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Prostatic hematuria can be a challenging clinical problem. In this Review we discuss the spectrum of methods for diagnosing prostatic hematuria and the pharmacologic and minimally invasive therapies currently available to treat primary disease and refractory cases. Before making a diagnosis and starting therapy, however, other, nonprostatic sources of hematuria must be ruled out. As part of diagnosis all patients should undergo a formal cystoscopy. Therapy should include functional and biochemical approaches. Inhibitors of 5-alpha-reductase have been shown to successfully treat prostatic hematuria when it is caused by benign prostatic hyperplasia. Intravesical instillations, using agents such as alum, silver nitrate and formalin, have been used as second-line therapies, with limited success. A novel, minimally invasive method, termed selective arterial prostatic embolization, offers another option for treating prostatic hematuria. Using interventional radiologic techniques during selective arterial prostatic embolization enables selective catheterization of the prostatic arterial circulation with subsequent embolization. This approach can rapidly stop hematuria. If more-invasive therapy is required, transurethral resection, or vaporization of the prostate and clot evacuation, should be performed before embolization or other surgical interventions.

Objectives: To assess SAPE as an alternative treatment option in patients with refractory hematuria of prostatic origin., Methods: A retrospective analysis of charts from 10 patients. Two patients were excluded from the analysis because of severe atherosclerotic disease that prevented selective angiography of the pelvic vasculature. Therefore, 8 patients, mean age of 78.3 +/- 7.1 years with a history of refractory hematuria of prostatic origin were analyzed. All patients failed conventional therapy. The selective embolization procedures were performed between 2000 and 2006. Success was monitored with postembolization angiography and cessation of hematuria clinically., Results: Of the 8 patients, 6 had a history of adenocarcinoma of the prostate (mean Gleason Grade 7, range 5 to 9); 4 were previously treated with external beam radiation. The remaining patient's histories were consistent with benign prostatic hypertrophy. SAPE was technically successful in all 8 patients and resulted in immediate cessation of gross hematuria. Mean follow-up postembolization was 20.0 months (range 1.5 to 86.3 months). One patient had gross hematuria develop 14 months after embolization that was attributed to a bladder tumor recurrence. One patient with T4 prostate cancer had a rectovesical fistula develop 1 month after embolization., Conclusions: SAPE results in cessation of refractory gross hematuria in patients with benign prostate hyperplasia and patients with prostate cancer previously treated with radiotherapy. SAPE may be considered an effective treatment for gross hematuria in patients with refractory hematuria regardless of the cause (radiation, cancer and/or hyperplasia).