Secondary refractory hematuria and urinary retention in patients with advanced prostate cancer?

Introduction Transcatheter arterial chemoembolization (TACE) has been widely used in the treatment of solid malignant tumors
.

TACE can selectively deliver anticancer drugs to target tumors and combine with tumor vascular embolization to produce selective ischemic and chemotherapeutic effects on tumors and reduce systemic toxicity
.

A recent article on the efficacy and safety of TACE in the treatment of refractory hematuria and urinary retention secondary to locally advanced prostate cancer was published in Prostate Cancer and Prostatic Diseases
.

Research Background About 6%-10% of prostate cancer patients present with persistent hematuria
.

Refractory gross hematuria (RGH) secondary to locally advanced prostate cancer is very difficult to treat, and traditional treatment options include drug therapy, radiation therapy, and surgery
.

If treatment fails, it can lead to a life-threatening condition for the patient
.

In addition, patients with complete urinary retention (UR) secondary to advanced prostate cancer may require long-term indwelling catheters, which reduce the patient's quality of life and increase the risk of infection
.

Therefore, new treatments are needed to improve patient conditions
.

Prostatic arterial embolization (PAE) is an effective treatment for lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH)
.

PAE is also used to treat prostate cancer and prostate hematuria
.

In patients with advanced prostate cancer secondary to RGH, the effect of PAE alone is limited due to rapid tumor recurrence after surgery
.

TACE can selectively deliver anticancer drugs to the target tumor, embolize the blood vessels of the tumor, exert selective ischemia and chemotherapy effects on the tumor, and reduce systemic toxicity
.

The purpose of this study was to prospectively evaluate the safety of TACE + epirubicin (EPI) eluting drug-loaded microspheres (HS) + docetaxel intraarterial (IA) infusion chemotherapy in the treatment of GRH and UR secondary to advanced prostate cancer patients and effectiveness
.

Study Methods Patient Data From January 2015 to May 2020, a total of 39 patients with prostate cancer (≥T3 stage) (mean age 70.
5±14.
5 years, range 60-87 years) received secondary RGH
.

All patients underwent ultrasonography (US), magnetic resonance imaging (MRI), digital rectal examination (DRE), cystoscopy, laboratory tests, and clinical review
.

Patients with prostate-specific antigen (PSA) >10 ng/ml also require a nuclear medicine bone scan
.

Seven patients were excluded, and 32 patients were finally included in the analysis (median age 71 years, mean age 71.
5 years, range 61-86 years), data are shown in Table 1
.

Table 1.
Baseline data of patients (N = 32) The study used digital subtraction angiography (DSA) combined with cone beam computed tomography (CB-CT) to confirm the anatomy of the prostatic arteries in the patients (Fig.
1)
.

Figure 1 DSA combined with CB-CT to confirm the anatomy of the prostate artery
.

Image of a 76-year-old male patient with advanced prostate cancer-related RGH Patient Follow-up Patients underwent clinical, biochemical, and MRI follow-up at 1, 3, 6, and 12 months after treatment
.

Thereafter, follow-up was performed every 6-12 months, including the International Prostate Symptom Score (IPSS), Quality of Life Score (QoL), International Index of Erectile Function (IIEF) and prostate volume (PV)
.

Biochemical success (BS) was defined as PSA value <2ng/ml in the first month after TACE, otherwise it was considered as biochemical failure (BF)
.

Biochemical recurrence (BR) was defined as a rise in PSA >2ng/ml after BS
.

When local tumor progression was suspected clinically or radiologically, patients underwent ultrasound-guided digital rectal examination
.

Local tumor progression was defined as tumor recurrence on follow-up MRI, positive biopsy, or BS according to Phoenix criteria (2 ng/ml increase in PSA nadir)
.

Study Results Surgical Results A total of 32 patients successfully completed 54 TACEs
.

The median number of patients undergoing TACE was 1.
5 (range 1-4)
.

Due to recurrence of gross hematuria (n=4) and tumor recurrence (without gross hematuria) after the first TACE, 43.
8% (14/31) of patients underwent multiple TACE
.

Eight patients received 2 TACE, 4 patients received 3 TACE, and 2 patients received 4 TACE
.

Typical cases are shown in Figure 2 and Figure 3
.

Figure 2 Image of a 70-year-old male patient with advanced prostate cancer-related RGH Figure 3 Prostate tumor recurrence after PAE
.

