Prostate Artery Embolisation for BPH
Southampton University Hospitals NHS Trust
Contents - Prostate Artery Embolisation for BPH
- Introduction to benign prostatic hyperplasia
- Symptoms of BPH
- Treatment of BPH
- Trans Arterial Embolisation
- Prostate Artery Embolisation
Benign prostatic hyperplasia (BPH) is the condition that occurs when the prostateA gland that surrounds the urethra near the bladder. It produces a fluid that forms part of the semen. glandAn organ with the ability to make and secrete certain fluids. is increasing in size without there being any malignantDescribes a tumour resulting from uncontrolled cell division that can invade other tissues and may spread to distant parts of the body. cause. As the prostate enlarges it leads to compression and then obstruction of the urethraThe tube that carries urine from the bladder, and in men also carries semen during ejaculation., which in turn affects urinary flow. The symptoms include urinary frequencyApplied to urination, needing to urinate more often than normal, for whatever reason., urinary urgency, hesitancy in urinationThe passing of urine from the body., poor stream and incomplete bladderThe organ that stores urine. emptying. Partial obstruction can ultimately become complete causing acuteHas a sudden onset. urinary retention and the urgent requirement for a bladder catheterA tube used either to drain fluid from the body or to introduce fluid into the body.. BPH is not however a pre-malignantA lesion, condition or syndrome that if left untreated may develop into cancer. condition.
This condition becomes increasingly common with age and has an impact on the quality of life for a considerable number of men aged over fifty years.
Traditionally, BPH has been managed with lifestyle changes and medication in the first instance but if the symptoms progress or become severe then surgery may be required. However, as this is an age-related condition fitness and suitability for surgery is often an issue. The process by which the prostate begins enlarging starts around the age of 30 and up to 50% of men will show histological signs (changes within the tissues) of BPH by 50 years of age. By 80 years of age this rises to 75% although not all of these men will have symptoms. Symptomatic BPH occurs in up to 50% of men of middle age or older.
The symptoms of BPH fall into two broad categories
- Voiding (weak stream, hesitancy, stop and start micturition)
- Storage (frequency, urgency, nocturiaNeeding to get up to urinate at night., leaking)
Both of the sets of symptoms set out above occur in BPH. The management of BPH varies according to the nature and severity of the symptoms. Lifestyle changes and medication (such as the drugs known as alpha blockers and 5ɑ-reductase inhibitors) are used initially, but if symptoms progress despite conservative therapy then surgery may well be suggested.
There are a number of different forms of surgery that will typically be offered depending on the size of the prostate gland including Trans Urethral Prostatectomy (TURPtransurethral resection of prostate) or Open Prostatectomy. However, minimally invasive thermal ablation using microwave energy (TUMT), radiofrequency (RF) and laser energy (PVP, HoLAP/HoLEP) have not gained widespread usage.
Trans-arterial embolisation, a non-surgical, minimally invasive procedure, has been used in many clinical settings. Initially introduced to stem life-threatening haemorrhageThe internal or external loss of blood from a blood vessel. it then evolved into more widespread use to block the bloodA fluid that transports oxygen and other substances through the body, made up of blood cells suspended in a liquid. vessels that serve tumours prior to surgery and then again for definitive palliative A therapy that gives relief from the symptoms of a disease rather than impacting on its course. Often known as 'end of life' care. treatment of tumours. It has been used in the setting of prostatic disease for many years either to stem acute or chronicA disease of long duration generally involving slow changes. bleeding due to advanced prostatic cancerAbnormal, uncontrolled cell division resulting in a malignant tumour that may invade surrounding tissues or spread to distant parts of the body., but also to control bleeding after prostatic surgery.
Uterine Artery Embolisation in the treatment of women with uterine fibroidsBenign tumours, most often in the uterus., has become one of the most common minimally invasive treatments for symptomatic fibroids in the UK and is fully recognised by NICE (National Institute for Health and Clinical Excellence).
Prostate arteryembolisation (PAE) has been the subject of two studies since 2010, one in Sao Paulo, Brazil and another in Lisbon, Portugal. The groups have been testing the hypothesis that trans-arterial embolisation of the prostate could lead to the death of the blood-rich and overgrown prostatic tissue, which in turn would result in a subsequent reduction in obstructive urinary symptoms. Their presentations to the International Interventional Radiology conferences during 2010, 2011 and 2012 have confirmed their initial optimism in over 400 cases. In February 2013 the Portuguese group published initial and mid term results on over 250 men. Clinical improvement was seen in around 80% at 6-12 months and still over 70% at 3 year follow up.
One Hour Procedure for BPH
The procedure is performed by trained Interventional Radiologists who are experienced in advanced embolisation techniques. It involves a groin puncture and then thin, hollow tubes known as catheters, are placed into both right and left prostatic arteries, these are then closed using 100-200 micronThe size of a micrometre, which is a one-thousandth of a millimetre-sized embolic particles. The procedure take approximately one hour to perform and the patient can be discharged after 4–6 hours provided he is fit. Men needing to travel out of the area or those who are less fit will require an overnight stay in hospital.
Post-procedural pain is usually minor, unlike the often severe post-procedural pain following fibroid and renalembolisation. Complications reported to date have been rare and mostly involve minor bruising of the groin. Three cases of non-target embolisation of the bladder and rectumhave been reported in over 400 cases; of these, one required surgical bladder repair. It is encouraging that the common side effects of TURPAn abbreviation for transurethral resection of the prostate, a procedure to shave away some of an enlarged prostate. This eases the pressure from the prostate on the urethra, the tube that carries urine from the bladder., such as transient incontinenceTemporary urinary incontinence, normally occurring during sneezing, coughing or laughing, erectile dysfunction Inability to maintain a penile erection for sexual intercourse, also referred to as impotence. and particularly retrograde ejaculationhave not been reported and improvement or relief of symptoms has been reported in 80% of patients with up to a one year follow-up.
In light of these results, a carefully Monitored Clinical Introduction in 20 men with proven and symptomatic BPH, not responding to medical treatment was instigated at Southampton University Hospitals in 2012. The procedure was technically successful in all 20 patients’ enrolled and clinical improvement, although modest in some has been seen in 90%. There have been no serious complications and post procedural pain has been mild to moderate only. In all but exceptional cases this has been performed as a day case procedure.
The first UK medical symposium on Prostate Artery Embolisation was held at the TEAM-UK 2012 meeting in Birmingham on 12th March 2012. Initial results from the Southampton series have been presented at the British Society of Interventional Radiologists in November 2012.
The PAE procedure is being considered by NICE and initial guidelines are expected early in 2013. National Registries and further studies are being planned for 2013.
For a referral
A GP or urology referral will be required and a full assessment with both Urological and Radiological assessment will be required before PAE can be offered. Please click the Dr Hacking's contact button (above).
Or, for further information on the author of this article, Consultant Radiologist, Dr Nigel Hacking, please click here.