January 2015 until August 2020 at two hospitals in a tertiary academic health system were queried. Data from all consecutive PAE patients (n = 215) for any indication were included in this study. The patient referral source was collected by review of electronic medical records.

The most common source of referral was urology (n = 104, 48 %), followed by self-referral (n = 64, 30 %), internal medicine/primary care provider (n = 23, 11 %), inpatient consult (n = 14, 6 %), emergency department (n = 5, 2 %), external interventional radiology (n = 4, 2 %), and oncology (n = 1, 1 %). These results are summarized in Table 1.

Table 1 Total referrals by source 2015 - 2020

Full size table

Referral sources were calculated by year and results are summarized in Table 2. While the sample sizes in 2015 and 2016 are small, the number of self-referred patients grew substantially from 6 patients in 2017 to 28 patients in 2019 (Fig. 1). There were 11 self-referrals in 2020 although the data only extends to August and is further limited by the institutional pause on elective procedures from March 16, 2020 to June 9, 2020 due to COVID-19. The proportion of self-referred patients also increased each year from the prior year. The proportion of self-referrals in 2015 was 0 % (n = 5), 20 % in 2016 (n = 5), 21 % in 2017 (n = 29), 29 % in 2018 (n = 64), 35 % in 2019 (n = 84), and 39 % in 2020 (n = 28). Urology is the largest referral source, but the share of urology referrals has decreased from 62 % to 2017 to 39 % in 2020. In 2020, the number of self-referrals was equal to urology referrals. Referrals from internal medicine/primary care provider increased from 7 % of total referrals in 2017 to 12 % in 2019. The distribution of referrals from urology, self-referral, primary care providers, and other sources between 2015 and 2020 is summarized in Fig. 1.

Table 2 Referral sources by year from 2015 - 2020

Full size table

The results of our retrospective review demonstrate the increasing popularity of PAE among patients. Excluding small samples in 2015 and 2016, PAE volume increased by 121 % from 2017 to 2018 and 31 % from 2018 to 2019. Our findings also demonstrate that while urology is the largest referral source, the share of urology referrals has decreased from 2017 to 2020. An increasing number of patients self-refer for PAE. Between 2017 and 2020, self-referral has grown from 21 % of PAE volume to 39 %.

Further study of patients who self-referred to determine the method through which they learned about PAE, such as word-of-mouth, advertising, media, or other sources, could allow IR practices to reach more patients directly. While our results indicate a growing appetite for PAE among our patient population, to our knowledge there have been no large studies assessing patient understanding of PAE. As the generalizability of the present study is limited by its single-system design, future work examining PAE referral and volume at the regional and national level will be useful in assessing broader patient knowledge of and access to PAE. Patients have a wide range of options for treatment for LUTS secondary to BPH, ranging from conservative medical management, to minimally invasive options including PAE, to more invasive procedures such as transurethral prostate resection, Urolift, Rezum, and prostatectomy. Greater understanding of the patients who self-referred to PAE may help interventional radiologists assess the methods by which they can educate BPH patients about minimally invasive alternatives.

In addition to further study of patient knowledge of PAE, assessment of awareness of PAE among primary care providers could be useful. Internal medicine/primary care provider referrals for PAE grew from 2 to 2017 to 10 in 2019, but comprised a smaller share of total referrals in 2019 (12 %) than urology (51 %) and self-referrals (33 %). Educating internal medicine, geriatrics, and family medicine departments on PAE as a treatment option for BPH could present an opportunity to reach more patients and cultivate another referral source.

As seen with the relatively low penetration of uterine fibroid embolization compared to hysterectomy, patient awareness of IR procedures can be concerningly low despite establishment of safety and efficacy (Makris et al. 2020). Further study of public awareness of PAE is crucial in spreading access to all patients who might benefit from the procedure.

These preliminary findings suggest that urology continues to be the most prevalent source of PAE referrals, with an increasing proportion of self-referrals. The growing number of self-referrals suggests an increasing awareness of PAE as a treatment option in the patient community. Further study of patient awareness and understanding of PAE could be useful in increasing access to the procedure.

The datasets generated and/or analyzed during the current study are not publicly available due to protected patient health information but are available from the corresponding author on reasonable request.

PAE:: Prostate Artery Embolization
LUTS:: Lower Urinary Tract Symptoms
BPH:: Benign Prostatic Hyperplasia
IR:: Interventional Radiology

Carnevale FC, Moreira AM, de Assis AM et al (2020) Prostatic Artery Embolization for the Treatment of Lower Urinary Tract Symptoms Due to Benign Prostatic Hyperplasia: 10 Years’ Experience. Radiology 296(2):444–451
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Makris GC, Butt S, Sabharwal T (2020) Unnecessary hysterectomies and our role as interventional radiology community. CVIR Endovasc 3(1):46
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Pisco JM, Bilhim T, Pinheiro LC et al (2016) Medium- and Long-Term Outcome of Prostate Artery Embolization for Patients with Benign Prostatic Hyperplasia: Results in 630 Patients. J Vasc Interv Radiol 27(8):1115–1122
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Young S, Golzarian J (2019) Prostate embolization: patient selection, clinical management and results. CVIR Endovasc 2(1):7
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None.

