Better Stream: Prostate Artery Embolization for the Treatment of BPH

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In this episode, we discuss prostate artery embolization for the treatment of urinary symptoms for men with an enlarged prostate, otherwise known as BPH. In recent episodes, we’ve discussed several procedures used to treat BPH. Now, what all these procedures have in common is that they all involve actually carving away part of the prostate that is obstructing the urinary stream. But what if I told you that a procedure exists to treat BPH that does not actually involve touching the prostate at all? Rather, this procedure called prostate artery embolization manipulates the blood vessels of the prostate. But how does this procedure actually improve urinary flow? Is it safe? What is involved and what is the recovery like? How effective is prostate artery embolization in the short term and for the long haul? And why should men consider the procedure as opposed to other procedures that actually involve cutting or shaving away the prostate. In order to answer these questions and many more, we’re lucky to be joined by Dr. Ari Isaacson.

This Episode's Guest:
Ari Isaacson, MD

Dr. Isaacson is a board certified and licensed interventional radiologist who specializes in prostate artery embolization. After graduating medical school at USC, Dr. Isaacson completed his radiology and interventional radiology training at the University of North Carolina, where he stayed on as an Assistant and then Associate Professor of Radiology and was appointed Chief of the Division of vascular and interventional radiology. He currently practices at the prostate Centers of America where he also serves as the chair of quality and research. Dr. Isaacson has served as a principal investigator for multiple academic studies of prostate artery embolization and has recently published a textbook on the subject.

Better Stream: Prostate Artery Embolization for the Treatment of BPH Transcript:

Better Man Clinics 

Our listeners and viewers are very familiar with urologists and everything they do, but there are probably a lot of them that do not know what an interventional radiologist is. How do interventional radiologists treat patients?

Ari Isaacson, MD 

Most people don’t know what an interventional radiologist is. That is one of the challenges that I face on a daily basis. I have two explanations. So one is, I guess, the more technical one: that is, I perform minimally invasive procedures using some kind of imaging to guide what we’re doing. That imaging may be x-rays, ultrasounds, or CT scans.  That is why my field is part of Radiology- because there is some kind of imaging that is happening while the procedure is going on. Some people ask, “Is somebody else doing the procedure and you’re doing the imaging?” No, we actually perform the procedures. Our procedures range from things that are simple like putting in central venous catheters for patients who need medication to complex things such as treating the prostate or treating cancer in the liver or the kidneys. So, we do a large breadth of things. So that’s one explanation. The other explanation is that we’re kind of glorified plumbers because we do a lot of stuff inside the blood vessels.

Better Man Clinics 

So let’s dive into prostate artery embolization or PAE.  What is prostate artery embolization (PAE) and what is the theory behind how it works?

Ari Isaacson, MD 

The “E” in PAE stands for embolization.  What is embolization?  It is the purposeful blocking off of blood supply (or stopping blood flow) for a therapeutic purpose. This is something that we have been doing as interventional radiologists for 30-40 years. Up to this point, it’s just been done in other places besides the prostate. Maybe I shouldn’t even say that because we have been treating the prostate as well, but not specifically for urinary symptoms.  We have been using the procedure for bleeding from the prostate.   We also know that this is a reasonable thing to do.  We treat cancer this way in other places like the liver and the kidney. Also, if someone comes in with bleeding bowels, we’ll do that as well and target them. So this concept of embolization is something that we’re very familiar with.

It just happened that an interesting case report was published around 2000 in our main journal. The article described a patient who presented with bleeding from his prostate and was having a lot of blood in his urine. The patient was referred to an interventional radiologist who embolized the prostate for bleeding. When the patient came back for a follow-up about six weeks later, not only was he no longer having blood in his urine, but he was also reporting that his urination was much better.  He had a stronger stream and he felt like he was emptying his bladder better every time he urinated. All of a sudden, a light bulb went off.  Maybe this is something we can do for more men with BPH (an enlarged prostate causing urinary symptoms)? From there, there were animal studies and trials.  So you asked, “What’s the concept behind it?”  The concept behind PAE to treat BPH is as follows. The prostate is a doughnut that squeezes down on the urethra and pushes up into the bladder, causing the bladder to be irritated. If we can reduce the size of the prostate (and also make it softer), then we’ll have less pressure on the urethra and less pushing up on the bladder. We can do that by starving it of blood, just like any other organ.   When it gets starved of blood, it tends to shrink down. And that’s what happens in the prostate. That’s the concept: we stop as much of the blood flow as we can to the prostate and it shrinks down and presses less on the urethra.

