Prostate Artery Embolization:
A Minimally Invasive Option to Treat Benign Prostatic Hyperplasia
A common condition among most aging men is benign prostatic hyperplasia (BPH), a noncancerous condition where the prostate becomes enlarged and urinary issues start to take hold.
In fact, approximately 50 percent of men who are 50 and older and 80 percent of men who are 80 and older struggle with BPH, symptoms of which include urinary urgency, frequent urination, straining to urinate, urinating multiple times in the night, incomplete emptying of the bladder, and sexual side effects. BPH can have a deeply negative impact on a man’s quality of life and leaves most searching for relief.
Why Does Urination Become a Problem for Some Men?
The prostate gland sits below the bladder, between the bladder and the penis. Running through the center of the prostate is a vessel or tube called the urethra, which allows urine to flow out of the body. When the prostate becomes enlarged, pressure is placed on the urethra and a man cannot urinate properly or efficiently. The goal of treatment is to remove this pressure.
Traditional Complex & Invasive Treatment Options for BPH
Treatment of BPH involves medication as well as several procedural options, some of which require invasive surgery, an inpatient hospital stay, and the potential for unpleasant side effects. Additionally, a patient must meet certain requirements to qualify. Treatment options include:
- Transurethral resection of the prostate (TURP) – The urologist essentially removes the parts of the prostate gland that are causing problems. While TURP is the “gold standard” and essentially eliminates BPH, it is also major surgery that involves an overnight hospital stay, blood loss, and many potential side effects. Additionally, if the prostate is too large, TURP is not an option.
- Prostatectomy – This procedure is a partial or complete removal of the prostate, and is widely used for men who have a very enlarged prostate. This treatment option presents the best overall improvement of symptoms, but also involves surgery, a hospital stay, and potential side effects.
- Laser treatment – Lasers are used to kill the prostate tissue and reduce the size of the gland.
- UroLift® system – A permanent device is implanted to lift and hold the enlarged prostate tissue, preventing it from blocking the urethra.
- Rezum™ Therapy – This minimally invasive treatment option uses hot steam to attempt “burning out” the parts of the prostate that are squeezing the urethra.
Benefits of Minimally Invasive Prostate Artery Embolization (PAE)
Dr. Ravi Dalal, an interventional and vascular radiologist with Raleigh Radiology, reports that there is a different way to approach treatment of BPH that does not involve burning or removing the prostate, is minimally invasive, and presents relatively few side effects. Prostate artery embolization (PAE) is a newer, intravascular treatment, introduced more widely within the past ten years. It has grown in popularity due to the benefits mentioned above and its success rate. Additionally, the patient receives moderate sedation, so general anesthesia is not necessary. The procedure takes anywhere from one and a half to three hours.
“The idea is that if we shrink the prostate by getting rid of the blood supply on both sides, it will have the same effect as other treatments, but it is safer,” said Dr. Dalal. “Without a blood supply, nutrients can’t reach the prostate, and the cells will die. This is called necrosis. The body’s immune system will then remove the cells and create scar tissue, the prostate will shrink, and the tissue around the urethra will open up allowing urine to flow freely and reducing many symptoms.”
Performed in the hospital by an interventional radiologist like Dr. Dalal, PAE is a technical procedure that requires precision and expertise. Dr. Dalal has had extensive training for PAE during his interventional radiology fellowship.
Depending on the patient’s height (shorter than six feet, due to the catheter length), the radiologist may decide to perform the procedure trans-radially, through the patient’s wrist. This method is easier on recovery, but is only available for patients shorter than 6 feet tall due to the catheter length. Otherwise, the radiologist goes in through the groin. Either option creates no more than a 2 mm incision and requires no stitches.
The radiologist will then inject microscopic beads into the artery that runs to the prostate. These beads will ultimately block the blood supply. Multiple techniques are employed during the procedure to ensure the beads are inserted into the correct artery.
Positive Results & Improved Symptoms
Before PAE, most men report a variety of negative symptoms that impact their quality of life using a symptom tracking score methodology known as the International Prostate Symptom Score (I-PSS) rubric. The I-PSS is an eight-question screening tool that tracks and assesses symptoms of patients with BPH. The questions determine a man’s difficulty with urination and also help select the best treatment options. Whether it’s sexual dysfunction or urinary symptoms – men want relief and to live their lives to the fullest. Interventional radiologists like Dr. Dalal determine their success rate based on patients’ improved I-PASS scores after the procedure.
“After a PAE, we want to see those scores trending in the right direction. Fortunately, we typically see a significant impact,” added Dr. Dalal. “In fact, 75 to 80 percent of men say they experience an improvement in symptoms after this procedure.”
Patients also appreciate that PAE comes with few side effects. While there may be pain with urination or blood in the urine afterward, symptoms are usually mild and improve within a few weeks. A patient spends about two hours in recovery and is then sent home. The patient is prescribed antibiotics and NSAIDs to help with any inflammation or pain.
Rarely, post embolization syndrome can occur after PAE (low-grade fever, nausea, chills, discomfort when urinating), but this is temporary and resolves within a week. After the procedure, a patient should meet again with his radiologist to assess progress.
Helping High-Risk Patients Face BPH
Interventional radiologists and urologists are very selective when choosing patients for PAE.
They will assess each patient via CT scan prior to the procedure so they can map out the prostate’s anatomy and ensure the blood vessels are healthy enough for a successful PAE. PAE is most helpful in patients who have a large prostate of 150-200 grams. It is also a good option for patients for whom medical therapies have failed and/or who have pre-existing medical conditions such that surgery is not an option (i.e., heart disease and chronic obstructive pulmonary disease).
PAE can also help patients who have chronic indwelling foley catheters by shrinking the prostate and removing the catheter, as well as men who have hematuria, or bleeding from the prostate. By blocking the blood supply, the radiologist can use PAE to help heal the hematuria and shrink the prostate.
“Urologists prefer to avoid surgery with their high-risk patients, making PAE a good option. The risk is less for PAE since it only requires moderate sedation and it is not a surgical procedure,” explained Dr. Dalal. The interventional radiologists at Raleigh Radiology will consult with your urologist to develop a multidisciplinary approach and develop the best treatment option for each patient.
“PAE takes a lot of skill and experience; we use all the tools and training we have. Every patient is different, but I enjoy the challenge,” reflected Dr. Dalal. “Patients report a significant improvement in their symptoms – I’ve actually had men tell me they feel like they are 20 years old again.
The fact that we can treat these patients with a minimally invasive approach and have such a significant impact on their symptoms, meanwhile enhancing quality of life, is very exciting and satisfying.”
To learn more about Dr. Dalal and Raleigh Radiology, visit www.raleighrad.com.
Ravi Dalal, MD
Interventional and Vascular Radiologist
- BS: Cornell University
- MD: University of Miami Miller School of Medicine
- Radiology Residency: Jackson Memorial Hospital/University of Miami
- Vascular and Interventional Radiology Fellowship: Jackson Memorial Hospital/University of Miami
- Member, Society of Interventional Radiology
- Member, American College of Radiology
- Member, Radiological Society of North America
- Interests: Prostate Artery Embolization
- Native of New York State
Joined Raleigh Radiology in 2017