Prostate Artery Embolisation (PAE) for Benign Prostate Hyperplasia (BPH)
By Dr Chris Rogan
Do you suffer from troubles with urinating?
- poor urine flow ?
- having to wake up to go many times at night?
- dribbling ?
If you have symptoms that are related to enlargement of the prostate (prostatic hyperplasia/hypertrophy), you may be suitable for consideration of minimally invasive therapy called prostate artery embolisation (PAE) which reduce the blood supply to the prostate with the aim of improving urinary symptoms. This treatment may delay the need for surgery or manage the symptoms of prostate enlargement as an alternative to a surgical operation (transurethral resection of the prostate).
What tests will I normally need before the treatment?
Most patients will have a basic assessment of their prostate and bladder to make the diagnosis of BPH which normally includes
- an ultrasound of the bladder and prostate to assess for any other causes
- a blood test called prostate specific antigen (PSA)
- a test of your urine flow.
- in selected cases, a prostate MRI or biopsy may also be needed.
- If, after you see the doctor, you are planned for PAE, a special CT scan of the arteries will be performed to plan the procedure.
What is Prostate Artery Embolisation (PAE)?
Prostate artery embolisation is a new non-surgical procedure performed by interventional radiologists. Under X-ray guidance, a micro-catheter ( a very fine tube) is navigated to the arteries supplying the enlarged prostate. Tiny plastic beads are then deposited to block the blood supply and shrink the prostate. The same technique has been used for over 20 years to shrink uterine fibroids in women and liver cancers, but has recently been applied to the prostate. It is a local anaethetic procedure with no down-time.
What are the treatment options for BPH?
(What medications are there?)
The standard 1st stage of treatment for prostate enlargement is medications and this is no different for patients considering PAE. It is usual to try the medications for at least 6 months before considering any further treatment options. Unless the medications do not work or you suffer from significant side effects, medications are the first choice as it is best to start with the least invasive treatment options first and medications normally fall into that category.
If you fail on the medications, the standard therapy that has been traditionally offered is transurethral resection of the prostate (TURP). This is a surgical procedure which is performed via a telescope which is advanced into the urethra (urine tube passing through the prostate) and the portions of the prostate around the urethra is surgically removed.
This is a very effective therapy but has some side effects, the most common of which is retrograde ejaculation “dry orgasm” which occurs in the majority of patients, where ejaculate no longer exits the penis on orgasm but is instead released into the urine within the bladder leading to a dry ejaculation. Other complications of surgery include urinary tract infections, heavy bleeding, temporary difficulty voiding or loss of bladder control and risks associated with general anaesthetic.
Which people are suitable for PAE?
Anyone considering PAE will need to firstly have the diagnosis confirmed that their symptoms are as a result of the enlarged prostate. Many people will have seen a urologist to come to this conclusion, others will need the tests listed above.
Secondly, a trial of medications as detailed above is necessary to make sure that a tablet cannot solve the issue with minimum fuss and risk.
If you are suitable for PAE, you will be referred for a planning CT scan and although most people can proceed to the treatment, a small number of patients will be excluded from being offered PAE based on this scan.
What are the risks?
The procedure involves an angiogram, which is a picture of your blood vessels taken using a small plastic tube which is placed into the artery in your thigh. This part of the procedure carries a 5% risk of bruising and a significant bleeding happens uncommonly <1%.
X ray dye (contrast) will be used (similar to a CT scan) to check internal anatomy throughout the procedure. This can cause kidney problems for those people with kidney disease – let the doctor know if you have kidney disease and a blood test will be performed to check this and minimise this risk.
The prostate blocking procedure itself is not usually painful but after the procedure, about 1 % of patients will experience mild pain and low grade fever as the prostate responds to it’s blood supply being reduced.
The more common risks (4-7% incident) include urinary retention needing a temporary catheter, experiencing transient bleeding on passing urine, ejaculating or blood in bowel motions, urinary infection or diarrhoea, or a bruise (hematoma) in the groin, which would normally settle within a week.
Very rare but serious risks relate to blocking of arteries near the prostate which supply nearby organs:
- one patient in the world needed surgery to remove a part of the bladder affected by the treatment
- two patients in the world have experienced an ulcer on the penis which healed.
In contrast to TURP surgery:
- no patients developed experience retrograde ejaculation
- no patients have developed impotence
- bleeding is uncommon
- incontinence is rare
- recovery is faster
- a general anaesthetic is not needed.
Example of Images used to guide the embolisation treatment:
What is the expected result from PAE treatment?
PAE is not as effective as TURP in reducing the size of the prostate.
It does however, result in a large improvement in the symptoms and patients are generally very happy with the outcome.
In the largest review paper to date, the average result from 788 patients reviewed was (at 6months post op):
- The overall technical success was >95% (the procedure was able to be completed)
- the prostate reduced in size by 30mL (Normal prostate volume is less than 30mL and enlarged glands offered TURP are generally 40-100mL).
- There was a large improvement in patient’s urinary symptoms (though less than post TURP) – (IPSS down 12.8pts)
- There was an improvement in Quality of Life (QoL up by 2.14 points)
It is important to realise that PAE does not treat prostate cancer and is only indicated for benign prostate enlargement.
Are there any preparations needed?
You will normally be asked to fast from midnight before the procedure and certain blood thinners such as warfarin will need to be witheld.
What happens during and after the procedure?
You will be made comfortable with twilight sedation and an injection of local anaesthetic into the upper thigh which is accessed to do the procedure.
On the upper thigh is cleaned and numb, a fine catheter (plastic tube the size of a piece of spaghetti) is threaded into the artery and guided towards the prostate with xray guidance. Once in position, a number of xray images will be taken to check your individual anatomy and blood supply to the prostate. A very fine tube called a microcatheter is then threaded through the catheter and passed into the artery supplying the prostate.
Once the correct blood vessel is verified, plastic microspheres are used to block the artery to the prostate. By reducing its blood supply, the prostate undergoes shrinkage over time (atrophy). Both the left and right sided arteries to the prostate can be treated through the one access pinhole in the thigh. It is also possible to treat the prostate via a wrist artery in some patients.
The pinhole access will then be sealed with a special absorbable plug and you will rest in bed and be monitored for 4 hours. You will normally be able to go home on the same day.
Standard recovery from any minimally invasive trans-arterial procedure like this involves:
- Do not drive for 24 hrs.
- Avoid strenuous exercise or lifting more than 10kg for 48 hrs
- Leave the dressing intact over the access pinhole for 48hrs (but you can shower as normal)
How can I find out more?
If you would like a consultation to discuss your situation, you will need a referral from your GP, which can be faxed or emailed to Sydney Interventional Radiology as per our contact page.
Recent article for SAN doctor – information for GPs
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