Better Man Clinics

Won’t you essentially kill off the prostate by cutting off his blood supply?

Ari Isaacson, MD 

The answer is yes.  Before I go any further, let’s state the purpose of the prostate. What does it do for men? The purpose of the prostate is to create a nourishing fluid for the sperm so that the sperm can go and do their job and fertilize an egg. Once you’re no longer interested in impregnating a woman, the prostate has very little positive function. It’s just an annoyance at that point and it gets more annoying as you get older and it gets bigger. And so, yes, I tell patients that I do want to kill off the prostate as much as I can. But, I want to do it in a way that doesn’t cause you any other problems.

Better Man Clinics

Is PAE FDA approved or is it still considered experimental?

Ari Isaacson, MD 

That is kind of a complex answer. It depends on who you ask. Is it an FDA-approved procedure? Yes, it is. There are several different embolic devices now that have been approved by the FDA specifically for this procedure. So, is it an FDA-approved procedure? Absolutely. Is it experimental? I don’t think it’s experimental. Most interventional radiologists don’t think it’s experimental.  Why? Because there’s been so much data that’s been published about it. We’ve had six randomized control trials, comparing it to TURP.  TURP stands for transurethral resection of the prostate. It is the gold standard procedure for reducing benign enlarged prostate (BPH). There have been six trials that have compared PAE to TURP. There’s been another trial that’s compared PAE to a sham procedure.  There have been maybe 30 other trials that have just looked at it in a single cohort. So, there is a large amount of data that has been ascertained for PAE and that’s why it’s not experimental. However. The American Urological Association (the organization that puts out treatment guidelines for BPH) still says that PAE is experimental. Unfortunately, that has some downsides when it comes to reimbursement from insurance and the way that a lot of urologists look at the procedure.  That is unfortunate.

Better Man Clinics 

In general, is prostate artery embolization (PAE) covered by insurance or do men have to pay out of pocket for it?

Ari Isaacson, MD 

In general, insurance does cover PAE.

Better Man Clinics 

Are there specific “good” candidates for prostate artery embolization or is any man with BPH symptoms considered a good candidate for prostate artery embolization (PAE)?

Ari Isaacson, MD 

Yes, some men are better candidates for PAE than others.  Those are candidates that have larger prostates. So, when I say larger, let’s get a little bit of a reference here. Normal prostate size is up to 30 grams, cubic centimeters, or milliliters (all those units are interchangeable). Once a prostate gets above 30 grams, that’s considered enlarged. That being said, in my mind,  30 to 50 grams is just mildly enlarged.  That group of patients can have a PAE- there is nothing wrong with that.  However, I also think there are other great procedures out there to treat prostates of that size such as Rezum, UroLift, or Aquablation. As you get a little larger (50 to 80 grams), you still have a lot of options; all those procedures that I just mentioned are still good. Prostate Artery Embolization is better for those larger prostates than for those measuring 30 to 50 grams. In other words, PAE is harder to perform when the prostate is smaller. When you get above 80 grams and especially over 100 grams, there are a lot fewer options available from a urologic standpoint. That is where PAE really shines because, as the prostate gets bigger, PAE tends to do better and have better outcomes. There is no maximum prostate size for PAE.  I’ve performed PAE on prostates as big as, believe it or not, 600 grams. That is where PAE, I think, really has a great place in the treatment algorithm. Additionally, when you have patients who can’t undergo most surgical procedures- whether due to the fact that they are on anticoagulation and can’t come off or they have surgical comorbidities that prevent anesthesia- that is also when PAE is a great option. But I’ll tell you, there are a lot of good urologic options out there right now. And there are more becoming available every day. It used to be that everyone with BPH underwent a TURP, but now we’re in a place where it’s much more nuanced and there are a lot more options.

Better Man Clinics 

It sounds like the sweet spot for prostate artery embolization (PAE) is the treatment of those really large prostates – similar to HoLEP or robotic simple prostatectomy – that is where PAE would shine. Now, are there any absolute contraindications to PAE?  Any situations in which men should absolutely not undergo prostate artery embolization?

