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BackTable / VI / Topic / Procedure
Prostate Artery Embolization
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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
Listen to leading physicians discuss prostate artery embolization on the BackTable VI Podcast. Get tips, tricks, and expert guidance from your peers and level up your practice.
Episode #220
STREAM Meeting Founders Ari Isaacson and Sandeep Bagla tell us about what to expect at the next meeting in September, including PAE and GAE practice building tips, as well learn about new embolization procedures such as adhesive capsulitis and thyroid arterial embolization.
Episode #164
Urologist Dr. Claus Roehrborn and Interventional Radiologist Dr. Sandeep Bagla discuss the pros and cons of Prostate Artery Embolization (PAE) compared to other Minimally Invasive Surgical Treatments (MISTS) for Benign Prostate Hyperplasia (BPH). They also discuss the importance of a collaborative, multidisciplinary approach when offering these treatment options, including agreeing on the best treatment for the patient.
Episode #148
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.
Episode #145
We talk with STREAM meeting founders Dr. Ari Isaacson and Dr. Sandeep Bagla about its origin story, as well as what they have planned at STREAM 2021 for docs who want to learn Prostate Artery Embolization, Musculoskeletal Embolizations, and new techniques for Pain Therapy.
Episode #96
Interventional Radiologist Ari Isaacson and Urologist Matt Raynor at UNC Health tell the story of how they successfully built a collaborative PAE program for the treatment of benign prostatic hyperplasia (BPH), including the challenges they faced along the way, and tips for success in working together.
Episode #17
Special guests Dr. Ari Isaacson and Dr. Sandeep Bagla sharing their experiences with prostate artery embolization, including a candid discussion on practice building, equipment, and a brief intro on what to expect at the upcoming STREAM PAE course Jan 13 in Washington DC.
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
Read our exclusive BackTable VI Articles for quick insights on prostate artery embolization, provided by physicians for physicians.
Prostate artery embolization technique may vary depending on which arterial access site is chosen (radial vs femoral). Different PAE techniques may also be utilized to minimize off-target embolization.
Understanding the variations in prostate artery embolization anatomy is crucial for improving technical success, reducing the chance of re-vascularization and minimizing non-target embolization. The variations in origin of the prostate artery can be sorted in a classification system.
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.
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.
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.
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.
Prostatic artery embolization (PAE) experts Dr. Ari Isaacson and Dr. Sandeep Bagla share how they built up benign prostate hyperplasia (BPH) referral from urologists and primary care physicians.
Prostatic artery embolization (PAE) microcatheter and guidewire selection is covered by experts Dr. Ari Isaacson and Dr. Sandeep Bagla for different PAE cases. They cover the Terumo Progreat microcatheter, Direxion microcatheter, Merit Maestro microcatheter, & more.
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
• Can be discharged day of procedure
• 1-3 hour recovery time
• Discharge pain regimen to include anti-inflammatory, opioids for break through pain, antiemetics
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 Tools
Check out prostate artery embolization apps, calculators, and decision aids to assist you in your day to day practice.
The prostate volume calculator is a tool that can be used to quickly determine the approximate size of the prostate, bladder, or ellipsoid lesions. It can also act as a prostate-specific antigen (PSA) calculator to provide you a PSA density value. Try it out for free!
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/shows/vi
Disclaimer: The Materials available on https://www.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.
Podcasts
Articles
Prostate Artery Embolization Technique: Advantages of Radial vs Femoral
Prostate Artery Embolization Anatomy
Imaging for Prostatic Artery Embolization (PAE): CTA, Cone Beam CTA, or DSA?
Contributors
Dr. Ari Isaacson
Dr. Blake Parsons
Dr. Matt Raynor
Dr. Claus Roehrborn