On 5 June, the Society of Interventional Radiology (SIR) held a briefing in Washington DC, USA, of which the focus was benign prostate hyperplasia (BPH). The briefing took place in conjunction with the US Congressional Men’s Health Caucus. Shivank Bhatia (University of Miami, Miami, USA) took to the podium to introduce prostate care as an “issue of great importance to men’s health”—all the more relevant the week before National Men’s Health Week (12–18 June) in the USA. His talk during the session centred around prostate artery embolization (PAE).
It was Bruce Kava, professor of urology at the University of Miami, who presented first during the session, outlining what BPH is—“bigger is not always better, and at some point [around the age of 30 for most men], the prostate begins to grow”. The more severe consequences of an enlarged prostate, the audience heard, can include “urinary retention, recurrent infection, bladder stones, or [even] kidney failure”. The symptoms as a whole are classified as lower urinary tract symptoms, or “LUTS”, Kava explained—“the burden of LUTS for people with BPH is immense”. The symptoms are not usually life-threatening, Kava went on, but they create bother, “which translates to lower quality of life, [including] anxiety, depression, and loss of productivity”. Kava then informed his audience that around 25% of men over the age of 50 have LUTS of “at least moderate severity”.
Access to care for BPH—namely medication or surgical procedures—differs based on race, Kava lamented, stating that it is “less for African American and Hispanic males”. Members of these groups, therefore, “present to the emergency room much more frequently than Caucasians do”.
BPH treatment options
Treatment, when it is accessible, centres on reducing symptom severity, namely improving urinary flow, reducing urinary tract infections, and improving renal insufficiency. Kava also noted that BPH treatment is designed to slow the growth of the prostate. However, he pointed out that medications show only “modest effects” in terms of International Prostate Symptom Score [IPSS] reduction. The minimally invasive surgical treatment transurethral resection of the prostate (TURP) can be an outstanding option, Kava suggested, but side-effects, which include an overnight hospital stay, occasional bleeding (in particular for larger prostate glands), and ejaculatory dysfunction may mean it is not always the perfect option for some men.
Nowadays, Kava explained that in urology, they have been offering treatment via other modalities, including a number of laser procedures, prostatic urethral lift, water vapour thermotherapy, and aquablation. Size of the prostate is often the key determinant of success with these modalities. For instance, prostatic urethral lift and water vapour thermotherapy are more efficacious with smaller prostate glands. There is demand for a minimally invasive modality that is highly effective in patients with larger prostates, that offers a rapid recovery, and that reduces the risks of transfusion and other adverse effects.
The advent and advantages of PAE
Bhatia, who is chair of the Department of Interventional Radiology and professor of urology, then took to the podium to speak about prostatic artery embolization (PAE) as the answer to other treatments’ size-related limitations. Bhatia first set out how image-guided interventions—such as PAE—are largely unknown to the public. He then explained that PAE involves using small microsphere to embolize and therefore cut off blood flow to large prostates, causing them to shrink.
“Ninety-nine per cent of men eligible for treatment for BPH do not receive invasive therapy,” Bhatia shared, adding that for some, their reason for avoiding treatment will be that they do not like the options available—such as resection. This is where minimally invasive options such as PAE come in. Bhatia noted that “PAE has been [US Food and Drug Administration]-approved since 2016.”
Bhatia relayed that advantages of PAE over surgical treatment are that it does not require general anaesthesia, is a same-day, outpatient procedure, with no size limit of the prostate. He explained that one can avoid the risk of bleeding and adverse impact on sexual function associated with surgical procedures. From the patient’s perspective, PAE offers a “90% success rate”, the benchmark for which Bhatia described as around a “50% improvement in symptoms [according to the IPSS]”. After PAE, he went on, the prostate will keep shrinking and will not start growing again “for three to five years”.
PAE at the University of Miami
Bhatia then shared his centre’s experience treating over 1,000 patients over six years, as presented at the SIR 2023 annual scientific meeting (4–9 March, Phoenix, USA), before thanking his patients for having put “their trust in [him]” to have the PAE procedure. Among the study’s notable findings was a persistent, years-long reduction in prostate size among the patients, he underlined, as well as dramatic decreases in patients’ IPSS and self-reported quality of life. Bhatia mentioned that one of the most crucial limitations of PAE was the lack of awareness about this procedure.
Following this, one of the first 25 patients treated by Bhatia, Roland Klein, spoke from his point of view on the merits of PAE.
“I started having symptoms long before PAE existed,” Klein provided as background to his experience, conveying how he began researching the various treatments available to him, with his symptoms worsening at this time. “I decided I was going to fly to Brazil to try PAE,” he explained, “because it was the least invasive treatment you could possibly get”. As he was continuing to read up on PAE, Klein reported that he saw that the University of Miami was starting a trial programme, “so [he] contacted Dr Bhatia […] was told [he] would be a candidate, and [he] went down and had the procedure”. Klein then emphasised how, in his eyes, “the procedure is a ‘nothing’ procedure”, involving only a “pinhole” incision and a few hours in the hospital pre-, during and post-procedure, in total. He reported how he experienced “a little pain” when urinating for “about three to five days” before returning to work. “It has [now] been nine years, and I still do not have any issues with urination,” he concluded.
In summary, Bhatia and Kava delivered a briefing to the Congressional Men’s Health Caucus, explaining different options available to treat symptoms related to enlarged prostate, with an emphasis on PAE, a minimally invasive option with no risks of sexual side-effects or leakage, no need for a urinary catheter, and efficacy similar to more invasive options.