Ari Isaacson, MD 

One contraindication is renal or kidney failure. We need to use iodinated contrast for the procedure which is restricted in people with poorly functioning kidneys. So, if someone comes in with moderate to severe chronic kidney disease, then it’s not a good idea for them to have the procedure because the dye could cause further damage to their kidneys. Also, if patients have very severe atherosclerotic disease, where they have occlusions of their arteries and a lot of calcific plaque, that’s probably another group of patients that shouldn’t have a PAE and that should, instead, consider transurethral treatment.

Better Man Clinics 

Is there any type of evaluation that needs to be performed before someone undergoes prostate artery embolization (PAE) for BPH?

Ari Isaacson, MD 

I usually do my initial consultation with patients over the phone. During that consultation, we discuss their history. I like all my patients to have seen a urologist before seeing me. Why?  Because it’s important to determine that their urinary symptoms are actually from an enlarged prostate.  Although that is the case in the vast majority of patients, there is going to be a patient once in a while who has a neurogenic bladder or urethral stricture or something along those lines that can also cause urinary symptoms. PAE won’t do anything for those types of patients and so we need to parse that out. I think that urologists are the people who do that the best. And so, I would encourage every patient to go see a urologist for a standard BPH workup. This workup may include a urine flow test, a post-void residual test, possibly a cystoscopy, and possibly a urodynamics test, all depending on the patient’s symptoms. Once that’s been done, and they’ve been officially determined to have lower urinary tract symptoms from BPH, the only additional tests that I would want is some kind of scan to tell me the size of their prostate and also what their arteries look like. I get a CT of the pelvis, with contrast which shows me both the arteries and the size of the prostate.

Better Man Clinics 

What are the risks of prostate artery embolization (PAE)?

Ari Isaacson, MD 

There are some expected side effects to PAE: those are the things that I expect to happen to pretty much every patient. This combination of side effects is what we call “post-PAE syndrome”. That usually happens the night after the procedure or the day after the procedure. Patients develop very frequent urges to urinate and burning with urination. And that burning usually extends through the penis into the tip of the penis. Those symptoms are occurring because there’s inflammation that travels through the urethra after the procedure. Those symptoms will last about three to four days or so and then resolve.  I expect that to happen in almost every patient. Now, additional complications that can occur after PAE can include blood in the urine, blood in the stool, or blood in the ejaculate.  Those things tend to happen to less than 10% of patients. But if they do happen, it’s not alarming. I tell the patients that it’s going to resolve on its own, within a week or two. There is also a rare complication that occurs in about one in 200 men (less than half of a percent). That complication is an ulceration on the tip of the penis or in the gluteal (buttocks) region. The reason that can happen is because some of the beads that we inject into the artery to stop the blood flow to the prostate, inadvertently go to the skin in those regions, and cause that ulceration. Now, it’s our expertise as interventional radiologists to try to keep that from happening. And we’re pretty good at that. But in about one in 200 men, that complication can develop.  If that were to happen. It causes pain for two to three weeks, but it does heal without any residual deficits. We just encourage people to keep it clean and give them pain medication as needed. As far as sexual function goes, that is another big question. What’s the effect of PAE on sexual function? Well, it should not affect erectile function. I’ve seen it only in a few cases. But in the vast majority of cases, whatever sexual function the patient has coming into the procedures is what they should leave with. Now, early on, there was some suggestion that PAE improved erectile function, but that’s not the case. What improves erectile function is coming off of the medications that you take for BPH because some of those can hinder your ability to have an erection. As far as ejaculatory function, it does not cause dry or retrograde ejaculation, but it can reduce the volume of the ejaculate because we are, in a sense, killing off some of the gland glandular parts of the prostate that produce the fluid of the ejaculate.

Better Man Clinics 

Is there a risk of urinary leakage or incontinence after prostate artery embolization (PAE)?

Ari Isaacson, MD 

Incontinence can occur during the first week (after the PAE procedure) when the inflammation is happening because you’re getting a lot of bladder spasms during that time. Those spasms are giving patients a lot of feelings like they have to go very frequently (urinary frequency). Some patients do report that they do have some urge incontinence during that time.  They have a little bit of leakage that resolves after the first week or two. I’ve never had a patient say that they’ve had permanent or prolonged incontinence once that period is over. So, if it does happen, it only happens in a small percentage of patients and it’s a temporary thing.

Better Man Clinics 

What preoperative preparations are required prior to a prostate artery embolization (PAE)?

