New Procedure Alternative to Surgery for Enlarged Prostate

Pam Harrison

March 12, 2015

VIENNA — Prostatic artery embolization provides excellent symptom control in men with lower urinary tract symptoms related to benign hyperplasia.

"The procedure is done in the catheter lab under local anesthesia and, after 2 hours, patients go home," said Francisco Cesar Carnevale, MD, from the University of Sao Palo Medical School in Brazil, who pioneered the approach.

"Right now, we consider this procedure an alternative to both surgery and medication," he told Medscape Medical News here at the European Congress of Radiology 2015.

Their overall clinical success rate with prostatic artery embolization is over 95% in 150 men with severe lower urinary tract symptoms from benign prostatic hyperplasia. Close to 200 patients have undergone the procedure, but follow-up was not long enough in some of them, so they are not included in the analysis.

Mean follow-up in the cohort was 2 years, but follow-up was as long as 6 years in some patients.

The researchers defined success as an International Prostate Symptom Score below 8. Before the procedure, the average score was close to 20.

After embolization, there was a 30% to 40% decrease in prostate volumes from baseline.

"Most importantly, this reduction occurs during the first 3 months after the procedure, and volumes stay at the same level during follow-up," Dr Carnevale said.

The procedure is done in the catheter lab under local anesthesia and, after 2 hours, patients go home.

Not surprisingly, prostatic-specific antigen levels decreased by at least 50% in parallel with the decrease in prostate volumes, and they, too, remained stable and low during the follow-up interval.

Improvements in quality of life corresponded to these decreases, and most patients were "mostly satisfied" with the results of the procedure.

"We are concerned about" potential complications, including ischemia of the rectum, the bladder, and the seminal vesicles, Dr Carnevale reported. "But so far, we haven't seen any serious complication using this technique."

After Dr Carnevale developed the concept of prostatic artery embolization in 2006, he went to Harvard University in Boston to perform animal studies and confirm that it would work in men. The first man was treated with the procedure by the Brazilian group 2 years later.

In the catheter lab, interventionalists create an arteriogram using digital subtraction angiography to identify all of the arteries that feed the prostate.

Pioneering Approach

"We navigate our microcatheter into the prostatic artery and embolize the artery using microspheres to block blood flow to the prostate and produce ischemia," Dr Carnevale explained. They take care to avoid important arterial branches feeding the bladder, the rectum, or the seminal vessels.

Because the team recently observed that the greater the ischemia, the greater the beneficial effect on the prostate, they now advance the microcatheter right into the prostate gland and inject more microspheres to produce greater degrees of ischemia.

"Patients with prostate volumes above 50 g are the best candidates for this procedure because they usually have bigger arteries," Dr Carnevale explained.

But because results to date "have been very good," the team now uses prostatic artery embolization for men with bothersome lower urinary tract symptoms, he reported.

Although there are some existing alternatives for benign prostatic hyperplasia, "there is clearly a need for a better and less invasive form of treatment for this common problem," said Aytekin Oto, MD, from the University of Chicago.

"Dr Carnevale and his team really pioneered this minimally invasive technology to treat benign prostatic hyperplasia, and what they do is very simple," Dr Oto told Medscape Medical News. "If you block the vessels supplying any organ, that organ shrinks; if you block the vessels supplying the prostate, you would expect the prostate to shrink, which is what you get. This translates into improvement in benign prostatic hyperplasia symptoms."

He pointed out that the procedure is still relatively new. Nevertheless, "initial results are very promising. In the United States, many centers are interested in trying to start a program of prostatic artery embolization, and some have already started one," Dr Oto said. "I think the procedure will become even more successful as we expand and improve the technique to minimize any potential collateral damage."

Dr Carnevale and Dr Oto have disclosed no relevant financial relationships.

European Congress of Radiology (ECR) 2015: Abstract A-331. Presented March 6, 2015.


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