Procedure Guides
Women's and Men's Health

Prostate Artery Embolization

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Procedure Guide

Indications

  • Benign prostatic enlargement (BPE) with lower urinary tract symptoms (LUTS)

    • IPSS symptom score (7 questions) >10-13 (0-7 mild, 8-19 moderate, 20-35 severe)

      • BPH symptoms caused by static component of hyperplasia as well as dynamic component of sympathetic nerve stimulation causing smooth muscle contraction

    • QoL questionnaire >= 2

    • PSA <2.5 but nonspecific, if higher, should rule out prostate cancer

      • 2.5-3.9 - consult urology for cancer risk

      • >4.0 probably needs a biopsy to exclude cancer

    • Uroflowmetry Qmax <12 mL/sec, >25 is normal, though not reliable

    • Prostate volume via US, CT, or MR > 40 mL

    • Failed trial of conservative therapy >3 months

  • Newer potential uses

Contraindications

  • Active urinary tract infection or prostatitis 

  • Prostate cancer – can still be performed for LUTS or bleeding in collaboration with cancer treatment

  • Urinary obstruction due to causes other than BPH 

  • Uncorrected coagulopathy

  • Relative contraindications - IPSS<12, median lobe >3cm, bladder dysfunction or cancer, prostate <50g

Efficacy and alternatives

  • Medications (alpha blockers and 5a reductase inhibitors) - average IPSS reduction ~3-7

    • Alpha blockers more effective than 5a reductase inhibitors. Combination therapy only showed benefit in larger glands.

    • Many sexual health complications occurring in ~15%, e.g. retrograde ejaculation

  • PAE - average IPSS reduction ~15

    • Superior to TURP in symptom relief at 1 and 3 months but equivalent at 6, 12, and 24 months

    • Average clinical success: 89% short term and 78% long term

    • Less complications and shorter recovery BUT greater symptoms recurrence

    • Cheaper - generally ⅓ the cost of TURP

    • Repeat PAE has a higher likelihood of clinical success in those who initially responded and relapsed (50-60%) vs those who never responded (20-30%)

  • TURP - average IPSS reduction ~15-16

    • Good for prostates as large as 80-100 g

    • Alleviates symptoms in 70%, but 18% morbidity, 50-65% ejaculatory disorders, strictures, hemorrhage, incontinence

  • Minimally invasive surgeries (UroLift, TUNA, Rezum, HoLEP, etc) - average IPSS reduction ~10-12

    • Less effective for large prostates or median lobe prominence

    • Generally, all minimally invasive surgical options have a 5-10 year recurrence rate

Pre-procedure care

  • Some obtain CTA pelvis to characterize prostatic vascular anatomy (excellent paper on prostatic arterial anatomy)

    • Protocol: 800 mcg nitro 3-5 min prior to scan, 4-6 mL/s trigger 300 HU

    • Internal iliac artery (IIA) branching (Yamaki classification)

      • A (79.5%) - IIA divides into superior gluteal and common trunk for internal pudendal and inferior gluteal (“common anterior gluteal-pudendal trunk”)

      • B (15%) - IIA divides into internal pudendal and common gluteal trunk with small anterior division

      • C (5.3%) - IIA divides into superior gluteal, inferior gluteal, and internal pudendal in trifurcation

      • D (0.2%) - IIA divides into anterior division with common trunk for superior gluteal and internal pudendal and posterior division with inferior gluteal 

    • Prostate Artery Origin (De Assis classification)

      • I (28.7%) - IIA gives off common superior and inferior vesical arteries, IVA continues as prostate artery

      • II (14.7%) - PA beaches directly from anterior division inferior to SVA origin; longer with fewer branches making catheterization easier

      • III (18.9%) - PA from upper to mid third of OA

      • IV (31.1%) - PA from upper to mid third of IPA

      • V (5.6%) - PA has other origin

    • Intraprostatic branching

      • 1A - single PA with CG and PZ branches

      • 1B - separate CG and PZ branches

      • 2 - two communicating CG pedicles with single CG compartment

      • 3 - two non-communicating CG pedicles with multiple CG compartments

  • Clinic visit with questionnaires, post void residual, PSA, UA, recent GFR

    • International Prostate Symptom Score (IPSS)

    • Quality of Life scale (QoL)

    • International Index of Erectile Function (IIEF)

    • Sexual Health Inventory for Men (SHIM)

    • PVR >50 mL is significant; >300 mL suggests chronic retention

Procedure

  • Can insert Foley during procedure to avoid bladder filling with contrast increasing dose and obscuring anatomy, but may increase risk of urethral and median lobe trauma or UTI

  • Radial or femoral access -> 4/5-Fr sheath.

    • Inject mixture of anesthetic, vasodilator, and patient blood via 20 cc syringe for radial access

  • Use base catheter to select each internal iliac arteries

    • Radial approach: 125-cm 5-Fr Berenstein and 0.035 hydrophilic wire

    • Femoral approach contralateral IIA: RUC, Cobra C2, Robert’s uterine catheter (Cook), Carnevale’s prostate catheter (Merit)

    • Femoral approach ipsilateral IIA: RUC, Simmons I or II or same vert or Cobra 2 with Waltman loop

  • DSA run to map out anatomy in 20-50* ipsilateral oblique (e.g. 12 mL, 4 mL/sec)

    • Per Justin McWilliams (UCLA) most useful view = 45* ipsilateral oblique

  • Advance microwire and microcatheter system to select prostatic artery 

    • Origin is variable (see DeAssis classification above). Tends to course lateral and then cross obturator in 97%. Often tortuous with more horizontal distal branches.

