Procedure Guide

Prostate Artery Embolization

An overview for this procedure is not yet available.

Step-by-step guidance on how to perform Prostate Artery Embolization. Review tools, techniques, pearls, and pitfalls on the BackTable Web App.

Pre-Procedure Prep

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

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

Prostate Artery Embolization Podcasts

Ep. 148

Radial vs. Femoral for Prostate Artery Embolization

We talk with Dr. Blake Parsons about his approach to Radial vs. Femoral access for Prostate Artery Embolization for BPH, including patient selection, device considerations, and practice pearls.

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Ep. 145

The History (and Future) of the STREAM Conference

We talk with STREAM meeting founders Dr. Ari Isaacson and Dr. Sandeep Bagla about what they have planned at STREAM 2021 for docs who want to learn Prostate Artery Embolization, Musculoskeletal Embolizations, and new techniques for Pain Therapy.

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Ep. 96

Building a Prostate Artery Embolization Program Alongside Urology

IR Ari Isaacson and Urologist Matt Raynor tell the story of how they successfully built a collaborative PAE program, including the challenges they faced along the way, and tips for success in working together.

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Ep. 17

Prostate Artery Embolization

Dr. Ari Isaacson and Dr. Sandeep Bagla sharing their experiences with prostate artery embolization, including a candid discussion on practice building and equipment.

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Procedure Steps

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

Prostate Artery Embolization Articles

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

Prostatic artery embolization (PAE) experts Dr. Ari Isaacson and Dr. Sandeep Bagla debate their preferred imaging modalities, and discuss what imaging techniques helped them get started with PAE.

Prostate anatomy imaging for prostate artery embolization

Minimizing Nontarget Embolization (and Maximizing Efficacy) in Prostatic Arteries

The consequences of nontarget embolization can deter interventional radiologists and patients from following through with a prostatic artery embolization (PAE) procedure. PAE experts Dr. Sandeep Bagla and Dr. Ari Isaacson discuss their PAE technique, why it's effective, and how it helps them minimize nontarget embolization.

Image of nontarget embolization in prostate artery embolization

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 and absolute contraindications to PAE.

Benign prosttic hyperplasia 3D drawing

Prostate Artery Embolization Side Effects

Prostate artery embolization side effects are uncommon and generally mild. PAE expert Dr. Ari Isaacson discusses his experiences with acute urinary retention, post-PAE syndrome, and what side effects interventional radiologists should expect.

Prostate artery embolization side effects

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

Post-Procedural 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

Follow-Up

• 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

Prostate Artery Embolization Demos

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.

Prostate Artery Embolization Tools

Prostate Volume Calculator

The prostate volume calculator is a tool that can be used to quickly determine the approximate size of the prostate. To use this tool, you will need the prostate length, width, and height (in centimeters). Since the prostate has an ellipsoid shape, you use the ellipsoid volume formula. The prostate volume calculator can also be used for the bladder and ellipsoid lesions. This calculation serves as an estimation.

After inputting the values into the prostate volume calculator, it will calculate both the ellipsoid volume and bullet volume. If the prostate gland is smaller than 55 mL, then the bullet volume may be a more accurate representation of the prostate volume. If you also have the prostate-specific antigen (PSA) in ng/mL, then the prostate volume calculator also acts as a PSA density calculator and provides you a PSA density value.

Prostate Volume Calculator on BackTable

Ellipsoid Volume Calculator

Ellipsoid volume calculator to estimate prostate size.

Ellipsoid Volume Calculator on BackTable

Related Content

No related content.

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Podcast

Prostate Artery Embolization

Prostate Artery Embolization Podcast Guest Dr. Sandeep Bagla
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Podcast

The History (and Future) of the STREAM Conference

The History (and Future) of the STREAM Conference BackTable Podcast Guest Dr. Ari Isaacson
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Practice Tool

Prostate Volume Calculator

Prostate Volume Calculator on BackTable
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Article

How to Build a Prostatic Artery Embolization (PAE) Practice

Physician shaking hands to build prostate artery embolization practice

Join The Discussion

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

Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients.