Case histories: A prostate artery embolization for my father

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Francisco Carnevale and his father, Jose Angelo Carnevale

This is the story of bonding over a prostate artery embolization. Many times, as physicians we share a closeness with our patients, and form a relationship with them that is based on caring for them at what is often a vulnerable time in their lives. This is a very different story: it is the story of performing a new medical procedure that I believe in, on a man that I am very close to—my father, writes Francisco Carnevale, São Paulo, Brazil.

Looking at it through the prism of clinicians, we have here a patient; a 78-year-old man with severe lower urinary tract symptoms (LUTS) due to an enlarged prostate. This patient is also my father. Benign prostate hyperplasia was affecting my father, Jose Angelo Carnevale. For nearly two decades, he had been taking medication to alleviate his symptoms. While he experienced some periods of improvement, overall, he had a poor quality of life. During his annual visits to the urologist, he had been told that, some day in the future, he would have to undergo a surgical procedure to alleviate his lower urinary tract symptoms. In the early years, transurethral resection of the prostate (TURP) was the only option. Then, newer technologies came along and it was suggested that he could have a laser procedure. However, due to the size of the hyperplasia, a prostatectomy was also mentioned as a treatment option. Faced with that difficult choice, he called me to discuss his final decision: “I will not have a surgery and do not want to be admitted into a hospital. Hospitals are your domain, my son. I have never been admitted to a hospital and I am not about to change that.”

Looking back, I realised that that was a true and accurate statement. By the grace of God, my father had never had to be hospitalised due to any serious disease or injury. Being a workaholic, he even used to squirm at the idea of a vacation. Put simply, my father loves to work, especially since my mother passed away.

Time went by and my father stuck to his decision. But it was not easy. There were some embarrassing episodes: urinary incontinence in a shopping mall; several other times that he needed to urgently get to a toilet while pushing on the brakes of his car. Then, he was removed from an airplane due to lower abdominal pain, and of course, there were the years and years of nocturia. One day, my father called me very early one morning and said (in his trademark soft Italian tones): “I give up. I woke up five times to urinate last night. It is just too much. I am now too tired to work. I cannot even drink a glass of wine or beer, or even water, in the evening… Either you treat me, or I will get my prostate removed.” The message was clear and his tone was final.

Francisco C Carnevale

So, after talking to his urologist, we decided to evaluate and check if he was a good candidate for prostate artery embolization. His results showed lower urinary tract symptoms with International Prostate Symptom Score (IPSS) of 27; normal blood tests, prostate-specific antigen of 5.2ng/mL. Imaging with ultrasound revealed a 95cm3 prostate bladder thickness and post void residual volume of 20mL. MRI showed an enlarged prostate (99.5cm3) with several benign hyperplasia nodules with an enlarged central gland; prominent median lobe; bladder thickness without diverticulum; and no signs of cancer. Urodynamic testing confirmed bladder outlet obstruction with Schafer VI score. So, yes, my father was a good candidate for a prostate artery embolization procedure. Now, we were faced with a decision: who was going to treat him? When presented with his options, his answer was: “My son, of course!” That was the moment I knew that all my studies had paid off, because a father’s recognition is priceless.

That is how on a Thursday morning in August 2014, my father got his prostate artery embolization at Hospital das Clinicas of the University of São Paulo Medical School, under local anaesthesia, using the Foley technique balloon, cone-beam CT. He had the PErFecTED technique (Proximal Embolization First, Then, Embolize Distal) bilaterally with Embospheres (Merit) microspheres. A closure device was used and two hours after the procedure, he was discharged. As per usual, he got medications for post-prostate artery embolization syndrome (dysuria, urethral burning, frequency and urgency). Three days later, during the “Fathers’ Day holiday” he drove his own car to our country house to enjoy a delicious Brazilian barbecue. It was recommended that he wear diapers in case of urinary urgency while driving. When he arrived at our country house, he was presented with an unusual gift from his grandchildren: a pack of diapers! But he has never needed them, because all his symptoms improved a lot and at the two-year follow-up evaluation, he had an IPSS of 2, without urinary residual volume, and a prostate size of 57cm3, which is a 43% prostate reduction by MRI.

But, what about the quality of life index? Well, here is another story. It was about 8pm one night when my cellphone rang and I saw that it was my father. I then heard the unmistakeable sound of beer being poured into a glass. “Now, I can drink without the need to wake up to pee in the middle of the night.” So his quality of life had distinctly improved as well.

Three years on, my father is 81 years old. He is still driving, drinking, and enjoying life with his friends and family. I figured that for all the things that he has done for me, this is the least I could  have done for him. So, thank you, dad.

Francisco Carnevale is associate professor of Medicine, University of São Paulo, São Paulo, Brazil, and director, Interventional Radiology Fellowship Programme. He designed the PErFecTED technique and reports no disclosures pertaining to this article.

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