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Prostatic artery embolization comparable to transurethral resection

Published on March 30, 2011 at 2:39 AM ,

Prostatic artery embolization: Study shows symptom improvement comparable to 'gold standard' transurethral resection of the prostate-without surgical risks of sexual dysfunction, urinary incontinence, blood loss, retrograde ejaculation

A new interventional radiology treatment that blocks blood supply to men's enlarged prostate glands shows comparable clinical results to transurethral resection of the prostate (or TURP), considered the gold standard (or most common) treatment. However, this minimally invasive treatment-prostatic artery embolization-has none of the risks associated with TURP, such as sexual dysfunction, urinary incontinence, blood loss and retrograde ejaculation, noted researchers at the Society of Interventional Radiology's 36th Annual Scientific Meeting in Chicago.

"Benign prostatic hyperplasia or BPH is so common that it's been said that all men will have an enlarged prostate if they live long enough. I believe that a minimally invasive interventional radiology treatment-prostatic artery embolization or PAE-will be the future treatment for benign prostatic hyperplasia or men's noncancerous enlarged prostates," noted Jo-o Martins Pisco, M.D., chief radiologist at Hospital Pulido Valente and director of interventional radiology at St. Louis Hospital, both in Lisbon, Portugal. "Prostatic artery embolization blocks blood supply to treat noncancerous benign prostatic hyperplasia. This study is significant because it shows comparable clinical results to transurethral resection of the prostate or TURP-without the risks of surgery, such as sexual dysfunction, urinary incontinence, blood loss and retrograde ejaculation (or entry of semen into the bladder)," added Pisco, who is a professor at the Faculty of Medical Sciences, New University of Lisbon. "While the gold standard treatment for enlarged prostates has been TURP, minimally invasive prostatic artery embolization is safe, performed under local anesthesia and has comparable clinical results-without TURP's limitations and risks," said Pisco. The interventional radiologist indicated that PAE patients experienced symptom improvement comparable to TURP; however, certain urodynamic results (such as flow rate of the urinary stream) did not improve as much as with TURP.

TURP can be performed only on prostates smaller than 60󈞼 cubic centimeters (cc); there is no size limitation for PAE treatment, said Pisco. "The best results are obtained on patients with prostates larger than 60 cubic centimeters and with very severe symptoms," he added. "Pelvic arterial embolization may be the only feasible and effective treatment for benign prostatic hyperplasia in those men who cannot have TURP due to the size of their prostate (80+ cubic centimeters) or because it is inadvisable for them to undergo general anaesthesia," said Pisco.

BPH is not cancer; it is a condition that affects a man's prostate, a gland found between the bladder and the urethra. As a man ages, the prostate gland slowly grows bigger (or enlarges) and may press on the urethra and cause the flow of urine to be slower and less forceful. BPH is characterized by urinary frequency, urgency, passing urine more often (particularly at night), weakened stream and incomplete bladder emptying. "Such symptoms can have significant negative impact in quality of life, leading many men to seek treatment," said Pisco. "We need innovative technologies, such as prostatic artery embolization, to continue to improve outcomes and minimize patient discomfort and morbidity when managing enlarged prostates," he added.

An estimated 19 million men in this country have symptomatic BPH, (14 million undiagnosed; 2 million diagnosed but untreated). Statistics show that a small amount of prostate enlargement is present in many men over age 40, as many as 50 percent experience symptoms of an enlarged prostate by age 60 and more than 90 percent of men over the age of 85 will report symptoms.

"The men who were treated with prostatic artery embolization showed significant clinical improvement," said Pisco. In this study, 84 men (ranging in ages from 52 to 85) with symptomatic BPH underwent prostatic artery embolization after failing other medical treatments for at least six months, said Pisco. The men were followed for more than nine months (on average), and PAE was found to be technically successful in 98.5 percent of the patients-with 77 men showing "excellent" improvement, six men "slight improvement" (but needing no medications) and one experiencing no improvement (due to receiving an incomplete embolization), he added. Two hours after PAE, most men were passing urine less frequently. It was impossible to embolize both prostate arteries in the men showing "slight improvement" due to advanced atherosclerosis, said Pisco. According to Pisco, he used angiography (by pelvic magnetic resonance and computed tomography) to evaluate the possibility of embolizing prostatic blood vessels.

Prostatic artery embolization is performed by an interventional radiologist, a physician who is trained to perform this and other types of embolization and minimally invasive procedures. An interventional radiologist makes a tiny nick in the skin in the groin and inserts a microcatheter into the femoral artery. Using real-time imaging, the physician guides the catheter through the artery and then releases tiny particles, the size of grains of sand, into the prostatic arteries that supply blood to the tumor. These tiny particles block blood flow to the tumor, causing it to shrink. Following PAE treatment, most men experience no pain to light pain and leave the hospital four to eight hours after intervention. "There is no sexual dysfunction following prostatic artery embolization, and a quarter of our patients report that sexual function improved after the procedure," added Pisco.

