Cheryl Martin (Host): Coming up, a closer look at a treatment option for men with benign prostatic hyperplasia, BPH, or an enlarged prostate. This is a very common problem, affecting 50 percent of men with BPH, over the age of 50. Here to discuss the procedure is Dr. Robert Dixon, an Interventional Radiologist and Professor of Radiology at UAMS.

This is UAMS Health Talk, the podcast from the University of Arkansas for Medical Sciences. I'm Cheryl Martin. Dr. Dixon, so glad you're on to talk about this procedure.

Robert Dixon, MD: Thanks for having me, Cheryl. I'm delighted to be here.

Host: First of all, what's the name of it?

Robert Dixon, MD: So this is called prostatic artery embolization or PAE. Embolization is just a fancy word for blocking up the blood supply to a target. We use it in all sorts of different places in the human body. But in this situation, the target is the prostate. And the effect of, what happens when we cut off the blood supply to the prostate is that it softens and it gets smaller.

So, this allows urine to pass more freely and more completely, because the tube from the bladder to the outside world, goes right through the prostate. And so this improves the symptoms that older men have, including a sense that they have to pee all the time, or urinary frequency, or an urgency, like they have to get to the bathroom right away, or the sense that when they do urinate, the bladder doesn't completely empty.

Another common problem that I hear about is nocturia, or having to get up in the middle of the night to urinate, and some men have to get up 3, 4, 5 times a night. That disrupts their sleep, which makes them tired all the time and obviously disrupts their, their life. So these symptoms as a group are known as lower urinary tract symptoms or LUTS, L-U-T-S.

Host: So, what are the indications for this procedure?

Robert Dixon, MD: So as you mentioned earlier, this is a very common problem. If the symptoms are not too severe, there's no need to do this procedure. As the symptoms become more severe, the usual treatments involve stopping things that make you urinate all the time, such as caffeine, coffee, and alcohol. It's difficult to do that for some people, so many times, medications are used, because that's a non invasive way, and the two main groups of medications that are used are called alpha blockers, like Flomax.

And that relaxes the smooth muscle within the prostate and allows men to pee more easily. And also medications that shrink the prostate. A group of medications that are known as 5-alpha reductase inhibitors. So the indications to do a PAE, which is a, it is a procedure that it's, I would call it a minimally invasive procedure.

But if the man is having moderate to severe symptoms, and there's a scoring system we use; but if they're moderately symptomatic or severely symptomatic; it makes sense to do something. This is one of the options that can be done. So you have to have an enlarged prostate, and a normal prostate is about the size of a walnut, under 30 grams.

So we usually see prostates that are at least 40 or 50 grams, and many times they might be 100 or 200, so they can be quite large. There's no upper limit to performing a PAE. Men who have tried the medications but have side effects, they don't want to take the meds, so this is a good option, or if the medications are no longer helping.

Sometimes they, after a couple years, they stop working well. And some men just wish to avoid surgery. The other options involve transurethral procedures, such as, uh, resection of the prostate, there are laser treatments, there's open surgery, but, some men just want to avoid that. And then some men can't have surgery. They might not be a surgical candidate. They have too many comorbidities to undergo surgery. And so this is good option for that group as well. And then finally, men who have a catheter, a Foley catheter through their penis into the bladder because they can't urinate. They have urinary retention. We can do this procedure and then after a few weeks, the catheter can be removed.

And then the other group are people who have bleeding from either the prostate or the bladder. Those two things can bleed for a variety of reasons. So sometimes we're asked not to embolize the region for an enlarged prostate, but because there's bleeding involved. So, I just said a lot of things, but the idea is, if you don't want to have surgery, can't have surgery, have side effects from the medicines, then this is a great option.

Host: So how is the PAE performed?

Robert Dixon, MD: This is done as an outpatient. We typically will give men a little bit of Valium by mouth just to help them relax, because the procedure might take one to two hours. You have to lay still for that amount of time, but we don't put people to sleep with general anesthesia. A small catheter is put into the arteries.

You can either go through the arteries in the wrist or the arteries in the groin. I typically use the femoral artery in the groin. It's relatively close to the prostate, and it's a fairly large artery. And we put a catheter in that's about the size of spaghetti, and we can use x-ray to see where we're going, and get into the area where the arteries start to get smaller.

And then we put an even smaller catheter in, and get right to the artery that feeds the prostate. Once we know we're there, we inject microscopic particles, and that's what cuts off the blood supply to the prostate. The procedure is not painful during the procedure, nor is it painful immediately after, but sometimes the night after or a few days after, the the men will have a sense that they have to urinate, they might have burning when they urinate. The area is inflamed and that's because we cut the blood supply off to it. We don't place a Foley catheter. We don't put anything through the penis to do this procedure. If there is a Foley in place, we typically wait a few weeks and then take that out and see if they can void without the catheter.

Host: And what's a Foley?

Robert Dixon, MD: A Foley catheter is a long rubber tube that's inserted through the end of the penis into the bladder. It has a balloon that's inflated to keep it in the bladder and it's put in when men's prostate gets so large that no urine comes out. So the bladder just gets filled up like a big balloon and we put the Foley catheter in to release the urine, drain the bladder. But then the Foley has to stay in place.

