Age-related diseases are a group of morbidities that significantly affect the senior population.
Nonetheless, age-specific medical interventions for this particular group of patients remain limited. The primary obstacle is the ineligibility for non-customized treatment that generally requires physical fitness for invasive treatment tolerance.
But what if a newly discovered method can allow older patients to undergo less demanding and more effective treatment?
This article aims to provide the latest information about an emerging surgical technique called prostate artery embolization (PAE), its possible side effects and complications, and who can benefit from this treatment option.
Prostate Artery Embolization: A Safe and Effective Procedure for Urinary Symptoms
What Is Prostate Artery Embolization (PAE)?
Understanding Benign Prostatic Hyperplasia (BPH)
The prostate is a walnut-sized gland located beneath the bladder and surrounding the urethra.
Typically, this gland is involved in the nourishment, protection, and ejaculation of the sperm through the urethra. However, as we age, the prostate naturally enlarges over time, constricting the urethra and leading to several urinary symptoms, such as difficult or frequent urination and urinary incontinence.
This naturally occurring prostate enlargement is called benign prostatic hyperplasia (BPH). Technically, this condition refers to the increase in the number of non-cancerous cells in the prostate.
Benign prostatic hyperplasia virtually affects all men above 50. According to the Mayo Clinic, about one-third of men experience symptoms of prostate gland enlargement by age 60. By age 80, this number can reach up to 50%. A family history of prostate problems, an unhealthy lifestyle, or comorbidities can also increase the risk of BPH.
Treatment Options for BPH
The impact of benign prostatic hyperplasia is variable among each individual. Some may experience stable, mild symptoms for many years. In contrast, others may suffer from several possible complications such as irritable bladder or even infection.
On this account, treatment for benign prostatic hyperplasia, usually surgical intervention, should be considered carefully by weighing the potential side effects and the degree of symptom improvement after the treatment.
Some traditional treatment options for BPH include:
- Medications (alpha-blockers or 5-alpha-reductase inhibitors)
- Transurethral resection of the prostate (TURP; resection of the prostate through the urethra)
- Prostatectomy (partial or complete removal of the prostate)
- Prostatic urethral lift (implantation of a capsular tab into the prostate)
PAE as a Minimally Invasive Treatment for BPH
Nevertheless, the traditional surgical approaches to treating BPH may cause multiple urinary and sexual side effects and complications, like temporary difficulty urinating or erectile dysfunction.
Medications typically prescribed for BPH, like 5-alpha-reductase inhibitors, also have similar unwanted effects on sexual functions, like decreased sexual desire, impotence, or ejaculatory disorder.
For this reason, prostate artery embolization (PAE) emerges as a novel, less invasive treatment for BPH that delivers superior efficacy to other traditional methods. PAE partially blocks the arteries that supply blood to the prostate, intentionally causing the prostate to shrink and releasing the pressure on the urethra.
PAE is a surgical procedure. However, it does not involve the physical removal of any part of the prostate. Therefore, PAE is appropriate for either disqualified candidates or fearful of traditional, more invasive operative techniques.
How Does Prostate Artery Embolization Work?
Prostate Gets Its Blood Supply From the Prostatic Arteries
Like any other organ, the prostate is connected with the arteries, from which it receives blood, nutrients, and oxygen supply. As we advance in age, the cells in the prostate grow and multiply at a faster rate than they are replaced or absorbed. Constant growth and multiplication of the prostatic cells lead to detrimental enlargement of the gland.
Embolization Causes Intended Occlusion of Blood Flow
On this account, doctors have proposed a rationale that precise constriction of the prostatic arteries with embolic particles will partially obstruct the blood supply for the prostate, causing the cells in this gland to die in a planned manner.
Occluded Blood Supply Results in Shrinkage of the Prostate
The dead cells in the prostate will then be absorbed by the body’s immune system, gradually reducing the size of the prostate.
Notably, PAE does not cause death or necrosis of the prostate. It is because the procedure only partially restricts the blood supply for the prostate, and it is impossible to block all of the blood flow to the prostate. The embolization effects on the prostate are also localized. They will not cause blood clots in other organs, like the lungs or brains.
Release of Urethra Compression Improves Urinary Symptoms
After the prostate has shrunk to its average size (<50 g), the compression surrounding the urethra is released, expanding the diameter of the tube and significantly improving the urinary symptoms.