    • Not uncommon to have multiple, e.g, accessory prostatic branch from the IPA some call the “pena cava”

    • Common microcatheters used: ProGreat 2.4 or 2.0, Direxion 2.4, Prowler Select, 2.2-Fr Sniper with compliant balloon (Embolx)

    • Some data suggests balloon occlusion catheter leads to better embolization, preventing reflux and diverting flow away from distal collaterals to the low pressure prostate bed

  • Some perform cone beam CT prior to embolization to confirm supply and assess for collaterals

    • Important ones include precapsular branches with anastomosis to the IPA (“lateral accessory pudendal arteries”), penile, bladder, and rectal collaterals, which can be quite distal within the gland

  • Coil embolize dominant collaterals, aka skeletonize the prostate vascular supply prior to delivery

  • Inject 100-200 ug nitroglycerin diluted in saline to prevent vasospasm or verapamil systemically. This also diverts flow away from smaller collaterals. Balloon occlusion microcatheter can have a similar effect revering flow in collaterals towards the prostate (e.g. Sniper).

  • Slow embolization with dilute 300-500 micron particles diluted in 20 mL contrast via 1 mL syringe (best data). Often requires 10-15 min.

    • Others use 50-250 um PVA particles or glue.

    • Can use PErFecTED technique where you start proximal before wedging the microcatheter into intraprostatic arteries to avoid spasm or other vascular injury preventing embolization while attempting to get distal.

    • Others do the opposite of PErFecTED and get as far out as possible

  • Embolization target = total stasis. Important to wait 3-5 min to ensure persistent stasis.

  • Pull back catheter to origin of prostatic artery and perform hand run to rule out additional branches.

  • (Optional) Coil embolization of prostatic artery on way out (“coiling out”). Debated as this can make repeat treatment dififcult without clear data-supported beneift.

  • Repeat process for contralateral side.

  • Obtain hemostasis.

Complications

  • Clavien-Dindo grading system (I-IV): I/II = minor; III/IV = major

  • Minor complications / side effects: common (~60%), postembolization syndrome (10%, N/V, fever, <POD2 to 7d), dysuria (40%, <POD2 to 7d), urinary spasm/urgency (14%, <POD2 to 7d), hematuria (12%), hematospermia (16%), proctitis (6%), access site hematoma

  • Major complications: rare (1-5%), urinary retention (3%), UTI (2.5-4.6%), non-target embolization (e.g. bladder, rectum, and penis)

  • Erectile function is NOT generally affected, less retrograde ejaculation than TURP where dysfunction can occur in 10-14%. 70-89% after prostatectomy

  • Can prescribe PPI, steroid, prophylactic abxs, and other symptomatic medications starting 24 hrs in advance or wait until after procedure. (See after procedure section).

Post-procedure care and follow up

  • Optional to leave Foley 24 hrs post-PAE due to risk of urinary retention, e.g., if history of urinary retention or self catheterization

  • PSA can increase up to 20x 24 hours after PAE then drops to normal value (50% of baseline) at 1 month after PAE

  • Maintain fluid intake, restrict sexual activity, limit physical stressors such as riding bicycles or motorcycles for 1 week

  • Post-procedure medication regimens

    • Academic center:

      • Ibuprofen 800 mg TID

      • Solifenacin 5 mg

      • Phenazopyridine 100 mg TID

      • Cipro 500 mg BID for 7 days

      • PRN methylprednisolone DosePak (6 days) and Bisocodyl 20 mg x 7 days

    • Anonymous OBL:

      • Ibuprofen 800 mg TID x 7 days - Pain 

      • 400 mg ciprofloxacin IV intra-procedure, then 500 mg BID x 7d - PPX 

      • Pyridium 100-200 mg TID x 7 days - Burning 

      • Oxybutynin 5 mg TID x 7 days - Bladder spasms 

      • Docusate 100 mg BID  x 7 days - Constipation  

      • Medrol dose pack – pain 

      • Percocet 5/325 mg, 1-2 tablets every 4-6 prn for pain 

    • Anonymous OBL:

      • Ibuprofen 800 mg TID x 7 days + Medrol dose pack

      • Cipro 500 mg BID x 7 days

      • Pyridium 100-200 mg TID x 7 days

      • Vesicare 5 mg daily x 7 days (avoid in narrow angle glaucoma); oxybutynin as other option

      • Dulcolax 20 mg daily x 7 days

  • Continue BPH meds (e.g. alpha blocker) 1 month after to reduce risk of urinary retention

  • Side effects often last ~5-7 days

    • Urinary retention >5 hrs -> ED/urgent care

    • Dysuria (occurs in 60-70%) -> can double pyridium dose for 2-3 days, AZO over the counter (turns urine orange), or Uribel (turns urine blue-green)

  • Clinical improvement in first 2-4 weeks with peak effect at 3 months

  • Bladder spasms, if persistent beyond 2 weeks, consider cystoscopy