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PAE Prostate Procedure: The Case for Early Intervention

Author Bryant Schmitz covers PAE Prostate Procedure: The Case for Early Intervention on BackTable VI

Bryant Schmitz • Jun 6, 2023 • 259 hits

Prostate artery embolization (PAE) has significantly evolved over the years, becoming an increasingly common procedure. Recent long-term studies underline the durability of PAE results and its robust safety profile, but there are still open questions around when the PAE prostate procedure should be utilized, who the right patient population is, and what the optimal procedure technique should be. Interventional radiologist Dr. Sam Mouli shares his view on the role of prostate artery embolization in the treatment of benign prostate hyperplasia (BPH), and explains when the PAE prostate procedure may be appropriate as a first-line therapy. He also discusses the evolution of prostate artery embolization, the role of urology in treating self-referral patients that desire PAE, and his view of the PAE retreatment data.

This article features transcripts for the BackTable Podcast. We’ve provided the highlight reel here, and you can listen to the full podcast below.

The BackTable Brief

• PAE stands out for its minimally invasive nature and the absence of major side effects like sexual dysfunction, urinary leakage, and hematuria, commonly seen in surgical resections. The PAE procedure does not preclude patients from pursuing other medical or surgical therapies in the future.

• The current treatment pathway for BPH with lower urinary tract symptoms (LUTS) often starts with medications like Flomax and finasteride, which patients often tolerate poorly. Urologists are increasingly advocating for early surgical intervention, particularly in cases with larger glands, to bypass ineffective medical management. PAE is proposed as a viable early intervention to avoid prolonging symptoms and potential adverse events associated with medication use.

• A significant number of patients for PAE come through self-referrals. Most self-referred patients are already diagnosed with benign prostatic hyperplasia (BPH) and have sought out PAE as a less invasive treatment option. Self-referred patients without a confirmed BPH diagnosis are typically advised to see a urologist for an official diagnosis to ensure the appropriateness of PAE.

• Unacceptably high retreatment rates are one point of controversy in early PAE treatment. According to Dr. Mouli, early PAE retreatments are often due to procedure technique issues. With the right technique, retreatment rates for PAE and other minimially invasive surgical techniques (MISTs) align, typically falling within a 10% to 30% range at 5 to 10 years.

• Mouli argues for standardizing PAE techniques to yield more reproducible results and facilitate informed decision-making for patients.

PAE Prostate Procedure: The Case for Early Intervention

Table of Contents

(1) The Evolution of Prostate Artery Embolization

(2) The Case for Early Prostate Artery Embolization

(3) The Role of Urologists and Patient Self-Referral in the PAE Prostate Procedure

(4) Retreatment Rates Following Prostate Artery Embolization

The Evolution of Prostate Artery Embolization

The PAE prostate procedure has seen an increased rate of adoption as a treatment option for benign prostatic hyperplasia. This trend is largely due to sustained research efforts that have led to the refinement of PAE techniques and tools. Recent studies have highlighted the long-term durability of PAE results and its notable safety profile, further supporting its acceptance within the medical community. Moreover, the utilization of PAE doesn't limit future therapeutic options, thus offering flexibility in patient treatment plans.

[Dr. Michael Barraza]
Sam, we're going to be talking about PAE. We already knew at the beginning we were going to talk about PAE, and usually what I do is I send out an email. It's like, "Hey, this is what we're going to talk about." For our listeners, I emailed Sam. Sam is one of the main guys for PAE right now in terms of research. I figured I better off just asking him, "What do you want to talk about?" One of the ideas he had suggested was some controversies in PAE. Certainly, they're there. We've done probably four or five podcasts on PAE.

Looking back on the first one, which is probably four or five years ago, the landscape has completely changed. I would say we're approaching this being, I don't want to say mainstream procedure, but it is a lot more common when I first interviewed Ari Isaacson and Sandeep Bagla on this. Then that there were really only a handful of people doing it in a handful of places. Now you can find somebody that does it in just about every major city.

[Dr. Sam Mouli]
Yes, we've come a long way since the beginning. I would say that Ari and Sandeep did the lion's share of work along with several other investigators from around the US and around the world to really democratize PAE for a variety of patients and allow us to really refine the techniques. Their lead has allowed industry to follow and develop new tools to make it easier to do. What we had 10 years ago compared to what we have today is a huge, huge change and so a lot of people are getting more and more comfortable in this space and more and more comfortable treating patients.

