Prostate artery embolisation (PAE)

What is prostate artery embolisation (PAE)?

The prostate gland is located beneath the urinary bladder and surrounds the water pipe (urethra). Enlargement of the prostate gland, also known as benign prostatic hyperplasia (BPH), can cause blockage to the flow of urine. This results in various troublesome symptoms including a reduced urine stream and the need to urinate at night.

Prostate artery embolisation (PAE) is a minimally invasive procedure used to treat BPH, in which the small blood vessels supplying the prostate gland are blocked off, thereby shrinking it. This is achieved by injecting small particles into these blood vessels. PAE can also be used in other situations, for example to control bleeding from the prostate gland.

Mild-moderate symptoms can be managed with medications. When these options fail, surgical options including transurethral resection of the prostate (TURP), green light laser or prostatectomy can be considered. PAE is an alternative procedure, which offers a minimally invasive and non-surgical treatment option.

Considering PAE was a decision made by both your Urology doctor and the Interventional Radiologist (IR) who will be performing the procedure. You do not have to proceed with PAE and you can withdraw your consent at any time. Interventional radiologists are doctors who are specially trained to perform minimally invasive treatments using imaging (such as ultrasound, x-rays, and CT) as guidance.

NICE (National Institute for Health and Care Excellence) reported in April 2018 of the benefit of PAE for patients with benign prostatic hyperplasia (BPH).

How is PAE done?

The procedure is performed by an interventional radiologist and normally takes approximately two to three hours.

You will lie on the X-ray table, flat on your back. A small tube (cannula) will also be inserted into the vein in your arm in case you need any painkillers or sedatives. We will be continuously monitoring your pulse, oxygen levels and blood pressure.

The interventional radiologist will keep everything sterile and will wear a theatre gown with operating gloves. Your wrist (or groin) will be thoroughly cleaned with antiseptic, and a sterile theatre drape will be put over your body and arm.

The wrist (or groin) artery is used to access the blood vessels of your prostate. Local anaesthetic is administered to numb your wrist. A wire and plastic tube are fed into the artery through a small hole.

Under X-ray guidance, the prostate arteries are found. You should not feel the wire or tube in your arteries. Contrast medium (dye) containing iodine is injected through the tube to ensure that we are in the correct place. You may have a hot feeling in the pelvis or the sensation that you want to urinate.

Once we are in the correct place, fluid containing particles are injected into the prostate arteries (this is known as embolisation). If it is not safe due to abnormal vessel connections with vital structures, we will not proceed to block the arteries. Dye is then used to confirm that the arteries are blocked. This will be repeated for both right and left prostate arteries.

The wire and tubes are then removed from your wrist (or groin). A small pressure balloon called a helix device is used to stop bleeding from the wrist. It is tightened around your wrist at the wound site and kept there for at least one hour. The balloon is slowly deflated over the hour until we are happy for it to be removed. (If we decide to access the arteries via the groin, you may need to lie flat for around four hours after the procedure).

PAE effectively reduces the blood supply to the prostate. Over time, the prostate gland will shrink, improving your symptoms.

Before your procedure

You will initially be seen by the Urology doctors who will arrange for you to have a CT scan to visualise the vessels supplying the prostate gland. After this, you will be seen in the Interventional Radiology clinic, where you will be assessed for suitability for PAE. The interventional radiology doctors will assess you to determine if it is technically possible and safe to proceed.

If you are happy after this discussion, you will be booked for PAE. For the day of the procedure, you will be asked to fast from midnight. You will also be given a rectal suppository for pain before we start.

The procedure is performed as a day case, and you can expect to be discharged on the same day as the procedure. You will be admitted to the Planned Investigation Treatment Unit (PITU) at the Royal Free Hospital and change into a hospital gown. You will also be given special stockings for your 
legs to prevent blood clots and an antibiotic.

The procedure will take place in the Interventional Radiology and Cardiology Unit (IRCU) on the ground floor.

After your PAE

Following the procedure, you will be taken back to your room in PITU where you will be looked after by nursing staff.

Depending on the mode of access (wrist or groin) you will lie flat after the procedure for at least two hours (for wrist) or four hours (for groin).

You may have some pain and discomfort for 10-12 days after the procedure and you will be given painkillers and antibiotics upon discharge.

Follow up

The IR team will call you on Monday the following week of the procedure to ask how you are doing. You will be asked to continue Tamsulosin for two weeks procedure.

If you had a catheter in before the procedure, the IR consultant will ask the Urology consultant to arrange a trail without catheter (TWOC) clinic follow up two to three weeks after the procedure. You should continue tamsulosin until this appointment.

A further follow up will be arranged in the Urology outpatient clinic with the Urologists three months after the procedure whereby we will test your urinary function in this clinic. 

Risks and side-effects

NICE has deemed this procedure safe, but as with any procedure, there are risks and complications that can arise.

• Wrist site: Bruising (or haematoma) at the site of needle puncture. This is quite normal, but if it becomes a large bruise then there is an infection risk whereby antibiotics may be required.
• Post embolisation syndrome: pain, difficulty urinating, frequency, and irritative symptoms which typically last less than one week. This can be treated with anti-inflammatories and antibiotics with symptoms often passing very quickly.
• Haematuria/rectal bleeding: a small volume of blood in the urine or stools can be expected after the procedure and will usually resolve. If there are any concerns, please contact the number below. Attend Accident and Emergency (A&E) if there is excessive bleeding.
• Urinary retention: if you are unable to pass urine after the procedure, the urologists may insert a catheter and ask you to continue your BPH medicine until follow up in two to three weeks in the TWOC clinic.
• Non-target embolisation- very small risk to bladder/ bowel/ genitals. These risks are uncommon but will be discussed at the time of your consent. 

Alternatives to PAE

Medications are used for mild to moderate symptoms. When this fails, operative alternatives including TURP, green light laser or prostatectomy can be considered.

Both your urologist and interventional radiologist have deemed PAE as the best treatment strategy for you.