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PAE and Artery Selection to be embolized

Posted , 9 users are following.

patrick196
patrick196

Just another question to the forum and if anyone can shed some light. I guess that may be several arteries that feed the prostate. So when they embolize the artery, can one radiologist embolize  certain arteries, while another radiologist may embolize other arteries, causing different results in the two cases.  So will an experienced radiologist select the better arteries to be embolized? Or is it so that any radiologist would embolize the same arteries and would produce the similar results.

 

2 likes, 14 replies

14 Replies

  • craig84609
    craig84609 patrick196

    Posted

    That is a question for your doctor. I would ask before you have it done.
  • stan38413
    stan38413 patrick196

    Posted

    They do angiogram before the procedure and identify arteries feeding the prostate. So before the PAE your radiologist would have a "map" and would know where to place the tip of the micro catheter.

  • peter03536
    peter03536 patrick196

    Posted

    As has been said by Stan38413, they already have a map of the arteries before the embolisation is carried out. There were two radiologists working together while doing the procedure in my case. I was their 15th patient and their previous 14 had all been successful. They were very careful and thorough and continually checking with each other how it was going and what arteries to do next. The whole procedure took well over 3 hours for me. There were some tricky twists and sharp turns to negotiate. They told me that they completely embolised one side of the prostate and about half the other side and were pleased with their work.

    About two months have since elapsed and I am peeing three times the quantities compared with before treatment and sleep the whole night without interruption. My bladder now empties completely. 

    My sex life has improved too and I couldn't be happier.

    Having a followup MRI scan next week to see how it's all looking.

    PAE in the UK is in its early days and only suitable patients who don't have too many other complications are selected to go onto what amounts to a clinical trial, so the success rate is high. 

    At the moment the only centres doing PAE in the UK are the Freeman hospital in Newcastle upon Tyne and the Southampton university hospital. The total number of patients treated so far at these two centres in the last two years since their first patient is in the low hundreds, which is not many.

    I wish you all the best with your treatment Patrick

    Peter03536

     

    • stan38413
      stan38413 peter03536

      Posted

      Peter03536,

      How long did it take for you to see the improvement in urinary frequency and increase in volume?

      Thanks.

    • peter03536
      peter03536 stan38413

      Posted

      I suffered quite a lot of pain for the first two days after the procedure because of inflammation but then took ibuprofin which cleared that problem very quickly. After that urine output quantities improved steadily week by week and night time visits to the bathroom were no longer needed after about one month. Throughout this time the prostate will have been gradually shrinking. I don't know for how much longer the shrinking will continue. I am having a MRI scan next week which will give give more answers. Before the procedure my prostate was about 160gr and urinary retention in the bladder was about 220 ml
  • craig84609
    craig84609 patrick196

    Posted

    There you have it. I live in the USA so not sure it is an option here. 
    • AndreUflackerMD
      AndreUflackerMD craig84609

      Posted

      craig,

      It certainly is an option in the US, both within and outside clinical trials. I would strongly recommend PAE within a clinical trial, however, as there are many unanswered questions about it.

      Medicare is paying for men to get PAE and the necessary diagnostics prior to and the follow up visits in our trial at UVA. For men with private insurance, it's on a case by case basis, but the majority of policies will not cover the procedure because it's investigational.

      Thanks,

      A

       

  • AndreUflackerMD
    AndreUflackerMD patrick196

    Posted

    hi Patrick196,

    This is a great question. As an Interventional Radiologist studying this procedure and the effects on BPH, the anatomy to me is one of the most interesting aspects.

    Most men have 1 or 2 prostatic arteries supplying the prostate per pelvic half. So for example, you may have 1 artery on the right and 2 on the left. These arteries may supply distinct portions of the prostate gland, namely the center of the gland versus the periphery of the gland. In rare cases, a pelvic half may have 3 arteries.

    There is some thought that the Anterolateral Prostatic branch, which is the branch which supplies the central part of the prostate, is the ideal target for PAE. There is a Posterolateral Branch, which feeds the capsule of the prostate gland, and prostate tissue to a lesser extent. This is based on literature from Pisco and Bilhim, who are from the group in Portugal that has extensively studied the pelvic arterial anatomy. 

    Most Interventionalists performing PAE today will try to target both branches. If only one branch can be targeted, we ideally want to target the anterolateral branch to get to the center of the gland around the urethra, which is likely the cause of the BPH symptoms. The most important thing to understand about PAE is that the anatomy is extremely difficult due to the small size of the vessels, and at this point we don't really know exactly why men with BPH symptoms improve after PAE. So we don't know if we need to treat both branches, or just one, etc...

