Prostate Artery Embolisation (PAE)

Prostate artery embolisation (PAE) is a new non-surgical day-case procedure for the treatment of symptoms resulting from benign prostatic hyperplasia (BPH). It is offered in Reading by Berkshire Imaging specialists.

Benign Prostate Hyperplasia (BPH)

Benign prostatic hypertrophy (BPH) is a very common condition affecting men, which is caused by the prostate gland enlarging with age. If affects 40 to 50 percent of men aged 50 to 60, and over 80 percent of men older than age 80. The condition can be debilitating; dominated by lower urinary tract symptoms (LUTS), patients often complain of a constant urge to pass urine, poor urine stream, needing to pass urine several times a night causing disturbed sleep, and not being able to completely empty the bladder. It is also well known that LUTS and BPH are associated with erectile dysfunction. Finally, incompletely emptying the bladder increases the risk of urinary tract infections.

Management of BPH is dependent on patient symptoms and is broadly categorised into watchful waiting, drug therapy, surgical management, or prostate artery embolisation, which is a new minimally invasive treatment.

Preparation for PAE

We work closely with our urology colleagues; a consultant urologist will assess your symptoms and take a thorough history of your medical problems prior to the procedure. A consultant interventional radiologist will then meet with you to explain what is involved (see below). Prior to the procedure you will have a CT scan with contrast to identify the small prostate arteries and look at the arteries in your pelvis. This enables the interventional radiologist to plan the procedure. At the same time, you will have an MRI or ultrasound of the prostate (if you are unable to have an MRI scan) to look at the anatomy of the prostate gland. You will be asked not to eat or drink anything for four hours before the procedure as light sedation is sometimes used to relieve anxiety. On the day of the procedure, you will be greeted in the radiology day case unit at The Royal Berkshire Hospital. You will be given a dose of oral antibiotic, which is continued for a week after the procedure to minimise the risk of a urinary tract infection. You will also be given a painkiller, which is continued as required for up to a week after the procedure. From our experience, patients can experience pelvic pain one or two days after the procedure, which is normally well managed with simple analgesia.

The Procedure

A consultant interventional radiologist performs prostate artery embolisation. Following administration of local anesthetic, a small plastic tube known as a catheter is placed into the artery in your groin. Small wires and catheters are then carefully manipulated into the small prostate arteries under x-ray guidance. Once the catheter is in the desired position, a specialist CT scan is performed whilst you lie on the x-ray table to confirm correct position. Once the position is confirmed the prostate arteries are blocked using small particles, which are like tiny grains of sand. Both right and left prostate arteries are blocked in this way, often from a single puncture of the artery overlying your right groin. Sometimes a second puncture of the artery overlying the left groin has to be performed. By blocking the arteries to the prostate, research has shown that the prostate gland shrinks, relieving the symptoms of an enlarge prostate gland. The procedure will take approximately 2-hours. At the end of the procedure, the hole in the artery will be closed either using a small dissolvable stich, or by pressing on the artery for 10 minutes.

Aftercare

You will be taken back to the radiology recovery area on a trolley. Nurses in the recovery area will carry out routine observations, such as taking your pulse and blood pressure, to make sure that there are no untoward effects. You will need to lie flat for two hours to enable the small hole in your groin artery to heal, you will then need to be monitored in bed for a further two hours. Once you have had something to eat and drink, and successfully passed urine, you will be able to go home in the afternoon. You will need someone to drive you home, and someone to stay with you overnight at home, as is standard practice following puncture of the artery in the groin.

Antibiotics are continued for a week after the procedure to minimize the risk of infection, and you will be given painkillers to take if needed. You will be reviewed 3 months after the procedure, at which time a repeat MRI or ultrasound will be performed to assess the volume of the prostate.

What are the risks?

Prostate artery embolisation is a relatively new procedure, but the risks are low from the published literature. There may occasionally be a small bruise, at the site where the needle has been inserted into the artery. There is also a small risk of infection, which is minimized by giving you a short course of oral antibiotics. Most patients feel some mild pain afterwards, which is controlled by simple painkillers. There is a very small risk of the particles used to block the prostate arteries going into nearby arteries (non-target embolization), which could result in reduced blood supply to the organs supplied. This is a potentially serious complication and we are obsessional about ensuring the correct placement of the catheter into the prostate artery, which is why we use a special CT scan to confirm position prior to injecting any particles-we believe the use of such a CT scan is best practice for PAE. Finally there is the risk associated with radiation exposure, as we use x-rays to guide where we place the catheters during PAE.

What is the success rate of prostate artery embolization?

PAE has been performed on several thousand patients worldwide now, with the largest series coming from Prof Pisco’s group in Lisbon, Portugal. In a recent study of 1000 men undergoing PAE, the success rate was over 75%. Importantly unlike the surgical alternatives there is negligible impact on sexual function following PAE. PAE has also been shown to be beneficial in patients with long-term urinary catheters with successful catheter removal following PAE in up to 80% of patients.

A patient's view of Prostate Artery Embolisation for benign prostatic hyperplasia

Dear Sirs,

I would like to give a patient’s point of view of the exciting curative opportunity PAE can offer, compared with surgery or long term drugs.

