Prostate Enlargement

Benign prostatic hyperplasia (BPH) is the non-cancerous enlargement of the prostate. Advanced stages impede on the ability to urinate, causing frequent urination and a decreased urinary flow rate.

BPH has a high prevalence rate of over 50% in men aged older than 50 and 90% in men over 80. Medical therapy is a first line treatment option for patients with moderate lower urinary symptoms.

BPH may be based on three diagnoses:

-microscopic detection of prostatic hyperplasia

-palpable enlargement of the prostate

lower urinary tract symptoms (LUTS):

-frequent urination particularly at night (nocturia)

-hesitance

-interrupted urinary stream

-urgent passing of urine

-urinary incontinence (leaking)

Prostate Artery Embolization

Prostatic artery embolization (PAE) shrinks the enlarged prostate thereby relieving symptoms without surgery or side effects like sexual dysfunction, incontinence (inability to control urination), retrograde ejaculation (ejaculation into the bladder), No Impotence or bleeding.

This is accomplished by temporarily blocking (embolizing) some of the arteries providing blood supply to the prostate thereby decreasing its size over time and relieving the symptoms of BPH. Basically, the patient gets his prostate back. It is a very delicate and sophisticated procedure, therefore only highly trained and experienced doctors can perform this procedure. Dr. Martins Pisco is the world expert and has performed hundreds of procedures since 2009.

Prostatic Artery Embolization is a new application of an old technology. Embolization has been successfully applied and accepted in modern medicine for about 50 years for various applications. Catheters, guide wires, and the particles of polyvinyl alcohol have been successfully used in medicine for over 50 years.

Requirements for a Candidate

Not every patient is a candidate. In fact only one third of the patients who apply for PAE treatment have been accepted. Only patients with severe lower urinary tract symptoms (LUTS), a prostate larger than 40cc, and urinary flow lower than 12 mL/s have indication to be treated. In order to exclude malignancy the following tests will need to be performed:
PSA, Prostatic ultrasound via rectum, and Biopsy may be performed. . lower urinary tract symptoms (LUTS):
-frequent urination particularly at night (nocturia) -decreased hesitance -decreased urinary flow -interrupted urinary stream -urgent passing of urine -urinary incontinence (leaking)

About a Doctor

The PAE procedure and all intervention techniques are performed by Dr. Martins Pisco and his interventional radiology team of assistant professors of radiology, anatomy, and urology and a professor of radiology. It is a very delicate and sophisticated procedure, therefore only highly trained and experience doctors can perform this procedure. Dr. Martins Pisco is the world expert and has performed hundreds since 2009. He personally performs the PAE procedure once a week on every patient.

Procedure of Prostate Artery Embolization

Just before, during, and after the procedure the patients take an oral anxiolytic. Analgesics and anti-inflammators are administered through an intravenous line. Local anesthesia is given in the inguinal zone, through which the femoral artery is punctured.

A slender flexible plastic tube (catheter) is placed in the femoral artery, then the prostatic arteries opposite the puncture site are catheterized using a 1mm diameter micro catheter. Placement of the catheter into the small prostatic arteries is done under X-Ray control. Polyvinyl alcohol particles (PVA) are used to block the arteries. This material is innocuous and non-reactive. It is absorbed within 6 months and has been used in the U.S. for over 40 years for other embolization.

A final test is performed to check that the smallest prostatic arteries are blocked. The catheter is then taken out, placed in the ipsilateral prostatic arteries, and embolized as mentioned above. Blockage of the prostatic vessels decreases the size of the prostate and corresponding symptoms improve.

How painful is the PAE procedure?

The PAE procedure is outpatient minimal invasive and performed under local anesthesia without pain or other side effects, with short hospitalization, immediate improvement, and short recovery.

How long will it take?

The procedure lasts between 1 and 2 hours.

Once the embolization is completed the catheter is removed out and the 1.5 mm puncture site in the inguinal zone is compressed for 10 minutes and a badge is placed over the area. After placement of the bandage, the patient is taken to his room and remains there for about 2 hours, after which the patient is able to use the restroom (W.C.).

Most patients leave the hospital 4 – 6 hours after the procedure. Patients with hypertension (high blood pressure), may spend the night in the hospital and be released the next morning. All patients can return to their normal life the next morning, but can’t drive for 1 day. After release from the hospital, the patient can contact the team with any questions. They will be available 24 hours day.

