PAE: a new option for men with enlarged prostate

NICE heralds the approval of prostate artery embolism (PAE) as a safe and efficacious option for men with lower urinary tract symptoms symptoms secondary to benign prostatic hyperplasia (https://www.nice.org.uk/news/article/a-new-option-for-men-with-enlarged-prostate). 

Nigel Hacking, who led the NICE, BAUS and BSIR sponsored ROPE study, welcomes this new guidance and thanks all the urologists and interventional radiologists from around the UK who worked hard to gain the evidence required to confirm that the results achieved from overseas single centre studies could be replicated by many in this first multicentre registry.

PAE can provide a bridge, along with Urolift for men not ready for prostate resection whether by laser or more traditional TURP.

NICE is keen to point out that the procedure is complex, and requires the specific skills of an interventional radiologist with additional training. PAE patients should be seen both by an interventional radiologist and a urologist, and selection should be made by this team – which really does offer men an increased choice.

The National press furore surrounding the release of these latest guidelines will undoubtedly lead to a lot of requests for PAE. The ROPE co-sponsors BAUS and BSIR will need to take a lead when re-writing their current guidelines and directing men to existing PAE Prostate Centres, and supporting the further education and training of interventional radiologists and urologists.

Read Dr Hacking’s article – Prostate artery embolization: ready for adoption?

What are your thoughts? What impact will the NICE approval have? Leave a comment below. 

Comments (2) Add yours ↓
  1. Brian Dye Patient

    I am a patient. The papers below I’ll be referring to are:

    Gao et al, Radiology 2014 Mar, 270(3): 920-928
    Foo, Asian J Urology 2017 Jul: 4(3): 152-157
    Kaplan, J Urol, 2017 Jul: 198(1):9-11
    Young, J Urol, 2017 Jul: 198(1):9-11
    Yu et al, Cardiovasc Interv Radiology 2017, Jan 40(1):33-40
    Little et al, Cardiovasc Interv Radiology 2017, May 40(5): 682-689
    Stamatiou, Arch Ital Urol Androl, 2018 Mar 31: 90 (1): 40-43

    I had a PAE in June 2017. Prior to that I had had 5 years of LUTS. Mild symptoms, controlled by lifestyle, not drugs. Eventually, during March – May 2017, I quickly progressed to an IPSS score of 30+ and, one day, I suddenly found myself in AUR.
    The MRI reported prostate volume at 157cc; no suspicion of carcinoma. I was advised to have HoLEP and told I would have “excellent result” but the downsides were 3 – 3 ½ hours under general anaesthetic; 3% need for repeat; 5% risk of a stricture; an outside chance of pulmonary embolism and/or stroke, and a 100% chance I would never ejaculate normally forwards again, quite a spoiler to an excellent sex life. I didn’t fancy the op.
    I went to one of the world’s top urologsts. He told me PAE could be a possibility. Then I talked to a urologist who had experience of 100+ PAEs. He told me that PAE fails in 20% of cases but that, since I was actually in AUR, my chance of success was, in fact, lower – slightly less than 50%. But he also told me he thought it was worth a shot, because if PAE failed, in all probability my worst case was that I would just have to do the HoLEP anyway, and if PAE worked, I would have avoided the operation and its side effects and risks. I was attracted to the negligible stricture risk with a PAE and that, as a young and athletic man of 62, I had decent shot of retaining full ejaculative potency. I was told I would probably know within 3 weeks of doing a PAE whether it was likely to work, and that if it was not working, I could go for a HoLEP.

    So I felt PAE was what snooker players call “a shot to nothing”. If PAE worked, there no need to do the HoLEP. If it failed, I would be in the same boat as I was already in anyway.

    I asked him why some Urologists tended to be against PAE. His answer to me was that he thought there was “confirmation bias” problem: since PAEs fail in 20% of cases, it is those 20% of men who tend to need to go to the surgeons after a failed PAE and hence the some of the pure surgeons tend to have a poor experience of PAE. Whereas, he said, a urologist who has done a lot of PAE cases, tends to have experience of its general success.

    To this, I would suggest there is another confirmation bias among urologists. Urologists are great surgeons so they have a natural tendency to feel “great surgery is the answer”, whereas a coward like me has the confirmation bias that U would rather avoid surgery if I can.