I think it's very clear from all of the data that we have from multiple trials that this is really something that should be offered to all patients with BPH who are considering surgical resection of their prostate. It's right up there with the other minimally invasive therapies.

[Dr. Michael Barraza]
Now, Sam, I feel like we've had some very convincing data for years now. We all know the issues with the AUA guidelines. I don't think we need to get into that. Do you think, has there been anything major in terms of data in the last 6 to 12 months that goes beyond what we already have?

[Dr. Sam Mouli]
Yes, I think the two biggest papers that came out in the last year or so, and I'm probably getting the dates incorrect, but we have the long-term studies from both the Portuguese group from Tiago Bilhim's group and then Francisco Carnevale's group that basically come out around the same time showing what the 10-year data for PAE is. I think the two biggest take-home points from those large data series is the durability of symptoms, how long these procedures typically last, and then also the safety profile.

I think the biggest positive for PAE and what I share with patients is amongst all of the minimally invasive surgical therapies, it's very, very safe. With experience, you can do this with a very great safety profile, especially in comparison to some of the other surgical therapies. We can do this in patients and they don't require a Foley catheter, et cetera. They don't really suffer from sexual dysfunction afterwards, urinary leakage, hematuria, all these other things that you might see with surgical resection. That's really the case to make for why PAE should be pursued maybe first-line instead of surgery because it's just very, very safe in patients.

Additionally, we can see even from those long-term data series that it doesn't preclude a patient from getting any other medical or surgical therapy down the line. Let's say their symptoms progress and they decide to go on to TURP or what have you, all of those options are still available. You haven't lost anything by trying, so to speak.

Listen to the Full Podcast

Current Controversies in Prostatic Artery Embolization with Dr. Sam Mouli on the BackTable VI Podcast)
Ep 280 Current Controversies in Prostatic Artery Embolization with Dr. Sam Mouli
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The Case for Early Prostate Artery Embolization

Some proceduralists consider prostate artery embolization as a first-line therapy alongside medical management for patients diagnosed with benign prostatic hyperplasia and lower urinary tract symptoms (LUTS). Dr. Mouli posits that medical therapies often yield poor patient tolerance and higher failure rates with larger glands, leading some urologists to advocate for early surgical intervention. As an alternative, he suggests that the PAE prostate procedure could be utilized similarly, skipping the medication stage and moving directly to a more effective treatment. The advantages of this approach, Mouli suggests, include avoiding the side effects and potential adverse events associated with prolonged medication use, particularly in patients with larger glands where the efficacy of medical management is expected to be lower.

[Dr. Michael Barraza]
Let's go through some of the other controversies that you had mentioned in your email. The first one was, we're going to call it controversy number one like you did in your email. PAE should be considered alongside medical management.

[Dr. Sam Mouli]
If you look at the AUA guidelines and what practices and what our understanding is, and so they branch off the treatment pathway in that patients can go after they declare that they have BPH with lower urinary tract symptoms and they are indeed symptomatic. They can start on medications like Flomax and finasteride, so 5-alpha-reductase inhibitors and alpha-blockers. However, everybody knows that patients don't really tolerate these medications. They get really bad side effects and the failure rates are higher with larger glands.

A lot of urologists are opting for what's called early surgical intervention, where they basically push for getting a patient to surgery when they have the right indication. They have a large gland, they know they're going to fail medical management, et cetera. So why wait to treat them and know that their symptoms are going to progress and just get early treatment for their BPH and lower urinary tract symptoms? If we know that's already happening in the surgical space, it would make sense that you could do the same thing with embolization. Obviously you make sure that the patient does indeed have BPH and LUTS and why not go straight to treatment instead of prolonging things when you know they're not going to work?

[Dr. Michael Barraza]
I think it makes a lot of sense and I think you can very easily make the argument, especially for a really large gland, you know those symptoms are coming, you know it's not going to fully improve with meds. I think that makes a lot of sense and especially there's a time factor too. I mean, that these people are in the meds for usually a good while before we get to the treatment part.

[Dr. Sam Mouli]
Yes, exactly. So why prolong that? Why have the side effects and the potential adverse events that can occur with just keeping patients on medication from a urinary retention standpoint or UTIs or other things when you know it's not going to work in a big gland and just get them to early treatment?

