Andrew Siegel MD 2/18/17
Note: Today’s entry was supposed to be on the topic of female stress incontinence, but this very interesting prostate topic presented itself to me, so the female incontinence entries will be continued next week.
Benign prostate enlargement (BPH) is a common condition of the middle-aged and older male in which the enlarging prostate gland obstructs urinary flow. It causes a number of annoying lower urinary tract symptoms, including a hesitant, weak and intermittent stream, prolonged emptying time, incomplete emptying, frequent urinating, urgency, nighttime urinating, and at times, urinary leakage.
There are numerous treatment options available and one of the newest minimally invasive options is “super-selective prostate artery embolization”—a.k.a. “PAE”—a procedure that is done by an interventional radiologist (a specialist x-ray doctor who does internal procedures without using conventional surgical techniques). The blood supply to the prostate is purposely blocked (embolized) using micro-particles that are injected into one or more of the arteries to the prostate. As a result of this embolization of the prostate artery, the part of the prostate served by the artery shrinks, opening up the obstructed urinary channel and improving the lower urinary tract symptoms.
Urinary difficulties attributable to BPH are commonly quantified using the International Prostatic Symptom Score (IPSS), a questionnaire consisting of seven symptom categories, with a range of increasingly severe symptom scores from 0 through 35. The score is based on the severity of each of the following lower urinary symptoms: hesitancy, decreased urinary stream, intermittency, sensation of incomplete emptying, nighttime urination, frequency, and urgency. The questionnaire responses are graded, with each of the seven symptom categories contributing a maximum of 5 points, for a total possible score of 35. Symptoms can be ranked as mild (0–7), moderate (8–19), and severe (20–35). This IPSS is a useful metric both before and after a procedure like PAE, in order to document clinical symptomatic improvement.
Before pursuing PAE, a CT angiogram of the prostate is performed to determine prostate arterial anatomy, to help plan the PAE and to exclude patients with severe arterial disease or anatomic variations that will not allow PAE to be a consideration. Prior to pursuing a PAE procedure, it is vital to check PSA, perform a digital rectal examination and rule out prostate cancer.
Technique of PAE
The PAE procedure takes place in the radiology department of the hospital under the supervision of the interventional radiologist. The femoral artery (thigh artery) is cannulated and by using an injection of contrast, the arterial supply to the prostate gland is identified. The prostate artery most commonly branches off the internal pudendal artery. Embolization of the anterolateral prostate artery, the main blood supply to the benign prostate growth, is attempted on both sides. The most challenging aspect is to identify and catheterize the tiny prostate arteries that are often only 1-2 mm in diameter. Micro-particles (polyvinyl alcohol, trisacryl gelatin microspheres or other synthetic biocompatible materials) are injected into the prostate arteries to purposely compromise blood flow and cause partial necrosis (death of prostate cells) and shrinkage. After the embolization on one side, an angiogram (x-ray of pelvic arterial anatomy) is done before the sequence is repeated on the other side.
Because of variation in prostate arterial anatomy and the types of micro-particles used, the extent of necrosis and shrinkage of the prostate is quite variable. Furthermore, prostate volume reduction does not precisely correlate with symptom improvement. Although ideally performed on both sides, when done only on one side (left or right prostate artery) it still results in improvement of symptoms without as significant a reduction in prostate volume.
Although clinical improvement in urinary symptoms is less predictable after PAE as compared to standard treatments including surgical removal or laser treatment of the obstructing part of the prostate, the PAE has numerous points in its favor. Advantages of this new procedure are avoidance of general anesthesia and surgery an preservation of ejaculation, as opposed to surgical treatments of BPH, which commonly cause retrograde ejaculation (ejaculating backwards into the bladder with semen following the path of least resistance). The PAE procedure is ideal for the older male with symptomatic BPH and significant prostate enlargement who for one of a variety of reasons is not a good candidate for conventional surgery.
Side effects of the PAE include urethral burning, fever, nausea and vomiting and perineal pain from prostate ischemia (damage to the blood supply), short-term inability to urinate as well as the radiation exposure necessary to perform the procedure.
Bottom Line: Growing evidence supports the use of prostate arterial embolization to treat benign prostate enlargement. Selectively occluding the prostate arterial supply results in damage to the prostate blood supply and ischemic necrosis (prostate tissue death) with reduction in the volume of the prostate gland with improvement in symptoms. Safe and effective, it is a promising minimally invasive option that is an attractive alternative to surgery for symptomatic patients with large prostates and concomitant medical problems who have failed to respond well to pharmacological treatments.
Dr. John DeMeritt is an interventional radiologist at Hackensack University Medical Center in Hackensack, New Jersey, who has particular expertise and experience in PAE. He reported the first case study of PAE in the USA, has conducted numerous studies on the topic as well as written several medical journal articles and has been interviewed on the subject by Dr. Max Gomez on CBS news: https://www.youtube.com/watch?v=SdV8ZxtLqZU
Thank you to Dr. DeMeritt for provided me with information on the subject matter, both verbally and in the form of several excellent articles, including his original case report. He also provided me with the PAE image.
Wishing you the best of health,
A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”: www.HealthDoc13.WordPress.com
Dr. Andrew Siegel is a practicing physician and urological surgeon board-certified in urology as well as in female pelvic medicine and reconstructive surgery. Dr. Siegel serves as Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community that is in such dire need of bridging.
Author of MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health http://www.MalePelvicFitness.com
Author of THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health http://www.TheKegelFix.com