BackTable / VI / Podcast / Episode #280
Current Controversies in Prostatic Artery Embolization
with Dr. Sam Mouli
In this episode, host Dr. Michael Barraza interviews interventional radiologist Dr. Samdeep Mouli about controversies in prostate artery embolization, including technique, durability, and how we can leverage the data to unite IRs and establish PAE as standard of care.
BackTable, LLC (Producer). (2023, January 9). Ep. 280 – Current Controversies in Prostatic Artery Embolization [Audio podcast]. Retrieved from https://www.backtable.com
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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
Dr. Michael Barraza is a practicing interventional radiologist (and all around great guy) with Radiology Associates in Baton Rouge, LA.
Dr. Mouli discusses his role as director of translational research in interventional radiology at Northwestern. He reviews the most recent major data on PAE. There have been two major papers, one from a Portuguese group and another from a Brazilian group. The take home points from these papers are regarding the durability of symptoms and the safety profile of PAE. The biggest positive of PAE is that it is the safest among all minimally invasive surgeries. Dr. Mouli argues that PAE should be pursued as first line treatment for benign prostatic hyperplasia (BPH) with lower urinary tract symptoms (LUTs). Another upside of PAE is that it doesn’t prevent patients from undergoing any other medical or surgical intervention in the future.
One of the barriers to PAE becoming first line therapy is that there is currently no standardization among operators. Everyone still does it differently, whether by using different microcatheters, particle sizes, or other technical factors. This gives urologists ground to stand on when they argue against PAE. Dr. Mouli feels IRs should approach BPH with the same rigor that urologists do. He believes we need to use the long-term data to prove that PAE is safe, durable and yields better sexual outcomes than TURP or other minimally invasive surgical procedures. This can be accomplished via publishing guidelines for IRs. He believes a good starting place is to only use 300-500 micron particles for de-novo PAE cases. It has been proven this size is safe and results in very low non-target embolization compared to the 100-300 micron size, which more commonly causes this complication and results in more sexual dysfunction.
Dr. Mouli says urologists are pushing for surgical intervention before exhausting medical management and argues that IRs should do the same. He believes offering PAE early is in the best interest of patients, because waiting to fail medical management can cause further complications. Dr. Mouli does not get pre-procedure vascular imaging or MRI. This is because he uses intra-procedure cone beam CT. He does this as part of his procedure to map out collaterals and other blood supply to the prostate. He then targets these arteries with coils before using particle embolization on the prostate gland itself. He does this because his goal is to match the 5 year success rate demonstrated in recent studies of over 80 percent, with a less than 20% recurrence rate. He ends by stating that the long-term data show a 10-30% re-treatment rate across all treatment modalities. Knowing this, he feels even stronger that PAE should be the first line therapy, considering it is the least invasive option, it is safe and has the lowest rates of sexual dysfunction. If patients prefer more invasive procedures in the future, they can still go that route, or they can elect for repeat PAE as needed.
Triago Bilhim Paper:
Francisco Carnevale Paper:
[Dr. Sam Mouli]
I think everybody has a different flavor of doing it right now. I won't really speak to the radial versus femoral approach because I don't think that makes a huge difference in terms of the actual outcomes. It's just patient preference at that point, but what catheters and wires to use, what your endpoints should be, perfected or not perfected, what size particles, we should do coils, should use liquids, et cetera. Everybody's doing it a little bit differently. It's not reproducible and the data is not consistent. That's been the big knock from the urology standpoint.
When you look at a TURP or an Aquablation or any of these minimally invasive surgical therapies, they're all done pretty much exactly the same way. There isn't a lot of room for artistic interpretation, if you will, for these cases when the urologists do them. When they have these large series, like everybody's trained up and they're all doing it the same way, we need to approach PAE with the same rigor. I think the best way to do that is to follow the data. We have a lot of long-term data, as I mentioned, from the Brazilian and Portuguese groups as to what the best techniques are and how we should be doing them, and what size particles to use and the techniques.
We should be implementing all of that because that's our best long-term data. If everybody's doing it that way, I really feel strongly that we can get the numbers that we should be getting in all these cases and getting the outcomes that make it very comparable to urologic therapies and very consistent.
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