By Dr Ravjit Sagoo, Consultant Interventional Radiologist at Aga Khan University Hospital Nairobi
If you are a man over 60 years, you probably have or are likely to have an enlarged prostate also referred to as benign prostatic hyperplasia (BPH). This is a non-cancerous increase of prostate tissue which can cause blockage of the bladder and urine flow. It is extremely common in middle-aged and elderly men, affecting up to 50% of men over the age of 60 and 90% of men over 85 years. Here’s what you need to know about this problem.
What symptoms does BPH cause?
Many men with BPH have no symptoms. However, in men with symptoms, the most common include; increased urinary frequency, with voiding small amounts of urine, especially at night, sensation of incomplete bladder emptying after urination, difficulty in starting urination, weak urinary stream, inability to urinate, leading to catheterization, urinary urgency, with difficulty in controlling urination and blood in the urine.
If I have symptoms, what are my treatment options?
Treatment is only necessary if symptoms become bothersome. Several treatment options are available depending on the severity of symptoms:
Lifestyle changes is appropriate for those with mild symptoms. This includes changes such as limiting fluid intake in the evenings, limiting caffeine intake, healthy eating and undertaking exercise.
Prescription drugs is an option for men with symptoms which are relatively more troublesome and not relieved with lifestyle changes. These includes medications such as alpha blockers and 5-alpha reductase inhibitors which relax the muscles of the prostate/bladder and reduce the volume of the prostate, respectively.
Surgery is reserved for men in whom medical therapy has not resulted in significant symptom improvement. There are many surgical options available which vary in their indications, invasiveness, effectiveness, and side-effect profile. Examples of surgical options include:
Transurethral resection of the prostate (TURP) – a common procedure in which a scope is introduced into the penis and the prostate tissue is cut away with electrical current
Laser enucleation of prostate – in this procedure, the excess prostatic tissue is destroyed by a laser
Thermal treatments – these procedures destroy excess prostatic tissue using materials such as water vapour, microwaves and other low-energy radio waves
Prostatic urethral lift – a needle is used to place implants into the prostate to aid in lifting and compressing the gland, which results in unblocking the urethra
Prostatectomy – the entire prostate gland is removed in this operation
Prostate artery embolization (PAE) is a non-surgical treatment for men who want to avoid a traditional surgical procedure (or who are deemed high risk for surgery) in which the blood supply to the prostate gland is blocked off resulting in its shrinkage. The success rate of PAE is over 85% (similar to TURP, a commonly performed invasive operation), with a low recurrence rate long-term. PAE resolves the problem rapidly and, as this procedure involves no open cut, normal activity can be rapidly resumed.
Is PAE an experimental procedure?
No. PAE is an established, minimally invasive procedure and represents a treatment option for BPH. In the UK and USA, national guidelines recommend that the procedure should be one of the options considered for certain men with symptomatic BPH. It is a relatively new application of a longstanding technology, as embolization has been performed successfully for decades by Interventional Radiologists to treat a variety of conditions throughout the body.
Where is the PAE procedure carried out?
The procedure is carried out in a Catheter Laboratory (Cath Lab). Patients normally need to spend one night on the ward after the procedure, usually being discharged the following morning. Certain patients can be discharged the same evening of the procedure.
What preparation is needed before PAE?
Following a full review and discussion of the treatment options with a urologist and interventional radiologist, a CT scan is carried out to look at the prostate gland and its blood vessels in detail to help determine the most appropriate treatment option. In addition, a urine flow test and a few blood tests may be required in preparation for PAE.
On the day of the procedure, you will be processed for admission where necessary, you must not eat or drink for 6 hours before the procedure and should continue with most of your medications which are normally pre-discussed before the procedure.
What is involved in the PAE procedure itself?
The procedure is carried out by a consultant interventional radiologist (a doctor who has specialised in treating a variety of conditions using minimally invasive techniques under X-ray guidance). Other staff in attendance includes nurses and radiographers.
PAE is performed under local anaesthesia (or very light sedation) and involves no blood loss. A tiny opening (1.5mm) is made in the skin (mostly in the left wrist, but sometimes above the right leg) to allow a very fine tube to be passed into a blood vessel, the tube is moved along the blood vessels until the blood vessels supplying the prostate are reached after which a special substance is then injected to block the blood vessels. All of this is visible on an X-ray screen. The procedure generally takes 1-2 hours to complete.
What can I expect after PAE?
Immediately after the procedure, you will be taken to the recovery area where the nurses will monitor your heart rate and blood pressure and check that you are not in any pain. Once they are satisfied, you will be sent to the ward to recover further.
Most patients experience no symptoms during the procedure, but a few may experience mild pain, burning or a hot feeling in the urethra or around the anus. The symptoms are easily controlled with appropriate medication.
In general, you can get out of bed and start walking 6 hours after the procedure (sooner if the left wrist was used for access).
You are usually able to go home the morning after the procedure (certain patients can be discharged on the same evening). We will give you a prescription for painkiller tablets which you can take for 3-5 days (if needed).
Avoid driving for at least 2 days after the procedure but you can return to work after one day.
The prostate will shrink slowly over the following few days/weeks and symptoms continually improve during this time.
Are there any risks?
As with all procedures there are occasional problems that can occur, these include;
Infections. There is a small risk of urinary tract infection developing after the procedure, even though antibiotics are routinely given before the procedure. Most of the time, this can be treated with simple antibiotics.
Bruising/Haematoma. This can sometimes occur at the site of access in the upper leg/left wrist, although it is usually self-limiting.
Blood in urine. This occurs in some patients but usually disappears in a day or two.
Post embolization syndrome. Sometimes following PAE, you may experience symptoms like the flu. This usually lasts a couple of days and is simply treated with paracetamol and bed rest
Urinary retention. This is quite rare, however if it does occur, a urinary catheter will be needed for a few days until settled.
Will my sexual function be affected?
Based on studies to date, we know that patients treated with PAE for BPH have not experienced a decline in sexual function (including retrograde ejaculation and erectile dysfunction).
Are there any patients who cannot have PAE?
The presence of urological cancer e.g., prostate or bladder is a contraindication for PAE.
It may not be possible to perform PAE in men with extremely tortuous (twisted) blood vessels leading to the prostate.