How Is Prostate Artery Embolization Performed?
Utilization of a Microcatheter Without Incision at the Surgical Site
Since PAE is minimally invasive, the whole procedure is performed with only moderate conscious sedation. First, a pinhole is opened at the femoral artery in the upper thigh area to introduce a microcatheter (0.020″ in diameter).
Confirmation of Prostatic Arteries Using Angiography
An injection of diluted contrast dye is administered into the artery at the surgical site to determine the prostatic arteries with angiography. This injection highlights the blood vessels that need to be intervened.
Navigation Through Pelvic Arteries Under Angiography Guidance
After confirming the prostatic arteries, the microcatheter is navigated from the pinhole through the pelvic arteries to the prostatic arteries.
This step is crucial since imprecision in detecting and confirming the exact location of prostatic arteries may cause non-target occlusion in the bladder, seminal vesicles, rectum, and penis.
Occlusion of Prostatic Arteries Using Microspheres (Embolic Particles)
After confirming the appropriate location at the prostatic arteries, embolization is performed using 300-500 μm gelatin microspheres (embolic particles). The particles are mixed with diluted saline and should be administered to the site very slowly to reduce the risk of reflux.
Following the embolization of the prostatic arteries, the microcatheter is removed from the surgical site. The pinhole in the upper thigh area is closed, possibly followed by prescriptions for antibiotics and NSAIDs to alleviate discomfort after the procedure.
PAE is an outpatient procedure. Therefore, the patient is only required to stay at the post-surgery care unit for several hours and then can be discharged on the same day.
Evidence for PAE as the Treatment of BPH
PAE for Treatment of BPH in Patients with Prostates >90 g
According to a clinical study by the Journal of Vascular and Interventional Radiology (JVIR), PAE is effective for lower urinary tract symptoms due to BPH in patients with a prostate over 90 g.
Specifically, PAE in 35 patients with BPH resulted in a mean prostate size decrease from 135.1 g to 91.9 g at three months of follow-up. In addition, the index for International Prostate Symptom Score (IPSS) and quality-of-life (QOL) were also significantly improved.
Medium- and Long-Term Outcome of PAE for Patients with BPH
Another study by the JVIR also showed that PAE had a positive effect on IPSS, QOL, and prostate volume in BPH in the medium and long term.
In particular, in 630 patients with BPH and moderate-to-severe lower urinary tract symptoms, clinical success rates were 81.9% and 76.3% in the medium term (1-3 years) and long term (>3-6.5 years).
Prostate Artery Embolization Safety and Side Effects
According to research, PAE is a generally safe procedure, with most side effects considered minor complications.
Specifically, the overall side effect rate is 32.9%, yet 99% of those cases are rated as minor. Additionally, most complications are self-limited and transient, meaning they will resolve on their own or have no long-term effect.
Possible Minor Side Effects
- Dysuria (discomfort when urinating)
- Hematospermia (blood in the semen)
- Hematuria (blood in the urine)
- Urinary retention (inability to empty the bladder)
- Increased urinary frequency
Possible Major Side Effects
Major complications of PAE occur even less frequently (<1%) and are only associated with imprecise, non-target embolization of the arteries in the bladder or other organs. The same research above found that only 3 out of 1253 patients displayed the following side effects:
- Bladder wall ischemia
- Urinary tract infection
- Pain in the upper thigh area
- Prostatic abscess
- Bladder obstruction
- Penile ulcers
When Should Doctors Choose PAE for BPH?
Patients With Advanced Age or Disqualified for Traditional Surgery
Older patients who are more vulnerable to complications and less capable of pain management after surgery can choose to have PAE since this procedure is almost painless and has a relatively low risk of side effects.
Patients who cannot undergo or have failed traditional methods like transurethral interventions may also be good candidates for PAE.
In one study, three patients who initially failed transurethral intervention achieved successful outcomes three months after PAE. The prostate gland size was reduced by approximately 32% in these patients.
Patients Who Wish to Avoid Traditional Surgery
Surgery is not for everyone, especially those who fear invasive medical procedures. In PAE, an incision is not required. Instead, only a tiny pinhole is opened in the upper thigh area to introduce a microcatheter.
