Prostate artery embolization (PAE) has emerged as a promising treatment for lower urinary tract symptoms secondary to benign prostatic hypertrophy (BPH). This article provides an up-to-date overview of this minimally invasive technique, including discussion of potential benefits, patient selection, and technical challenges.
Current evidence suggests PAE is an effective option for patients with large prostate volume and multiple comorbidities, as well as for younger patients with medication-induced erectile dysfunction and suboptimal results from pharmacotherapy. However, larger randomized studies with long-term follow-up data are needed for this technique to be formally established in the treatment regime for benign prostatic hypertrophy.
Ultrasound showing enlarged prostate measuring 46 cc A 66-year-old patient with an International Prostate Symptom Score (IPSS) of 29 and prostate volume of 46 cc. All images courtesy of Dr. Jamal Al Deen Alkoteesh. Angiogram of the left internal iliac artery and selective catheterization of the left prostatic artery Angiogram of the left internal iliac artery showing the origin of the left prostatic artery and then very selective catheterization of the left prostatic artery by microcatheter. Angiogram of the right internal iliac artery and selective catheterization of the right prostatic artery Angiogram of the right internal iliac artery showing the origin of the right prostatic artery and then very selective catheterization of the right prostatic artery by microcatheter. How the treatment works
As men age, the prostate gland grows larger and may begin to press on the urethra. Enlarged prostate affects more than half of men by age 60 and causes symptoms such as frequent urination, weak urine stream, and a persistent feeling of having to urinate. Surgery is the standard treatment for the condition, but it can cause complications such as sexual dysfunction.
Prostate artery embolization is a noninvasive procedure that can bring long-term relief from symptoms caused by an enlarged prostate. This procedure works by closing the blood supply to the prostate, and, as a result, the prostate shrinks in size, reducing blockages and improving the symptoms.
PAE is an option for patients with a variety of prostatic issues, including lower urinary tract symptoms secondary to benign prostatic hypertrophy, hematuria of prostatic origin, and prostate cancer. After initial medical therapy, transurethral resection of the prostate (TURP) remains the gold standard surgical treatment, but its role is undermined by the associated risks of bleeding and lasting sexual dysfunction.
With the considerable prevalence of BPH and an associated impact on national healthcare in the United Arab Emirates (UAE), less-invasive options and minimally invasive procedures have been continually examined. Since performing the first PAEs in 2008, the multidisciplinary team at the University of São Paulo in Brazil has been encouraged by patient outcomes. Al Ain Hospital has been offering PAE since 2015, and more than 25 patients with BPH have been treated.
Dr. Jamal Alkoteesh
Dr. Jamal Al Deen Alkoteesh conducts an interventional procedure at Al Ain Hospital in the United Arab Emirates. Coping with technical challenges
Technically, PAE is challenging. Unnecessary catheterization increases procedure time and radiation exposure. Knowledge of anatomical features to identify and catheterize target arterial branches is paramount to achieve the best clinical outcomes. The prostate receives its arterial supply via the medial and the capsular/lateral branches but is variable among patients.
Assis et al proposed an angiographic classification of prostate artery anatomy and analyzed 286 pelvic sites to find that most inferior vesical arteries and their prostatic branches arise from the internal pudendal artery. Conebeam CT (CBCT) angiography has been utilized to evaluate the many variants of the prostatic artery. With direct contrast injection and 3D angiography, subtle prostatic feeders are better identified when compared with digital subtraction angiography and CT angiography.
Traditionally, PAE has been performed via a transfemoral approach (TFA), but the transradial approach (TRA) has garnered increased interest recently. Evidence has suggested that TRA results in shorter postprocedure hospital stays, decreased access-site complications, and improved patient satisfaction. This method would also allow patients to ambulate immediately post-PAE, which could facilitate urination. The distance from the forearm to pelvis along with the arterial tortuosity and previously mentioned variant anatomy has deterred initial attempts for PAE via TRA. Further, prior to selecting TRA patients, collateral circulation must be adequate as determined using a Barbeau test (i.e., a modified Allen tes
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