Evo Terra (Host): Benign prostatic hyperplasia or BPH is a commonly known term. What's less known is a treatment for BPH called prostatic artery embolization or PAE. Doctors Chadi Diab and Andrew Shabila, both interventional radiologists with UK HealthCare, will discuss that with us today.

This is UK HealthCast, a podcast from UK HealthCare. Thanks for listening. I'm Evo Terra. Doctors, thanks for joining me.

Dr. Andrew Shabila: Thank you for having us.

Dr. Chadi Diab: Thank you for having us, Evo.

Host: There's a lot for us to get through, but I want to do a quick level set. Can you briefly explain what benign prostatic hyperplasia or BPH is?

Dr. Andrew Shabila: Absolutely. So, benign prostate hyperplasia, BPH, is an enlargement of the prostate gland that is situated right underneath the urinary bladder in men. And as men age and it enlarges, it compresses on the urethra, hence obstructing urine to freely flow from the bladder. And this can cause a lot of symptoms and difficulties in passing urine in elderly men. And a lot of the symptoms related to BPH, maybe frequent urination, especially at night; weak urinary stream, hesitancy or difficulty in initiating urination, dribbling at the end of urination or incomplete bladder emptying.

Dr. Chadi Diab: And it's pretty quiet common, BPH, just like my colleague, Dr. Shabila, was explaining, this prostate increases in size, especially with aging. It is estimated that more than 50% of men in their 60s and up to 90% in their 70s have some degree of BPH, whether symptomatic or not.

Now obviously, the question, like how do we diagnose BPH, right? Some patients may have these symptoms. Typically, like they would go to a urologist, that's going to be their go-to provider or their PCP where they start kind of having one of these symptoms that we just mentioned earlier, and they would consult with their provider who would usually start with doing a physical examination, digital rectal examination. And they would order some studies like urinary flow study, where they measure how much urine is remaining in the bladder. We call it post-void residual. That tells us how bad this prostate is big and compressing and not allowing the bladder to empty. So, that kind of gives a good idea. And then, they would order some of the tests like prostate-specific antigen, PSA, to rule out like cancer, because that's another cause of enlargement of the prostate. BPH, just to make sure, it's a non-cancerous enlargement. So, we want to make sure it's not cancer before we jump to treatment. And that's one of the key things to do in earlier evaluation.

And recently because of the development of imaging and also radiology, we do obtain often MRI and it's a kind of a new study. It does give us an idea of how big is the prostate, the anatomy, and also allows to see if there are any suspicious lesions also to take into consideration with the treatment.

Host: Before we get into talking about this new treatment I know we're going to get into, just for the level set here for the listening audience, what are the traditional treatments for BPH?

Dr. Andrew Shabila: So, the traditional treatments for BPH are usually, if very minimal or no symptoms, just watchful waiting. And as the symptoms progress, the providers may be prescribing medications or to relieve the symptoms of the compression by the enlarged prostate onto the urinary bladder and the urethra. Hence, we're relieving some of these symptoms. Ultimately, the more definitive treatments for an enlarged prostate would be surgical intervention, minimally invasive surgeries or entire removal of the prostate or prostate artery embolization, which is what we're going to discuss today.

Host: Yeah. And so, let's get into that because I know of the others, but this is brand new to me, this idea of PAE or prostatic artery embolization. What is it and how does it work?

Dr. Chadi Diab: So, prostatic artery ablation is an interesting procedure. I'm just going to explain each of the terms to try to kind of make it easy. Embolization, we use often this word as interventional radiologists where we embolize a vessel, what that entails is blocking the vessel. We use this technique, it's an old technique, it's a not a new technique. We use it often for patients who are bleeding and for a patient who have cancer, where we try to selectively catheterize the vessel that's bleeding or having problem and we block that vessel. So, that's the technique of embolization.

The other words in PAE is prostatic artery. So technically, what we're doing is procedure, pretty much trying to block the arteries that feeds the prostate. And the end goal is to make this prostate starve from blood and shrink and decrease in size. As we said, one of the main mechanism of prostate causing problem is like it is enlarged.