Several steps of Embolization

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Fig. 1 – Angiographic suite with the table where the patient will be laid down.

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Fig. 2 – Patient laid down on table, covered except inguinal zones.

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Fig. 3 – Local anesthesia in inguinal zone with small needle.

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Fig. 4 – Catheter in femoral artery through an 1.5mm hole

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Fig. 5 – Medical team 2 interventional radiologists and a radiographer. Under X-Ray control, the catheter is placed in each of the prostatic arteries. Angiography of the prostatic arteries is obtained by contrast medium injection trought the catheter.

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Fig. 6 – Syringe with polyvinyl alcohol particles used to block the prostate arteries.

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A – Catheter placed in right iliac artery

B – Catheter placed in right prostatic artery, before embolization the prostatic vessels are opacified

C – After embolization, only some vessels are shown because the others are blocked

D – Catheter placed in left iliac artery

E – Catheter placed in left prostatic artery, before embolization the prostatic vessels are opacified

F – After embolization, only some vessels are shown because the others are blocked

G – Cateter

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Risk & Complications

The most frequent complication are:

1) Urinary tract infections (treated with antibiotics)and blood in urine (self limited) occur in about 8 – 10%

2) Blood is in semen (self limited) is about 5%

3) Blood is stool in 3% (self limited)

4) Burning in anus and uretra for some hours (self limited) it last for some hours

5) Urinary retention during the procedure (1%) treated with a bladder catheter for a couple of hours

Fertility after the procedure

Results of PAE

PAE can shrink prostate volume up to 50%.

The sexual performance improved in about one third of the treated patients. Two thirds of the patients remain as before the PAE.

Can the PAE procedure be repeated?

Yes.

if you still have good prostatic arteries, for the purpose another Angio CT will be performed

Will PAE affect Fertility (ability to have children)?

No. PAE does not affect fertility and ability to have children. The sexual performance improved in about one third of treated patients. The remaining patients’ performance was unaffected. In fact, some patients had children after the PAE procedure.

standley DSCF5107 antonio-goncalves-old- From March 2009, up to January 2014, 600 patients with BPH have been treated. There was improvement in about 85% and 15% did not improve. The patients who do not improve they stay as they were, nobody get worse, and they can have surgery if then wish. Between 1 and 4 years there are recurrence of symptoms in about 10% of the cases. The embolization can be repeated, by 1.500€ of payment to cover part of the material used , in those with good prostatic arteries and they may improve again. Most patients go home the same day. There was just one major complication a small area of ischemia of the bladder that was removed by surgery. The patient, 72 years old, is our friend and he is very happy because his sexual activity improved. There were some no significant complications that were self-controlled. Twelve patients had previous TURP and 2 prostatectomy by open surgery. Sixty two were in urinary tract obstruction and had a bladder catheter. The bladder catheter was removed some days after the procedure, in 60 of them. Most patients did not feel any pain or slight pain during or after the procedure. The mean prostate volume decreased between 10 and 30% in 80% of the patients. The sexual performance improved in about a third of the treated patients, and in the remaining persisted as it was.  

Patient 369 sent us the photo of 2nd child, together of 1st child.

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Other options

PAE is the only treatment for BPH which doesn’t impair sexual performance. All other treatment options below have some sexual side effects.

Alpha blockers  or treated patients and 5-reductase inhibitors are the first line therapy in men with symptomatic BPH. However, these medications are sometimes associated with sexual dysfunction.

Prostatectomy (the resection of the prostate) is the traditional way to treat BPH. However, most men with BPH come from an age group which is commonly affected with comorbid cardiovascular diseases. This makes surgical interventions high risk in many patients. Urinary tract infections, strictures, postoperative pain, incontinence or urinary retention, sexual dysfunction, and blood loss are complications associated with surgical treatments.

Minimally invasive treatments were originally conceived as an attempt to offer equivalent efficacy to transurethral resection without the risk of operative morbidity, less blood loss, and lower risks of sexual side effects such as ejaculation disturbance and erectile dysfunction. However, these treatments have major disadvantages such as less effective improvement, greater risk of continued catheterization, and reoperation. There is a need for innovative technologies which improve outcomes and minimize patient discomfort and morbidity when managing BPH. Embolization has been used mainly to control massive hemorrhage after prostatectomy. We have seen excellent results with embolization of uterine fibroids in over 1600 women patients and over 600 BPH patients since 2004.

Demonstrative Films

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