    So I went to see a team of interventional radiologists with experience of 50+ PAEs. After MRI and CT, their advice was that I had simple vascular anatomy so that access to my prostate would be easy; that I “a hope of success” because PAE tends to work in big prostate cases (“the bigger, the better”), and because my prostate was “adenomatous dominant”, as to which see the Little et al and Stamatiou papers cited above. They thought the chance of success in AUR cases was 70+%, and indeed, since then the Yu paper cited above gives examples of 80+% chance of success.

    I decided to try a PAE and give it a 3 month shot, not 3 weeks, to see if it worked. The urologist I chose changed my Foley catheter to a superpubic one, because this was an arrangement that put me in control of continuous trials for voiding. The photos taken inside my prostate showed that I did not have middle lobe – and so also confirmed that there was no “ball valve” problem that PAE might find difficult to deal with.

    My private GP and I checked out the radiation risk I would expose myself to. In simple terms, it was calculated as five summers in England, which I thought was very acceptable.

    It was suggested that I take Tamsulosin to aid the trials of voiding but I found that I was intolerant of it and I declined to take it. The day I went to have the PAE done, I asked the interventional radiology team there whether there was any documented case that they knew of for someone in AUR getting out of retention by having a PAE without taking alpha blockers. They said “No.” “Right”, I said “I’ll be the first.”

    So, in we went to the radiology suite. There was a tiny scratch in a vein and I lay back and listened to music from my Iphone on my own headphones and well enjoying the team’s choice of music from the suite’s own loudpeakers. It was all very pleasantly and enjoyably over in 45 minutes, with successful full bilateral embolization, followed by a cup of tea. A very different scenario from a 3 – 3 ½ hour HoLEP under general anaesthetic, I say.

    After two hours in bed, I was allowed to get up. I went to the loo, not knowing what to expect. I immediately voided naturally. I went home that afternoon. There were then a few hours of searing pain, until the prostatic nerves, deprived of blood, died, and when they did, the nerves switched off like a light – there was no pain after that at all.

    It was tough going to the loo for 10 days during the period the adenomas in my prostate were necrotising, but gradually a bigger and bigger aperture opened. The very first day I voided 2 ½ litres and I never looked back from that. Within 3 weeks, the aperture was no longer restricted and I was voiding completely normally and freely without any feeling of discomfort. My private GP and I checked every few days for urine infections since it was odds on I would get some because the effect of a PAE is to necrotise tissue. Sure enough, I got two, but we expected and anticipated them and, with active management, we were onto them straight away, so they were not a problem.

    My GP and I tracked my progress using the Gao paper, cited above, which gives charts showing what improvement one can expect as the weeks go by. After a month, I had the superpubic catheter taken out.

    My IPSS score was now zero, yes, zero, where it has remained for the last year since I had the PAE done. My peak flow is 20mm/sec. Within 6 months, a second MRI showed that my prostate volume had nearly halved.

    So, here I am, a documented case of someone in AUR, who escaped AUR through a PAE with no surgery and no drugs, and has an IPSS score of zero. How many others who had LUTS can say that? I have retained a great sex life. Needless to say, I am a fan of PAE and, with enormous respect to him, and based on my experience, I look at Kaplan’s well written and learned criticism of PAE set out in his article cited above, but my answer to him is that PAE works, and the proof of the pudding is in the eating.

    So, why did the PAE work in my case, and yet why does it not work in 20% of cases? Leaving aside non-prostatic causes of LUTS, in cases where the prostate itself is the issue I reckon the truth is that it is often not only, or at least not primarily, the prostate size that causes LUTS. For example, there are papers that show that some men with big prostates may have no LUTS but that other men with small prostates may have significant LUTS. Rather, I think, in non-ball valve cases, one should think of at least three possible “models”. Model 1 is of a “tennis ball” (ie the prostate) filled with marbles (ie adenomas). As multiple adenomas each expand within the gland at the same time, the resistance of the prostatic cap reverses the direction of pressure, transmitting it back through the expanding adenomas and back towards the urethra and causing a restriction. With multiple adenomas near each other all expanding at the same time, the overall pressure force on the urethra is also magnified. Thus, when a PAE necrotises the internal adenomas, they contract releasing the pressure. Model 2 may be termed “two croquet balls” (ie two or more adenomas surrounding the urethra and near to touching each other. As the these adenomas expand, they ‘squeeze’ the urethra. Model 3 could be called the “oxbow bends” of a river – eg two adenomas that are so positioned that they cause a kink in the urethra such that the kink that restricts flow in much the same way as an oxbow effect in a river. There may be other models too.

