Prostatic artery embolization (PAE, or prostate artery embolisation) is a non-surgical technique for treatment of benign prostatic hypertrophy (BPH). [1]
The procedure involves blocking the blood flow of small branches of the prostatic arteries using microparticles injected via a small catheter, [2] to decrease the size of the prostate gland to reduce lower urinary tract symptoms. It is a minimally invasive therapy which can be performed with local anesthesia, as an outpatient procedure. [2]
Men with an enlarged prostate may suffer from symptoms of lower urinary tract obstruction, such as sensation of incomplete urination, inability to urinate, weak urinary stream, or having to urinate frequently (often awakening from sleep). [3] If the symptoms cause a significant disruption to quality of life, a man may undergo initial treatment by oral medication, such as alpha-1 receptor blockers, 5-alpha-reductase inhibitors, or phosphodiesterase-5 enzyme inhibitors. Those with severe/progressive symptoms or those who do not experience symptom relief from medication have traditionally been considered for surgical intervention, with transurethral resection of the prostate or TURP as the standard of care.[ citation needed ]
However, there are problems with both medical and surgical treatments, including undesired side effects and variable effectiveness. For example, sexual dysfunction and orthostatic hypotension are side effects of 5-alpha-reductase inhibitors. [4] Prostatic artery embolization is an emerging treatment alternative which avoids the risks of systemic medication and of surgery.
The first report of selective prostatic artery embolization resulting in relief of prostate gland obstruction was published in 2000. [5] Since then, prospective trials with large numbers of patients, up to approximately 1000 patients/trial, have been carried out internationally.[ citation needed ]
After local anesthesia is placed, an interventional radiologist obtains access to the arterial system by piercing the femoral or radial artery, usually under ultrasound guidance, with a hollow needle known as a trocar. Through the needle a guidewire is threaded and subsequently the trocar is removed. The guidewire allows a 4 to 5 French sheath to be inserted into the artery.8 Contrast material is injected through the sheath or a catheter under fluoroscopic imaging or digital subtraction angiography which outlines the anatomy of the blood vessels. This technique is used to help locate the prostatic artery and advance a microcatheter (≤2.7 French) to the ostium of the prostatic artery. There are usually two prostatic arteries, one on either side of the pelvis. Microparticles, usually Microspheres, are then injected into the prostatic artery until full stasis distal prostatic artery and the proprietary prostatic vessels. They function by causing embolization (blockage of the artery) preventing blood flow to the prostate, functionally resulting in reduced prostate size. [6]
A 2022 Cochrane review of studies involving men over 40 with enlarged prostates and lower urinary tract symptoms found that prostatic arterial embolization (PAE) may work similarly to common surgical options (transurethral resection of the prostate) to relieve symptoms and improve men's quality of life in the short term (up to a year). [7] This review found that PAE may increase the need for retreatment. In the longer term (13–24 months), this review is very uncertain about the positive and negative effects of PAE in comparison with transurethral resection surgery. [8]
The incidence of adverse events with PAE is very low. The majority of adverse events during PAE are likely due to non-target embolization, and are generally self-limited in nature. The Cochrane review from 2020 assessed the current evidence and found that there are great uncertainties whether PAE differs in terms of serious side effects or problems with erections compared with transurethral resection of the prostate. However, PAE may reduce problems with ejaculation. [7]
The most common adverse effects include acute urinary retention, temporary rectal bleeding, pain, blood in the urine/sperm, and urinary tract infection. Serious complications are rare (0.3% [9] ), and include arterial dissection, bladder wall ischemia, and persistent urinary tract infection. Post-embolization syndrome, consisting of pain, mild fever, malaise, nausea, vomiting and night sweats, is sometimes observed after the procedure, and is treated with NSAIDS and other forms of analgesia.
The prostate is both an accessory gland of the male reproductive system and a muscle-driven mechanical switch between urination and ejaculation. It is found in all male mammals. It differs between species anatomically, chemically, and physiologically. Anatomically, the prostate is found below the bladder, with the urethra passing through it. It is described in gross anatomy as consisting of lobes and in microanatomy by zone. It is surrounded by an elastic, fibromuscular capsule and contains glandular tissue, as well as connective tissue.
Benign prostatic hyperplasia (BPH), also called prostate enlargement, is a noncancerous increase in size of the prostate gland. Symptoms may include frequent urination, trouble starting to urinate, weak stream, inability to urinate, or loss of bladder control. Complications can include urinary tract infections, bladder stones, and chronic kidney problems.
Tadalafil, sold under the brand name Cialis among others, is a medication used to treat erectile dysfunction, benign prostatic hyperplasia, and pulmonary arterial hypertension. It is taken by mouth. Onset is typically within half an hour and the duration is up to 36 hours.
Interventional radiology (IR) is a medical specialty that performs various minimally-invasive procedures using medical imaging guidance, such as x-ray fluoroscopy, computed tomography, magnetic resonance imaging, or ultrasound. IR performs both diagnostic and therapeutic procedures through very small incisions or body orifices. Diagnostic IR procedures are those intended to help make a diagnosis or guide further medical treatment, and include image-guided biopsy of a tumor or injection of an imaging contrast agent into a hollow structure, such as a blood vessel or a duct. By contrast, therapeutic IR procedures provide direct treatment—they include catheter-based medicine delivery, medical device placement, and angioplasty of narrowed structures.