BPH can be treated by TURP, a procedure in which a scope is inserted through the penis and the prostate is removed piece by piece, or surgery through an abdomen incision (prostatectomy). During surgery, a man generally undergoes general anaesthesia and needs to spend several days in a hospital. Major complications are frequent, such as blood loss, severe pain, sexual dysfunction, impotence, retrograde ejaculation, urinary incontinence, pain, infections and urethral stricture, said Pisco.

Other treatments for enlarged prostrates-besides prostatic artery embolization, TURP and prostatectomy-include watchful waiting, drugs (to relax muscles near prostate to ease symptoms or help shrink the prostate) and other minimally invasive therapies (such as transurethral needle ablation and laser surgery), which have major disadvantages, such as providing less effective improvement in symptoms, poorer durability of symptomatic benefit, and greater risk of continued catheterization and reoperation. "Additional research is needed to explain why some patients improve better than others," said Pisco.

Source: Society of Interventional Radiology


http://www.businessweek.com/lifestyle/content/healthday/651229.html

New Therapy for Enlarged Prostate May Bypass Unpleasant Side Effects

Procedure apparently avoids risk of impotence, incontinence, associated with surgery, but more study needed

By Amanda Gardner
HealthDay Reporter

TUESDAY, March 29 (HealthDay News) -- A minimally invasive treatment for enlarged prostate that limits blood supply to the prostate seems to be just as effective as surgery but without the risk of debilitating side effects, such as impotence and urinary incontinence.
The treatment -- called prostatic artery embolization, or PAE -- is ready to be used in certain patients, namely those with a prostate larger than 60 cubic centimeters, "with severe lower urinary tract symptoms and a weakened urinary stream," said Dr. Joao Martins Pisco, lead author of a study slated to be presented March 29 at the annual meeting of the Society of Interventional Radiology in Chicago.

But other experts aren't so sure.

Drugs are used to treat most patients with an enlarged prostate, with only about 10 percent qualifying for surgery to remove the entire gland, said Dr. Elizabeth Kavaler, a urologist at Lenox Hill Hospital in New York City.

"Because medication is so effective, most of the patients that we treat surgically are in pretty bad shape," she added. And while this study showed some symptomatic improvement, it didn't have enough objective data to show that the new technique would surpass surgery, she said.

Benign prostate hyperplasia, also known as enlarged prostate, is a non-cancerous condition familiar to millions of aging males. The condition occurs when the prostate gland slowly enlarges and presses on the urethra, constricting the flow of urine.

Enlarged prostate is characterized by a host of unpleasant symptoms, including weak or slow urine flow, an urgent need to urinate frequently, incomplete bladder emptying and having to get up repeatedly at night to urinate.

The surgery for enlarged prostate -- transurethral resection of the prostate, or TURP -- is used for men whose prostates are smaller than 60 to 80 cubic centimeters. The procedure is performed under general anesthesia and involves a hospital stay.

Meanwhile, there is no size limitation for PAE, which requires only local anesthesia and also lowers the risk of other side effects, such as blood loss and retrograde ejaculation, which occurs when semen leaks into the bladder, researchers said. PAE can be an outpatient procedure as well.

For the procedure, a catheter is inserted into the femoral artery in the groin. The catheter delivers tiny "grains" to the arteries that lead to the prostate, which block blood flow and lead to shriveling of the gland.

In this study, PAE helped most of the 67 patients who underwent the procedure, according to the researchers, who noted that 66 men who had not responded to medications experienced improvements in symptoms as well as a reduction in prostate volume. After nine months, none had experienced sexual dysfunction and 25 percent still reported improvements.

However, the authors did not see as great an improvement in "urodynamic" results, such as improved flow rate of the urine, which would indicate how well the bladder and urethra are performing; in this area, the patients did not improve as much as those who underwent TURP surgery, they noted.

Another drawback is that few doctors are trained in PAE so far, said Pisco, chair of radiology at Hospital Pulido Valente and professor in the Faculty of Medical Sciences at New University of Lisbon in Portugal.

Other minimally invasive treatments for enlarged prostate that are currently available are less effective and have a greater risk of a need for reoperation, according to background materials that accompanied the study.

Dr. Franklin Lowe, associate director of urology at St. Luke's-Roosevelt Hospital in New York City, said PAE was "unlikely" to be used much to treat enlarged prostate.

