Prostatic Artery Embolization

Definition: What Is Prostatic Artery Embolization (PAE)?

Prostatic artery embolization (PAE) is a newer procedure for treating benign prostatic syndrome (BPS, benign prostate enlargement).

Over 70% of men over the age of 60 have problems urinating, which is often due to an enlarged prostate gland. The disease of the benign prostate syndrome (BPS, formerly benign prostatic hyperplasia = BPH) is caused by a benign proliferation of inconspicuous prostate cells. Due to the increased growth of the prostate gland, the urethra, which runs through the prostate, is squeezed, and the urinary stream is weakened. Because of the narrowed urethra, men suffer from nocturnal urination, urinary retention, or weak urinary stream with high bladder pressure.

The BPH will steadily worsen without treatment due to further growth of the prostate. In the early stages of the disease, therapy consists primarily of drug approaches. In later stages or the presence of complications such as blood in the urine, kidney damage, or deposits in the bladder (calculi), invasive therapy is recommended. There are various options for either directly removing the prostate tissue (primary ablative, e.g., TURP = transurethral resection of the prostate, open prostate surgery, laser procedure) or damaging the tissue in various ways to reduce the volume of the prostate gland (secondary ablative, e.g., transurethral microwave thermotherapy, transurethral needle ablation, PAE = prostatic artery embolization). Prostatic artery embolization (PAE) is one of the newer procedures in treating benign prostatic hyperplasia. PAE falls under the specialty of interventional radiology.

Indications: When Is Prostatic Artery Embolization (PAE) Used?

PAE is increasingly becoming an alternative to current surgical procedures for patients with benign prostatic enlargement.

Patients with proven obstruction and moderate to severe symptoms are indicated for invasive surgery. Prostate artery embolization (PAE) is particularly suitable for patients who are afraid of the conventional surgical procedure. PAE is also recommended for patients whose surgical risk would be too high, for example, due to impaired blood clotting or due to an increased risk of anesthesia. Exclusion criteria for prostate artery embolization (PAE) include prostate cancer (a malignant tumor of the prostate gland), protrusion of the bladder, or acute prostate or urinary tract infections.

Procedure and Duration: What Is the Procedure of Prostatic Artery Embolization?

PAE is a minimally invasive treatment that is carried out with a vascular catheter through the arteries. The smallest blood vessels (capillaries, pre-capillaries) of the prostate gland are occluded with embolization, with tiny microspheres of 250-400µm in size.

This vascular occlusion leads to shrinkage of the enlarged prostate via several mechanisms. First, the interruption of the blood supply in the area of the pathologically enlarged organ leads to the formation of edema and an inflammatory reaction in the prostate. As a result, the prostate gland scars and shrinks.

During the procedure, a vascular catheter is inserted through the inguinal artery and advanced through the iliac artery directly to the vessels that supply the prostate. Through the catheter, the interventional radiologist delivers plastic pellets into the tiny vessels to occlude them. Embolization is carried out on both sides since the prostate is supplied by a left and a right prostatic artery. The procedure is performed under X-ray monitoring with local anesthesia. Prostatic embolization usually requires a short inpatient stay of one to two days. The patients receive antibiotics during the procedure to protect them from infection and anti-inflammatory medications (e.g., ibuprofen). Patients usually report only mild pain and a feeling of pressure in the pelvis for up to two days. Improvement in patients' symptoms usually occurs after a few weeks as the remodeling processes of the prostate gland proceed.

Advantages of Prostate Artery Embolization (PAE)

Initial studies show similarly good results of PAE with transurethral prostate resection (TURP), which is the gold standard to date. In addition, PAE has significantly fewer side effects, especially about possible incontinence or retrograde ejaculation after the procedure.

As a particular advantage, the procedure is targeted and particularly gentle. As a result, the urethra remains unaffected by PAE, which is why there is no need to worry about post-operative bleeding or incontinence.

In addition to the excellent effect of the procedure, the PAE is associated with a much lower surgical risk than the conventional surgical procedures carried out under general anesthesia due to the local anesthesia.

Prostatic Artery Embolization (PAE): Costs and Coverage by Health Insurance Companies

The cost of prostatic artery embolization is usually covered by health insurance. However, international patients should inquire about costs with specialized clinics.

Sources:

• Teichgräber U, Aschenbach R, Diamantis I et al.: Prostate Artery Embolization: Indication, Technique and Clinical Results. Fortschr Röntgenstr 2018; 190: 847–855
• Leitlinie zur Therapie des benignen Prostatasyndroms der Qualität S2e, 2014
• www.unimedizin-mainz.de/radiologie/methoden/angiographie-und-interventionen/prostataembolisation.html