Prostate artery embolisation is a relatively new therapy for treating benign prostatic hypertrophy (BPH). BPH is a common non cancerous enlargement of the prostate gland affecting many older males. This exciting new treatment was first reported in 2010 (Carnevale) with two patients treated for BPH. Embolisation (blocking of arterial blood supply) of the prostate has been performed for many years for other prostate problems, this has largely been in the setting of haematuria (bleeding), particularly following either surgical interventions or malignancy.
The gold standard treatment for BPH remains surgical approaches, at least until further randomised evidence becomes available.
Prostate artery embolisation is performed through angiographic embolisation where the arteries feeding the prostate are blocked with small particles to cause shrinkage of the prostate. The procedure is usually performed under light anaesthesia and takes 40 to 90 minutes in good hands. The procedure is usually performed through the femoral artery in the right groin and in an angiographic suite (operating room with angiographic capability). Patients are up and walking two hours after the procedure. Access for this procedure has recently been advocated from the left wrist. However, patients need to be aware that this (anecdotally) has added to longer procedures with higher radiation doses, than more orthodox approaches. Patients can usually go home some 4 hours after the procedure. It is common to have some low pelvic pain and increase in lower urinary tract symptoms (LUTS) for a number of hours to days following the procedure.
This procedure is performed for patients with lower urinary tract symptoms (LUTS) which are urinary frequency, urgency, intermittency, poor stream, straining, nocturia and incomplete bladder emptying. It is important that patients are reviewed in rooms prior to the procedure, to not only adequately explain the procedure and potential complications, but also to assess severity of symptoms. It is important to perform a quality of life symptom scores for BPH (IPSS or AUA). Patients with mild symptom scores are treated conservatively or medically. Patients with moderate symptoms usually are treated medically and patients with severe symptoms may be offered prostate artery embolisation or surgery. It is important to rule other causes of LUTS, including the various causes of bladder instability, prostatitis and malignancy.
Data so far suggests that Prostate Artery Embolisation (PAE) is effective in relieving symptoms within a number of weeks following the procedure, whilst side effects are generally mild. Major complications of PAE appear to be rare. There is one randomised trial of PAE versus TURP. Results demonstrated (at 12 month and 24 month follow-up) that both groups had similar improvements in IPSS, quality-of-life, peak flow rate and post void residual volumes. Technical failures were higher in the PAE group (5.3% versus 0% for TURP) and clinical failures were higher again in the PAE group (9.4% versus 3.9%). Major complications only occurred in the TURP group. It should be noted that many patients in this country will have green light laser rather than TURP, which is believed to have similar success rates to TURP but with lower complication rates.
The effect of treatment with PAE appears to be significant, with marked reduction in IPSS and improvements in urinary flow rates. Quality-of-life scores and patient follow-up demonstrate high satisfaction with the results. The outcomes appear to be durable given recent published results. However, research is ongoing. Potential complications of PAE include bladder and rectal ulceration, non-target embolisation and infection. These appear to be rare. It should be noted as many as 25% of patients may not show significant reduction in IPSS or improvement in peak flow rates. Unlike the surgical approaches PAE is not limited by the size of the prostate.
If you would like to discuss this procedure please fill out an AUA score and call us on 8060 4270 too make an appointment to see A/Prof Stuart Lyon.