1st August, 2018, Dr Chee L Khoo
Benign prostatic hyperplasia (BPH) is increasingly more common when men gets older. Transurethral resection of prostate (TURP) is still the gold standard treatment for most patients. Since alpha-adrenergic antagonists (also called alpha blockers) came to market, TURP is performed a lot less often. 5-alpha reductase convert testosterone into 5-alpha-di-hydrotestosterone (DHT), which is responsible for prostate hypertrophy and blocking this enzyme prevents further prostate growth. In addition, tamsulosin blocks alpha receptors in the prostate and bladder, relax smooth muscles of the prostate and bladder, and facilitates urination.
There is now a new kid on the block for the treatment of lower urinary tract symptoms (LUTS) secondary to BPH. Prostatic artery embolisation (PAE) is a minimally invasive procedure that can be performed under local anaesthesia. Prostatic catheters are carefully guided towards the prostatic arteries and embolised with microspheres. Naturally, interrupting the blood supply of the prostate through embolization leads to shrinkage of or atrophy of the prostate gland thereby improving LUTS.
This mode of treatment for LUTS is relatively new and was first reported in 2000. A systematic review in June 2018 looked at 13 studies representing 1254 patients and found that PAE improved International Prostate Symptom Score (IPSS) by 67%. Major complications after PAE are very rare.
In a recent open label non-inferiority trial, PAE was compared with TURP in the treatment of LUTS. At 12 weeks, improvement in LUTS in the PAE group was comparable to the TURP although PAE had smaller improvements than TURP. TURP was also more superior if there were other causes of obstruction such as strictures, stones and detrusor muscle impairment. Adverse events appeared to be in favour of PAE over TURP but these are early days yet. The incidence of ejaculatory function is still unsettled.
The UK National Institute for Health and Care Excellence (NICE) issued a guidance on PAE in April 2018:
“Current evidence on the safety and efficacy of prostate artery embolisation for benign prostatic hyperplasia is adequate to support the use of this procedure provided that standard arrangements are in place for clinical governance, consent and audit”. Read more here.
This study and other studies showed that PAE can be safely performed in an outpatient setting. Guess what? PAE is now available in South West Sydney. Dr Glen Schlaphoff at Spectrum Interventional Radiology has pioneered this procedure successfully in Australia. For more information, click here.
Malling B, Roder MA, Brasso K, Forman J, Taudorf M, Lonn L. Prostate artery embolisation for benign prostatic hyperplasia: a systematic review and meta-analysis. Eur Radiol (2018). https://doi.org/10.1007/s00330-018-5564-2
Dominik Abt et al. Comparison of prostatic artery embolization vs transurethral resection of prostate for benign prostatic hyperplasia: randomised, open label, non-inferiority trial. BMI 2018; 361: k2338.