No outside funding or grants were received to assist in completion of this study.

Affiliations

Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, 10029, New York, NY, USA
Himanshu Sharma, Samuel Z. Maron & Aaron M. Fischman
The Smith Institute for Urology, Northwell Health, Lenox Hill Hospital, 245 E 54th St., 320 Central Park West, Apt 2A, NY, 10022, New York, USA
Ardeshir R. Rastinehad

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Himanshu SharmaView author publications
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Samuel Z. MaronView author publications
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Ardeshir R. RastinehadView author publications
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Aaron M. FischmanView author publications
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Contributions

HS and SM analyzed the data and wrote the manuscript. The authors read and approved the final manuscript.

Corresponding author

Correspondence to Himanshu Sharma.

Ethics approval and consent to participate

Institutional Review Board (IRB) approval was obtained for this study.

Consent for publication

Not applicable.

Competing interests

AM Fischman, MD is a paid consultant for Terumo and Boston Scientific; on the advisory board for Terumo, Embolx, and Boston Scientific; a speaker for Terumo and Boston Scientific; provided research support from Boston Scientific; has a royalty agreement with Merit Medical; and is an investor in Adient Medical.

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Sharma, H., Maron, S.Z., Rastinehad, A.R. et al. Prostate artery embolization: increasing self-referrals and awareness of treatment options. CVIR Endovasc 4, 64 (2021). https://doi.org/10.1186/s42155-021-00251-5

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Received: 03 April 2021
Accepted: 30 July 2021
Published: 23 August 2021
DOI: https://doi.org/10.1186/s42155-021-00251-5

中文翻译：

前列腺动脉栓塞：增加自我转诊和对治疗方案的认识

前列腺动脉栓塞术 (PAE) 是一种微创治疗，作为继发于良性前列腺增生 (BPH) 的下尿路症状 (LUTS) 的选择性门诊手术。多项研究证明了 PAE 在中长期减少 LUTS 方面的功效（Pisco 等人，2016 年；Carnevale 等人，2020 年）。PAE 正在从研究环境过渡到作为常规临床程序的实施（Young and Golzarian 2019）。近年来接受 PAE 治疗的患者数量有所增加，但目前的文献并未很好地描述患者对 PAE 作为治疗选择的认识。随着 PAE 变得越来越普遍，患者可能不想等待泌尿科医生或初级保健医生的转诊，而是直接自我转诊介入放射学 (IR)。

查询了 2015 年 1 月至 2020 年 8 月在三级学术卫生系统中的两家医院的 PAE 病例。来自所有连续 PAE 患者 ( n = 215) 的任何适应症的数据都包括在本研究中。通过查阅电子病历收集患者转诊来源。

最常见的转诊来源是泌尿科 ( n = 104, 48%)，其次是自我转诊 ( n = 64, 30%)、内科/初级保健提供者 ( n = 23, 11%)、住院咨询 ( n = 14, 6%)、急诊科 ( n = 5, 2%)、外介入放射科 ( n = 4, 2%) 和肿瘤科 ( n = 1, 1%)。这些结果总结在表 1 中。

表 1 2015 - 2020 年按来源分列的转诊总数

全尺寸表

转诊来源按年份计算，结果汇总于表2。虽然2015年和2016年的样本量较小，但自转患者的数量从2017年的6名患者大幅增加到2019年的28名患者（图1）。2020 年有 11 次自我推荐，尽管数据仅延伸到 8 月，并且由于 COVID-19 导致机构暂停了 2020 年 3 月 16 日至 2020 年 6 月 9 日的选修程序，这进一步受到限制。自我转诊患者的比例也比上一年逐年增加。2015年自我推荐比例为0%（n =5），2016年20%（n =5），2017年21%（n =29），2018年29%（n =64），35% 2019 年 ( n = 84)，2020 年为 39% ( n = 28）。泌尿外科是最大的转诊来源，但泌尿外科转诊的份额从2017年的62%下降到2020年的39%。2020年，自我转诊数量与泌尿外科转诊数量持平。来自内科/初级保健提供者的转诊从 2017 年转诊总数的 7% 增加到 2019 年的 12%。 2015 年至 2020 年期间来自泌尿科、自我转诊、初级保健提供者和其他来源的转诊分布如图 1 所示。 1.