Ari Isaacson, MD 

The only thing that is required is to stop eating the night before. We do that just because we will give sedation during the procedure and we don’t want people to accidentally have an event where some of the food in their stomach goes into their lungs. That really is the only preparation. The only other thing I’d say is don’t stop any of your medications. If you take hypertension medication, keep taking it.  If you take BPH medication, definitely keep taking it. I think the only caveat to that is when people take five alpha-reductase inhibitors (Finasteride/Proscar or Dutasteride/Avodart). If you take those medications, we have you stop them on the day of the procedure.  The reason for this is that those medications have long-acting kinetics. They don’t really leave your system for a good month or so afterward as opposed to alpha-blockers (like Flomax), which are very fast-acting medications. We keep the patients taking the alpha-blockers (Flomax, Hytrin, etc)  for a good month to six weeks afterward because we want the procedure to work well before they stop.  The procedure doesn’t work immediately.

Better Man Clinics 

How long does prostate artery embolization (PAE) usually take to complete?

Ari Isaacson, MD 

That’s a good question. If you come to see me, we do this at an outpatient center. I’m not working at a hospital, I’m working at an outpatient center. When you arrive, we get an IV started and then we bring you back to the procedure room. We give you a little bit of IV medication to relax you. We give you a numbing shot in the groin area where we’re going to put the catheter into the artery. That numbing shot is really the only thing that’s painful for the whole procedure. You just feel a little bit of a sting, and then it’s over. After that, we insert a catheter about the width of a piece of spaghetti into the arteries. We direct it through the arteries using an X-ray to show us where we’re going. Every so often, we inject a little contrast dye to show us the arteries and then we get into both sides of the prostate and inject those microscopic spheres that block off the artery. Once we’ve done that on both sides, we take the catheter out and use a closure device to close up the hole in the artery that we’ve made. The procedure part takes about an hour or so. That can be variable depending on how torturous or how windy the arteries are. Sometimes, it can take longer than that. But, typically, it’s about an hour. Then, the patient usually recovers for two hours.  After two hours, as long as they can urinate, they can go home.

Better Man Clinics

When people talk about catheters in relation to BPH, we think about catheters going into the penis. That is not the type of catheter to which you are referring. You are saying that there’s a catheter that gets inserted into a blood vessel. Can you help us understand where exactly that catheter is inserted during prostate artery embolization (PAE)?

Ari Isaacson, MD 

In the interventional radiology world, a catheter is more like a tiny little tube that goes into a blood vessel rather than a bigger tube that goes into the penis. These catheters can either be inserted into the artery at the top of the thigh (in the groin area) or into the artery in the forearm. We can get to the prostate from either location.  I tend to prefer the top of the thigh because it’s just a little simpler to do in general. But we can go both ways. Sometimes it’s actually advantageous to go through the arm. I’ll give you an example. I did a case today where the patient could not come off his anticoagulation because he had a coronary stent placed pretty recently and his cardiologist was pretty adamant about keeping his anticoagulation going. In those circumstances, you can reduce the chance of getting a hematoma or aneurysm substantially by going through the small artery in the arm, the radial artery. And so that’s what we did for him today. And it made a lot of sense for him. But for most patients, their procedures can be done through the artery in the groin area.

Better Man Clinics 

Are you making an incision on both sides of the body (both groin areas) to get to both sides of the prostate or is it just one incision on one side sufficient for prostate artery embolization (PAE)?

Ari Isaacson, MD 

It is just one and I hesitate to call it an incision because it’s not really an incision. It is more of just a puncture, like as if you were getting an IV started. But, yes, it is one puncture and we’re able to get to both sides of the prostate from the one puncture site.

Better Man Clinics 

Is general anesthesia required for prostate artery embolization (PAE) or is local anesthetic and/or sedation sufficient?

Ari Isaacson, MD

No, we do not use general anesthesia.  We give patients oral valium before they come back to the procedure suite. Then, we will give a little bit of an IV anxiety medication and an IV pain medication. Usually, the medication is worn off by about half an hour or 20 minutes after the procedure.

Better Man Clinics 

When your patients are undergoing prostate artery embolization (PAE), are they awake? Are they cognizant of what’s going on? Are they dreaming?  What is their experience?

Ari Isaacson, MD 

I kind of customize it to the patient.  Some patients will tell me they don’t really care and that they don’t want to be sedated that heavily. They just want to lie there. Some of them want to chat with me throughout the whole procedure, which I’m fine with. They ask me periodically how the procedure is going and I give them an update on how things are going. That is probably the most common scenario. However, other patients don’t want to know anything. For those patients,  we go a little bit heavier on the sedation and try to get them to a place where they’re sleeping.

