Prostate Artery Embolization (PAE)

Benign Prostatic Hyperplasia (BPH)

Benign Prostatic Hyperplasia (BPH) is one of the most common health conditions of aging men worldwide, accounting for up to 4.5 million office visits annually.

At age 70, 40% men are symptomatic and by age 75, 50% of men.

Men may experience Lower Urinary Tract Symptoms (LUTS) consisting of:

Hesitancy in starting a stream
Straining
Prolonged voiding or weak flow
Terminal dribbling
Sensation of incomplete emptying
Retention
Overflow incontinence
Frequency or nocturia (night time awakening to urinate)
Urgency
Urge incontinence

BPH is a condition which may treated by Prostate Artery Embolization (PAE).

PAE is a minimally invasive, outpatient procedure performed through a quarter inch incision in the right grown or left wrist enabling you to return to your normal activities quickly without any risk of urinary incontinence or sexual disfunction.

stock-photo-benign-prostatic-hyperplasia

Why does prostate artery embolization (PAE) work?

Symptoms result from an increase in size of the prostate gland, specifically the transitional zone of the gland which surrounds the urethra or "pee channel". As this multifactorial histopathologic process continues in aging men, the prostatic urethra or "pee channel" becomes more and more narrow, eventually resulting in urinary retention, an inability to urinate, in some men.

Prostate Artery Embolization (PAE) has emerged as a minimally invasive, low risk, treatment option for patients with BPH. PAE is an outpatient procedure which I perform in the Interventional Radiology fluoroscopy (live X-ray) suite with conscious sedation, also known as "twilight sleep". As general anesthesia is not required, patients with contraindications to surgical intervention may still undergo the procedure.

The goal of the procedure is to decrease the blood flow to the prostate gland, thus depriving the cells of the nutrients which they need to survive, resulting in cell death and an overall reduction in prostate gland size, increasing the caliber of the "pee channel" and alleviating the symptoms of BPH.

A multitude of medical and surgical therapies are available for the treatment of BPH, but are wrought with undesirable side effects and complications, including retrograde ejaculation and urinary incontinence, neither of which are reported with PAE.

What does the procedure entail?

Upon arrival in the Interventional Radiology department, an IV is started and pre-procedural antibiotics are administered to prevent infection, as well as a one-time dose of IV steroids to help decrease the inflammatory response to the embolization procedure. During the procedure, conscious sedation, or "twilight sleep" is administered by myself and highly trained nursing personnel with continuous monitoring of the patient's vial signs.

Once the patient is sedated, a Foley catheter is placed within the bladder lumen, if an indwelling catheter is not already in place. Of note, in non-catheter dependent patients, this will be removed at the end of the procedure while the patient is still sedated.

The procedure is performed through a small, quarter inch incision in the right groin enabling access to the common femoral artery. If you are on blood thinners which may not be held pre-procedurally, due to other medical conditions, I may alternatively perform the procedure through the left wrist utilizing the radial artery.

Specially designed wires and catheters are used to gain access into the left and then right prostatic arteries. The x-ray, or fluoroscopy, machine is used to create a specialized 3D reconstruction of the x-ray data in the form of a cone beam CT scan, to ensure access into the prostatic arteries. Small particles, called Embospheres are then delivered into the prostatic arteries, thus blocking the flow of blood into the prostate gland. Without sufficient blood supply, the cells within the prostate gland will begin to die and the gland will decrease in size over time.

Patients remain in the Interventional Radiology recovery area for approximately 3 hours post-procedure and are then discharged home. Both a seven day course of oral antibiotics and a short steroid taper are routinely prescribed to prevent infection and decrease the inflammation within the prostate gland caused by the procedure, respectively.

Post-procedure care

In the first 3-5 days following the procedure, increased urinary frequency (up to several times per hour), bladder spasms and pelvic burning are common. Additional medications to decrease these symptoms may be prescribed at the discretion of Dr. Wolf and called into the patient's pharmacy.

Outcomes...

At approximately 4-6 weeks after the procedure the prostate gland will begin to decrease in size, thus those patients with indwelling catheters prior to the procedure will be scheduled to undergo a voiding trial at 6 weeks post-embolization.

At 3 months following the procedure an imaging study is ordered, namely a transabdominal prostate ultrasound, a CT scan, or a prostate MRI. Of note, several factors are considered when choosing the appropriate imaging modality for the patient and usually the examination selected matches that which was performed pre-procedurally for initial gland measurement.

An approximately 15-30% reduction in prostate gland size is expected by three months after the procedure, and up to 50% at 12 months. Additional success measures both observed clinically and reported in medical literature include significantly increased urinary flow rates and bladder emptying with decreased post void residual bladder volumes. Thus, the number of night time awakenings to urinate drops off significantly.

In peer-reviewed literature, a clinical success rate of 88% is reported for PAE, with repeat intervention rates at 1 year equivalent to those in patients having undergone transurethral vaporization, laser resection or thermal ablation.

A randomized clinical trial including 114 patients documents equivalent symptom improvement at 6 months post procedure in patients having undergone TURP (transurethral resection of the prostate) and PAE, with equivalence remaining out to 12 and 24 months post-procedure. Of note, erectile dysfunction, and incontinence are not reported in PAE patients.

I routinely see patients in follow-up at two-weeks post procedure, and then subsequently at 3, 6 and 12 months post-procedure, with imaging examinations performed at the 3 and 12 month time points for the purpose of prostate gland measurement.

All patients will be provided with a cell phone number at the time of initial consultation, such that Dr. Wolf may be reached directly. All calls and texts are returned within 24 hours.

Men's Health