Host: And you're saying for this procedure, you do not put one in.

Robert Dixon, MD: I do not. And for many of the other procedures for enlarged prostate that men are offered, the devices go through to, many times people call it roto rooter, but kind of drill out the prostate. Or a laser can be used, or there's even sort of a high power water pic that can be used to take away the prosthetic tissue. But after all those procedures, a Foley catheter is left in place. And many men don't want to have to deal with that. So we don't put one in for this procedure, and you don't end up with one when we're done with this procedure.

Host: You touched on this a little bit, but are there potential complications?

Robert Dixon, MD: With any procedure, there's always risks of complication. And, I like to say that the prostate is in an area that's expensive real estate. There are important things around the prostate. The bladder, the rectum is another, and the penis is the third one. So, we don't want those particles to go to the bladder or the rectum.

If that happens, it's usually only for a short time, but it can irritate the walls of those structures and you can get bleeding in the blood in the urine or blood in the stool. But remarkably that typically heals up within a couple weeks without any problem. Sometimes within just a few days. And that's because there's such a rich collateral blood supply, meaning that there are many other blood vessels that feed those structures, so they bounce back.

 The one that's perhaps feared the most, because it's so obvious is if particles go to the penis. The chance of that happening is exceptionally low, about 0. 4%. And what happens is the particles go and cut off the blood supply to the skin of the penis and you, a man can get an ulcer.

 Fortunately, that heals. It might take a couple, two, three weeks. It's very disturbing to the patient. But because this is so rare, I tell men not to worry about it. You just have to be super careful. So the chance of that is very low, 0. 4%. The chance of the other areas, the bladder and the rectum, is probably, well under 15%. And then it's not a complication, but most men have some discomfort, after the procedure, but we give medications including steroids, antibiotics, and a medication that just helps the bladder relax. And that will help diminish those symptoms over the few days following the procedure.

Host: So PAE is not a painful procedure?

Robert Dixon, MD: The only pain involved is, me numbing the local anesthesia, before we get access into the artery. While we're working in the arteries, while we're putting in those particles, it's not painful at all. In fact, sometimes men are awake and they can chit chat with us or ask us questions, but many, many patients will drift off to sleep because we give them the Valium beforehand and maybe a little sedation medicine in the IV if they want.

Host: Now is PAE FDA approved?

Robert Dixon, MD: It is. It's been FDA approved since 2017 and most insurance companies and Medicare pay for this. So, even though this concept has been around actually for decades and over the last 20 years, we've learned a lot more about it, and in my circles, it's very popular; the general public doesn't know about this, especially here in Arkansas, I have found.

So I'm trying to get the word out about it, because some people think it's experimental or it's not FDA approved. There's been many, many studies done on this procedure, comparing it to other options, and it is FDA approved, and insurance pays for it.

Host: Great. Now, talk about the success of this procedure.

Robert Dixon, MD: Right, most men who have this procedure done, and when I say most men, I mean 80 to 85 percent of men, are very happy with the results after the procedure. That's important because that means it's not 100 percent effective. That's a pretty good success rate though. And if men no longer have to get up in the middle of the night, and they don't have to rush to a bathroom in the middle of the day, their life is better.

 It is very successful, but not 100 percent successful. It's important that the patients know that the effects are not felt immediately, rather they'll experience improvement typically over a few weeks. They'll start to notice improvement, but then the maximum benefit will be realized at about two to three months.

And then, the effects don't last forever. We have found that they typically last five to seven years. That means that the procedure can be repeated, and it also means if they're in that small group of patients where it didn't help, that they can have another procedure. This does not negate doing any other prostatic procedure that's available out there. And if the patient wishes the PAE to be repeated, we simply can repeat it. Why does it not last forever? It doesn't last forever because the prostate will recruit other blood vessels, so you cut off the blood vessels of the main pipeline, and over time, vessels in that expensive real estate neighborhood will be recruited to the prostate, the prostate will start to enlarge again after a few years.

Host: So, how can a patient get in touch with you?

Robert Dixon, MD: I think the best way, since I'm on the move so much, the best way is to get in touch with my clinical coordinator. Her name is Christine Starr, and she can be reached at 501-686-6918. You probably could also find me easily through the UAMS information system and the website there and you'd be free to email me. But Christine is the best contact. My email is rdixon@uams.edu.

Host: Well, Dr. Robert Dixon, thank you so much for discussing in detail this treatment option, PAE, for prostate problems. Thank you.

Robert Dixon, MD: You're very welcome. Cheryl, it's been my pleasure and thanks so much for having me on.

Host: Once again, the best way to get in touch with Dr. Dixon is to contact our clinical coordinator, Christine Starr, by calling 501-686-6918. That's 501-686-6918, and she can arrange for a consultation. If you found this podcast helpful, please share it on your social channels and check out the entire podcast library for other topics of interest to you.

This is UAMS Health Talk, the podcast from the University of Arkansas for Medical Sciences. Thanks for listening.