Growing old can mean a lot of changes. For one, it can be that we are wiser, with years of experience under out belt. We may be more confident and comfortable with ourselves, having grown impervious to societal expectations. And if you are a man, it more than likely means you are awake what seems like every hour at night to urinate thanks to that damn prostate. BPH or benign prostate hypertrophy affects nearly 50 percent of men in their 60s and almost 90% of men aged 70-90 years. These symptoms include:
An urgent need to urinate
Increased frequency of urination, especially at night (nocturia)
Inability to urinate or straining while urinating
Weak urine stream
Dribbling at the end of urination
Sound familiar?
And if you're like most men maybe you've tried supplements. Maybe you've tried medications like alpha blockers (Flowmax) or 5-alpha-reductase inhibitors (Proscar) and found that these work okay but the side-effects (dizziness, fatigue, erectile dysfunction) are completely intolerable. And perhaps the idea of an invasive surgery isn't that exciting-can't imagine. But you are thinking about therapy and that's a good thing. Left untreated, BPH can lead to other health complications such as kidney stones, infection, lack of bladder control, and complete bladder outlet obstruction or blockage. So what's a guy to do?
In 2017 the FDA approved a new, minimally invasive therapy called prostate artery embolization (PAE). Embolization means to block the blood flow to a particular part of the body and has been around since the 1970s in one form or another. Embolization of the prostate was initially performed for prostatic bleeding in 1976. In 2000 physicians noticed a side effect of prostate shrinkage after embolization. Finally, in 2010 physicians performed the first PAE for LUTS (Lower Urinary Tract Symptoms). Since then technology has advanced tremendously and numerous studies have found this technique to be safe and effective in thousands of treated men.
How is PAE performed?
PAE is an outpatient procedure performed under moderate sedation. A small incision (about this big --) is made in your groin and the artery accessed with a small catheter. X-ray dye is injected to map out the vessels supplying your prostate. The catheter, about the size of spaghetti, is manipulated into the artery feeding your prostate under x-ray guidance. Once in position, small, inert, round particles are injected into the artery to stop the blood flow (embolize). Once deprived of it's blood supply the prostate begins to shrink. Patients walk out of the clinic after a few hours and have few post-procedure restrictions. Side-effects and recovery are minimal. To learn more click here
Is PAE effective?
Ok, so now we get to the meat of the issue. Does this thing really work? The short answer is yes, absolutely, and hundreds of men can attest to that. But let's not take their word for it, let's take a look at the data. I'll try to keep from sounding too technical here but in terms of outcomes, most studies use the International Prostate Symptom Score (IPSS) as a marker for improvement after intervention. The IPSS is a 7 question questionnaire taken before and after PAE. Click here to take the questionnaire. The largest study we have was published by a Portuguese interventional radiologist by the name of JM Pisco (1). This study looked at 630 men who underwent PAE and measured their IPSS before and at 1, 3, and 6 years after the procedure. They found a mean improvement of 13.7, 14.5, and 16.94 points respectively. This means that at one year, if you started with an IPSS of 20 (severe symptoms) you would have only mild symptoms after treatment. And not only is the treatment effect durable, it continues to improve as time goes on! This makes sense when you think about the mechanism, i.e. the shrinkage of prostate tissue secondary to lack of blood flow. Subsequently, the findings of Pisco's study were duplicated by several studies further adding to the validity of the conclusions (2-3). "So I've dropped 17 points on a questionnaire, what does this mean about my quality of life?" I'm so glad you asked. While BPH associated LUTS can be a significant medical issue, the disease is significant because of the toll it can take on your quality of life. The quality of life score (QoL) is the last question of the IPSS and ranges from delighted (0) to terrible (6). Numerous studies have shown that PAE significantly improves Quality of Life when compared to baseline, and this remained improved over time (4-6).
