2. Prostate Artery Embolization for
Benign Prostatic Hyperplasia
Case study, anatomy, and technique
Justin McWilliams, MD
Western Angio and Interventional Society 2012
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6. Patient MB
• 62 year old male
• Severe lower urinary tract symptoms
• Intermittency,urgency, nocturia, weak
stream, straining, frequency
• Prostate volume 140 cc
• Too big for TURP
• Patient did not want open surgery
• Had researched PAE, and wanted it done
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8. Urology residency in one slide
• BPH affects 40% of men over age 60
• “LUTS”: Hesitancy, decreased urinary stream, incomplete
emptying, nocturia, frequency, urgency
• Medical therapy
• Selective alpha-blockers (relax smooth muscle tone of the prostate)
• 5-alpha-reductase inhibitors (reduce size of the prostate)
• Surgical therapy
• TURP for prostates up to ~80 grams
• Hospitalization 2-3 days, indwelling Foley
• Capsule perforation (2%), voiding dystunction, blood transfusion (1%)
• Open prostatectomy for prostates > ~80 grams
• Hospitalization 3-5 days, indwelling Foley
• Urinary incontinence, erectile dysfunction (4%), retrograde ejaculation
(90%), bladder neck contracture (4%), blood transfusion (5-10%)
Image courtesy of harvardprostateknowledge.org
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9. Quantifying
symptoms
• IPSS: International Prostate Symptom Score
• 7-item questionnaire, score 0-35
• 0-7: mild, 8-19: moderate, 20-35: severe
• Patient MB: 29
• Peak flow: Maximum urinary flow rate during
voiding
• Normal >12-25 cc/sec
• Patient MB: <5 cc/sec
• Urinary QOL:
• How would you feel about living the rest of your life with
your urinary condition the way it is?
• Patient MB: “Terrible”
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11. The world literature on PAE safety and
efficacy
Pisco et al, JVIR 2011 Carnevale et al, CVIR 2010
• 15 patients with symptomatic BPH who failed • 2 patients with acute urinary retention and
medical therapy indwelling Foley
• PAE with 200 micron PVA • PAE with 300-500 micron Embospheres
• 93% technical success • Foley removed in both patients, 3-15 d later
• Mean f/u 8 months • 6 mo follow-up
• IPSS decreased 6.5 points (p = .005) • Both patients voiding normally
• Peak flow increased 4 mL/sec (p= .015) • Prostate volume decreased 25-40%
• Prostate volume decreased 26 cc (p=.0001) • No complications
• 4 clinical failures
• 1 major complication (ischemic bladder wall)
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12. Additional data
Pisco, SIR 2012 • 52 clinical successes (91%)
• 57 patients with symptomatic BPH • Mean prostate volume decreased 28%
• IPSS decreased 9.8 points
• PAE performed using 100-200
• QoL increased 1.9 points
micron PVA
• IIEF increased 1.8 points
• Mean follow-up 9 months • Peak urinary flow increased 6.1 cc/sec
• 96% technical success rate (3/57 • PSA decreased 26%
unilateral) • Results better with 100 micron than 200 micron PVA
• 52/57 treated as outpatients • Complications
• 1 major (bladder wall ischemia), 11 minor
• 6 patients had pain during the procedure
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13. Additional data
Carnevale, CIRSE 2012
• 52 patients with symptomatic BPH
• PAE performed using Embospheres
• Mostly 300-500 micron, 7 cases used 100-300
micron
• Bilateral PAE in 90%
• Unilateral PAE in 10%
• Clinical success in 98%
Slide courtesy of Francisco Carnevale, MD
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14. Additional data
Carnevale, CIRSE 2012
• 52 patients with symptomatic BPH
• PAE performed using Embospheres
• Mostly 300-500 micron, 7 cases used 100-300
micron
• Bilateral PAE in 90%
• Unilateral PAE in 10%
• Clinical success in 98%
Slide courtesy of Francisco Carnevale, MD
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16. Timeline
• 2/9/12: Patient contacts me for possible PAE, discussed by phone
• 2/13/12: Clinic visit, history and physical
• 2/14/12: Receive return emails from 2 urologists caring for patient (3rd urologist did not respond)
• #1: “I have no clinical objection to your proceeding, as long as you follow proper protocol for a non-FDA-approved interventional procedure.”
