By Paul Hulsberg, MD
Benign prostatic hyperplasia (BPH) is a common condition that many men face as they age. BPH can lead to bothersome urinary symptoms, such as incomplete bladder emptying, increased urinary frequency, intermittency, urgency, weak stream, straining and nocturia. This can have a significant effect on patients’ quality of life. While traditional treatments like medications and surgical procedures have been the standard of care, a minimally-invasive option called Prostate Artery Embolization (PAE) is gaining attention as an effective alternative.
Understanding BPH
Benign Prostatic Hyperplasia is a non-cancerous enlargement of the prostate. The prostate gland surrounds the urethra, which is the tube that carries urine from the bladder. As the prostate enlarges, it can compress the urethra leading to urinary symptoms such as frequent urination, weak urine flow, and incomplete emptying of the bladder. These symptoms can significantly interfere with men’s daily activities and sleep.
Traditional Treatment Options
Medications such as alpha blockers (tamsulosin/Flomax, terazosin/Hytrin, doxazosin/Cardura, alfuzosin/Uroxatral, and silodosin/Rapaflo) and 5-alpha reductase inhibitors (finasteride/Proscar, Dutasteride/Avodart) can help manage the symptoms of BPH, but they may come with side effects and they may not be effective for all patients. When medication is not effective, several procedural options are available for treatment of BPH. Transurethral resection of the prostate (TURP) or holmium laser enucleation of the prostate (HoLEP) are more minimally invasive options, but can sometimes be complicated by side effects such as sexual dysfunction and incontinence. Surgical resection of the prostate is a more invasive option for massively enlarged prostates, but typically requires a more extended recovery period.
The Emergence of Prostate Artery Embolization (PAE)
Prostate Artery Embolization (PAE) is a relatively new and minimally invasive treatment option for BPH. Performed by an interventional radiologist, this procedure can provide relief from lower urinary tract symptoms with reduced risk, shorter recovery times, and no need for a hospital stay.
How PAE Works
The entire procedure is typically performed through a small pinhole puncture in the groin or the wrist, as the interventional radiologist uses live X-ray imaging (fluoroscopy) to guide catheters and wires from the accessed artery into the bilateral prostate arteries. After confirming position of the catheter with contrast injections and cone-beam CT imaging, the radiologist injects microscopic particles into the prostate arteries, which work by blocking the blood flow to the prostate. This causes the abnormal prostate tissue to shrink, which relieves the obstructive pressure on the urethra, allowing urine to flow more easily from the bladder to the penis.
Benefits of PAE
• Minimally Invasive: no incisions or surgical resection involved
• Shorter Recovery Time: typically an outpatient procedure. Patients may have some post-embolization pain related to inflammation that is self-limiting and managed with oral medications.
• Preservation of Sexual Function: PAE has shown a lower risk of sexual side effects compared to some traditional treatments.
• No need for general anesthesia: typically performed with local anesthetic and light IV sedation, making this an excellent option for patients with multiple comorbidities who may not be candidates for more invasive surgical procedures
Risks and Limitations
Like any medical procedure, PAE isn’t without risks. Some potential complications include access site bleeding, infection, and non-target embolization.
With advancements in imaging and technique, these risks are minimal in expert hands. In the initial postprocedural phase, there is a small risk of complete bladder obstruction related to prostate inflammation. This is typically managed with Foley catheterization for a few days until the inflammation subsides.
Who is a Suitable Candidate for PAE?
PAE is not suitable for everyone, and a thorough evaluation and multidisciplinary discussion between a urologist and interventional radiologist is essential in determining eligibility. Patients with prostates larger than 100cc are typically better candidates for this procedure because the arteries supplying the prostate are much larger and easier to catheterize. Patient with significant atherosclerotic disease may have more technically challenging arterial anatomy, but it is usually not a contraindication to PAE. Patients with a history of aortic endograft or previous pelvic artery embolization may also pose difficulties in arterial catheterization. Careful consideration of prior procedures by the urologist and the interventional radiologist is an important factor in deciding on a treatment approach.
Conclusion
Prostate artery embolization represents a significant advancement in the treatment landscape for benign prostatic hyperplasia. For referring providers, understanding PAE and its benefits ensures that patients are offered the most comprehensive care options. For potential patients, knowledge is empowerment. The more you know about your treatment options, the more confidently you can make decisions about your health. If you or someone you know is struggling with the symptoms of BPH, it may be worth discussing PAE with your urologist to determine if this option may be right for you.
Paul Hulsberg, MD is board-certified in both diagnostic and interventional radiology. He completed his diagnostic radiology residency at Case Western Reserve University in Cleveland, OH and completed his fellowship at University of Florida in Jacksonville, FL.
Dr. Hulsberg and his family have lived in Naples since 2019. He has been instrumental in building and growing the interventional radiology practice at NCH and Proscan along with his partners Scott Peterson, MD, Ashley Wood, MD and Bruce Bordlee, MD. The Proscan team of talented physicians, together with the caring and professional technologists and nurses at NCH, provide compassionate and comprehensive care to their patients using the latest imaging technology and procedural innovation.
For more information or to schedule an appointment, call 239-624-4443. proscan.com