Introduction to Benign Prostatic Hyperplasia (BPH)

This article updates a very promising and now fully recognised new treatment for benign prostatic hyperplasia (BPH) called Prostate Artery Embolisation (PAE). This emerging therapy will be of particular interest to men who have previously received medical or even surgical treatment for this condition that has not proved successful.

Contents - Prostate Artery Embolisation for BPH

Introduction to benign prostatic hyperplasia

Benign prostatic hyperplasia (BPH) is the condition that occurs when the prostate gland is increasing in size without there being any malignant cause. As the prostate enlarges it leads to compression and then obstruction of the urethra, which in turn affects urinary flow. The symptoms include urinary frequency, urinary urgency, hesitancy in urination, poor stream and incomplete bladder emptying. Partial obstruction can ultimately become complete causing acute urinary retention and the urgent requirement for a bladder catheter. BPH is not however a pre-malignant condition.

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.

Symptoms of BPH

The symptoms of BPH fall into two broad categories

  • Voiding (weak stream, hesitancy, stop and start micturition)
  • Storage (frequency, urgency, nocturia, leaking)

Treatment of BPH

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 (TURP) and various forms of Laser Prosatectomy (Green light and HoLEP) . Urolift and Rezum have recently been approved for men with modest prostatic enlargement. However, minimally invasive thermal ablation using microwave energy (TUMT), radiofrequency (RF)  and Water Vapour have not yet gained widespread use.

Trans Arterial Embolisation

Trans-arterial embolisation, a non-surgical, minimally invasive procedure, has been used in many clinical settings. Initially introduced to stem life-threatening haemorrhage it then evolved into more widespread use to block the blood vessels that serve tumours prior to surgery and then again for definitive palliative treatment of tumours. It has been used in the setting of prostatic disease for many years either to stem acute or chronic bleeding due to advanced prostatic cancer, but also to control bleeding after prostatic surgery or even biopsy.

Uterine Artery Embolisation in the treatment of women with uterine fibroids, 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 Artery Embolisation

Prostate artery embolisation (PAE) has been the subject of several studies since 2010, notably from Sao Paulo, Brazil, Lisbon, Portugal, China and the UK. 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.

Several Randomised Controlled Trials (RCTs) have now been published and in 2017 Pisco presented the results of his 1000 patient study at the Society of Interventional Radiology (SIR) meeting in Miami. This series includes the longest follow up data with over 800 patients followed out to 3 years and over 400 followed beyond 3 years.

As in all published PAE series to date symptomatic improvement is seen in just over 80% of men at 3-12 months and these improvements are sustained at medium and long term follow up with cumulative success rate of 78%.

The results from the UK-ROPE (Registry of Prostate Embolisation), sponsored by NICE as well as the National Professional Societies of both Interventional Radiology (BSIR) and Urology (BAUS) was published in 2018 and NICE approval for PAE was issued with new Guidelines published in April 2018.

Two Hour Procedure for BPH

The procedure is performed by trained Interventional Radiologists who are experienced in advanced embolisation techniques. It typically involves a unilateral groin puncture or occasional wrist puncture, under local anaesthetic and then thin, hollow tubes known as catheters, are placed into both right and left prostate arteries under direct X-Ray guidance. These prostatic arteries are then closed using 100-500 micron-sized embolic particles. The procedure takes approximately 2 hours to perform and the patient can be discharged after 4 hours provided he is fit. Men needing to travel out of the area or those who are less fit may require an overnight stay in hospital.

Post-procedural pain is usually mild to moderate, unlike the often severe post-procedural pain following fibroid and kidney embolisation. This discomfort can be managed by simple anti- inflammatory and pain killing oral medications.

Fig 1 (below) shows microcatheter placed deep into right and left prostate arteries under fluoroscopic control

 

 