Now going to the technicality, because the patient will ask like, "Hey, is it like a big surgery? Is it small surgery? How is it performed?" Correct? It is a minimally invasive procedure. And that's the key thing about this technique where there is no cut, there is no scars. I don't know if the people who are listening, they've had the cardiac cath. It's pretty much similar, the concept where we try to access with a small needle, the wrist or the groin artery. And from there, we do the entire procedure. We start inserting a small catheter using image guidance, and we try to selectively insert that catheter into the prostatic artery. And we embolize or we occlude both vessels on each side using particles. This is more like a specific way how we do it.

Host: So, a question about that. So, we're blocking the artery so that it causes the prostate to shrink. But when we block blood flow to organs, there can be more than shrinking. They're dying. I'm assuming the prostate is fed blood other ways than just this prostatic artery.

Dr. Chadi Diab: So, it's interesting. Remember we can take the prostate, so one of the treatments of BPH, complete removal of the prostate, surgical resection of the prostate. So yeah, we don't really worry if the prostate has no blood supply because, in fact, that's what we want to do. We want it to shrink and die or get smaller in size. But you're right, in fact, it may still get the blood supply and that's one of the reasons there's a very low risk it may not completely work. But most of the time, it does. But that's a very good point that you brought up. In fact, the technique has been developed over years and now we do it better because we developed new catheters and different types of particles. And in fact, to make sure we block the blood as much as we can. In fact, that's the end goal, to make sure we starve this prostate from blood supply.

I want to also mention talking about minimally invasive because we know a lot of surgeries are performed under general anesthesia. This procedure can be performed, or in fact, most of the time we perform it under either local anesthesia or conscious sedation. So, the patient will come here, like in the procedure, they'd be awake. They'll be comfortable at the same time, but they won't have to go through the risk of general anesthesia. Especially that this is a pathology of elderly, where like they may have comorbidities and they may be contraindication to be under general anesthesia, so they may still get the benefit of this procedure even if they have significant heart comorbidities or lung comorbidities that may preclude them from being like a surgical candidate or general anesthesia candidate.

And it's not a painful procedure. I know some people may get worried like, "Hey, I don't want to feel anything." It's pretty much almost like getting an IV. You feel that's stick, and the rest of the procedure is really not painful, especially when we give medication that makes them relaxed like sedatives.

Host: Typically, how long does the procedure take?

Dr. Andrew Shabila: So, the procedure can take anywhere between one to three hours to be honest. And then, that really is going to depend on the anatomy that we encounter, the difficulties in identifying and safely selecting the prostate arteries on both sides. And once we're there, we want to safely administer the particles to block the blood vessels while carefully watching, making sure that these particles don't end up elsewhere in unintended targets. So, a lot of it requires expertise, being cautious and time to perform the procedure safely and effectively.

Host: Yeah. I would assume that those particles going somewhere else is one of the risks of a side effect, or are there others people should be concerned about?

Dr. Andrew Shabila: Yeah. So, there are some potential risks, as with any procedure. But these risks and side effects are actually very, very low with prostate artery embolization, especially when done in a center or being performed by an experienced interventional radiologist. Some of these kind of side effects would be pain or discomfort in the pelvic region after the procedure or temporary difficulty in urination. This typically subsides after a few days after the procedure. And also, possibly urinary tract infections or blood in the urine, which are actually even less of the side effects or risks associated with the procedure than comparable, like surgical, minimally invasive techniques.

The unintended embolization or delivery of particles to adjacent organs is something that we essentially pay meticulous attention to during the procedure to when we're performing, make sure that that does not end up in unintended targets. And this is something that experience teaches us and also our technique that has developed over time has allowed us to do this safely.

Dr. Chadi Diab: I would add one more point, just to support that with some numbers, the complication, like risk overall is not treated. Like I'm talking about minor complication, like some blood in the urine, which is transient as we mentioned, this resolves in five to seven days. These are not common and we're talking about like almost less than 5%. And these cases of non-target embolization, again, this is like case by case. We're talking about case reports and we're talking about like less than 1%, like very rare. So, they're not common. But obviously, we still watch for them and try to avoid them. And if the patient asks us, we still have to mention it even if they're rare, because to be kind of thorough on everything that can happen.

Host: And this PAE procedure, how widely accepted of a treatment is this?