Better Man Clinics 

Is there any pain experienced during prostate artery embolization (PAE) aside from the injection of numbing medicine before the puncture into the blood vessel at the beginning of the procedure?

Ari Isaacson, MD 

There aren’t any nerves inside the arteries so you can’t feel the catheter traversing the arteries.  Patients do feel when we deliver the microscopic beads because, just prior to doing so, we give a little bit of a vasodilator, which is a medication to open up the arteries wider. The one we use is Verapamil. It does sting a little bit. I usually warn all the patients about that and they usually feel it in their penis.

Better Man Clinics 

Do men need to maintain a catheter in their bladder for a while after prostate artery embolization (PAE) as is often required for other prostate surgeries?

Ari Isaacson, MD 

The vast majority of the patients do not require a catheter after the procedure.  There is one small group for which I do place a catheter after the procedure. That group is composed of people who have gone into acute urinary retention (they could not urinate) in the past and have needed catheters to urinate. I’m talking about patients whose urinary stream is so slow to come out that sometimes it doesn’t come out at all and gets stuck and they have to go into the emergency room and get a catheter placed. If a patient has a history of that happening, then I will give them two choices. One is I can place a catheter ahead of time for their procedure, and then they’ll have it taken out a week or two afterward. Or, if they’re willing to, they can self-catheterize after the procedure.  Then I feel secure knowing that they have a way to urinate. What I don’t want to happen is for the patient to go home and have an emergency where they can’t urinate and then have to go to the emergency room. That’s what we try to avoid.

Better Man Clinics 

Does the prostate initially swell after prostate artery embolization (PAE)? Is that why a catheter is occasionally needed?

Ari Isaacson, MD 

That’s correct.  Yes, it swells a little bit after the procedure. So, if they’re on the brink of not being able to urinate prior to the procedure, then there is a high risk of not being able to urinate at all after the procedure. We have to parse out who those patients are and make sure that we account for that.

Better Man Clinics

You mentioned that, after the procedure, when they get home after prostate artery embolization (PAE), most men are going to feel a little bit of stinging in the penis, some urinary frequency, and a little pain with urination. Is there any significant pain otherwise after PAE: abdominal pain, groin pain, pelvic pain?

Ari Isaacson, MD 

No, not really.  If I’ve done my job correctly, then there shouldn’t be. On occasion, some of the beads can go to the blood vessels supplying the bladder, accidentally.  If that happens, then there is a little bit more pain afterward. It doesn’t do anything horrible to the bladder.  The bladder still functions.  The bladder has a lot of blood supply so it will make up for that. But, most patients, when they go home, will just say “Yes, I had to urinate quite frequently and it burned a lot when I did urinate. But, other than that, I’m surprised I even had a procedure.”

Better Man Clinics 

Are there any restrictions after undergoing prostate artery embolization (PAE)?  Heavy lifting? Driving?

Ari Isaacson, MD 

Yeah. When a patient leaves our procedure, we want someone else to be driving them home just because they’ve gotten sedation medication. We also do give them restrictions on heavy lifting, because we don’t want the hole that we made in the artery to reopen and bleed. I will tell my patients to avoid heavy lifting or straining for 3 days.  However, I also tell the patients that I don’t want them to be sedentary and sitting on the couch or in bed for a while. I want them to be moving around in a leisurely fashion. I think that helps the recovery.   I usually tell them to give it three or four days before they can go back to golf. An interesting question is when they can get back to bike riding after PAE.  I have a theory about biking, especially mountain biking.   When you bike, you have a lot of vibration on the perineum or the area underneath where the prostate is. As a result, I usually tell patients that biking too soon is counterproductive to their recovery because I think it’s going to continue to cause some inflammation. As such, I recommend about three weeks off the bike after PAE. Sometimes you have some people who are really fanatics and need to get back. And you know, I think everything is flexible and customized to the patient. But, all in all, it’s three days of no heavy lifting and, after a week, you can do anything you want except for biking.

Better Man Clinics 

Can most people resume driving the day after prostate artery embolization (PAE), once the anesthetic wears off?

Ari Isaacson, MD 

Yeah, absolutely. They can drive themselves.

