Originally published 2/11/2018
Prostatic artery embolization (PAE) is a minimally invasive prostate treatment alternative to TURP (“reaming out”), a surgical widening of the urethra to relieve urinary symptoms due to BPH. It can help men avoid long-term use of oral medications. A description of the procedure is in the original blog below. By way of updating that blog, here are some nuggets of wisdom from subsequent published literature.
Patient selection is very important: “those who do well tend to be those with the larger prostate with large lateral lobes … without a significant middle lobe, with big prostate vessels…” and without kidney dysfunction.[i]
With the aid of state-of-the-art imaging, a “superselective” has been developed in order to accurately place the embolic material (substance that blocks blood flow) in order to avoid nontarget embolization (embolic backflow into adjacent blood vessels which can cause harmful side effects).[ii]
Treatment side effects, while relatively uncommon, can include any of the following which are treatable and short-lived: urinary tract infection, acute urinary retention, dysuria, and persistent urinary symptoms. However, according to Chung (2021), aftereffects can be very serious if “…nontarget embolization of intravascular particles refluxes [backflows] into adjacent penile, vesical, or rectal arteries.”[iii] These blockages can lead to depriving organs of necessary oxygen, as in the very rare case reported by Chung in which the head of a patient’s penis began to suffer tissue death. Fortunately, it was diagnosed in time and it responded to oxygen therapy.
As with any medical procedure, if you are a BPH patient considering non-pharmaceutical treatment to manage urinary symptoms, you should a) consult with your own doctor first, and b) choose an experienced practitioner for the treatment you choose.
What happens to a man’s prostate gland when he hits middle age? If he’s lucky – and most men are – not much changes. However, millions of men will develop urinary problems as a result of the most common prostate disorder: benign prostatic hyperplasia, or BPH.
What is BPH?
BPH is a noncancerous enlargement of the prostate gland. It is not life-threatening, and many men don’t even know they have it until they go for an annual exam. A digital rectal exam (DRE) of the prostate may reveal that the gland is larger than normal. BPH can also cause a rise in PSA, so the doctor may want to rule out prostate cancer.
When the gland enlarges, it begins to narrow the urethra (the passage through the prostate that carries urine from the bladder toward the penis). This narrowing, or constriction, can cause urinary symptoms: difficulty urinating, urge to urinate more frequently, weak stream, inability to empty the bladder completely, getting up at night to urinate, etc.
If symptoms become severe enough to reduce quality of life, many men seek treatment, starting with medication. However, if medication doesn’t work, there are several types of procedures to widen the urethra. One of these is called prostatic artery embolization (PAE).
What is PAE?
The term embolization comes from a Greek word, embolus, that means a clot or plug in a blood vessel. If you have ever heard the word embolism it meant a blockage in a vein or artery. Embolisms are dangerous since certain types can lead to death. However, in the case of BPH, embolization is a strategic blockage of blood vessels that “feed” the excessive growth of the prostate gland. When the extra tissue does not get enough oxygen and nutrients, it gradually shrinks, leading to a widening of the urethra. In turn, this alleviates the urinary difficulties.
Thus, prostatic artery embolization is a procedure to intentionally decrease the flow of blood to the enlarged prostate by blocking specific arteries.
How is PAE done?
PAE is an outpatient surgical procedure that involves injecting very small beads (microspheres) into small prostate blood vessels. The beads are placed using a flexible hollow tube called a catheter that is threaded to their target through an artery in the upper thigh. When done correctly, PAE has a good safety record. However, side effects can occur due to inflammation or misplaced beads.
A word of caution
Since the procedure was first developed in 2009 (use in the U.S. began in 2011) studies have shown that when done correctly, the procedure is safe. However, the Sperling Prostate Center echoes many of the concerns and cautions that experts have pointed out. These include:
- Need for accurate image guidance – the procedure is performed by an interventional radiologist under CT scanning. This requires expert knowledge of anatomy since placing the beads in the wrong blood vessel can cause serious harm.
- Exposure to radiation – CT scans involve some exposure to radiation. It’s important that the doctor performing the procedure be experienced in order to be efficient, and minimize exposure to radiation.
- Lack of long term data – clinical trials are ongoing to determine the effects of PAE over time. Given that the procedure itself is less than 10 years old, it will be a while before results of long-term, randomized controlled clinical trials are available.
Summary
PAE is one of several types of surgical procedures designed to reduce the urinary symptoms of BPH. It involves the permanent placement of microspheres into prostate blood vessels. Many doctors and patients prefer PAE to procedures that widen the urethra by inserting a device through the penis in order to widen the prostate urethra by cutting or ablating it. Such procedures often have a longer recovery period than PAE. It is important to note that all surgical procedures to ease BPH urinary problems have a risk of side effects, though in most cases they are minor and resolve quickly.
While PAE is considered promising, BPH patients who are not comfortable with the idea of using microspheres left in the body to block blood flow should discuss PAE with their doctor before making a treatment decision.
The Sperling Prostate Center uses Focal Laser Ablation (FLA) to reduce prostate size by ablating prostate volume away from the urethra. As the gland gradually shrinks in the weeks following FLA, urinary symptoms clear up. Because FLA is not done through the urethra (unlike vaporization laser procedures) there is minimal-to-no risk of urinary side effects, and no impact on sexual function. Contact the Sperling Prostate Center for more information.
NOTE: This content is solely for purposes of information and does not substitute for diagnostic or medical advice. Talk to your doctor if you are experiencing pelvic pain, or have any other health concerns or questions of a personal medical nature.
References
[i] Popert, R. “Editorial: Prostate Artery Embolization.” BJUI International, Aug. 1, 2018. https://www.bjuinternational.com/article-of-the-week/prostate-artery-embolization/
[ii] Carnevale, F.C., Moreira, A.M. & Antunes, A.A. The “PErFecTED Technique”: Proximal Embolization First, Then Embolize Distal for Benign Prostatic Hyperplasia. Cardiovasc Intervent Radiol. 2014;37:1602–1605.
[iii] Chung E. Penile Glans Necrosis following Prostatic Artery Embolization for the Treatment of Benign Prostatic Hyperplasia: A Rare but Serious Complication. Case Rep Urol. 2021; 2021: 6662899.
About Dr. Dan Sperling
Dan Sperling, MD, DABR, is a board certified radiologist who is globally recognized as a leader in multiparametric MRI for the detection and diagnosis of a range of disease conditions. As Medical Director of the Sperling Prostate Center, Sperling Medical Group and Sperling Neurosurgery Associates, he and his team are on the leading edge of significant change in medical practice. He is the co-author of the new patient book Redefining Prostate Cancer, and is a contributing author on over 25 published studies. For more information, contact the Sperling Prostate Center.