Dr. Andrew Shabila: So as with any new technique, it becomes more and more popular as our patient population gets to know more about it. And as we've done more and more studies, they're determining its safety and efficacy. This procedure is becoming more popular. So, one of our jobs here during this podcast is to essentially educate our community, our fellow colleagues about this procedure, how safe it is and effective it is, so that it could be added as a treatment option for our patients to consider.

Dr. Chadi Diab: And an additional point I want to mention in the medical field in general, there are so many subspecialties and there are so many developments that, believe it or not, even us as physicians, we may not be aware of what our colleagues can offer to the patient. Even in the same healthcare system, believe it or not. That can be tricky. And this is where like education and processs come into play, where like we try to educate the patient and even us as colleagues, like the procedure that we can offer for some of the patients. Because again, the goal is to have more options for each patient because some patients may not be candidate for surgery, they're not tolerating the medication. It's good to have options, right? To have an opportunity, to have additional option that you can go for. And this is where PAE is not the only treatment option. It's more to be added to the different modalities that can be offered to our patient population.

Host: I know a lot of patients are really concerned with the outcome. And I guess that makes sense, right? "Is this going to improve my life?" So, how long does the relief from symptoms last after a PAE procedure?

Dr. Andrew Shabila: So, the PAE is actually quite effective in relieving symptoms. And basically, the significant improvement in urinary symptoms and the quality of life after undergoing PAE has been studied, up to 80% relief of symptoms at three years or up to 75% at five years. So, this is a very substantial amount of data supporting this.

In addition to that, one of the advantages of the procedure, I would say is that the procedure can be repeated. So if there is not relief of symptoms, the procedure can be repeated and the arteries can be targeted again and embolized. And this can be done if they didn't have a good first outcome or as expected, or it could be done down the road three or five years later if there is a recurrence of symptoms.

Host: You mentioned earlier, I'm not sure which of you, it doesn't really matter, you talked about this being a relatively new procedure. And again, I want to stress the fact that relatively new in medicine means it's been going on for years, you haven't heard about it. But how has it evolved over those years and are we expecting further advancements?

Dr. Chadi Diab: Yeah. That will also kind of support the point that we just talked about, the how effective it is. And this all started like the procedure, as I mentioned, embolization is a well known technique that interventional radiology use a lot for patients who are bleeding trauma. And it has been also used for tumor that are bleeding. Anytime there's a vessel that's bleeding, we got consulted to go like embolize, try to stop, help with embolizing the vessel. And early case reports where this patient had a big prostate that kept the bleeding, that's one of the complications of a big prostate, you can have blood in the urine. And after using multiple other techniques, the bleeding didn't stop to the point they requested embolization. And embolization was performed by occluding a prostatic artery, that's the organ that's problematic in this case. So, it was a PAE technically. But the bleeding stopped or that they noticed that the patient's BPH-related symptoms also improved.

So, there were like couple of case reports that this is how initially it started. They were like with occluding these vessels, like the prostate symptoms are improving. And this is where studies kept going and like bigger numbers of patients. And they were able to show that there's a good amount of improvement in symptoms just for BPH even if they're not bleeding anymore.

And you can tell that's already a big progress from like where we started to now being offered for BPH patients and the techniques and interventional radiology, which we call minimally invasive, and continuous development on smaller microcatheters. We have better imaging systems, so we were able to be more safe and more effective to even provide the procedure for patients who were not candidates or were difficult or not doable with previous kind of tools and imaging. So, there's always a progress and we're getting better and better on how to do it to have better results. And there's always continuous research as well.

Host: I'm going to ask some rapid fire questions. I think a lot of men listening to this may have these questions in their mind. So, I'm hoping to get some quick answers as we roll towards the end of the conversation here. Can a man still father children after undergoing PAE? I know that's a concern sometimes with other prostate surgeries in the past.

Dr. Andrew Shabila: Absolutely. Embolizing the prostate artery does not affect fertility in men.

Dr. Chadi Diab: And the key thing to mention because it does not affect ejaculation to be more specific. Because one of the surgical, like one of the side effect of some procedures, I would say some of the surgical procedure, the known, like TURP, for example, which is still the gold standard where it stands for transurethral resection of the prostate, may have a side effect on the ejaculation, which is called retrograde ejaculation. PAE does not have any side effect on that which is something that really patient really considers because of that.

Host: And what about erectile dysfunction?