Better Man Clinics 

Do most people go back to work within a couple of days of prostate artery embolization (PAE)?

Ari Isaacson, MD 

It kind of depends on what you do. Most men that I treat in this age group tend to either be retired or be in a position where they’re not doing something too strenuous. If you have a desk job, or you’re doing something behind the counter, you can go back to work the first day or second day after the procedure, depending on how much urinary frequency you have. If you’re feeling like you really have to pee very often, then may not be able to go back so soon but there are a lot of men who do go back to work the next day.

Better Man Clinics 

How soon after the PAE procedure would you anticipate somebody to have a meaningful improvement in their BPH symptoms?

Ari Isaacson, MD 

Yeah, that’s a great question. And this is a differentiator I think between some of the other procedures that are out there.  PAE is slower to work and, so, I usually tell patients, “You’re probably going to have to wait about 10 days to two weeks to really notice changes. And the changes that you see are not going to be dramatic. It’s not like turning on a light switch. And they’re going to be subtle at first, and they may not be consistent. So, you know, you may have one day where you feel like you’re urinating really well, and emptying well, and then the next day might not be that good anymore.” I know that some of them are alarmed and thinking that maybe, you know, it’s not working. But that’s just the nature of it- that it’s going to take time. And, usually, it can even take three to four months to get the full effect of the procedure. And so that is definitely a differentiator. When patients come to me and they are in a place where they really want results quickly, I tell them that this isn’t the procedure for them and that they should look at some of the other options.

Better Man Clinics 

Can you quantify how effective the prostate artery embolization (PAE) procedure is in resolving BPH symptoms?

Ari Isaacson, MD 

PAE is not 100% effective by any means. Depending on the size of the prostate, it can range anywhere from 80 to 90% effective.  The larger the prostate gets, the more effective the procedure gets. For a 50 gram prostate, I would say its about 80% effective.   And, so, that’s another reason that I really want patients to follow up with urologist because, if at three to four months the procedure didn’t work (if it wasn’t effective for the patient), they need to know what the other options are. The good thing about having this procedure is it doesn’t prevent you from having any other procedure. Patients have gone on to have TURP, Rezum, and Urolift after this procedure without a problem. And so, I think that is one of the benefits of PAE- you can have this procedure first as the least invasive procedure and still have another one if this doesn’t work.

Better Man Clinics 

When you say that PAE is 80-90% effective, how are you judging efficacy? What criteria are you using?

Ari Isaacson, MD 

My criteria is more subjective.  I ask the patient at three months or four months after the procedure whether they are satisfied with their urination or whether they want to have another treatment of some sort? It all comes down to how the patient feels.

Better Man Clinics 

Are most patients off of their BPH medications 3-4 months after PAE?

Ari Isaacson, MD 

Yes, most of them are. Some of them say, “Well, you know, I do a little bit better if I stay on my alpha-blocker”, and I say, “Well, does it cause you any side effects?” And they say, “Not really”. And I say, “Okay, well, then there’s no harm in that”. But I would say the majority of patients do come off their meds.

Better Man Clinics

Can you please describe some of the studies comparing PAE with other BPH treatments such as TURP?

Ari Isaacson, MD 

I would say, probably, a small majority of the studies have shown that TURP is more effective that PAE. All in all, there’s been one study that showed PAE is more effective than TURP. And then there were a couple of studies that showed that, after about six months, TURP and PAE were similar or the same in their effect. Personally, from my own experience, I think that TURP is probably more effective at reducing lower urinary tract symptoms. But, you know, there’s a trade-off.  You’re going to have more potential risks with the TURP. I think  that, with what we do during PAE, you’re never going to do as well as with a procedure that removes tissue.   That is because, with a TURP, you are clearing a channel. What we’re doing in PAE is not only shrieking the prostate, but also causing Alpha-adrenergic ischemic neurolysis.  What that really means is that we are causing the nerves that innervate muscle inside the prostate to die and cause that muscle to relax. So in essence, we’re doing something very similar to what Flomax does in the prostate, but just for a long time. So it’s kind of like combination therapy- it’s like, you get the effect of Flomax and you also get the effect of Finasteride of shrinking the prostate together. And that’s what improves the symptoms. Either way, you’re never going to have quite the same effect as creating a channel, but we can get pretty close.