Urinary retention is an inability to completely empty the bladder. Onset can be sudden or gradual. When of sudden onset, symptoms include an inability to urinate and lower abdominal pain. When of gradual onset, symptoms may include loss of bladder control, mild lower abdominal pain, and a weak urine stream. Those with long-term problems are at risk of urinary tract infections.
Transurethral resection of the prostate is a urological operation. It is used to treat benign prostatic hyperplasia (BPH). As the name indicates, it is performed by visualising the prostate through the urethra and removing tissue by electrocautery or sharp dissection. It has been the standard treatment for BPH for many years, but recently alternative, minimally invasive techniques have become available. This procedure is done with spinal or general anaesthetic. A triple lumen catheter is inserted through the urethra to irrigate and drain the bladder after the surgical procedure is complete. The outcome is considered excellent for 80–90% of BPH patients. The procedure carries minimal risk for erectile dysfunction, moderate risk for bleeding, and a large risk for retrograde ejaculation.
Dutasteride, sold under the brand name Avodart among others, is a medication primarily used to treat the symptoms of a benign prostatic hyperplasia (BPH), an enlarged prostate not associated with cancer. A few months may be required before benefits occur. It is also used for scalp hair loss in men and as a part of hormone therapy in transgender women. It is usually taken by mouth.
Nocturia is defined by the International Continence Society (ICS) as "the complaint that the individual has to wake at night one or more times for voiding ". The term is derived from Latin nox – "night", and Greek [τα] ούρα – "urine". Causes are varied and can be difficult to discern. Although not every patient needs treatment, most people seek treatment for severe nocturia, waking up to void more than 2 or 3 times per night.
Tamsulosin, sold under the brand name Flomax among others, is a medication used to treat symptomatic benign prostatic hyperplasia (BPH) and chronic prostatitis and to help with the passage of kidney stones. The evidence for benefit with a kidney stone is better when the stone is larger. Tamsulosin is taken by mouth.
Transurethral needle ablation is a technique that uses low energy radio frequency delivered through two needles to ablate excess prostate tissue. A cystoscope/catheter deploys the needles toward the obstructing prostate tissue and is inserted into the urethra directly through the penis under local anesthetic before the procedure begins. The energy from the probe heats the abnormal prostate tissue without damaging the urethra. The resulting scar tissue later atrophies, reducing the size of the prostate which in turn reduces the constriction of the urethra. It can be done with a local anesthetic on an outpatient basis. It takes about an hour to perform the procedure. It takes about 30 days for the ablated prostate tissue to resorb.
Saw palmetto extract is an extract of the fruit of the saw palmetto. It is marketed as a dietary supplement that may help with benign prostatic hyperplasia, but there is no clinical evidence that it is effective for this purpose.
A prostatic stent is a stent used to keep open the male urethra and allow the passing of urine in cases of prostatic obstruction and lower urinary tract symptoms (LUTS). Prostatic obstruction is a common condition with a variety of causes. Benign prostatic hyperplasia (BPH) is the most common cause, but obstruction may also occur acutely after treatment for BPH such as transurethral needle ablation of the prostate (TUNA), transurethral resection of the prostate (TURP), transurethral microwave thermotherapy (TUMT), prostate cancer or after radiation therapy.
Lower urinary tract symptoms (LUTS) refer to a group of clinical symptoms involving the bladder, urinary sphincter, urethra and, in men, the prostate. The term is more commonly applied to men – over 40% of older men are affected – but lower urinary tract symptoms also affect women. The condition is also termed prostatism in men, but LUTS is preferred.
Transurethral microwave thermotherapy (TUMT) is one of a number of effective and safe procedures used in the treatment of lower urinary tract symptoms caused by benign prostatic hyperplasia. It is an alternative treatment to pharmacotherapy such as alpha blockers, transurethral resection of the prostate (TURP), transurethral needle ablation of the prostate, photoselective vaporization of the prostate and prostatic removal or prostatectomy.
Alpha-blockers, also known as α-blockers or α-adrenoreceptor antagonists, are a class of pharmacological agents that act as antagonists on α-adrenergic receptors (α-adrenoceptors).
GreenLight Laser Therapy is a medical procedure for treating benign prostatic hyperplasia. It uses a laser beam to remove prostate tissue. The laser treatment is delivered through a thin and flexible fiber, which is inserted into the urethra through a cystoscope.
If medical treatment is not effective, surgery may need to be performed for benign prostatic hyperplasia.
Aquablation therapy (AquaBeam) is a surgical procedure for men with lower urinary tract symptoms resulting from benign prostatic hyperplasia (BPH). It is in the early stages of study. It is not categorized as minimally invasive as general anesthesia is required. The procedure was developed by PROCEPT BioRobotics and combines real-time visualization through a cystoscope and a bi-plane ultrasound, while using a high-velocity sterile saline heat-free waterjet and autonomous robotics to remove prostate tissue.
Prostate steam treatment (Rezum), also called water vapor thermal therapy (WVTT), is a minimally invasive surgical procedure for men with lower urinary tract symptoms resulting from prostate enlargement. It uses injections of steam to remove obstructive prostate tissue from the inside of the organ without injuring the prostatic part of the urinary tube.
Prostatic urethral lift is a minimally invasive procedure for the treatment of benign prostatic hyperplasia. One of the First Surgeons to perform this procedure is Dr. Simon Barkagan. Located in Forest Hills queens. This procedure can be done under local anesthesia in an outpatient consultation.