Men with an enlarged prostate may suffer from symptoms of lower urinary tract obstruction, such as sensation of incomplete urination, inability to urinate, weak urinary stream, or having to urinate frequently. If the symptoms cause a significant disruption to quality of life, a man may undergo initial treatment by oral medication, such as alpha-1 receptor blockers, 5-alpha-reductase inhibitors, or phosphodiesterase-5 enzyme inhibitors. Those with severe/progressive symptoms or those who do not experience symptom relief from medication have traditionally been considered for surgical intervention, with transurethral resection of the prostate or TURP as the standard of care. However, there are problems with both medical and surgical treatments, including undesired side effects and variable effectiveness. For example, sexual dysfunction and orthostatic hypotension are side effects of 5-alpha-reductase inhibitors. Prostatic artery embolization is an emerging treatment alternative which avoids the risks of systemic medication and of surgery. The first report of selective prostatic artery embolization resulting in relief of prostate gland obstruction was published in 2000. Since then, prospective trials with small numbers of patients, up to approximately 200 patients/trial, have been carried out internationally. Results show that PAE decreases prostate gland size, prostate specific antigen level, peak urinary flow, post-void residual, and subject urinary symptoms.
Adverse Effects
As PAE is a relatively new procedure, more data is needed to determine the incidence of adverse effects. The majority of adverse effects during PAE are likely due to non-target embolization, and are generally self-limited in nature. A post-embolization syndrome, consisting of pain, mild fever, malaise, nausea, vomiting and night sweats, is commonly observed after the procedure, and is treated with NSAIDS and other forms of analgesia. According to a systematic review of trials, the most common adverse effects include acute urinary retention, rectal bleeding, pain, blood in the urine/sperm, and urinary tract infection. Serious complications are uncommon, and include arterial dissection, bladder wall ischemia, and persistent urinary tract infection. One single-center prospective study reported an overall complication rate up to 20.6%, with mostly minor complications including hematospermia, diarrhea, and urethral trauma from foley insertion, with one major complication of UTI requiring intravenous antibiotics.
Procedure
After local anesthesia is placed, an interventional radiologist obtains access to the arterial system by piercing the femoral or radial artery, usually under ultrasound guidance, with a hollow needle known as a trocar. Through the needle a guidewire is threaded and subsequently the trocar is removed. A cannula is slid over the guidewire and once in place the guidewire is removed. This cannula allows a sheath to be inserted into the artery.8Contrast material is injected through the sheath under fluoroscopic imaging which outlines the anatomy of the blood vessels. This technique is used to help locate the prostatic artery and advance the catheter to the ostium of the prostatic artery. Polyvinyl alcohol particles are then injected into the prostatic artery. They function by causing embolization preventing blood flow to the prostate, functionally resulting in reduced prostate size.
