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Melanie Cole: Welcome to UAB Med Cast. I'm Melanie Cole, and I invite you to listen in, as we discuss prostate artery embolization. Joining me in this panel discussion is Dr. Theresa Caridi. She's an Interventional Radiologist and an Associate Professor at UAB Medicine and Dr. Aliaksei Salei. He's an Interventional Radiologist and an Assistant Professor at UAB Medicine. Doctors, thank you so much for joining us today. Dr. Caridi, I'd like to start with you. What happens to the prostate as men age? What are some of the symptoms of prostate trouble that a primary care provider might notice?

Dr. Caridi: So as men age, there's a particular disease process known as benign prostatic hyperplasia that tends to occur and gets worse with men who age, particularly over the age of 50. And so they can have urinary urgency, frequency, difficulty, urinating, and additional symptoms related to urination. And this is a benign condition as is stated in its name, but it can be very troublesome for quality of life, whether during the daytime or nighttime as men age.

Host: Dr Salei, as long as we're talking about symptoms, is it true that men don't often seek treatment until their symptoms become quality of life? Limiting, tell us about some tools that you might use to quantify symptom burden and how do you stratify that burden, whether it's lower urinary tract symptoms or anything else, the BPH symptoms that they might be experiencing?

Dr. Salei: That is true men often don't seek immediate treatment when they experience symptoms related to BPH. And this is partially related to fear of adverse outcomes that may be related to those treatments. Usually man, perceive treatments for BPH as something invasive often required surgery. And even though that historically has been true, there are now multiple other options that men may use for treatment of the BPH. Usually they get treated with medications first and a surgery reserved for those who don't respond to medications. And now we have the option of prostate artery embolization that kind of explains the options that those men may have for treatment of this condition. The symptoms that usually measured using international prostate symptom score or IPSS score system, which asseses multiple symptoms that Dr. Caridi already mentioned that men might experience due to prostate enlargement.

Host: Then Dr. Caridi tell us about prostate artery embolization. How did this procedure become useful for select men?

Dr. Caridi: You know, it actually started similar to the way that some of our women's health procedures started, which is women or men come in bleeding from an organ. And in this case it was the prostate. And so, when individuals and referrers, think about the need to stop bleeding from somewhere, there are surgical options and there's interventional radiology options or vascular endovascular options where we go in via the vessel and stop bleeding at a source. The prostate was a source of bleeding in some men who had enlarged prostates and therefore interventional radiology was consulted usually as an inpatient procedure to use a technique called embolization, to stop bleeding, which we do again in many organ systems. Now it evolved into treatment of benign prostatic hyperplasia for men with lower urinary tract symptoms. Based on that experience that we had with treating what's known as hematuria or bleeding of prostatic origin.

So, we were able to notice changes that were positive for the patient after treating bleeding from the prostate and adapt those to treating men as outpatient procedures with prostate artery embolization for symptomatic BPH. The way prostate artery embolization procedure, which we shortened to PAE, is an outpatient procedure that is often done with either a little bit of sedation or no sedation at all, because it's not a painful procedure per se. We access the artery someplace, superficially whether in the upper leg or in the wrist. And we traveled to the branches of the vessels that supply the prostate known as the prostatic arteries. And those are of course in the pelvis where the prostate is. And we treat those arteries with what's known as embolic. Sometimes it's casually referred to as bead or embolic, but in essence, we're blocking those arteries with some type of particle. And that's why sometimes it's called a bead because they are microspheres.

So, they're very small on the micron level. And we're blocking these with this embolic so that the prostate tissue can no longer expand. And in fact, actually decreases in size and causes volume reduction of the prostate so that it can alleviate some of those difficulties in urination. We know that there's more than just the effect of actual volume reduction of the prostate. We think that there's some other mechanism that also helps aid the sort of a softening of the prostate to allow for better urination as well. And that's being looked into in further studies.

Host: Then Dr. Salei, does this offer an alternative to trans urethral resection of the prostate with fewer adverse reactions? Tell us why you would choose this procedure over other options, give us the clinical indications for use.

Dr. Salei: So TERP actually considered to be the gold standard for treatment of BPH. And it still is a gold standard. And the man would benefit from getting TERP, which is done by urologists. Prostate artery embolization is something that may be a better option for select group of matter. And there is still a debate and there is still no consensus on what those groups can be. But what they can say now that it's maybe beneficial for men with multiple comorbidities who are not surgical candidates, and this is because of the very good side effect profile of the prosthetic category embolization. Also, this might be a good treatment option for younger men who are sexually active and don't want to experience known sexual side effects of TERP, such as well-known complication of retrograde ejaculation after TERP. So retrograde ejaculation happens rarely after the PAE. That is something that may sway some them into this treatment option. Another group of men who might be interested in this procedure or those who don't want any manipulation of their urinary tract, some men just don't want anybody to touch their urethra and they would rather have this option.

Dr. Caridi: I would agree with that Dr. Salei, and I would just add that we have more and more data coming out regarding prostate artery embolization with randomized trials, actually that are published in both the radiology literature and the urology literature that do direct head-to-head comparisons. We have eight or nine of these already in the literature. And what's interesting is that there are some factors that fair better for PAE and some factors that fair better for TERP. But the bottom line is the quality of life has significantly improved with both and very similar in essentially all of these studies, the most recent one that I just want to mention that was published in 2020, it was a European trial actually looked at prostate artery embolization versus a sham procedure. So it took out what, what we call the placebo effect, because some of the naysayers, I would say felt that maybe this procedure, when you have it done that there's a placebo effect. Just like there can be with taking a medication and that all these men were randomized and they were either the procedure was performed with the embolic or without which is unknown to the man on the table. And this is a long way to trial because it really helped us show in the literature that PAE fares remarkably better than the SHAM procedure. So that was a long awaited to trial, really needed to happen to convince some of our, your logic colleagues, that prostate artery embolization is real, is very effective as it has been in all of these trials and is here to stay.