Better Man Clinics 

It seems like if you’re comparing PAE to TURP, it’s almost like you’re doing PAE a disservice. Because TURP is meant for prostates that are less than 80 grams. As you mentioned previously, to receive maximal benefit from PAE, you’re looking at the really big prostates.   For those large prostates, the typical treatment options are HoLEP or simple robotic prostatectomy. Have there been any studies to compare those procedures head-to-head against PAE?

Ari Isaacson, MD 

Yeah, there was one study that did. It wasn’t a randomized control trial, but it was a matched pair analysis. What they did was they matched patients who had similar attributes (size of prostate, severity of symptoms) and this was compared to simple prostatectomy. Simple prostatectomy, to me, was far better at reducing symptoms than PAE.  However, PAE had a lot fewer complications than simple prostatectomy. And it’s exactly what you would expect. There hasn’t been a head-to-head with HoLEP that’s been done.

Better Man Clinics 

How durable is Prostate Artery Embolization (PAE)?  How many years is the procedure effective for in men with BPH?

Ari Isaacson, MD 

There are two research groups that have been doing PAE now for about 10 years or more, one from Portugal and one from Brazil. They have each published their 10 year data. What they have both shown is that the most typical durability of PAE is five to seven years. That is very similar to the data for Rezum and for your UroLift. I tell patients that this isn’t a forever procedure- you’re likely going to need another procedure.  Patients always ask why is that the case. Well, you know, one of the body’s responses to tissue that is starved of blood or oxygen, is to release chemicals that cause new blood vessels to grow. That’s just a survival mechanism. And, so over the years, these new blood vessels grow and start supplying blood to the prostate, and the prostate then starts to grow again. And some of those nerves that we were talking about before with the smooth muscles start to regenerate. And so you can then get symptoms again. The good news is that you can have another PAE at that point. There is data on repeat PAE as well.  It isn’t quite as effective as de novo or initial PE, but it’s still pretty effective. Or, alternatively, you can go on and have any other procedure. Again, PAE doesn’t prevent that. So you still have a lot of options.

Better Man Clinics 

Do all interventional radiologists perform PAE?  Is this a standard procedure for interventional radiologists? Or is it just a small subset of interventional radiologists that focus on this?

Ari Isaacson, MD 

PAE is known within interventional radiology as being a more technically challenging procedure. It is a technically challenging procedure because the arteries that we’re trying to get into are less than two millimeters in diameter (they’re usually one to 1.5 millimeters) and they often branch from other arteries at very extreme angles. And, so, it can be difficult to get the catheter where it needs to go. And then in addition to that, the arterial anatomy of the pelvis is quite complicated. Arteries are coming off in all directions and they often connect with one another. And, so, just recognizing where the artery (the prostatic artery)  is located is a skill in itself. And so, for those reasons, not every interventional radiologist wants to take on PAE.  But I would say there’s a subset of interventional radiologists who do more advanced embolization procedures. And this is one of them. It does take some study and some practice to have the skills to do this regularly.

Better Man Clinics 

How can men find qualified interventional radiologists that perform prostate artery embolization (PAE)?

Ari Isaacson, MD 

There is the Society of Interventional Radiology- if you go to their homepage, they have a directory of physicians who identify themselves as doing PAE.

Better Man Clinics 

Lets say that I’m in the office of one of these other interventional radiologists.  What questions should I be asking them to make me feel comfortable that they’re going to do a great job for me? Is it a question of their experience (how many procedures they have performed)?  What are those proper vetting questions that would help you feel more comfortable?

Ari Isaacson, MD

I think, like in any specialty, the more you do of a procedure, the more you’ve seen of the variants and of the potential complications.  You know how to deal with things. So, I think experience plays a big role. Having different imaging equipment can be helpful. When you’re starting out performing this procedure, it’s particularly helpful to either have what’s called a CT angiogram ahead of time to show the arteries.  That is a little bit different than what I get. I don’t quite get a CT angiogram, I just get a standard CT. There is also something called Cone Beam CT, which is part of your angiography equipment, which can also be helpful, and especially if you don’t have a lot of experience doing this. If physicians did 10,20 or 30 of these procedures, it’s helpful to have that type of equipment.  But, I would say that there’s nothing as valuable as just plain old experience in doing this – how many cases have you done?

Better Man Clinics 

What’s a reasonable number of PAE cases performed with regards to experience?

Ari Isaacson, MD

I think somewhere between 50 and 100 cases.  I think somewhere in there is where the learning curve kind of becomes less steep.