Prostate embolisation - the artificial closure of blood vessels - is a new and effective method of treating benign prostate enlargement (benign prostatic hyperplasia). For certain patients, this minimally invasive procedure is an alternative to proven medication and surgery. A urologist makes an evaluation and indication after the patient has seen their family doctor. The embolisation is carried out by microtherapy specialists.
Benign prostate enlargement, or benign prostatic hyperplasia (BHP), is one of the most common organ changes in men and is typically a condition of older age. It occurs in more than 50% of men over the age of 50 and in nearly all very elderly men. It is a growth of the inner area of the gland that lies immediately around the urethra. The result is a narrowing of the urethra, with the related problems (see Fig.1) Symptoms range from a frequent need to urinate at night, to painful urination and urination disorders, to a complete inability to urinate (urine retention), which may result in a kidney damage.
PROCEDURE FOR PROSTATE ARTERY EMBOLISATION
Prostate artery embolisation is a new microtherapeutic process for treating BPH in which the affected blood vessels are closed artificially. A catheter is inserted via the groin under X-ray guidance and pushed into the vessels that supply the prostate with blood. When the catheter is securely positioned, tiny particles (microspheres) are injected through it into the prostate artery, which result in its closure (see Fig. 2). Special imaging processes enable three-dimensional guidance. Closure of the blood vessel reduces the blood flow to the prostate. This in turn causes it to shrink and reduces the pressure on the urethra. This minimally invasive procedure is carried out under local anaesthetic. It is usually painless and takes about 1 to 1½ hours.
Fig.2
Prostate artery embolisation: Small particles are injected through a catheter into the blood vessels that supply the prostate with blood. This leads to closure of these vessels and subsequently to shrinkage of the prostate.
PROVEN EFFECTIVENESS
Prostate artery embolisation is a new but not an experimental process. It has been investigated in numerous studies and its effectiveness has been proven for up to four years after the procedure. Blockage of the blood vessel is successful in 95% of patients, which is a very high rate. A comparative study has shown that the traditional loop surgery (see the box) results in faster clinical improvement in the first three months than embolisation. However, in a further assessment period of up to 24 months, the results were the same in both patient groups.
SIDE-EFFECTS AND COMPLICATIONS
Relevant side-effects can be effectively avoided by good imaging guidance of the correct catheter position. Other side-effects include temporary lower abdominal pain and urine retention, which usually disappear within three days of the procedure. In addition, catheterisation has rare general risks, such as post-operative bleeding at the catheter insertion site or an intolerance to the contrast medium. Short or medium-term adverse effects on sexual potency or continence have not been reported to date. Since a general anaesthetic is not required, the procedure can be carried out on patients who cannot tolerate anaesthesia.
SUPPLEMENT TO ESTABLISHED TREATMENT OPTIONS
Prostate artery embolisation does not replace established treatments (see the box), but it expands the range of treatment options. In general, prostate artery embolisation can be considered for all patients who have not benefited sufficiently from medication and for whom surgery is not possible. Good results have been achieved in patients with a large prostate and pronounced symptoms. The process is suitable for patients who cannot tolerate medication due to side-effects, or where there is an increased surgical risk. The urologist and the microtherapy specialist will prescribe prostate artery embolisation jointly after the patient has seen their family doctor.
Proven treatments for benign prostate enlargement
Whenever possible, the first treatment method is medication. Various drugs are administered individually or in combination, depending on the symptoms and stage of prostate enlargement. The goal is rapid and lasting symptoms relief. Surgery becomes necessary when these medications are no longer effective or cannot be taken due to intolerence. In almost all cases today, surgery is based on a minimally invasive procedure in which the excess tissue is removed. Today various techniques, including laser-based, exist, but the conventional loop operation, or transurethral resection of the prostate (TURP), is still the gold standard. Prostate glands of well over 100 g can be operated on with this method, thanks to ongoing development. You should not be afraid of incontinence or impotence: these minimally invasive techniques avoid these problems. However, a declining ejaculation of semen into the bladder (hence dry orgasm) may occur. But this does not disturb most men. A technique where the tissue is not removed, but vaporised is used for patients who take blood-thinners. In the case of a very large prostate, tissue 'peeling'(adenoma enucleation) is sometimes indicated. Today, this procedure can be performed laparoscopically with robot assistance (keyhole surgery).
TWO QUESTIONS FOR PROF. JACOB AND PROF. DUDECK
What is microtherapy?
Prof. Jacob: Microtherapy is the therapeutic branch of radiology. This relatively young subject is also called interventional radiology. Microtherapy uses imaging processes, such as ultrasound or X-rays, for minimally invasive treatment of a wider range of diseases. Under imaging guidance, milimetre-thin instruments, such as catheters or probes, are brought to the diseased organs through tiny incisions or puncture sites. In the last 20 years, microtherapy has developed considerably and is an important addition to the treatment spectrum for many diseases within the context of highly specialised medicine (HSM). Consequently, Zurich cantonal health department has made it obligatory for microtherapy specialists to be available at hospitals that carry out specific HSM procedures.
What are the advantages of microtherapy?
Prof. Dudeck: Microtherapeutic procedures are usually less stressful for patients than traditional operations, since there are no major incisions. General anaesthetic is necessary only in exceptional cases. Thus, the risks are lower, the pain is less and the recovery time is shorter than with surgery. Finally, the hospital stay is also usually shorter with microtherapeutic procedures.
Article from Prof. Dr. med A. Ludwig Jacob and Prof. Dr. med Oliver Dudek, radiology specialists.
Glossary:
- Benign prostate hyperplasia (BPH): benign prostate enlargment
- Embolisation: minimally invasive catheterisation to close the blood vessels
- Indication: reason for treatment
- Turp: transurethral (through the urethra) resection of the prostate