Prostatic artery embolization (PAE) is a minimally invasive procedure for the treatment of lower urinary tract symptoms caused by Benign Prostatic Hyperplasia (BPH). BPH is a noncancerous enlargement of the prostate gland which is common and can be seen in more than 50% of men by the age of 60 years and up to 80% of men older than 70 years. The PAE procedure is performed through a small access to the artery and is done by a physician whose sub-specialty is using advanced imaging modalities to treat different conditions without major incisions or surgeries. This subspecialty is called Interventional Radiology (IR) and this field has successfully treated men with BPH for more than two decades. IR physicians can diagnose and treat complex conditions with lower risk profile and less pain and recovery period compared to surgery.
Symptoms of BPH:
The lower urinary tract symptoms related to BPH include slow flow of urine, inability to empty the bladder, the need to urinate frequently, the urgent need to urinate, and straining during urination. In some patients bleeding in the urine is from the result of BPH. Symptoms of BPH not only affect quality of life but can also cause a loss of sleep, or severe infection and even damage to the kidneys
What is prostatic artery embolization (PAE)?
Prostatic artery embolization is an outpatient procedure that involves a small skin nick (not even big enough to place a stitch in) in the groin or wrist through which a small tube called a catheter is placed into the arteries. Then using image guidance and minimal live X-ray (fluoroscopy) the arteries feeding the prostate gland will be identified. A tiny noodle-like catheter will be passed into the prostate arteries and microscopic beads will be sent into these arteries. The beads will block the blood flow to prostate and therefore cause the prostate gland to shrink and soften. This in turn will result in significant improvement of the BPH related symptoms as the pressure on the urethra (the organ through which urine drains from the bladder) will be relieved. This procedure typically takes about 2 hours. The procedure is done with sedation (IV medications to relax you and make you drowsy). General anesthesia is not needed for this procedure as it is not very painful.
Who is a candidate for PAE?
- Moderate to severe lower urinary tract symptoms due to BPH uncontrolled by medicines.
- Hematuria (blood in the urine) due to BPH.
- Decreased urinary flow or difficulty voiding.
What to expect after the procedure?
Usually the positive results are seen as soon as the first days after the procedure. In about a month after the procedure most men have relief of their symptoms. Most patients can go home the same day after the procedure and need to recover for a few days at home before returning to regular activities.
What are the risks involved with PAE?
When the procedure is performed by an experienced interventional radiologist the procedure is extremely safe. Some of the risks involved are transient such as small blood in the urine or semen, or acute urinary retention for few days following the procedure, or painful urination. Other rare complications include hematoma (bruising) or infection at the incision site or blood in stool.
Is a referral needed for PAE?
No. You do not need a referral for this procedure but a full evaluation by urology is important and we will make sure that a full multidisciplinary evaluation is performed before performing the procedure.
In your appointment we will review your symptoms and will discuss the treatment options. Additionally we will evaluate the size of the prostate by MRI or CT scan and also in some cases we will assess for prostate cancer. PAE is for candidates who are either ineligible or not interested in surgery.
What are the other options?
Compared with more invasive surgical options such as Trans-urethral resection of prostate (TURP), PAE has less or no risk of erectile dysfunction or urinary sphincter injury (incontinence, urine leakage). Additionally there is less blood loss and less post-procedural need for hospitalization compared to TURP. On the other hand the typical medical and surgical options for BPH may cause sexual dysfunction (impotence), or a condition called retrograde ejaculation. As seen in the diagram below, the symptoms related to the enlarged prostate will be improved after PAE and TURP to similar extent but TURP has more complications compared with PAE. (The IPSS is a score of BPH related symptoms)
If you have BPH symptoms you should talk to your urologist about the available treatment options, ranging from surgery to medications. PAE is a new modality which can result in relief of symptoms in patients who did not respond adequately to medications and can be considered for selective group of patients.
Clinical success which results in significant improvement of the urinary symptoms after PAE are reported in 85% at 1 year, 82% at 30 months, and 76% at as long as 6 and half years. In some select group of patients there will be also improvement in their sexual function after PAE.
Here at Washington University St. Louis we have a team of experts who will evaluate your symptoms and discuss all the treatment options including PAE. We are one of the few medical institutions in the world that currently perform this type of procedure.
Angie Hester RN, Clinical Nurse Coordinator
Nassir Rostambeigi, MD, MPH
Carlos Guevara, MD, FSIR