Has a sudden onset. Full medical glossary
A medication that reduces sensation. Full medical glossary
A blood vessel that carries blood away from the heart. Apart from the pulmonary artery and umbilical artery, all arteries carry oxygenated blood. Full medical glossary
Not dangerous, usually applied to a tumour that is not malignant. Full medical glossary
Enlargement of the prostate, which may cause difficulty in passing urine. Full medical glossary
The removal of a small sample of cells or tissue so that it may be examined under a microscope. The term may also refer to the tissue sample itself. Full medical glossary
The organ that stores urine. Full medical glossary
A fluid that transports oxygen and other substances through the body, made up of blood cells suspended in a liquid. Full medical glossary
blood pressure Full medical glossary
An abbreviation for benign prostatic hyperplasia, which is enlargement of the prostate that may cause difficulty in passing urine. Full medical glossary
Abnormal, uncontrolled cell division resulting in a malignant tumour that may invade surrounding tissues or spread to distant parts of the body. Full medical glossary
A tube used either to drain fluid from the body or to introduce fluid into the body. Full medical glossary
The basic unit of all living organisms. Full medical glossary
A disease of long duration generally involving slow changes. Full medical glossary
The abbreviation for computed tomography, a scan that generates a series of cross-sectional x-ray images Full medical glossary
A benign tumour, most often in the uterus. Full medical glossary
Benign tumours, most often in the uterus. Full medical glossary
A viral infection affecting the respiratory system. Full medical glossary
An organ with the ability to make and secrete certain fluids. Full medical glossary
The internal or external loss of blood from a blood vessel. Full medical glossary
Prefix suggesting a deficiency, lack of, or small size. Full medical glossary
intermittent claudication Full medical glossary
One of two bean-shaped organs that are located on either side of the body, below the ribcage. The main role of the kidneys is to filter out waste products from the blood. Full medical glossary
Describes a tumour resulting from uncontrolled cell division that can invade other tissues and may spread to distant parts of the body. Full medical glossary
The size of a micrometre, which is a one-thousandth of a millimetre Full medical glossary
Needing to get up to urinate at night. Full medical glossary
A therapy that gives relief from the symptoms of a disease rather than impacting on its course. Often known as 'end of life' care. Full medical glossary
pulmonary embolism Full medical glossary
A craving to eat non-food substances such as earth or coal. Full medical glossary
A lesion, condition or syndrome that if left untreated may develop into cancer. Full medical glossary
A gland that surrounds the urethra near the bladder. It produces a fluid that forms part of the semen. Full medical glossary
Randomised controlled trial. A study comparing the outcomes between one or more different treatments for a disease (or in some instances, preventive measures against that disease) and no active treatment at all (the placebo group). Study participants are allocated to the various groups on a random basis. Full medical glossary
A group of cells with a similar structure and a specialised function. Full medical glossary
An abnormal swelling. Full medical glossary
transurethral resection of prostate Full medical glossary
An 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. Full medical glossary
Involving or affecting only one side. Full medical glossary
The tube that carries urine from the bladder, and in men also carries semen during ejaculation. Full medical glossary
The passing of urine from the body. Full medical glossary
micro catheter

SA">Fig 1a Right Prostate Artery DSA                     Fig 1b Left Prostate Artery DSA

septic arthritis Full medical glossary

Figure 2. Shows Dyna-CT image of left hemi-prostate acquired during a rotational angiographic study. The microcatheter was placed deep in the left prostate artery (Fig 1b) and contrast injected. No enhancement of the bladder or rectal mucosal gives extra confidence that non-target embolisation should not occur.

Post-procedural pain is usually mild to moderate, unlike the often severe post-procedural pain following fibroid and kidney embolisation. This discomfort can be managed by simple anti- inflammatory and pain killing oral medications.

Relating to X-ray imaging of the blood vessels following the injection of a dye to improve visibility Full medical glossary
A blood vessel that carries blood away from the heart. Apart from the pulmonary artery and umbilical artery, all arteries carry oxygenated blood. Full medical glossary
The organ that stores urine. Full medical glossary
A tube used either to drain fluid from the body or to introduce fluid into the body. Full medical glossary
The abbreviation for computed tomography, a scan that generates a series of cross-sectional x-ray images Full medical glossary
A benign tumour, most often in the uterus. Full medical glossary
One of two bean-shaped organs that are located on either side of the body, below the ribcage. The main role of the kidneys is to filter out waste products from the blood. Full medical glossary
A gland that surrounds the urethra near the bladder. It produces a fluid that forms part of the semen. Full medical glossary
Relating to the rectum, the lowest part of the bowel leading to the anus. Full medical glossary

Fig 3. 3 month contrast enhanced MRI shows large almost symmetrical areas of infarction in the BPH adenoma and this correlates very well with symptomatic and long term improvement

A benign tumour that forms from glandular cells. Full medical glossary
blood pressure Full medical glossary
An abbreviation for benign prostatic hyperplasia, which is enlargement of the prostate that may cause difficulty in passing urine. Full medical glossary
Death of a piece of tissue owing to obstruction of its blood supply. Full medical glossary
Death of a portion of tissue due to inadequate blood supply Full medical glossary
An abbreviation for magnetic resonance imaging, a technique for imaging the body that uses electromagnetic waves and a strong magnetic field. Full medical glossary

Potential Complications

Complications reported to date have been rare and mostly involve minor bruising of the groin. One case of non-target embolisation of the bladder and several minor self-limiting ulcerations to the rectum have been reported in over 2,500 cases; of these, one required surgical bladder repair. Minor again self- limiting penile ulceration has been reported in small numbers.