Host: Dr. Caridi thank you for that. Do you feel that this will be established as a standard of care treatment option and has it even been considered for other conditions such as ovarian cysts or fibroids? Tell us a little bit.

Dr. Caridi: Prostate artery embolization is here to stay. I think trial after trial, we're gaining traction with more experience. I think that having the ability for men to have an alternative treatment that is minimally invasive, a nonsurgical same-day procedure with a very short recovery and then the trials to back it up, I can't see where this would go away. And I think it's hugely beneficial for the male population who suffer from BPH. I would say that there's a lot of comparisons to other things that we do in interventional radiology already. And you asked about fibroids. This treatment is well established. Embolization is well established in uterine fibroids and it's called uterine fibroid embolization or uterine artery embolization. We have 25 years or so of data in that. So, it's well ahead of the prostate in terms of data collection, but I expect that there are some similarities and some differences, but what I expect to be similar in the long-term is that the data will continue to play out in support of prostate artery embolization, as it has for uterine fibroid embolization.

Dr. Salei: And I wanted to add that prosthetic artery embolization has already been recognized by the British National Institutes for Health and Care Excellence. And is considered one of the options that should be discussed with the patients who are interested in treatment of their BPH.

Host: Dr. Salei, how have been your outcomes?

Dr. Salei: The outcomes of this procedure, the outcomes that I had are encouraging, even though we did not have large volume of patients yet at our institution. Yeah. I, my first patient was extremely pleased with the results and he was treated about six months ago and still happy with the results of this procedure.

Dr. Caridi: Let me just add that while our program at UAB is just beginning in terms of increasing the volume of patients that we treated. I recently transitioned from Georgetown to UAB and I bring with that, my experience from my prior institution, where I've had a growing practice in this as well and prostate artery embolization, my experience has been extremely promising similar to the literature. I don't consider this experimental in any way at this point, given the depth of literature and the volume of patients that I've treated as well as many of my colleagues around the country, my experience has been positive in so many different populations. As Dr. Salei mentioned, whether it be the patient who's relatively young and has BPH and doesn't want to undergo a more invasive procedure for it, and doesn't want to suffer the potential sexual side effects of procedures.

 

Or whether it be someone who's on the older spectrum of the population who really can't undergo a surgery or is concerned about their other comorbidities or the urologist may be concerned about the patient's comorbidities. They may be on blood thinners, other issues of that nature. And then finally we have a patient population that's already catheter dependent that they have to actually walk around with a full catheter and are unable to get fully catheter free, but they really are not the appropriate candidate for an invasive surgery. And this population has been extremely promising and in our ability and my personal ability at my prior institution to perform this procedure and have that patient become catheter free, which tremendously increases their quality of life.

Host: Dr. Salei first, last word to you, what would you like other providers to know about prostate artery embolization and when you feel it's important that they refer?

Dr. Salei: So, I wanted the other providers to know that it is actually a good option for treatment of BPH, that this is a minimally invasive option with very little side effects and the option that offers men to have this treatment, essentially without major interruptions in their normal lifestyle, as usually it's an outpatient procedure and most patients get discharged the same day. I also wanted to mention, this is not the procedure that is suitable for all the patients, but it's something that is worth discussing with the patient. And it's a treatment option that is worth offering to the patient.

Host: Dr. Caridi last word to you. What would you like other providers to take away from this episode and maybe reiterate the importance of good patient selection?

Dr. Caridi: Yes. I agree with Dr. Salei that there are many patients who are appropriate for this procedure, not all, but the key for other refers is whether it be urologists or whether it be primary care physicians who are the most likely who are going to encounter this disease process. I think what I'd like them to know is that when a patient is sent our way, we do a clinic evaluation and really present the option to the patient of PAE, but we would also let them know if they were not the best candidate for them. So sending them our way is not a bad thing because we can guide them in whether PAE is an appropriate procedure for them and whether it's not. And so I think it's great for men to hear all of their options and this may or may not be an option for them. And since we're the experts in doing PAE, it would be great for them to be able to hear that opinion from us.

The other thing that I would add is that men don't necessarily have to go through a referring physician. We have plenty of ways in which they can contact whether here in the UAB area or elsewhere, they can contact interventional radiology clinic directly, including at UAB. So they can, what's known as self-refer, we're perfectly capable of working them up. And if they need further your logic evaluation, or if they haven't discussed the neurologic available to them, we can also refer them back to urology. So the key is, in my opinion, working collaboratively with urology or primary care to make sure that men are hearing what options are best for them or are available to them and whether they're appropriate or not.

Host: Thank you both so much for joining us today and telling us about this interesting procedure. Thank you again. And a community physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST. And that concludes this episode of UAB Med Cast to refer your patients or for more information on resources available at UAB Medicine, please visit our website at UABmedicine.org/physician. Please also remember to subscribe, rate, and review this podcast and all the other UAB Medicine podcasts. I'm Melanie Cole.