Prostate Artery Embolization

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Pre-Procedure

Indications:
• Benign prostatic hypertrophy (BPH) with lower urinary tract symptoms (LUTS)
• Intractable hematuria

Patient population:
Treat patients with moderate to severe LUTS
Patients who have failed or cannot tolerate conservative medical management
• Hypotension
• Retrograde ejaculation
• Decreased sexual drive
Surgery
• Patients often concerned about potential morbidity or complications
• Contraindication to surgery related to patient comorbidities
Prostate size > 40 g

Workup
IPSS
• Many agree with an International Prostate Symptom Score (IPSS) < 8, PAE not indicated
• Quality of Life (QoL)
• IPSS a a good survey for assessing LUTS

Urodynamics:
• Specialized test to assess detruser strength
• Can discern between neurogenic bladder and bladder outlet obstruction
• Neurogenic bladder can be seen in spinal cord injury, MS, diabetics.

Uroflowmetry
• Qmax: > 10 mL/s unlikely to benefit from PAE
• If Qmax > 10 mL/s, consider other causes of LUTS

Labs: PSA, BMP and urinalysis
Imaging
• Ultrasound: can evaluate prostate size and evaluate bladder for post void residual (PVR) volume.
• CTA or MRA: can estimate prostate size and potentially evaluate prostate arteries
• MR: can evaluate prostate size and underlying neoplasm. Can compare pre MRI with post MRI to assess change in volume and enhancement

In summary:
• Recommend consistent preprocedural workup for patients
• Use IPSS
• Need basic understanding of uroflowmetry and post void residual volume
• Need algorithm for prostate cancer evaluation
• Preprocedural imaging can range from basic to complex
• LUTS are not always secondary to BPH

Procedure

Antibiotic:
• 400 mg Ciprofloxacin IV preprocedure
• Continue 500 mg Ciprofloxacin PO BID x 5-7 days following procedure

Outpatient procedure
Sedation: ranges from local to MAC
Foley helpful especially when starting out, but try to avoid as comfort level and experience increase
BB marker on base of penis also helpful when starting out

Procedure in Summary:
• Access: radial vs femoral
• Catheterize left internal iliac artery (IIA)
• DSA: 45° ipsilateral oblique
• 2.1 or 2.4-Fr microcatheter for prostate artery
• Confirm placement with DSA
• Confirm placement and potential non-target embolization with cone-beam
• 100 mcg nitroglycerine into prostate artery before embolization
• Many choices for embolics. Sizes range from 100-500 μm
• Endpoint: stasis or near stasis
• Repeat for contralateral prostate artery

Radial
• Good vector to catheterize the internal iliac arteries
• May have challenges for cone-beam CT
Femoral - sometimes bilateral access needed

Catheterize IIA
• Depends on tortuosity
• Can start with basic C2 catheter if using femoral approach
For femoral access and ipsilateral IIA
• Can pull reverse curve catheter like Sos into the IIA
• Waltman loop or RUC helpful to access anterior division of IIA

Identify prostate artery
Consider cone beam CT at beginning of procedure with flush catheter in aorta
• Gives nice overview of anatomy
• Can observe anatomic variants
• Can be helpful when choosing an obliquity for IIA DSA to identify origin of prostate artery
• Potential cone beam protocol: 6 mL/s for 42 mL (allows for 2 seconds to fill artery and a 5 second spin)
• Dilute contrast: 1:1 ratio of contrast to saline
DSA in IIA
• Helpful to access anterior division of IIA
• 45° ipsilateral oblique
• Prostate artery crosses main trunk of obturator artery (if present) > 95% of time
• Obturator easy to identify with distal fork
• Recommend looking at lots of angiograms prior to first case
• Understanding branches of IIA will help identify prostate artery

Catheterize prostate artery
• Many different techniques and tools
• Average diameter 1.6 mm
• Artery prone to spasm
• Recommend starting with 2.1-Fr microcatheter
• Preshaped microcatheters can be helpful
• Shapeable microwire usually fine
• 0.016" double angle Glidewire GT (Terumo) helpful
Confirm placement and evaluate for non-target embolization with cone-beam CT
• Many protocols
• Consider 0.5 mL/sec for 8 mL with 8 second delay (will obtain arterial information and parenchymal filling)

Potential non-target embolization
• Often easiest maneuver is to advance microcatheter distal to potential non-target branch
• Embolize with non-target vessel with Gelfoam or coils
• Larger particles (300-500 μm) may reduce chance of end tissue necrosis

Post-Procedure

Complications:
Non-target embolization: rectum, bladder and penis
Urinary retention
• Up to 8%
• More likely with larger volume prostates
• Treated with 1-2 weeks of indwelling Foley catheter
• Some operators will tell patients with > 150 g prostates to expect to go home with Foley
Minor complications
• Hematuria
• Hematospermia
• Pain

Postprocedural care:
• Can be discharged day of procedure
• 1-3 hour recovery time
• Discharge pain regimen to include anti-inflammatory, opioids for break through pain, antiemetics

Followup:
• 1, 3, 6 and 12 month visits
• IPSS at each visit
• Similar to UFE, maximal benefit between 3-6 months
• Post procedure imaging and urodynamics usually reserved for troubleshooting

Outcomes at 12 months:
• IPSS improved by 20 points
• QoL improved by 2.5 points
• PVR decreased by 86 mL
After 2 years, IPSS, Qol and urinary flow similar. TURP better at reducing prostate size

Related Procedures

No related procedures.