Patients Who Wish to Remove Indwelling Foley Catheter
PAE may also benefit BPH patients with indwelling catheters (also known as Foley catheters). According to research, PAE results in catheter removal in 33 of 43 catheter-dependent patients (81%) who were not candidates for traditional surgery.
Patients With a Large Prostate (>80 g)
Prostate size can also be important when doctors should choose PAE for BPH.
One study compared large prostate size (>80 g) with medium prostate size (50-80 g). The study found that patients with large prostates had significantly better outcomes than those with medium-sized prostates.
Recent Findings in PAE for BPH
PAE Has a Lower Rate of Major Complications Than TURP
According to research, PAE results in fewer complications and side effects than the traditional approach – TURP.
In particular, a trial found that PAE resulted in only half as many complications as TURP did after one year (36 vs. 70 adverse events), with discomfort and urinary tract infections being the most common.
Another study revealed that PAE patients had shorter hospital stays and could return to normal activities more quickly than TURP patients (5 vs. 14 days).
Incorporating Drug Delivery Can Enhance the Embolization Effects
Research shows that using drug-loaded microspheres instead of bland microspheres may potentiate the effects of embolization.
These drugs include bleomycin and finasteride, demonstrating an excellent biocompatibility profile in animal models. In addition, several comparative studies have shown a more significant reduction in prostate volume with drug delivery compared to the bland group.
Bottom Line: PAE Offers a Superior Treatment Option for BPH
PAE is a new and more effective approach to BPH than other traditional methods. In addition, this procedure minimizes the disadvantages of more invasive surgery like post-operative pain, longer recovery time, or qualifications for surgery.
The procedure only takes anywhere from 1-4 hours, depending on the complexity of the condition. The possibility of detecting the prostatic arteries’ location is one factor affecting the complexity of BPH. Overnight hospitalization after surgery is often unnecessary, and patients can be discharged on the same day.
The effects of PAE will likely appear within the first six months from the procedure, as the prostate is expected to shrink by 20-40%, leading to significant improvement in urinary symptoms while maintaining normal sexual functions.
However, the PAE procedure can be challenging due to the microscopic size of the prostatic arteries, which causes difficulties in navigating the catheter. Thus, by all means, PAE must always be performed by interventional radiologists under the guidance of angiography.
In conclusion, creating a successful PAE practice requires a multidisciplinary strategy incorporating urologists and interventional radiologists. The goal is not to replace current surgical treatments for BPH but rather to provide an extra option that would be appropriate for some men, including those with larger prostates, those with surgical comorbidities, or those with a strong desire to maintain sexual function.
Prostatic Artery Embolization. Johns Hopkins Medicine. Hopkins University School of Medicine.
Benign Prostatic Hyperplasia. Johns Hopkins Medicine. Hopkins University School of Medicine.
Benign Prostatic Hyperplasia. Mayo Clinic.
Transurethral Resection of the Prostate. Mayo Clinic.
Prostatic Artery Embolization. UNC Medical Center. UNC School of Medicine.
Assis, A., Moreira, A., Rodrigues, V., Yoshinaga, E., Antunes, A. et al. (2015). Prostatic Artery Embolization for Treatment of Benign Prostatic Hyperplasia in Patients With Prostates > 90 g: a Prospective Single-center Study. The Journal of Vascular and Interventional Radiology.
Pisco, J., Bilhim, T., Pinheiro, L., Costa, N., Duarte, M. et al. (2016). Medium- and Long-term Outcome of Prostate Artery Embolization for Patients With Benign Prostatic Hyperplasia: Results in 630 Patients. The Journal of Vascular and Interventional Radiology.
Picel, A., Hsieh, T., Shapiro, R., Vezeridis, A., Isaacson, A. (2019). Prostatic Artery Embolization for Benign Prostatic Hyperplasia: Patient Evaluation, Anatomy, and Technique for Successful Treatment. RadioGraphics. The Radiological Society of North America (RSNA).
Naidu, S., Narayanan, H., Saini, G., Segaran, N., Alzubaidi, S. et al. (2021). Prostate Artery Embolization—review of Indications, Patient Selection, Techniques and Results. Journal of Clinical Medicine. Multidisciplinary Digital Publishing Institute.
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