The Role of Urologists and Patient Self-Referral in the PAE Prostate Procedure

Dr. Michael Barraza and Dr. Sam Mouli discusses the role of urologists and patient self-referral in the practice of prostate artery embolization. To initially grow his practice, Dr. Barraza felt that having a urologist on board was crucial, but he gradually noted an influx of self-referred patients, many of whom were already seeing a urologist or were uninterested in doing so. Dr. Mouli also identifies that a significant portion (75-95%) of his patients are self-referrals. A typical patient, according to Dr. Mouli, has already been diagnosed with BPH and has sought out less invasive options like PAE. When patients self-refer without a confirmed BPH diagnosis, Dr. Mouli advises them to see a urologist for an official diagnosis to ensure the most accurate and effective treatment path.

[Dr. Michael Barraza]
…should PAE be performed only alongside a urologist, not in the same room, but basically, patient who's already seeing urology? I'll tell you to start off when I started doing this, I felt very strongly that I needed to have urology on board. I went out and spent some time with Ari when he was still at UNC maybe five years ago and saw how they were doing it and I came out of there convinced it's like this is the way they follow up with urology.

Then I got into practice and I just waited and waited and continued to wait for any referral from urology. I did a lot of work trying to get these referrals, do a lot of good work outside of the prostate space with these guys and nothing came. What I started to see was a lot of self-referred patients, and some of them were already seeing a urologist, some were not interested.

Sam, for me, I've got where I haven't really had much of a choice. Some of these I just have to deal with on my own. I've got a urologist that I can refer to for anything like that, but I am kind of interested in getting your take on it. I'm sure you guys have a very robust relationship with urology there, so it's a little bit easier for you, but I'm sure you find self-referred patients too.

[Dr. Sam Mouli]
Speaking openly, probably 75% to 95% of my practice is self-referrals, honestly.

[Dr. Michael Barraza]
Wow. Okay.

[Dr. Sam Mouli]
Most patients, what I've found is unlike fibroids and gynecology, most men have a transactional relationship with their urologist. This is something I learned from Bob [unintelligible 00:15:05] saying, actually. You only really go and see your urologist when you have a problem. You're not seeing them after childbirth for your whole life, and so a lot of men are not wedded to continuing to see their urologist. Once they have the diagnosis of BPH, they're looking for all their options. Totally reasonable to see them after that.

[Dr. Michael Barraza]
When you get a patient who self-referred, do you have them see urology as well?

[Dr. Sam Mouli]
Typically, what I've found is, and I think it's probably different everywhere, is a man will not show up in my clinic unless they've been told they have BPH and they've been diagnosed with it because otherwise, they have no reason to see me.

[Dr. Michael Barraza]
Okay.

[Dr. Sam Mouli]
They're a very well-educated population in general. They know what the treatment options that are out there, they've been told about TURP or other invasive surgical therapies and they're like, "It doesn't really sound like that's what I want to have a scope, et cetera." I won't get too vulgar on the podcast. They already know what they're in for and so they've already educated themselves and that's why they've come and seen me. I typically have patients who have already had the diagnosis of BPH. That being said, occasionally, you see ones that somehow find you anyways and I do like them to see somebody to confirm in the EMR.

Retreatment Rates Following Prostate Artery Embolization

Dr. Sam Mouli tackles the ongoing controversy regarding retreatment rates in prostatic artery embolization (PAE), arguing that these rates do not imply a lack of efficacy for the treatment but rather are reflective of the natural history of BPH. He attributes early retreatments to technique-related issues such as failure to treat both sides of the gland, likening it to performing only half a transurethral resection of the prostate (TURP). Mouli points out that the long-term retreatment rates for PAE align with those of other minimally invasive surgical therapies (MIST), indicating a consistent trend rather than a failing of PAE. He advocates for PAE as a less invasive option, allowing for the preservation of sexual function and the possibility of later retreatment or progression to more invasive treatment if necessary.

[Dr. Michael Barraza]
Sam, the next thing I have for you…retreatment rates depict a false narrative of PAE utility. We touched on this a little bit, but I want to take it a little bit further, and just have you run through this one.

