Prostate artery embolization

The prostate is a small gland that sits just below the bladder and wraps around the urethra, the tube that carries urine out of the body. In most men the prostate slowly grows after age 40. When it grows large enough to squeeze the urethra, it is called an enlarged prostate, or benign prostatic hyperplasia (BPH). Benign means it is not cancer, and BPH does not turn into cancer.

BPH is very common. About half of men in their 60s and most men in their 80s have some symptoms. The size of the prostate does not always match how bad the symptoms are, so treatment is based on how much the symptoms bother you.

Prostate artery embolization (PAE) treats BPH from inside the blood vessels. An interventional radiologist, a doctor who uses X-ray and ultrasound to guide small tubes through the body, places a thin catheter into the small arteries that feed the prostate. Tiny beads are then released to reduce the blood flow. Over the following weeks the prostate softens and shrinks, which takes pressure off the urethra.

Only you can say how much your symptoms affect your life. To track them in a fair and repeatable way, we use a short questionnaire called the International Prostate Symptom Score (IPSS). You fill it out before treatment and again at follow-up visits, usually around 1, 3 and 6 months, so we can see how much you have improved.

Each of the seven questions is scored from 0 (not at all) to 5 (almost always, or 5 or more times a night). The total runs from 0 to 35. 0 to 7 is mild, 8 to 19 is moderate, and 20 to 35 is severe. An eighth question asks how you would feel if you had to live with your urinary symptoms as they are now. It is scored separately, from 0 (delighted) to 6 (terrible), and tells us about your quality of life.

Most men who come to us for PAE have moderate or severe scores. After a successful treatment, it is common for the score to drop by many points, and for the quality-of-life answer to move from unhappy toward pleased.

You can find the full IPSS questionnaire online or ask us for a copy. Bring your completed form to your first visit.

PAE is a good option for many men whose urinary symptoms still bother them despite medicine, or who cannot tolerate the side effects of medicine. It is also a choice for men who want to avoid surgery, who want to protect their sexual function, or who have health problems that make surgery and general anesthesia riskier.

Before we decide, we usually review a PSA blood test, a urine test, and imaging of the prostate, most often an MRI. Some men also have a CT scan of the pelvic arteries to plan the route, and a test of urine flow and how much urine stays in the bladder after you go. Many of our patients also see a urologist, a surgeon who specializes in the urinary tract, so that every option is on the table.

When I meet a man with BPH, I look at three things together: how much his symptoms bother him, how his bladder is working, and what his prostate and its arteries look like on the MRI or CT. A large prostate with a big middle lobe and healthy arteries is usually an excellent setup for PAE. If something else is driving the symptoms, like a tired bladder or a stricture, I tell him honestly that PAE is not the right tool and help him find the one that is.

Fabio Komlos, MD, interventional radiologist · About Dr. Fabio Komlos

There is no single best treatment for everyone. Medicines are usually the first step. Alpha blockers such as tamsulosin relax the muscle around the urethra, and 5-alpha reductase inhibitors such as finasteride slowly shrink the prostate. They help many men, but can cause dizziness, tiredness, a stuffy nose, and changes in ejaculation or sex drive.

When medicine is not enough, the choices include PAE and several surgical procedures done by a urologist through the urethra. These include transurethral resection of the prostate (TURP), laser enucleation (HoLEP), water vapor therapy (Rezum) and implants that hold the prostate open (UroLift). Surgery through the urethra often gives the fastest and largest improvement in urine flow. PAE avoids instruments in the urethra and has a lower chance of sexual side effects, but its effect builds more slowly.

PAE does not rule out surgery later. If symptoms return or the result is not enough, a urologist can still perform any of the surgical options.

You can read more in before your procedure and what to expect from sedation.

PAE is done at El Camino Hospital in an interventional radiology suite, a procedure room with a large X-ray camera. A team of nurses and a radiology technologist care for you alongside your interventional radiologist.

1. 1
   Getting ready

   A nurse places an IV in your arm and checks your vital signs. In the procedure room you lie on your back and are connected to heart, blood pressure and oxygen monitors. You receive moderate sedation, sometimes called twilight sleep, so you are relaxed and drowsy but breathing on your own.

2. 2
   A pinhole in the wrist or thigh

   The skin over the artery in your wrist or upper thigh is cleaned and numbed. Using ultrasound, the doctor places a thin tube into the artery through a puncture about 2 mm wide. You may feel pressure, but it should not be painful.

3. 3
   Mapping the prostate arteries

   Under X-ray guidance, a catheter about the width of a strand of spaghetti is guided into the pelvis. A small amount of contrast dye shows the arteries on the screen. A cone-beam CT, a quick 3D scan taken on the table, confirms which branches feed the prostate and which feed nearby organs.

4. 4
   Embolization

   An even thinner microcatheter is advanced into each prostate artery and tiny beads, each smaller than a grain of sand, are slowly released until the flow slows. The same steps are repeated on the other side. You may feel warmth or a brief urge to urinate.

5. 5
   Closing and resting

   The catheter is removed. A wrist band or a small plug or pressure closes the puncture, with no stitches. You rest in recovery for about 2 hours, eat and drink, see your family, and most men go home the same day.

What we see

Most men feel tired for a day and then return to light activity. As the prostate reacts to the treatment it becomes inflamed for a while, which can temporarily make urinary symptoms worse before they get better. This is expected and usually settles within 1 to 2 weeks.

1. Day of the procedure
   Rest at home. No driving, alcohol or important decisions for the rest of the day because of the sedation. Eat light meals and drink plenty of fluids.
2. First 24 hours
   No exercise, heavy lifting or strenuous activity. If the wrist was used, avoid pushing or lifting with that hand. You may shower the next day, but do not soak the puncture in a bath, hot tub or pool for 1 week.
3. Days 2 to 7
   Return to normal daily activities and driving. Urinating more often, getting up at night, urgency, mild burning, pelvic ache, and a little blood in urine or semen are common and improve day by day.
4. Weeks 2 to 12
   Irritation fades and the flow gradually gets stronger as the prostate shrinks. Most men notice the main change within 1 to 3 months.
5. 1, 3 and 6 months
   Follow-up visits and a repeat IPSS. We may talk about slowly reducing your prostate medicines, never all at once.

In published studies, about 3 in 4 men notice a clear improvement in their urinary symptoms and quality of life after PAE, with results best when both sides of the prostate are treated. On average the IPSS drops by roughly 10 or more points. The benefit lasts for years in most men, but symptoms come back in some, about 1 in 5 over several years, and a repeat PAE or surgery can then be considered.

Serious problems are uncommon. Most side effects are short-lived and part of what is called post-PAE syndrome: urinary burning and frequency, pelvic discomfort, mild fever, nausea and tiredness for a few days.

Unlike most prostate surgeries, PAE rarely causes erection problems, leaking urine, or dry orgasm (retrograde ejaculation). Some men notice a smaller amount of semen.