A 77-year-old male patient with advanced prostate cancer-related RGH imaged adverse events (AEs) with minor AEs in 12 patients (Table 2)
.

All AEs resolved within 1 week after conservative treatment
.

No significant chemotherapy-related toxicity was found
.

Table 2.
TACE-related adverse events in patients with follow-up.
Two patients died within 30 days after surgery (the patient's RGH was cured, and the death was not related to surgery)
.

The follow-up results of patients with advanced prostate cancer after TACE are shown in Table 3
.

Compared with baseline, patients' overall IPSS, QoL score, Qmax and PVR were significantly improved (p < 0.
05)
.

And the above indicators remained stable during the follow-up period of 3-36 months, indicating that the patients continued to maintain disease improvement during the follow-up period
.

Patients were followed for a median of 27 months (range, 8-56 months), of whom 8 (26.
7%) died of disease progression, and the median overall survival (OS) was 19 months (range, 7-37 months).
)
.

As of last follow-up, 22 (73.
3%) patients were alive with a median OS of 30 months (range 9-52 months)
.

The 1-, 2-, and 3-year survival rates of patients were 96.
7%, 86.
7%, and 73.
3%, respectively
.

Table 3 Follow-up results of patients with advanced prostate cancer after TACE Bleeding control 7 patients stopped gross hematuria within 24 hours after TACE, 10 patients stopped gross hematuria within 48 hours after surgery, and 13 patients stopped within 72 hours after surgery Gross hematuria, 2 patients stopped gross hematuria within 5 days after surgery, and the success rate of surgical control of bleeding was 100%
.

The mean follow-up period of patients was 24 months (range, 8-56 months), and 26 of 30 patients (86.
7%) had well-controlled bleeding during the follow-up period and did not require hospital admission for further treatment
.

Hematuria recurred in 4 patients after initial TACE, and all symptoms were controlled after re-TACE
.

Removal of Indwelling Bladder Catheter after TACE In 5 of the 22 patients (relying on a catheter before TACE), 5 patients had difficulty urinating after TACE and needed to continue using a catheter.
These 5 patients used a catheter before TACE Time ≥ 5 months
.

The remaining 17 patients (77.
3%) had their urinary catheters removed after TACE, and the time of using urinary catheters in these patients was ≤4 months before TACE
.

Among them, 2 patients had symptoms of urinary obstruction at 6 and 14 months after surgery and needed catheterization; the other 15 patients (88.
2%) did not need a catheter to assist in urination until the last follow-up
.

Changes of PSA after TACE 1 month after TACE, 26 patients (86.
37%, 26/30) obtained BS; the remaining 4 patients were still PSA > 2ng/ml
.

Four more patients developed BR between 6 and 24 months postoperatively
.

Therefore, a total of 22 (73.
3%, 22/30) patients acquired BS with a mean follow-up time of (29±15) months (range 12-47 months) and a median follow-up time of 26 months
.

MRI follow-up and biopsy after TACE One month after TACE, the area of ​​prostate ischemia ranged from 80% to 100%, with a median of 90%
.

The objective response rate (complete response [CR] + partial response [PR]) was 100% at 1-month postoperative and 3-month postoperative follow-up (CR in 22 patients and PR in 8 patients)
.

As of the last follow-up, the 22 patients were followed up for an average of 36 months ± 14 months (range 36-56 months), and the mean prostate volume reduction ratio was (55.
5% ± 15%) (range 47%-91%; median value 80.
5%), which was statistically different from baseline
.

From 12 to 47 months after TACE, 19 of 30 patients underwent ultrasound-guided transrectal puncture, of which 16 were negative (84.
2%)
.

Conclusion The study confirms that TACE+EPI-eluting HS+docetaxel (IA) infusion chemotherapy is safe and effective in the treatment of GRH and UR secondary to advanced prostate cancer, and can be used as a clinical treatment option
.

Reference: Mao Qiang Wang, Jin Long Zhang , Feng Duan et al.
Prostate arterial chemoembolization for treatment of refractory hematuria and urinary retention in patients with localized advanced prostate cancer.
Prostate Cancer and Prostatic Diseases.
2022 Mar 5.
doi: 10.
1038/s41391 - 022-00516-7.
Editor: LR Reviewer: Mia Execution: LR