[Dr. Sam Mouli]
The big knock against prostate embolization is that when urologists look at the data, especially from the RCTs that were published out of the Swedish trial and others, there was a 20% retreatment rate at one year. Then they're like, "Well, it doesn't work in a large number of patients." Then looking more globally at the long-term data that we talked about earlier in the podcast, at 5 to 10 years, there's probably also a 20% retreatment rate, and so what are these retreatment rates?

I think the early failures are really contingent upon technique. How are you doing it? Are you identifying all the vessels? Are you treating both sides of the gland? Those early papers, those big RCTs that the app trial and such, a large number of patients were only treated with unilateral embolization. Hence why they have recurrence of symptoms very, very early. It makes sense. You've treated on one side, we know that that's not going to work. Same thing with the UK-ROPE trial, and so when urologists bring up those issues, that's basically the argument can be made. That's like doing half a TURP, or half a Rezum, or Aquablation. Of course, it's not going to work.

The long-term retreatment rates really speak to the natural history of the disease. I don't think it's possible to get a retreatment rate that's zero, and when you compare PAE to other minimally invasive surgical therapies and there are a lot of nice systemic meta-analyses that are both from the PAE literature and also the MIST literature, they all really show that the long-term retreatment rates for both groups of therapies are in the 10% to 30% range at 5 to 10 years.

[Dr. Michael Barraza]
Interesting.

[Dr. Sam Mouli]
Lines up pretty nicely. PAE has a retreatment rate of that, so do all the other MISTs. It's really consistent. If we have this similar retreatment rate and we know what the natural history of the disease is, why wouldn't you want to choose something that is less invasive, has a better safety and side effect profile, and won't affect sexual function rather than something that's more invasive, and so I think that's a better option for patients.

If you were to counsel them appropriately and present everything like this, I would argue that a patient would rather undergo something like a PAE and preserve his sexual function early on and then progress if he needs to, to something more invasive later on in life. Or have a repeat PAE if he needs to, rather than move forward to something more invasive surgically.

[Dr. Michael Barraza]
Man, I think you just nailed that one. One of the benefits of this, this does not take anything off the table for any further treatments. We do this, you are still available to have any of the other treatments that are out there after this. This does not stop anything. Sam, that's about all I got. Is there anything else that you want to talk about?

[Dr. Sam Mouli]
I think we covered a lot. I think I'm very passionate about this space and this technique, and I really think we're doing a good job as a specialty of really trying to bring it to as many patients as possible. I think the next goal, as we touched on as a group, is we just have to really agree and draw a line in the sand of, "This is how we should all be doing it." Let's all agree to do it the same way. Maybe that comes in the form of guideline documents, et cetera. That way everybody's doing it the same way. The results are very reproducible and patients can have really good outcomes.

Why do I think that's achievable? If you compare the long-term data from the Portuguese group and the Brazilian group, they're very similar, and those are guys who are high-level operators who are doing it exactly the same way for case-in-case-in-case-out. We should be doing it the same way. In our own experience, we've tried to adapt those techniques and we see similar outcomes. I think it's conceivable that everybody can do it this way. Everybody can have very similar outcomes and then a patient can look at the data, and make an informed decision knowing that it's not really contingent upon what particle the further uses or microcatheter, et cetera.

It's going to be a reproducible result, and they can rest assured that they know what they're getting into.

[Dr. Michael Barraza]
I'm with you. I think that's a great way of putting it. Sam, thank you. I really appreciate you taking the time out of your day to join us, and I look forward to begging you to come back on, once you publish some of this new data you guys have coming down the pipe. Thank you and thanks again to our listeners and we'll catch you guys on the next one.

Podcast Contributors

Dr. Sam Mouli discusses Current Controversies in Prostatic Artery Embolization on the BackTable 280 Podcast

Dr. Sam Mouli

Dr. Samdeep Mouli is an Assistant Professor of Vascular and Interventional Radiology at Northwestern University Feinberg School of Medicine.

Dr. Michael Barraza discusses Current Controversies in Prostatic Artery Embolization on the BackTable 280 Podcast

Dr. Michael Barraza

Dr. Michael Barraza is a practicing interventional radiologist (and all around great guy) with Radiology Associates in Baton Rouge, LA.

Cite This Podcast

BackTable, LLC (Producer). (2023, January 9). Ep. 280 – Current Controversies in Prostatic Artery Embolization [Audio podcast]. Retrieved from https://www.backtable.com

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. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.

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