Dr. Andrew Shabila: No effect on erectile dysfunction as well compared to other surgical, minimally invasive surgical techniques or more invasive like prostatectomy.

Dr. Chadi Diab: Again, we're not saying the other surgical procedures, they have always the side effect. But with PAE, this hasn't been reported. It's not even something that's been reported

Host: And no increase in the risk of prostate cancer, I assume.

Dr. Chadi Diab: True. No increased risk of prostate cancer, whether from the BPH or PAE. Nothing has been reported so far in the literature.

Host: Earlier, we talked about how long this procedure takes, but we didn't cover the recovery time, and that's always a concern. So, tell me a little bit about how does someone recover from this?

Dr. Andrew Shabila: So, typically, the recovery time from prostate artery embolization is a lot shorter compared to the more traditional surgical, minimally invasive procedures performed. The procedure, the patients can go the same day home or the next day. And usually, their discomfort from this type of procedure is very, very minimal and may have some minimal urinary symptoms the days after the procedure, two to three days after the procedure, and for which we would be seeing them in clinic. And we can follow up these patients very, very closely.

Another advantage of this procedure would be the lack of Foley catheter placement or obligation to place a Foley catheter for this procedure, which is a huge, huge plus I would say or advantage of undergoing prostate artery embolization.

Dr. Chadi Diab: I would add as well that besides the rapid kind of recovery, fast recovery for next couple of days, patients should expect some improvement in their BPH symptoms in the next couple of months. And we reassess them at that point and we may be able to stop their medication, if not, decreasing the doses of the medication, because we know this medication may have some side effects and that's also a big benefit of that.

Host: The size of the prostate I know is sometimes a factor. So, how does that work with PAE? Can a prostate be too big to be fixed with PAE?

Dr. Chadi Diab: That's a very good question. As we mentioned, who can be a good candidate for PAE, that's a key thing. There is no prostate size limit. And as you mentioned, it does offer additional treatment options for these patients who may not receive like minimally invasive surgeries like TURP or the only option is prostatectomy, removing entire prostate, which can be a big surgery. PAE comes also as a minimally invasive procedure for these very large prostate.

Dr. Andrew Shabila: And in fact, I just want to add the larger the prostate, the bigger it has recruited blood supply. So, the more effective that prostate artery embolization can be. So the larger the prostate we see, the greater the difference in the volume and reduction of the prostate. That just speaks to the physiology and how effective the procedure can be if we're using the right tool to treat the problem.

Host: Very good news. Two final questions, I think. If someone is considering this procedure, PAE, what questions other than those that I've asked right now, what questions should they be asking their doctor?

Dr. Andrew Shabila: So, I think the most important thing is discussing this with your primary care physician, consulting with a specialist like a urologist or being referred to or directly contacting interventional radiology clinic or expertise in that field. They will know more about prostate artery embolization.

Host: Okay. Got it. So, check with you or primary care, check with your urologist and go from there. But what happens if they are unfamiliar with this technique? Is there something people should do to find healthcare providers or institutions that offer PAE?

Dr. Chadi Diab: That's a very good question. In fact, one of the things we're doing, is try to spread the knowledge. There is some role on the patient too, especially with the amount of resources we have, the internet, like a lot of search engine s that you can really type PAE provider locally. And try to search reputable medical centers, I would say. Typically, academic centers are the ones who are going to offer this kind of technique because it does require good amount of imaging and resources. We do have it obviously at University of Kentucky for our Kentucky male population. But I would say search engine, ask like your PCP, mainly look for interventional radiologists. They can reach out to their colleague, interventional radiologist who is going to be able to answer this question. If they don't do it themselves, they may send them to someone who can.

Host: That's great. Doctors Diab and Shabila, thank you very much for joining me on the show today.

Dr. Andrew Shabila: Thank you very much.

Dr. Chadi Diab: Thank you very much. Thank you very, Evo.

Host: And once again, that was Dr. Chadi Diab and Dr. Andrew Shabila, both interventional radiologists with the UK HealthCare. And I have been your host, Evo Terra. For more information, please visit our website at ukhealthcare.com. Again, that's ukhealthcare.com. If you found this episode helpful, please share it across your social media channels. Thanks again for listening to UK HealthCast from UK HealthCare.