    The thing that I have noticed is that Urologists, save for the brilliant Professor KT Foo who has published a recent paper touching on this in the Asia Journal of Urology (see above citation), have not got far enough in setting out an anatomical explanation of LUTS as an adenomatous disease – they mainly consider it a disease of “size”. But I say size is a symptom, not the primary cause. The reason for this error, if I may be so bold, on the part of Urological thinking is, I would suggest, that today Urologists either use drugs to deal with LUTS, in which case they are not really interested in the internal prostate anatomy as such, or they deal with BPH surgically in which case they burn or excoriate the internal anatomical features of the prostate, so they are not really interested in the detail of them as pressure transmission mechanism.

    However, when one is asking why a PAE may work and why it may not, I suggest the individual anatomy can be quite important, because PAE works by necrotising tissue, so the initial structure of that tissue counts for something as to whether PAE will work. If you can zap key adenomas, cause them to collapse and create a void space, that is a route to success.

    There is a question to consider too of why I found, in my case, that it did not impede the PAE that I did not take Tamsulosin, and certainly my interventional radiology team were happy in my case to try the PAE route without it. The reason, I suggest, is that the mechanism by which Tamsulosin works is to relax the sphincter, but the real cause of this type of LUTS is not a sphincter problem – it is, as I suggest, an adenoma problem. This drug therefore does not address the root of that problem, but PAE does. So, I suggest that Tamsulosin may have little bearing on the success of a PAE, and, in fact, I would even suggest, to the contrary, that one really wants to develop a strong and active sphincter, and not a sphincter in a state of induced relaxation.

    Turning therefore to the OP’s questions, I would suggest the following answers as my own: (1) Where it works, PAE beats a HoLEP, and beats it hands down, and if PAE fails, well, one then considers doing the HoLEP. (2) The broad majority of Urologists are well meaning but at present they do not fully understand PAE and there are some who suffer from confirmation biases that they will need to overcome in order to accept it. (3) From a patient point of view, such as mine, PAE can offer a complete solution to BPH with no surgery and no drugs and so why on earth would anyone want to take the risks of a HoLEP or have to take drugs every day if, as in my case, there is a direct answer that can address the root problem safely at the “cost” of 45 minutes in a radiology suite listening to Adele? (4) I would say that PAE must inevitably have a huge impact in Urology – demand for Greenlight and HoLEP must drop, and anyone who recommends long term medicalisation of the patient on drugs to tackle LUTS, whether Tamsulosin or Finasteride, without mentioning a PAE as an alternative possibility will eventually, I would say, be seen as someone not offering a whole service to the patient. (4) As for the role of the Urologist, those experienced in PAE are going to be a lot of help to the patient; but I suspect most Urologists do not – yet – regularly read enough of the Radiology journals where month by month the exciting PAE literature is being published, nor have they yet developed a sufficient underlying theoretical underpinning of anatomical causes of LUTS to assess when PAE will work, and when not. Last but not least, the OP is right: teamwork is essential and I am ever so grateful to my own “dream team” who gave me a solution to LUTS and AUR without surgery and drugs. PAE has a great future.

    May 19, 2018 Reply
  2. Michael Kirby Professor

    Great to get a personal view from someone who has been through the procedure.
    NICE rightly point out that the key is the skill of the operator, and choice of the right patient for the procedure as described by Brian above.
    Shared decision making gets complicated & is time consuming, but an essential part of modern medical pracice.
    Many men do want to retain normal sexual function & this is an option for them.
    The ROPE study provides the necessary evidence supporting the new technique which will mean close collaboration with our radiology colleagues.

    May 24, 2018 Reply

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