Current surgical procedures typically require no more than one night in the hospital and complications such as incontinence and impotence are uncommon, he said.

"PAE is potentially fraught with complications," Lowe said, adding that the study follow-up of less than one year was short for a disease that lasts decades.

Since the study is being presented at a medical meeting and has not yet been published in a peer-reviewed journal, the findings should be considered preliminary.

More information

The U.S. National Institutes of Health has more on enlarged prostate.

SOURCES: Joao Martins Pisco, M.D., professor and chair of radiology, Hospital Pulido Valente and professor, Faculty of Medical Sciences, New University of Lisbon, Portugal; Elizabeth Kavaler, M.D., urologist, Lenox Hill Hospital, New York City; Franklin Lowe, M.D., associate director, urology, St. Luke's-Roosevelt Hospital in New York City; Society of Interventional Radiology, study abstract and news release, March 29, 2011
Copyright , 2011 HealthDay. All rights reserved.


http://www.medpagetoday.com/MeetingCoverage/SIR/25598

SIR: Embolization Promising for BPH

By John Fauber, Reporter, Milwaukee Journal Sentinel/MedPage Today
Published: March 29, 2011

Reviewed by Zalman S. Agus, MD; Emeritus Professor
University of Pennsylvania School of Medicine and Dorothy Caputo, MA, RN, BC-ADM, CDE, Nurse Planner

Action Points

  • Note thatthis study was published as an abstract and presented at a conference. These data and conclusions should be considered to be preliminary until published in a peer-reviewed journal.
  • Note that for men who require an invasive procedure and are in good health and not responding with medical therapy, transurethral resection of the prostate is currently recommended because of good long-term results and excellent symptomatic response although there can be significant adverse effects.
  • Point out that this study, a small, uncontrolled clinical trial, demonstrates good results with relatively few adverse effects at nine months.

CHICAGO -- Embolization, which has gained acceptance as a treatment for uterine fibroids, may also be an alternative to surgery for benign prostatic hyperplasia.
However, doctors cautioned that the benefits found in the small, uncontrolled clinical trial presented a the annual meeting of the Society for Interventional Radiology need to be duplicated in a bigger more rigorous study.

"The main thing they are showing is that it is safe," said Bill Rilling, MD, medical director of interventional radiology at Froedtert Hospital in Milwaukee and a professor radiology and surgery at the Medical College of Wisconsin.

The procedure, which causes the prostate to shrink by cutting off blood supply, is done under local anesthesia. Known as prostatic artery embolization, it uses a catheter through the femoral artery to place polyvinyl alcohol (PVA) particles into prostatic arteries.

The study, which was done by doctors in Portugal, involved 84 men ages 52 to 85 who were followed for an average of nine months.

Nonspherical PVA particles 200 ,m were used in the first 14 patients and 100 ,m were used in the remaining patients.

The researchers said 77 men showed excellent improvement, six had slight improvement, and one had no improvement.

In some cases, urinary problems improved with two hours of the procedure.

One potential problem is that the procedure seemed to be less effective in men who had advanced atherosclerosis, which also is more common in older men.

The gold standard surgical treatment, transurethral resection of the prostate, can cause sexual dysfunction, urinary incontinence, and blood loss.

"This will be the future for BPH," said lead author Joao Martins Pisco, MD, director of interventional radiology at St. Louis Hospital in Lisbon. "I don't have any doubt about it."

Doctors in the U.S. said the procedure has garnered more attention in Europe, though US physicians now are traveling to Portugal to study it.
"We are really just learning about it," said James Spies, MD, chairman of radiology at Georgetown University Medical Center. "I would hesitate to say it looks like a panacea, but it is very promising."

Another issue is whether urologists, often the physicians who treat BPH, will accept the therapy if it is approved in the U.S.

Already, several less invasive surgical approaches are available to treat some men with BPH, noted Matthew Johnson, MD, an urologist who practices at Aurora St. Luke's Medical Center in Milwaukee.

"Urologists are open to any and all legitimate options, even when the option would reduce the number of surgeries performed," Johnson said. "This is the only way progress is made in medicine."

Pisco's results were based on symptoms nine months after undergoing the procedure.

Marshall Hicks, MD, a professor of diagnostic and interventional imaging at the University of Texas MD Anderson Cancer Center in Houston, said rigorous, longer-term data comparing the procedure with other therapies will be needed before it will be accepted in the U.S.

Primary source: Society of Interventional Radiology

Source reference:
Pisco, JM et al "Prostatic artery embolization to treat benign prostatic hyperplasia,short- and medium-term outcomes" SIR 2011; Abstract 5.

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