Benign prostatic hyperplasia (BPH) is an aging-related, noncancerous enlargement of the prostate gland. The exact cause is not yet known, but it is theorized that testosterone plays role (e.g. men whose testicles were removed before puberty do not get BPH). I will return to this theory in a bit.
The problem with BPH
BPH is not life-threatening, but it can create urinary problems that interfere with quality of life. These problems begin when the urethra (urine passageway from the bladder to the penis) becomes squeezed where it passes directly through the gland. The growing tissue bulk narrows the urethra. Urinary symptoms include: trouble starting flow, interrupted or weak flow, increased sense of urgency, inability to fully empty the bladder, and having to get up more than once during the night to urinate. Any one of these can complicate life, and some of them raise the chances of urinary tract infections.
Early symptoms can often be eased by changing habits (e.g. drinking less fluid before bedtime, avoiding caffeine, etc.). As symptoms get worse, a doctor can prescribe medications, thought not everyone likes the idea of taking drugs. If urination problems become more severe, there are surgical interventions to widen the urethral passage through the prostate. Some are minimally invasive outpatient procedures but others require a brief hospitalization. Most procedures are done using instruments inserted through the penis into the prostate gland, to physically remove or destroy (ablate) the urethra’s lining.
Treating BPH by blocking blood supply (embolization)
There are two fairly recent methods to shrink prostate tissue by cutting off prostate blood supply. One of them blocks arterial blood (arteries carry oxygenated blood from the heart to the rest of the body) and the other blocks venous blood (veins carry de-oxygenated blood back to the heart). Blocking blood flow is called embolization. Both methods are minimally invasive and done under image guidance, and nothing is inserted into the urethra so the urethra lining is not damaged.
- Prostate artery embolization (PAE) involves threading a catheter (very slender, flexible hollow tube) through a slit in the wrist or groin to access an artery leading to the prostate. The catheter follows the artery path to where it begins to branch into small blood vessels that feed the prostate. When it reaches the target, tiny beads called microspheres are fed into the catheter. They flow through until enough of them block or clog up the vessels so no oxygenated blood can infuse that part of the gland. Since there is a prostate artery on both sides of the gland, first one side is treated, then the other. Without oxygen, the affected prostate cells gradually die off, which naturally shrinks the gland. In a recent published study with 630 BPH patients, the authors report, “The medium- (1-3 y) and long-term (> 3-6.5 y) clinical success rates were 81.9% and 76.3%, with no urinary incontinence or sexual dysfunction reported.”[i] Other studies have reported side effects and complications such as prostate inflammation, infection risk, and misplaced microspheres, among others.
- The Gat-Goren technique does not affect the arterial blood supply to the gland. Instead, the embolization occurs in the veins leading upward from the testicles as they carry de-oxygenated blood back toward the heart. Here’s where the theory mentioned earlier comes in, that testosterone is a factor in stimulating benign prostate overgrowth. First, it’s important to understand that blood in the testicular veins must “defy gravity” to flow upward. In order to sustain upflow, the veins have small inner valves that keep blood from flowing back down. However, as men age, these valves can weaken and completely stop functioning. If this occurs, the blood begins to pool just above the testicles, forcing the building of new vein pathways in order to accommodate the extra fluid. These new veins are called varicoceles. Second, as you learned in sex education class, the testicles produce the majority of the testosterone in your body, and release it into the testicular veins for circulation. Most of the circulating testosterone is “bound” to other molecules for selective absorption by certain organs. However, a small amount is called “free testosterone” because it is not bound to anything. In this form, it is readily absorbable in a rather indiscriminate fashion. The blood that is pooling in the varicoceles is “enriched” with a concentrate of free testosterone. As the blood level increases, it is forced upward, thus backing up into the prostate itself. Now the normal prostate cells are literally bathed in more free testosterone than nature intended. This male hormone acts on the gland cells the way an engine is supercharged by a gas additive. According to this line of thinking, it is indeed the high level of free testosterone that causes BPH to being with. Therefore, if the testicular veins are strategically embolized, the testosterone-rich venous blood does not reach the gland. As a result, the gland gradually returns to its normal size. How successful is it? Well, it’s such a new procedure that there is not meaningful published data. According to Rauch & Strunk (2017), “The medium-term results are promising but data on long-term results and comparisons with alternative treatments are missing.”[ii] They note that the procedure could be difficult to perform since varicocele anatomy varies with individual patients.
Focal Laser Ablation (FLA) for BPH
Dr. Dan Sperling is the pioneering specialist in Focal Laser Ablation (FLA) to reduce BPH and alleviate urinary symptoms. Under 3T mpMRI guidance, a laser optic fiber is placed in the dense BPH tissue at a safe distance from the urethra lining. FLA destroys a selected area of BPH. In turn, this diminishes the gland volume that is compressing the urethra, so urine once again flows normally. No microspheres are implanted, and no cells are deprived of oxygen. For more information, visit our website.
[i] Pisco JM, Bilhim T, Pinheiro LC, Fernandes L et al. Medium- and Long-Term Outcome of Prostate Artery Embolization for Patients with Benign Prostatic Hyperplasia: Results in 630 Patients. J Vasc Interv Radiol. 2016 Aug;27(8):1115-22.
[ii] Rauch M, Strunk H. Interventional treatment of benign prostatic hyperplasia: embolization of the testicular vein. Radiologe. 2017 Aug;57(8):652-58.