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What is Prostate Artery Embolisation (PAE)?
By Dr Christopher Rogan
Prostate artery embolisation is a minimally invasive procedure performed by interventional radiologists to treat an enlarged prostate. Under X-ray guidance, a micro-catheter (a very fine tube) is navigated to the arteries supplying the enlarged prostate. Tiny plastic beads are then deposited to reduce the blood supply which shrinks the prostate. The same technique has been used for over 20 years to shrink uterine fibroids in women and liver cancers, but been applied to the prostate over the last 10 years. It is a local anaesthetic procedure with minimal down-time.
Why would my doctor refer me to have this procedure?
If you have symptoms that are related to enlargement of the prostate (prostatic hyperplasia/hypertrophy), you may be suitable for (PAE) \with the aim of improving urinary symptoms, as an alternative to surgery (such as transurethral resection of the prostate- TURP). This treatment may delay or remove the need for surgery altogether.
Patients being considered for PAE will undergo a basic assessment of their prostate and bladder to make the diagnosis of BPH which normally includes:
an ultrasound of the bladder and prostate to assess for any other causes
a blood test called prostate specific antigen (PSA)
a test of your urine flow.
in selected cases, a prostate MRI, biopsy or further tests may also be needed.
If, after you see the doctor, you are planned for PAE, a special CT scan of the arteries will be performed to plan the procedure.
How do I prepare for the procedure?
You will normally be asked to fast from midnight before the procedure and certain blood thinners such as warfarin may need to be withheld.
What happens during the procedure?
The procedure can be performed under local anaesthetic or with additional twilight sedation.
On the upper thigh or wrist is cleaned and numb, a fine catheter (plastic tube the size of a piece of spaghetti) is threaded into the artery and guided towards the prostate with xray guidance. Once in position, xray images will be taken to check your individual anatomy and blood supply to the prostate. A very fine tube called a microcatheter (<1mm) is then threaded through the catheter and passed into the artery supplying the prostate.
Once the correct blood vessels are verified, plastic microspheres are used to block the artery to the prostate. By reducing its blood supply, the prostate undergoes shrinkage over time (atrophy). Both the left and right sided arteries to the prostate can be treated through the one access pinhole in the artery.
The pinhole access may then be sealed with a special absorbable plug and you will rest in bed and be monitored for a few hours. You will normally be able to go home on the same day or an overnight stay can be arranged if needed.
How long does the procedure take?
The procedure takes approximately 2-3 hours to perform.
Are there any after- effects from the procedure?
Standard recovery from any minimally invasive trans-arterial procedure like this involves:
Do not drive for 24 hrs.
Avoid strenuous exercise or lifting more than 10kg for 48 hrs
Leave the dressing intact over the access pinhole for 48hrs (but you can shower as normal)
It is normal to experience some irritation of the prostate for the first week after the procedure which includes discomfort when urinating.
What are the risks?
The procedure involves an angiogram, which is a picture of your blood vessels taken using a small plastic tube which is placed into the artery in your thigh. This part of the procedure carries a 5% risk of bruising and a significant bleeding happens uncommonly <1%.
X ray dye (contrast) will be used (similar to a CT scan) to check internal anatomy throughout the procedure. This can cause kidney problems for those people with kidney disease – let the doctor know if you have kidney disease and a blood test will be performed to check this and minimise this risk.
The prostate blocking procedure itself is not usually painful but after the procedure, most patients will experience mild pain and low grade fever as the prostate responds to it’s blood supply being reduced.
The more common risks (4-7% incident) include urinary retention needing a temporary catheter for ~ 1 week, experiencing transient bleeding on passing urine, ejaculating or in bowel motions, urinary infection or diarrhoea, or a bruise (hematoma) in the groin, which would normally settle within a week.
Very rare but serious risks relate to blocking of arteries near the prostate which supply nearby organs:
one patient in the world needed surgery to remove a part of the bladder affected by the treatment
two patients in the world have experienced an ulcer on the penis which healed.
In contrast to TURP surgery:
no patients developed experience retrograde ejaculation, which is a common side effect of TURP
no patients have developed impotence
bleeding and need for blood transfusion is uncommon
incontinence is rare
recovery is faster
a general anaesthetic is not needed.
What are the benefits?
Men who have undergone PAE have reported high satisfaction, no urinary incontinence, or sexual side effects.
PAE has shorter recovery and fewer complications than traditional surgery and improves symptoms and quality of life to a greater degree than medical therapy.
When can I expect the results of my procedure
Most patients report a noticeable improvement within the first month however the gradual shrinkage of the prostate continues over about 6 months.