PAE practice: A decade in review

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PAE
Shivank Bhatia and Vedant Acharya

Shivank Bhatia and Vedant Acharya highlight the importance of multidisciplinary collaboration between urologists and interventional radiologists when it comes to forming a successful prostate artery embolization (PAE) clinic, citing a decade of experience at the Miami Miller School of Medicine (Miami, USA).

Prostate artery embolization (PAE), an endovascular treatment for benign prostatic hyperplasia (BPH)-related lower urinary tract symptoms (LUTS), was initially performed to control pelvic bleeding of prostatic origin. It was found that the prostate decreased in size. With this insight, the first use of PAE to intentionally treat BPH-associated LUTS was performed in 2000. Larger case series published in 2010–2011 reproduced these initial findings. The presentation of these results at the Society of Interventional Radiology (SIR) 2011 conference [26–31 March, Chicago, USA] led to increasing international interest in studying the effects of PAE.

Over the past 10 years, the PAE landscape has seen a tremendous explosion of research interest.

At the University of Miami Miller School of Medicine, we have developed one of the largest PAE practices in North America. From the outset, we applied a multi-disciplinary approach, working with the department of Urology to better evaluate and identify optimal candidates for PAE. This effort allowed our urology colleagues to evaluate the data regarding PAE’s safety and efficacy and observe, first-hand, the benefit provided to patients who otherwise were not surgical candidates. We have continued to take this multidisciplinary approach by creating data-driven PAE educational materials to build relationships with local urologists and primary care physicians in academia and the community.

At our institution, we have performed more than 850 PAE procedures since 2014, and we currently see over 250 PAEs per year. We have consistently optimised our technique and standardised our preprocedural evaluation and post-procedure follow-up to create a robust clinical practice. Additionally, we have moved to a primarily radial (left wrist) approach. This access is optimal for most patients as it allows immediate ambulation, faster recovery, and features lower risks overall compared to the femoral approach. In addition, we have performed over 250 procedures in a surgery centre with no incidence of need for transfer to the hospital.

Our team is excited to be at the forefront of research in PAE and contribute to the broader interventional radiology and urology communities. The University of Miami Miller School of Medicine hosted Evolution: Miami 2019 [15–17 November, Miami, USA], a multi-disciplinary conference with over 270 attendees, at which PAE best practices and current debates were discussed by international leaders. Over the past decade, we have presented more than 50 manuscripts on PAE at national and international conferences and in peer-reviewed journals. Recognising the necessity of high-quality data to advance the field, we are delighted to be sharing our results in the presentation titled “Prostate Artery Embolization—Single centre experience of 576 patients with five years follow up” at SIR 2021 [20–26 March, online]. To our knowledge, this is the largest series of the patients treated with PAE in North America presented to date.

Brian Malling (Rigshospitalet, Copenhagen, Denmark) et al conducted a meta-analysis and evaluated the clinical outcomes of 1,254 patients who underwent PAE and found that PAE improved International Prostate Symptom Score (IPSS) by 67% at 12 months and reduced prostate volume by 32% at three months. Several high-quality randomised control trials evaluating PAE versus transurethral resection of the prostate (TURP) have shown consistent and reproducible results. Most recently, Gabriel Knight (Northwestern University, Chicago, USA) et al performed a meta-analysis comparing PAE and TURP and found no significant differences between changes in IPSS, IPSS quality of life, and erectile function.

Future developments in PAE include: gaining a greater understanding of the effects of PAE on ejaculatory dysfunction, performing a randomised control trial comparing PAE with Holmium laser enucleation of the prostate (HoLEP; the current gold-standard size-independent prostate procedure), and evaluating the long-term durability of the procedure. We hope that the development of research will provide the American Urology Association (AUA) the required evidence to recommend PAE as a treatment option.

Research on PAE has developed from a small case series to a multicentre international effort over the past decade. We are excited to have built a robust multidisciplinary clinical practice, to have contributed to the literature, and to be a part of further developments to bring this minimally invasive treatment option to more patients with BPH.

Shivank Bhatia is professor of Interventional Radiology and Urology at the University of Miami Miller School of Medicine, Miami, USA.

Vedant Acharya is a fourth year medical student and past Interventional Radiology Research Fellow at the University of Miami Miller School of Medicine, Miami, USA.


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