It is encouraging that the common side effects of TURP, such as transient incontinence, erectile dysfunction and particularly new retrograde ejaculation have not been reported. Unlike TURP and laser prostatectomy fertility is preserved after PAE and there have been several children fathered by PAE patients reported around the world.

Southampton Experience

A carefully Monitored Clinical Introduction in 25 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 patients’ and clinical improvement, although in some cases modest was been seen in 90%. There were no serious complications and post procedural pain was mild to moderate only. In all but exceptional cases these were performed as a day case procedure.

NICE considered PAE as an option for treating men with significant Lower Urinary Tract Symptoms (LUTS) caused by benign prostate enlargement in 2013 and decided that at that time the evidence was still not strong enough to recommend approval for PAE. They suggested that more studies were needed and that included the setting up of a National Registry comparing PAE with traditional surgical techniques using TURP or HoLEP.

Dr Nigel Hacking, as the Pioneer of PAE in the UK, was appointed as Chairman of the UK-ROPE Steering committee and it’s Clinical Lead. 

Results from the UK-ROPE study

A total of 305 patients (PAE, 216; transurethral resection of the prostate [TURP], 89) were recruited from 17 centres and followed out to 12 months post procedure. PAE produced a 10-point reduction in the International Prostate Symptom Score (IPSS) at 12 months with no significant complications compared to a 15-point IPSS reduction in the TURP cohort. On a 6-point quality-of-life scale, there was a 3-point reduction with PAE compared with 4 points after TURP.

Urinary flow improved by 3 ml/s compared with 7.5 ml/s after TURP. P volume was reduced by 28% after PAE. There was also a significant reduction in hospital stay.Over 70% of PAE cases were performed as a same-day discharge, whereas 30% of TURP patients spent one night in hospital and 49% spent two nights. A few patients needed even longer stays after their TURP. 

Erectile function showed a slight improvement. Retrograde ejaculation was reported only half as often after PAE compared with TURP. 

To date Dr Nigel Hacking and his team at Southampton University and Spire Hospitals have performed over 400 PAE cases with excellent results. A few patients have shown early symptom recurrence at 3-12 months and have undergone a limited TURP to remove an enlarged ‘Median lobe’. This limited surgery can still avoid the side effects seen after full TURP and this 2-stage procedure may be helpful in some cases.

For a private PAE referral

Due to training issues PAE is not widely available on the NHS, but is available by Dr Hacking privately at Spire Southampton Hospital and at the Wellington and Princess Grace Hospitals in London.

Following a request for an appointment a set of medical questionnaires will be sent to you. I would be grateful if these could be completed and forwarded prior to your initial consulation.

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. This Urology assessment can be arranged in Southampton or London.

Click here if you would like a referral from a private GP and click here if you would like me to arrange for you to see a private Urologist.

Or, for further information on the author of this article, Consultant Radiologist, Dr Nigel Hacking, please click here.

 

Not dangerous, usually applied to a tumour that is not malignant. Full medical glossary
The organ that stores urine. Full medical glossary
blood pressure Full medical glossary
An abbreviation for benign prostatic hyperplasia, which is enlargement of the prostate that may cause difficulty in passing urine. Full medical glossary
The basic unit of all living organisms. Full medical glossary
A condition that is linked to, or is a consequence of, another disease or procedure. Full medical glossary
The discharge of semen from a man’s penis at the time of sexual climax. Full medical glossary

Inability to maintain a penile erection for sexual intercourse, also referred to as impotence.

Full medical glossary
One of the three main food constituents (with carbohydrate and protein), and the main form in which energy is stored in the body. Full medical glossary
intermittent claudication Full medical glossary
The involuntary passage of urine or faeces. Full medical glossary
pulmonary embolism Full medical glossary
A gland that surrounds the urethra near the bladder. It produces a fluid that forms part of the semen. Full medical glossary
Surgical removal of the prostate, a gland that surrounds the urethra near the bladder. Full medical glossary
The last part of the large intestine, where faeces are stored before being passed. Full medical glossary
The surgical removal of part of the body. Full medical glossary
transurethral resection of prostate Full medical glossary
An 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. Full medical glossary
Any abnormal break in the epithelium, the outer layer of cells covering the open surfaces of the body. Full medical glossary
The presence or formation of an ulcer - an abnormal break in epithelium, the outer layer of cells covering the open surfaces of the body. Full medical glossary
The tube that carries urine from the bladder, and in men also carries semen during ejaculation. Full medical glossary
Relating to the urethra, the tube that connects the bladder to the genitals. Full medical glossary