If primary care physicians and urologists suspect that they are seeing high numbers of older male patients with symptoms of prostate enlargement, the facts bear them out. One report estimates that benign prostate hyperplasia (BPH) is responsible for 4.5 million doctor visits annually.
Benign prostatic hyperplasia (BPH) is a problem that may affect many of your male patients. Prostatic artery embolization (PAE) is one of the latest treatment approaches, and vascular and interventional radiologists with the Froedtert & the Medical College of Wisconsin health network are leading the way locally in offering PAE for moderate to severe disease.
“The standard of care for BPH is transurethral resection of the prostate (TRUP),” said Matthew Scheidt, MD, vascular interventional radiologist and MCW faculty member. “It’s tried and true, but many men want an alternative to that method. Prostatic artery embolization has picked up interest in the last two to three years, and there are finally some better studies proving its efficacy.”
Minimally Invasive, Catheter-Based Procedure
Prostatic artery embolization is a minimally invasive, catheter-based procedure that shrinks the prostate by blocking blood flow to the gland. As with cardiac catheterization, radiologists enter through either the radial artery in the wrist or the common femoral artery in the hip. With a small wire and catheter, they navigate the blood vessels in the pelvis to reach the prostate. Angiographic imaging confirms the catheter is positioned correctly and clear of other organs like the bladder and bowel.
“The prostate gland has two arteries, a right and a left,” said Mustafa Haddad, MD, interventional radiologist and MCW faculty member. “We use the one puncture and just reposition the catheter to reach each artery and embolize, or close if off.”
Tiny particles, about 300 microns in size, of polyvinyl alcohol (PVA) or other embolization agents are injected into the prostate arteries until blood flow significantly diminishes.
“The prostate basically atrophies, decreasing its size and reversing the symptoms of BPH,” Dr. Haddad said. “When we cut off the blood supply, large portions of the peripheral or central prostate will shrink but not totally disappear because of collateral circulation.”
Macrophages of the body’s immune system reabsorb the dead prostate tissue and replace it with scar, which contracts to open up the central part of the gland.
A Significant Improvement
The procedure itself can take from one-and-a-half to four hours, depending on anatomy, and is performed with mild sedation. Patients go home the same day after two to three hours’ recovery in Vascular and Interventional Radiology. They can experience some soreness at the puncture site and take antibiotics to minimize the risk of infection as well as medication to reduce bladder inflammation. Men can resume normal activities in five to seven days.
“Within about two weeks after the procedure, 80 to 90% of patients experience improvement in their symptoms,” Dr. Haddad said. “Our goal is also to get patients off medications and we’re having success at that.”
Identifying the Right Candidate for PAE
Key to the effectiveness of PAE is identifying the right candidates by confirming the diagnosis, measuring prostate size and examining blood vessel anatomy.
“It requires a urologic workup,” Dr. Scheidt said. “It needs to be proven that what the patients are experiencing—lower urinary tract symptoms—fits perfectly with BPH rather than other causes such as muscle or bladder dysfunction.”
Other conditions to be ruled out are prostate cancer and prostatitis. To ensure patient compatibility, the workup should include a PSA test and an ultrasound or CT scan. The latter help establish prostate size, which is an important determinant of procedure effectiveness.
“We know that we see the best results with a larger gland—greater than 100 grams measured off of imaging. It’s not the same with smaller glands,” Dr. Scheidt said.
The “highway system” of blood vessels in each patient is also a consideration and makes the procedure technically demanding.
“Prostate artery anatomy is incredibly variable, no two are the same,” he said. “If the vessels are twisty and tortuous, we might not be able to get the catheter in there. The same with vascular disease and occlusions. We use MRI or CT angiography to make sure the anatomy in the vascular system is suitable for safe catheterization.”
Interventional radiologists at the Froedtert & MCW health network have been performing PAE for about three years, and Froedtert Hospital is one of the few sites in Wisconsin where it is available. Results to date have been positive, and the procedure preserves a patient’s options for the future.
“We know we could go back again and intervene if necessary,” Dr. Scheidt said.
Prostatic artery embolization is not appropriate for every case of BPH, and patients should try conservative measures like lifestyle changes and medications first. When symptoms persist or become unbearable, however, PAE presents a safe and effective alternative.
“It is another tool, another option for providers to offer patients with BPH,” Dr. Haddad said. “It’s minimally invasive, very low risk, 80 to 90% successful, and patients can still go on to surgery if necessary. We work collaboratively with providers and urologists to personalize the care for every patient, to find the best solution for that patient.”
For Our Referring Physicians:
Academic Advantage of Prostatic Artery Embolism Procedure
The Froedtert & MCW health network gives patients and their referring physicians a distinct advantage.
Contact our physician liaison team for more information about prostatic artery embolization or if you would be interested in meeting with any of the urological team members.