表2 2015-2020年各年转诊来源

全尺寸表

我们的回顾性审查结果表明 PAE 在患者中越来越受欢迎。排除 2015 年和 2016 年的小样本，PAE 数量从 2017 年到 2018 年增加了 121%，从 2018 年到 2019 年增加了 31%。我们的研究结果还表明，虽然泌尿科是最大的转诊来源，但泌尿科转诊的份额从 2017 年到 2020 年有所下降. 越来越多的患者自我转诊为 PAE。从 2017 年到 2020 年，自我推荐已从 PAE 数量的 21% 增长到 39%。

对自我推荐的患者进行进一步研究以确定他们了解 PAE 的方法，例如口耳相传、广告、媒体或其他来源，可以让 IR 实践直接接触更多患者。虽然我们的结果表明我们的患者群体对 PAE 的胃口越来越大，但据我们所知，还没有大型研究评估患者对 PAE 的理解。由于本研究的普遍性受到其单一系统设计的限制，未来在区域和国家层面检查 PAE 转诊和数量的工作将有助于评估更广泛的患者对 PAE 的了解和获取。对于继发于 BPH 的 LUTS，患者有多种治疗选择，从保守的医疗管理到包括 PAE 在内的微创治疗，到更具侵入性的手术，如经尿道前列腺切除术、Urolift、Rezum 和前列腺切除术。更好地了解自我推荐 PAE 的患者可能有助于介入放射科医生评估他们可以教育 BPH 患者有关微创替代方案的方法。

除了进一步研究患者对 PAE 的了解外，评估初级保健提供者对 PAE 的认识也可能有用。PAE 的内科/初级保健提供者转诊人数从 2017 年的 2 人增加到 2019 年的 10 人，但在 2019 年总转诊人数 (12%) 中所占的份额小于泌尿科 (51%) 和自我转诊 (33%)。对内科、老年科和家庭医学科进行 PAE 作为 BPH 治疗选择的教育可以提供一个机会来接触更多的患者并培养另一个转诊来源。

与子宫切除术相比，子宫肌瘤栓塞术的渗透率相对较低，因此尽管确定了安全性和有效性，但患者对 IR 手术的认识仍然很低（Makris 等人，2020 年）。进一步研究公众对 PAE 的认识对于向可能从该程序中受益的所有患者传播可及性至关重要。

这些初步发现表明泌尿科仍然是 PAE 转诊的最普遍来源，自我转诊的比例越来越高。越来越多的自我转诊表明患者社区越来越意识到 PAE 作为一种治疗选择。进一步研究患者对 PAE 的认识和理解可能有助于增加对手术的访问。

由于受保护的患者健康信息，当前研究期间生成和/或分析的数据集未公开提供，但可根据合理要求从相应作者处获得。

PAE：: 前列腺动脉栓塞术
LUTS：: 下尿路症状
前列腺液：: 良性前列腺增生症
红外线：: 介入放射学

Carnevale FC、Moreira AM、de Assis AM 等人 (2020) 前列腺动脉栓塞治疗良性前列腺增生引起的下尿路症状：10 年经验。放射学 296 (2): 444-451
文章谷歌学术
Makris GC、Butt S、Sabharwal T (2020) 不必要的子宫切除术和我们作为介入放射学界的角色。CVIR Endovasc 3 (1): 46
文章谷歌学术
Pisco JM、Bilhim T、Pinheiro LC 等人 (2016) 前列腺动脉栓塞治疗良性前列腺增生患者的中长期结果：630 名患者的结果。J Vasc Interv Radiol 27 (8): 1115-1122
文章谷歌学术
Young S, Golzarian J (2019) 前列腺栓塞：患者选择、临床管理和结果。CVIR Endovasc 2 (1): 7
文章谷歌学术

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没有收到外部资金或赠款来协助完成这项研究。

隶属关系

西奈山伊坎医学院，西奈山医院，10029，纽约，纽约，美国
Himanshu Sharma、Samuel Z. Maron 和 Aaron M. Fischman
The Smith Institute for Urology, Northwell Health, Lenox Hill Hospital, 245 E 54th St., 320 Central Park West, Apt 2A, NY, 10022, New York, USA
Ardeshir R. Rastinehad

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贡献

HS 和 SM 分析了数据并撰写了手稿。作者阅读并批准了最终手稿。

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本研究已获得机构审查委员会 (IRB) 的批准。

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利益争夺

AM Fischman, MD 是 Terumo 和波士顿科学公司的付费顾问；Terumo、Embolx 和波士顿科学的顾问委员会成员；Terumo 和波士顿科学公司的发言人；提供波士顿科学的研究支持；与 Merit Medical 有特许权使用费协议；并且是 Adient Medical 的投资者。

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