Minimally Invasive Tumor Therapy (MITT)

Department of Radiology, Charité – Universitätsmedizin Berlin

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References

  1. Thorpe A, Neal D. Benign prostatic hyperplasia. Lancet 2003; 361: 1359–1367
  2. Rosario DJ, Bryant R. Benign Prostatic Hyperplasia. Surgery (Medicine Publishing) 2002; 20: 268–272
  3. Carnevale FC, Da Motta-Leal-Filho JM, Antunes AA, et al. Quality of life and clinical symptom improvement support prostatic artery embolization for patients with acute urinary retention caused by benign prostatic hyperplasia. J Vasc Interv Radiol 2013; 24: 535–542
  4. Pisco JM, Rio Tinto H, Campos Pinheiro L, et al. Embolisation of prostatic arteries as treatment of moderate to severe lower urinary symptoms (LUTS) secondary to benign hyperplasia: results of short- and mid-term follow-up. Eur Radiol 2013; 23: 2561–2572
  5. Golzarian J, Antunes AA, Bilhim T, et al. Prostatic Artery Embolization to Treat Lower Urinary Tract Symptoms Related to Benign Prostatic Hyperplasia and Bleeding in Patients with Prostate Cancer: Proceedings from a Multidisciplinary Research Consensus Panel. J Vasc Interv Radiol 2014

Prostate Artery Embolization (PAE) for Benign Prostatic Hyperplasia (BPH)

 

Benign prostatic hyperplasia (BPH) is a noncancerous enlargement of the gland of the male reproductive system. It is the most common benign tumorous condition of men and typically occurs with aging. More than half of all men above the age of 60 have an enlarged prostate and as many as 70 percent of men at age 70. About one third of the men with an enlarged prostate will develop symptoms that affect their quality of life. The primary symptom is the frequent or urgent need to urinate, including nighttime trips to the bathroom. At the same time, the enlarged prostate leads to a weak urine stream and dribbling at the end of urination, making it difficult to empty the bladder completely. Some men with BPH will develop more serious problems such as painful, acute urinary retention (a sudden inability to pass urine), incontinence, kidney damage due to chronic backup of urine, and frequent urinary tract infections (UTI).

 

Medical therapy is the first choice for men with symptomatic BPH and achieves good results, especially when symptoms are mild. If the symptoms are not relieved with medication, men are usually recommended to have surgery to remove part of the prostate (transurethral resection (TUR) or prostate enucleation). Prostate artery embolization (PAE) has recently emerged as a novel, minimally invasive treatment alternative to surgical removal of excess prostate tissue.

 

How Does PAE Work?

 

Through a small incision (cut) in the groin (about 2 mm), the interventional radiologist guides a thin catheter into the arterial system of the pelvis and then advances an even thinner catheter (about 1 mm in diameter) into the branches that supply blood to the prostate. The radiologist uses X-ray guidance to ensure proper catheter placement before releasing very small plastic particles (embolic agents) into the bloodstream to block blood flow to the enlarged prostate. The reduced blood supply causes the prostate to shrink. Three out of four men experience rapid and permanent relief of their symptoms after PAE. Patients undergoing PAE are not exposed to the risks of general anesthesia, which is not required for this minimally invasive intervention. Instead, patients receive appropriate pain medications before, during, and after the procedure to minimize discomfort.

 

Who are Candidates for PAE?

 

When assessing a candidate for PAE treatment, the doctor will first make sure that the symptoms are in fact cause by BPH. The nature of symptoms and their severity will be documented in a standardized questionnaire specifically developed for the assessment of patients with BPH. Additional diagnostic tests include evaluation of urinary flow dynamics and estimation of prostate size by magnetic resonance imaging (MRI) or ultrasound. Prostate cancer must be ruled out as the underlying cause of prostate enlargement as prostate cancer is treated differently. Therefore, a prostate-specific antigen (PSA) test is done to measure the amount of PSA in the blood. A high PSA level does not always mean prostate cancer is present, but patients with an elevated PSA reading require additional diagnostic tests like prostate MRI and possibly even a biopsy. Up to here, the diagnostic procedure is comparable to that required before surgery for BPH. To optimally plan PAE treatment, the interventional radiologist additionally needs MR images or a computed tomography (CT) scan for a detailed assessment of the pelvic arteries supplying the prostate. This information makes the procedure more reliable and easier for the patient. Moreover, careful vascular assessment before PAE allows the radiologist to identify patients with severe vascular calcifications. These patients cannot have PAE, and identifying them beforehand spares them an unnecessary intervention.

 

What are Possible Complications and Side Effects of PAE?

 

Side effects related to PAE are rare. Most side effects are easy to treat, and late adverse effects can thus be avoided. About 9% of patients will experience mild pain or a burning sensation in the urethra or the anus during the intervention despite pain medication. Urinary tract infections occur in 7%-8% of men and can be managed by antibiotic treatment. In some cases (2%-3%), acute urinary retention may require placement of a catheter into the urinary bladder for a short period of time. Other, less common side effects include blood-tinged urine and blood on the stool for a couple of days after PAE. Finally, there are the risks that are associated with any catheter examination such as the formation of a hematoma (accumulation of blood) at the puncture site in the groin or an allergic reaction to the contrast agent. We pay great attention to meticulous preparation and thorough aftercare to minimize the risk of complications.

 

While prostate surgery may have short-term or long-term adverse effects on erectile function or continence, so far, no such side effects have been reported for PAE.

 

Aftercare

 

Patients scheduled for PAE are generally admitted to hospital for about 3 to 5 days. About 50 percent of patients will notice marked improvement of their symptoms by the time of discharge from hospital. The final outcome can be assessed 4 to 6 weeks after PAE. Using the same questionnaire as before, the interventional radiologist will assess any remaining symptoms and compare them with the situation before PAE. Follow-up at our hospital also includes another MRI examination of the prostate for objective assessment of the change in prostate size. The MRI data will be used for the scientific study of this new treatment option.

 

  • Contact:

Minimally Invasive Tumor Therapy (MITT)

Charité, Campus Virchow-Klinikum

Department of Radiology

Augustenburger Platz 1

13353 Berlin, Germany

Phone: +49 (0)30/450-557309

Fax: +49 (0)30/450-557947

minimal-invasive-ambulanz@charite.de oder mia@charite.de

 

Case Examples

 

Magnetic resonance imaging (MRI) is very well suited for imaging the prostate and identifying changes like those associated with benign prostatic hyperplasia (BPH). In the cases presented here for illustration, the MR images in the left column are frontal views, while the images in the right column show the prostate and nearby organs from the side. The black asterisk indicates the urinary bladder above the prostate. It appears bright in these MR images. Figure 1 depicts a prostate of normal size. The cases presented in Figures 2 to 4 show increasingly severe BPH with nodular enlargement of the prostate gland. With increasing size, the prostate expands upwards and protrudes into the urinary bladder. This impingement on the bladder and compression of the urethra by the enlarged prostate explain the problems with urination experienced by men with BPH.

 

Figure 1

 

Figure 2

 

Figure 3

 

Figure 4