    However, in most cases, the Anterolateral branch and Posterolateral branch usually arise from a common trunk. This means that if we can put a catheter into that common trunk, we can treat both branches, and the whole prostate, from that position. If the enlargement of the prostate is caused by continued hormone exposure, then blocking all of the branches would be important.

    This is an extremely intersting question which we hope to answer by prospective trials. Like you mentioned, it's possible that if there is variabilty in which arteries we embolize, this is going to translate in variable results. 

    Thanks for the great question. Feel free to ask anything!

    Regards,

    Andre Uflacker, MD

    University of Virginia, Interventional Radiology

    • waveydavey
      waveydavey AndreUflackerMD

      Posted

      I have the choice between Green Light Laser or PAE treatments. Whichever I chose it will be the second procedure since a TURP a bit more than three years ago. Is there any documented evidence as to which procedure may have the longest lasting beneficial effect? I'm pushing 70 and would like to make this next treatment my last.

      The PAE would be performed by a team of radiologists who have only performed five procedures-four of them on permanently catheterised patients.

      Thanks for your thoughts.

    • peter03536
      peter03536 waveydavey

      Posted

      I was advised by the urologist and radiologist that the long term benefit of  PAE was not well known at the moment and that some years down the line I might need further treatment by another method.

      I had my PAE done 2 months ago and the initial outcome has been very good.

    • AndreUflackerMD
      AndreUflackerMD peter03536

      Posted

      We have data showing that PAE is effective in about 70-80% of men at 2 years. Beyond that we do not have any idea if the benefit from PAE is sustainable. I would agree that everyone that gets a PAE should consider the fact that the results may not be sustainable beyond this time period and that one may require additional therapies.

    • patrick196
      patrick196 AndreUflackerMD

      Posted

      Hi Andre

      Thank you very much for your feedback, it is greatly appreciated.I am 56 years old and my prostate size is 60 and have two median lobes. Well I am going to do the PAE procedure soon. But for personal reasons I cannot mention the hospital or the doctors names.  We are four men doing it. My urologist refered me to the trial. I am third in line to do it. The radiologist doing it has done over 1000 embolizations on women an fibroids and is now venturing unto prostates. So he is going to be trained that day by a radiologist who has done over 200 PAE's . Everyone in this forum keeps saying to get your PAE done by a radiologist who has done at least 50. That is why I am worried. My urologist has assured me that they will be extra careful during the procedure and not to worry as the experienced radiologist will guide him carefully through the procedure. Thank you once again.

      Patrick

    • tom86211
      tom86211 AndreUflackerMD

      Posted

      Dr. Uflacker,

      In Sept. 2014 I had HDR Brachytherapy treatment for Gleason 6 prostate cancer. All went well and my PSA is now 0.3 and stable. However, I still have issues with an enlarged median lobe and really wanted to have the PAE procedure done last year. However, the IR doctors turned me down because of the prior radiation to the prostate. Are you aware of anyone who has had the PAE procedure after having had prior radiation of the prostate?

      Tom

    • AndreUflackerMD
      AndreUflackerMD tom86211

      Posted

      hi Tom,

      I'm sorry that I don't know the answer to that. We really don't know how your prostate would respond to PAE.

      Theoretically, radiotherapy makes the PAE procedure higher risk, because we have radiation damage to nearby blood vessels. The likelyhood of success from PAE after radiation may also be lower because of the altered blood vessels. We just don't know what actually would happen with PAE.

      While we still have blood flow to the prostate, the radiation damage will make the blood supply to other parts of the pelvis like bladder and rectum, be somewhat reduced.

      The risk would be that when you embolize the prostate, inevitably some blood flow reduction to the bladder and/or rectum occurs, mostly not clinically significant, which may not be made up for by collateral flow which would be expected in an otherwise normal (non-radiated pelvis).

      That said, we do perform embolization of bladder vessels routinely for bleeding, including in patients that have had pelvic radiotherapy before. Causing infarcts to the bladder, even after radiotherapy, with embolization is very very rare, maybe around 1-2% of cases. I would expect that PAE would be a viable alternative in patients with prostate radiation, but we are not sure of the risks/benefits yet. This is a question that we would like to answer as well, but it will take time.

      Thanks for the question.

      Regards,

      Andre Uflacker, MD

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