Safety
But now you say that there are so many options to choose from, how does PAE compare to these? To compare a new treatment you must compare it to the historical "gold standard". For BPH, trans-urethral resection of the prostate (TURP) is that gold standard. Both treatments can result in immediate symptom improvement. That said TURP initially demonstrates slightly better outcomes in terms of urine flow compared to PAE within the first 3 months. However, beyond 3 months, studies have shown that PAE provides similar outcomes in terms of urine flow rate and quality of life (7). So although the long-term outcomes of PAE vs TURP were not different, the studies did demonstrate a significant difference in complication rates. Studies report a minor complication rate for PAE as half that of TURP. Futhermore, the major complication rate for PAE has been reported to be between 0.002-0.03%, the majority of which involve off-target embolization requiring an escalation in care. The reported complication rate for TURP, on-the-other-hand, is around 2-9%. These include bleeding requiring transfusion, the so-called TUR syndrome from irrigation fluids, urine retention, infection, urethral strictures, and bladder neck contractures.
Societal Guidelines
By-and-large, PAE has been endorsed by medical societies around the world as a safe and effective, minimally-invasive treatment for BPH-induced LUTS. This includes the Society of Interventional Radiology and the American College of Radiology in the United States as well as the European Society of Interventional Radiology. In 2018, the United Kingdom National Institute for Health and Care Excellence updated their recommendations in support of PAE based on the results of the UK-ROPE trial. In June, 2017 the Federal Food and Drug Adminstration approved the use of PAE for men with BPH associated lower urinary tract symptoms. Despite this, the American Urological Society continues to downplay the utility of PAE as a treatment option stating the lack of high level evidence. It should be noted, however, that the number of randomized controlled trials ( a RCT is the pinnacle of high-level scientific evidence) evaluating PAE is greater than several other minimally-invasive treatments endorsed by the AUS including water vapor thermal therapy (Rezum), Aquablation, and Photoselective Vaporization of the Prostate (PVT).
Conclusion
Prostate artery embolization (PAE) is a safe and effective procedure for men with lower urinary tract symptoms and bladder outlet obstruction from prostate enlargement. It's indicated for men with moderate to severe symptoms. Call 801-810-2999 to set up a discussion with a CiC physician regarding your options today!
1. Pisco JM, Bilhim T, Pinheiro LC, et al: Medium- and long-term outcome
of prostate artery embolization for patients with benign prostatic hyperplasia:
Results in 630 patients. J Vasc Interven Radiol JVIR 27:1115-
1122, 2016
2. Malling B, Roder MA, Brasso K, et al: Prostate artery embolisation for
benign prostatic hyperplasia: A systematic review and meta-analysis.
Eur Radiol 29:287-298, 2019.
3. Kuang M, Vu A, Athreya S: A systematic review of prostatic artery
embolization in the treatment of symptomatic benign prostatic hyperplasia.
Cardiovasc Interv Radiol 40:655-663, 2017.
4. Ray AF, Powell J, Speakman MJ, et al: Efficacy and safety of prostate
artery embolization for benign prostatic hyperplasia: An observational
study and propensity-matched comparison with transurethral resection
of the prostate (the UK-ROPE study). BJU Int 122:270-282, 2018.
5. Torres D, Costa NV, Pisco J, et al: Prostatic artery embolization for
benign prostatic hyperplasia: Prospective randomized trial of 100-300
mum versus 300-500 mum versus 100- to 300-mum + 300- to 500-
mum Embospheres. J Vasc Interv Radiol JVIR 30:638-644, 2019.
6.Wang MQ, Zhang JL, Xin HN, et al: Comparison of clinical outcomes of
prostatic artery embolization with 50-mum Plus 100-mum polyvinyl
alcohol (PVA) particles versus 100-mum PVA particles alone: A prospective
randomized trial. J Vasc Interven Radiol JVIR 29:1694-1702,
2018.
7. Gao YA, Huang Y, Zhang R, et al: Benign prostatic hyperplasia: prostatic
arterial embolization versus transurethral resection of the prostateA
prospective, randomized, and controlled clinical trial. Radiology
270:920-928, 2014.