We successfully embolized the prostate in two men with HA for severe LUTS and BPH with no hemorrhagic adverse events and good clinical effect. To our knowledge, this is the first report of a novel treatment for BPH in men who are often rejected for surgery due to the high risk of surgical complications.
BPH can manifest with a variety of symptoms. In addition to LUTS, microscopic or gross hematuria is present in approximately 2.5% of patients without bleeding disorders (Tapping et al., 2018). There are no studies investigating the incidence of spontaneous hematuria in patients with hemophilia, but a link between anticoagulation and increased hematuria rates has been well-described in the literature (Wallis et al., 2017). BPH-related hematuria can result in blood loss requiring transfusion, especially as the prostate volume increases and developing optimal management strategies for patients with HA is of clinical importance.
TURP is still regarded as the golden standard in the surgical treatment of BPH, but it is associated with higher complication rates compared to newer minimally invasive treatments (Rassweiler et al., 2006). In a recent study, TURP was associated with increased risk of bleeding in patients with HA, particularly after the patients have returned home (Mesnard et al., 2021). PAE is rapidly being established as a robust and safe alternative to surgery, especially in patients with larger prostates. In contrast to TURP and other minimally invasive alternatives, PAE does not involve direct manipulation of prostate tissue, which results in fewer hemorrhagic adverse events (Moreira et al., 2017). This could make PAE the procedure of choice in patients with bleeding disorders.
Both patients were on a routine prophylactic regimen of 4000 IU EHL rFVIII, administered every 72 h for Patient 1 and every 96 h for Patient 2. Pharmacokinetic profiles of EHL rFVIII were known for both patients. The hemostatic regimens we designed aimed at maintaining FVIII level of 0.8–1.0 kIU/L for the first 24 h, and gradually lowering the target levels to 0.4–0.6 kIU/L for the following 6 days. The rationale for this decision was to secure hemostatic capability comparable to that of the general male population in which there is previous PAE experience.
Literature concerning the safety of endovascular procedures and optimal factor replacement strategies in patients with severe HA is sparse. Guidelines for factor replacement in surgery in severe HA refer to general surgery, with no specific mention of endovascular procedures (Srivastava et al., 2020). Few factor replacement protocols in endovascular procedures exist, but good outcomes with intermittent factor replacement strategies have been published in case reports of patients undergoing transjugular intrahepatic portosystemic shunt (TIPS) placement and endovascular abdominal aortic repair (EVAR), though no prospective trials investigating the optimal approach exist (Beirne et al., 2007; Marrocco-Trischitta et al., 2009). The general approach used in the published literature is to maintain a factor level of between 50 and 100% throughout the procedure, in addition to any antithrombotic agents as per existing guidelines for the normal population. In our experience, intermittent factor replacement provides satisfactory factor levels while helping to minimize the overall cost. Following PAE, transient hematuria and hematospermia can occur as minor complications in about 10% of patients (Moreira et al., 2017; Zhang et al., 2018). To account for that, TA was added to the management plans as an antifibrinolytic agent with good effect.
To conclude, further studies are needed to investigate the optimal regimens in patients with severe HA undergoing PAE, but intermittent factor replacement seems to provide good hemostasis in the perioperative period.