I had a PAE in June 2017. Previously, I had had 5 years of mild LUTS, controlled by lifestyle. But over two months I progressed to an IPSS score of 30+ and found myself in AUR. The pre-PAE MRI reported prostate volume at 116cc; no suspicion of carcinoma.

I was offered HoLEP but the downsides were 3 – 3 ½ hours under general anaesthetic; 3% need for repeat; 5% risk of a stricture (I was now catheterised); an outside chance of pulmonary embolism and/or stroke, and a 100% chance I would never ejaculate normally forwards again, I didn’t fancy the op.

I talked to a urologist with experience of 100+ PAEs. His advice: PAE fails in about 20% of cases but since I was actually in AUR, my chance of success was 50%. However, if I PAE failed, my worst case was that I would just have to do the HoLEP anyway; if PAE worked, I would have avoided HoLEP and its side effects and risks. I’d know within 3 weeks of doing a PAE whether PAE was working; I could go for a HoLEP if it wasn’t.

So, for me, PAE was what snooker players call “a shot to nothing”. If PAE worked, I’d retain, as a young and athletic 62 year old, full sexual function and avoid taking the risk a stricture or stroke/pulmonary embolism.

My interventional radiology (experienced in 50+ PAEs) advised after CT that I had simple vascular anatomy; access to my prostate would be easy; and my prostate was “adenomatous dominant”, a factor in recent successes: see the Little et al paper cited below.

I decided to give PAE go for three months. My urologist changed my urethral catheter to superpubic, to put me in control of continuous trials for voiding. Cystoscopy photos showed I did not have middle lobe, nor a “ball valve” problem; these are other factors in recent PAE successes.

My GP checked out the radiation risk I would expose myself to. In simple terms, it was calculated in my case as five summers in England, which I thought was very acceptable.

Intolerant to alpha blockers, I did the PAE without using them, the first such documented case, I was told. From my viewpoint, there was a tiny scratch in an artery. I lay back and listened to music on my headphone. Within 45 minutes, full bilateral embolization was successfully accomplished, using the “PErFecTED technique”. It was all very pleasant.

Within 2 hours, I was voiding naturally. I went home that afternoon. There were a few hours of searing pain, until the prostatic nerves, deprived of blood, died, but they soon switched off like a light – there was no pain at all after that. I never looked back from the first day, voiding 2 ½ litres. It was tough going until an aperture widened. But within three weeks I was voiding completely normally and freely without any feeling of discomfort. My GP checked every few days for urine infections, since PAE works by necrotising internal tissue. We were onto the two I got straight away, so they were not a problem. We used the charts in the Gao paper, cited below, to monitor progress; they detail a timescale for measured improvements in IPSS and flow seen in other cases.

Within a month, my IPSS score was zero where it has remained; my peak flow was 20mm/sec. The superpubic catheter was removed. Within 6 months, a second MRI showed that my prostate volume was 53cc, as compared with 116cc before the PAE, a reduction of 54%.

Here I am, therefore, a documented case of someone in AUR, who escaped AUR through a PAE with no surgery and no drugs, has an IPSS score of zero, is asymptomatic, and retains full sexual function. How many others who have had LUTS can say that?

Why did the PAE work for my type of LUTS? KT Foo (see citation) has been explaining that some types of LUTS are primarily caused by adenomas, not prostatic size per se. Imagine internal adenomas as if they were marbles inside a tennis ball (the prostate) and you can imagine how, when all the adenomas expand, the prostatic cap resists and a reverse force is exerted back to compress the uethra. Or imagine two large adenomas as if croquet balls side by side growing so as to “squeeze” the urethra. Or imagine one large adenoma growing to as to kink the urethra, as if an “oxbow” bend in the channel of a river. A PAE can attack such adenomas, resolving the problem directly.

An MRI generated picture of an example of an “oxbow bend” case of a steep kink in a urethra induced by an enormous prostatic adenoma has been produced by Dr Mark Little in his Oxford Surgery video lecture cited below (minutes 31 – 36). The urethra is later straightened out after the patient has a PAE that destroys the adenoma, enabling the urethra to straighten.

This is why I suggest alpha blockers might not resolve this type of LUTS problem. They work by relaxing the sphincter. But, if the real cause of this type of LUTS is adenomatous in nature, alpha blockers might not address the root of that problem. PAE does.

PAE is going to be very popular. Lots of men will want to preserve full sexual function and avoid stricture, or other, risks. But it is not yet fully appreciated is LUTS drugs can have some tedious side effects and PAE may offer men at least the chance of avoiding drugs in cases where the true nature of the LUTS is adenoma-generated.

References:

Gao et al, Radiology 2014 Mar, 270(3): 920-928.
Foo, Asian J Urology 2017 Jul: 4(3): 152-157.
Little et al, Cardiovasc Interv Radiology 2017, May 40(5): 682-689.
Oxford Surgical Lecture “Prostate Artery Embolization in the Management of LUTS

https://www.youtube.com/watch?v=bcricbWiq1M

If you would like to discuss your suitability for this procedure with a Consultant Interventional Radiologist please call 0118 921 3177 or email us at info@berkshireimaging.co.uk

Berkshire Imaging LLP . The Forbury Clinic . 23 Craven Road . Reading . Berkshire . RG1 5LE . Telephone: 0118 921 3177
Click here to email us >