Most individuals with spinal cord injury (SCI) perform clean intermittent catheterization (CIC) to void bladder. Since the life expectancy of people with SCI is increasing thanks to medical advances, old men are frequently experiencing difficulties during CIC because of concomitant benign prostatic hyperplasia (BPH), increasing the risk of urethral trauma, macrohematuria and urinary tract infection. People with SCI are usually frail and require minimally invasive approach to treat BPH. The aim of this study was to assess the safety and efficacy of prostatic artery embolization (PAE) to reduce prostate volume (PV) and ease CIC in spinal cord injured individuals with concurrent BPH.

From January 2015 to December 2020, we prospectively collected all data of individuals with SCI followed by a tertiary referral centre and undergoing PAE because of BPH-related problems during CIC. PAE was performed under local anaesthesia with superselective catheterization of the prostatic arteries, using hydrophilic microcatheters and 300-500 μm microspheres. Technical success was defined as bilateral embolization. We determined the PV by MRI pre-operatively and 6 months after the procedure. This study was approved by our Institutional Review Board.

We enrolled 10 cases with tetraplegia (n=5) and paraplegia (n=5). The median age was 70 years (range: 59-86 years). Five out of 10 cases were under antiplatelet therapy. Seven patients had indwelling urinary catheter (IDC), while 3 cases performed CIC experiencing different-graded complications. Nine out of 10 procedures were technically successful, while we performed unilateral PAE in one case due to excessive tortuosity of the prostatic vasculature on one pelvic side. The median procedure time was 130 min (range: 105-155 min). The median fluoroscopy time was 45 min (range: 34-114 min), while the median radiation dose was 597 Gy*cm2 (range: 227-1,420 Gy*cm2). The median pre-operative PV was 61 ml (range: 40-114 ml). After 6 months, all patients experienced significant PV reduction (median: 19.6%; range: 10.2-28.3%); seven out of 7 cases with IDC successfully started CIC, while the other 3 patients continued CIC without experiencing any complication. Neither intra- nor post-operative complications occurred within a median follow-up of 33 months (range: 6-59 months).

Our study outlined a significant PV reduction in people with SCI, who were poor surgical candidates for other prostate surgery. In all cases the CIC-related problem was solved, even in unilateral PAE, without experiencing intra- or post-operative complications. Six months after PAE, seven out of 7 (100%) cases with IDC successfully started CIC, while the other 3 individuals continued CIC without any problem (e.g., haematuria). Since the morbidity of PAE proved to be minimal, the authors advocate further multi-centre studies to evaluate definitively this technique in frail individuals with SCI.

PAE proved to be a safe and effective treatment for BPH to ease CIC in people with SCI. Considering the increasing life expectancy of individuals with SCI, PAE should be considered as a valid treatment option in this frail population.