• #2: “I have read about this procedure in some very sketchy papers out of Israel.”
• 3/1/2012: Authorization initiated by clinic staff
• 3/12/2012: First peer-to-peer with Blue Cross (denied)
• 3/24/2012: Met with Dr. Pisco and Dr. Carnevale at SIR meeting in San Francisco
• 3/26/2012: Second peer-to-peer with appeal reviewer
• 3/28/2012: Insurance authorization approved
• 4/3/2012: Prostate artery embo performed
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21. Internal iliac angiograms, ipsilateral oblique with slight tilt of II toward the head.
Green arrow = Superior vesical. Blue arrow = Superior gluteal. Purple arrow = Inferior gluteal. Orange arrow = Obturator. White arrow =
internal pudendal. Long red arrow = Origin of prostatic. Short red arrow = Distal prostatic.
22. Anterior division
Common inferior
Obturator gluteal – pudendal
Middle rectal Superior vesical Umbilical trunk
12%
28%
Internal pudendal Inferior Gluteal
56% 4%
Prostatic-inferior vesical artery origin
Bilhim et al. Prostatic arterial supply: demonstration by multirow detector angio CT and catheter angiography
23. L internal pudendal, from just beyond the origin of the L prostatic artery. Obvious prostate blush without
prostatic. Tiny branches feed the prostate from this nontarget branches. I embolized from here to stasis with
artery, but they were too small to microcatheterize. 300-500 micron Embospheres.
24. AP spot film showing stasis in the prostatic AP view of anterior division post-embolization. Slowed
artery. flow in L internal pudendal with no filling of prostatic
artery and no obvious prostate blush.
25. R internal pudendal artery, just above prostatic artery R prostatic artery superselected.
take-off.
26. Total time spent in room = 3.5 hours
Sheath = Standard 10 cm 6 French sheath in R common femoral artery.
Base catheter = RUC catheter (vs Cobra)
2.8F microcatheter (smaller may be better in difficult cases)
Embolic material = Total of ½ vial of 300-500 micron Embospheres
Contrast used = 210 cc
Fluoro time = 41 minutes
Procedure details
29. PAE Lessons Learned
• Screen patients carefully pre-procedure
• Not surgical candidate or refuses surgery
• Exclude prostate CA (PSA +/- prostate biopsy)
• Patent IIA without excessive atherosclerosis
• Place Foley catheter with contrast
• Marks position of bladder and prostate
• Use oblique projection to open up IIA branches
• 35 degree ipsilateral oblique, 10-15 degree caudal-cranial
• Identify branches to prostate, bladder and rectum
• Superselective angiography and embo
• Small size microcatheter
• Consider Dyna-CT to confirm safe position
• Embolize to stasis
31. PAE Case – 1 month f/u
• Occasional mild pain x 1 week (no medication required)
• Improvement noted in urinary symptoms within several days
• By 1 week post-procedure, symptoms almost completely
alleviated
• No hematuria, painful urination, frequency, urgency.
• Able to empty bladder fully without straining
• Erectile function normal
• Prostate volume 110 cc (from 140 cc)
• IPSS 2 (from 28!)
• Peak flow 13 cc/sec (from <5 cc/sec)
• Urinary QOL: “Delighted”
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32. PAE Case – 3 month f/u
• Flow slightly less and some
urgency recurred
• Self-limited episode of
hematuria occurred ~2 months
after the procedure
• Prostate volume 97 cc
• IPSS 9
• Urinary QOL: “Pleased”
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33. PAE Case – 6 month f/u
• Getting up once during the night
• Pressure of urine stream much better than pre-
procedure, but has reduced somewhat from 1st week
after procedure
• Occasional episodes of mild painless hematuria
• IPSS 11
• Urinary QOL: “Pleased”
• Patient remains very happy with procedure results
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35. BEST Study
BPH with EmboSphere Treatment
Phase III, FDA IDE approved, international study
Sites have been selected (number limited by FDA)
Randomized to TURP 2:1 with 186 patients
Primary endpoint = IPSS at 12 months, plus 4 years follow up
Co-investigators IR and Urology
Slide courtesy of Francisco Carnevale, MD