Treatment of BPH
The treatment of BPH varies according to the nature and severity of the symptoms. Lifestyle changes and medication (such as the drugs known as alpha blockers and 5ɑ-reductase inhibitors) are used initially, but if symptoms progress despite conservative therapy then surgery may well be suggested.
There are a number of different forms of surgery that will typically be offered depending on the size of the prostate gland including Trans Urethral Prostatectomy (TURP) or Open Prostatectomy. However, minimally invasive thermal ablation using microwave energy (TUMT), radiofrequency (RF), laser energy (PVP, HoLAP/HoLEP), Rezum, Aquablation and the Urolift procedure have not yet gained widespread usage.
The choice of treatments for symptomatic BPH is growing and further details can be found using this link Prostate Matters Website
Trans Arterial Embolisation
Trans-arterial embolisation, a non-surgical, minimally invasive procedure, has been used in many clinical settings. Initially introduced to stem life-threatening haemorrhage it then evolved into more widespread use to block the blood vessels that serve tumours prior to surgery and then again for definitive palliative treatment of tumours. It has been used in the setting of prostatic disease for many years either to stem acute or chronic bleeding due to advanced prostatic cancer, but also to control bleeding after prostatic surgery or even biopsy.
Uterine Artery Embolisation in the treatment of women with uterine fibroids, has become one of the most common minimally invasive treatments for symptomatic fibroids in the UK and is fully recognised by NICE (National Institute for Health and Care Excellence).
Prostate Artery Embolisation
Prostate artery embolisation (PAE) has been the subject of several studies since 2010, notably from Sao Paulo, Brazil, Lisbon, Portugal, China and the UK. The groups have been testing the hypothesis that trans-arterial embolisation of the prostate could lead to the death of the blood-rich and overgrown prostatic tissue, which in turn would result in a subsequent reduction in obstructive urinary symptoms.
Several Randomised Controlled Trials (RCTs) have now been published and in 2017 Pisco presented the results of his 1000 patient study at the Society of Interventional Radiology (SIR) meeting in Miami. This series includes the longest follow up data with over 800 patients followed out to 3 years and over 400 followed beyond 3 years.
As in all published PAE series to date symptomatic improvement is seen in just over 80% of men at 3-12 months and these improvements are sustained at medium and long term follow up with cumulative success rate of 78%.
The UK-ROPE (Registry of Prostate Embolisation), sponsored by NICE as well as the National Professional Societies of both Interventional Radiology (BSIR) and Urology (BAUS) performed between 2014 and 2016 reported its findings in 2018.
NICE fully approved PAE in April 2018.
Two Hour Procedure for BPH
The procedure is performed by trained Interventional Radiologists who are experienced in advanced embolisation techniques. It typically involves a unilateral groin puncture, under local anaesthetic and then thin, hollow tubes known as catheters, are placed via an artery in the groin or sometimes the wrist into both right and left prostate arteries under direct X-Ray guidance. These prostatic arteries are then closed using 100-500 micron-sized embolic particles.
3D (Dyna-CT) is performed during the PAE procedure, which further improves safety and the PErFecTED technique, or second generation PAE is offered when appropriate. This further improves results.
The procedure takes approximately 2-3 hours to perform and the patient can be discharged after 4 hours provided he is fit. Men needing to travel out of the area or those who are less fit may require an overnight stay in hospital.
Post-procedural pain is usually mild to moderate, unlike the often severe post-procedural pain following fibroid and kidney embolisation. This discomfort can be managed by simple anti- inflammatory and pain killing oral medications.
Complications reported to date have been rare and mostly involve minor bruising of the groin. One case of non-target embolisation of the bladder and several minor self-limiting ulcerations to the rectum have been reported in over 2000 cases; of these, one required surgical bladder repair. Minor again self- limiting penile ulceration has been reported in small numbers.
It is encouraging that the common side effects of TURP, such as transient incontinence, erectile dysfunction and particularly retrograde ejaculation have not been reported.
A carefully Monitored Clinical Introduction in 25 men with proven and symptomatic BPH, not responding to medical treatment was instigated at Southampton University Hospitals in 2012. The procedure was technically successful in all patients’ and clinical improvement, although in some cases modest was been seen in 90%. There were no serious complications and post procedural pain was mild to moderate only. In all but exceptional cases these were performed as a day case procedure.
NICE considered PAE as an option for treating men with significant Lower Urinary Tract Symptoms (LUTS) caused by benign prostate enlargement in 2013 and decided that at that time the evidence was still not strong enough to recommend approval for PAE. They suggested that more studies were needed and that included the setting up of a National Registry comparing PAE with traditional surgical techniques using TURP or HoLEP.
Dr Nigel Hacking, as the Pioneer of PAE in the UK, was appointed as Chairman of the UK-ROPE Steering committee and it’s Clinical Lead. Over 300 patients were recruited into UK-ROPE from 18 centres’ between 2014 and its close in early 2016. 1-year follow up data was completed in early 2017 and this data was published in 2018.
There were no serious concerns over safety of the PAE procedure.
To date Dr Nigel Hacking and his team at Southampton University have performed over 400 PAE cases with excellent results. A few patients have shown early symptom recurrence at 3-12 months and have undergone a limited TURP to remove an enlarged ‘Median lobe’. This limited surgery can still avoid the side effects seen after full TURP and this 2-stage procedure may be helpful in some cases.
NICE approved PAE in April 2018.
A Sham Trial comparing PAE with a sham procedure was published by the Lisbon Group in 2019 confirming the beneficial effects of PAE. Click here
For a private PAE referral
A GP or Urology referral will be required and arranged by Dr Hacking, and a full assessment with both Urological and Radiological assessment will be required before PAE can be offered.
For further information on the author of this article, Consultant Radiologist, Dr Nigel Hacking, please click here