Step-by-step guidance on how to perform Cone Beam CT. Review tools, techniques, pearls, and pitfalls on the BackTable Web App.
 

References

[1] Moradzadeh N, Ranade A, McWilliams J. Angiographic features to aid identification of the prostatic artery during prostatic arterial embolization [abstract]. In J Vasc Interv Radiol. 2019;30(3):Supplement, Page S59. Abstract No.126.
[2] Bagla S, Isaacson AJ. Tips and Tricks for Difficult Prostatic Artery Embolization. Semin Intervent Radiol. 2016;33(3):236‐239. doi:10.1055/s-0036-1586145
[3] Carnevale FC, Iscaife A, Yoshinaga EM, Moreira AM, Antunes AA, Srougi M. Transurethral Resection of the Prostate (TURP) Versus Original and PErFecTED Prostate Artery Embolization (PAE) Due to Benign Prostatic Hyperplasia (BPH): Preliminary Results of a Single Center, Prospective, Urodynamic-Controlled Analysis. Cardiovasc Intervent Radiol. 2016;39(1):44‐52. doi:10.1007/s00270-015-1202-4
[4] Uflacker A, Haskal ZJ, Bilhim T, Patrie J, Huber T, Pisco JM. Meta-Analysis of Prostatic Artery Embolization for Benign Prostatic Hyperplasia. J Vasc Interv Radiol. 2016;27(11):1686‐1697.e8. doi:10.1016/j.jvir.2016.08.004
[5] Gao YA, Huang Y, Zhang R, et al. Benign prostatic hyperplasia: prostatic arterial embolization versus transurethral resection of the prostate--a prospective, randomized, and controlled clinical trial. Radiology. 2014;270(3):920‐928. doi:10.1148/radiol.13122803
[6] Martins Pisco J, Pereira J, Rio Tinto H, Fernandes L, Bilhim T. How to perform prostatic arterial embolization. Tech Vasc Interv Radiol. 2012;15(4):286‐289. doi:10.1053/j.tvir.2012.09.002
[7] BackTable, LLC (Producer). (2017, November 27). Ep 17 – Prostate Artery Embolizations [Audio podcast]. Retrieved from https://www.backtable.com/podcasts

Join The Discussion

 

Demos

Demos are not yet available for this procedure.

Please check back soon.

New BPH Treatment: Prostate Artery Embolization

Bilateral prostatic artery embolization in a 66-year-old patient with severe urinary symptoms secondary to BPH without response to pharmacological treatment.

PAE Presentation at STREAM 2.0

Dr. Tiago Bilhim discusses the use of balloon occlusion microcatheters for prostate arterial embolization (PAE) procedures.

Transradial Prostate Artery Embolization for Benign Prostatic Hyperplasia (BPH)

At Mount Sinai Hospital in New York City, Interventional Radiologists, Drs. Aaron Fischman, Art Rastinehad and Marcin Kolber perform embolization of both prostatic arteries (PAE) as a minimally invasive non-surgical treatment for benign prostatic hyperplasia (BPH) via the radial artery in the wrist.

 

Tools

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Ellipsoid Volume Calculator

Ellipsoid Volume Calculator on BackTable

Ellipsoid volume calculator to estimate prostate size.

Prostate Volume Calculator

Prostate Volume Calculator on BackTable

Measures prostate tumor volume and PSA density.

 

Literature

Literature is not yet available for this procedure.

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Seminars in Interventional Radiology (Sep 2016)

Tips and Tricks for Difficult Prostatic Artery Embolization

Endovascular technique for optimal prostatic artery embolization.

 

Podcasts

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Is Radioembolization a Future Option for Prostate Cancer? BackTable Podcast Guest Dr. Sam Mouli

Dr. Sam Mouli

Dr. Sandeep Bagla

Dr. Sam Mouli from Northwestern University and Dr. Sandeep Bagla discuss new research examining Y-90 Radioembolization as a novel therapeutic option for treating prostate cancer.

&

Prostate Artery Embolization Podcast Guest Dr. Sandeep Bagla

Dr. Ari Issacson

Dr. Sandeep Bagla

Dr. Ari Isaacson and Dr. Sandeep Bagla sharing their experiences with prostate artery embolization

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Blog Articles

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Minimizing Nontarget Embolization (and Maximizing Efficacy) in Prostatic Arteries

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The Most Common Complications of Prostatic Artery Embolization

Side effects of prostatic artery embolization (PAE) are uncommon and generally mild, but interventional radiologists should be prepared to navigate exception...

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How to Build a Prostatic Artery Embolization (PAE) Practice

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Catheter Selection for Prostatic Artery Embolization (PAE)

Prostatic artery embolization (PAE) experts Dr. Ari Isaacson and Dr. Sandeep Bagla discuss their go-to catheters and guidewires for different PAE cases, cove...

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Imaging for Prostatic Artery Embolization (PAE): CTA, Cone Beam CTA, or DSA?

CTA, Cone Beam CTA, and digital subtraction angiography (DSA) are equally viable options for pre-procedure imaging of the prostatic arteries. Prostatic arter...

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Contraindications to Prostatic Artery Embolization (PAE)

Patient selection is key to achieving good outcomes. Dr. Ari Isaacson describes his ideal prostatic artery embolization (PAE) patient, and discusses relative...