Dec 20, 2018
Many treatments for BPH, or enlarged prostate, can cause side effects such as erectile dysfunction or headaches. Dr. Saher Sabri and Dr. Keith Horton discuss prostate artery embolization, a new treatment that can improve BPH symptoms without side effects.
Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.
Host: Thanks for joining us today. We’re talking to Dr. Saher Sabri, Director of Interventional Radiology at MedStar Washington Hospital Center, and Dr. Keith Horton, an interventional radiologist at MedStar Washington Hospital Center. Welcome to you both.
Dr. Keith Horton: Thank you.
Dr. Saher Sabri: Thanks for having us.
Host: Today, we’re talking about prostate artery embolization, a minimally invasive treatment for an enlarged prostate, also known as benign prostatic hypertrophy. The condition can cause lower urinary tract symptoms and is one of the most common prostate problems occurring in men older than 50. In fact, it strikes 50 percent of men between the ages of 51 and 60, and up to 90 percent of men older than 80. A new device to perform prostate artery embolization received FDA approval in June 2017 and is now available to patients at MedStar Washington Hospital Center. Dr. Sabri and Horton, how does this procedure work to treat an enlarged prostate?
Dr. Sabri: So, the procedure involves a minimally invasive technique. It involves a catheterization and the catheter is a plastic tube that is placed in the artery in the top of the thigh of the patient and we’ll use X-ray guidance to advance the catheter, which is that plastic tube, into the arteries that supply the prostate. We watch the catheter go into the artery under X-ray guidance and then we inject small beads, which are like, grains of sand, into the arteries that supply the prostate, and that would result into the prostate shrinking. And once the prostate shrinks, with time, the symptoms that the patients would have will start to improve.
Host: What are those beads made of?
Dr. Sabri: They’re gelatin microspheres. That’s a long term, but it’s something that would stay in your body. It doesn’t cause a lot of inflammation or any issues, but it’s very effective at blocking the arteries, and we’ve used them in other applications in the body before and this is a new application for them.
Host: Is there a certain patient population for whom this treatment would be most effective?
Dr. Horton: Yes. For most male patients above the age of 50, a lot of them are going to start to have symptoms, and symptoms are generally related to urinary straining, frequency, they start to notice bathrooms in places they never had used them before, and it’s quite common, so we’re trying to appeal to those patients.
Host: Now, does this cure the condition, or does it just relieve and manage the side effects?
Dr. Sabri: It will relieve and manage the side effects, or the effects of the prostate being enlarged. It would not cure the prostate enlargement, but it would just make it more manageable. The symptoms can be really lifestyle limiting--you know, having to wake up several times at night to go to the bathroom--you know, not having a good stream, and all these issues that affect men at this age. It can, you know, have a negative effect on their lifestyle. So, this will decrease the severity of the symptoms, can improve it, improve the quality of life. It would not get rid of the entire prostate altogether, but it will shrink it to a level that would allow the… what’s called the urethra, which is the tube that connects the bladder and allows for the urine to come out, for that to actually expand and then for the urine stream to get better.
Host: How has benign prostatic hypertrophy been treated in the past?
Dr. Horton: Currently, most patients who have these symptoms are seen by doctors - urologist, and the urologist will oftentimes start with medications. And, a lot of those patients have a lot of side effects, and as this disease actually affects patients who are a little older, those side effects become more significant with age. One of the biggest side effects is dizziness, and also, they have difficulty with ejaculation and other problems. And, so as you increase the medications, the more the side effects occur. Other ways of treating it include surgery, which is where they actually place a scope via the penis and try to remove a lot of the prostate tissue internally, and that also is accompanied by bleeding and other problems, such as inability to ejaculate externally, so because of that, a lot of patients don’t seek treatment, and so this gives them an alternative for those patients.
Host: How does the preparation for this procedure compare?
Dr. Horton: Well, the preparation isn’t much different. Generally, those patients who’ve been on the medications and who have had a bad experience with the medications come to see us in the clinic. We can evaluate them. We can determine how strong their stream is and other urological testing, and then they generally come in. It’s a procedure that’s done as an outpatient. They can come in and have the procedure, as Dr. Sabri described, where we go into the blood vessel, do that, we can generally do that in a couple of hours. And then we watch them afterwards and then they’re able to go home.
Dr. Sabri: I would like to add that the surgeries that are performed, there are several levels of them. There’s the one with the scope. There are some other technologies, including laser and other options. There’s no one right answer for all patients. You know, each patient can be treated individually and that’s something that we would evaluate. We would work collaboratively with other urologists at MedStar Washington Hospital Center, and then talk about what’s the best option for this patient. And offer the patient all these options and they can choose what works best for them. This treatment that we’re proposing, the prostate artery embolization that’s performed by us in Interventional Radiology, and that’s our specialty, which is an image-guided procedure in Interventional Radiology, this is something we can discuss and see. It may not be amenable to get that procedure, and they may be better suited to have surgery, so, or some sort of minimally invasive surgery that’s done by the urologist, and that’s something we would collaborate on. We’ll evaluate the patient and decide what’s the best option for them. I mean, there's several things that we have to look at in terms of the size of the prostate, how healthy the blood vessels are. Is it possible for us to go and perform this procedure through the blood vessels and, you know, several other issues related to testing that we do to patients who have actually have, cancer in their prostate. So, there’s a different process that we have to look at and make sure that they truly just have the benign prostate hypertrophy, and this is what we’re dealing with and have, you know, somewhat healthy blood vessels that we can perform the procedure. For some of the others, you know, surgery would be better suited.
Dr. Horton: The biggest divider is that the prostate grows. I mean, it starts at the size of a walnut, and as it enlarges a lot of therapies are available up to the size of about 100 grams. At that point, there are no minimally invasive options other than what we perform. Then, you move into the realm of where you have to have a surgical procedure, which is where a lot of patients tend not to really want to have an open prostatectomy. But, we have a model already. We also do uterine fibroid embolization, and it started out much the same way as this did. And because of our collaboration with OB/GYNs, we developed what we call a fibroid center, and so a lot of those patients we saw them together in the same setting. And hopefully, in the future, we may be able to do this with the urologists, so the patients are able to get proper counseling. They have options put before them and they can make a decision based on being truly totally informed.
Host: How effective is this procedure compared to the traditional surgery?
Dr. Horton: Well, the data goes out to about six years now. It’s been a fairly new procedure, but it was started by the Portuguese, and the Portuguese have seen about 1,000 patients now. And, at this point, it’s about a 70 percent efficacy out to five to six years, which is basically on par with other minimally invasive therapies, and actually exceeds some of the efficacy of some of the minimally invasive therapies they’re offered today.
Host: What would you consider to be a successful outcome for the surgery?
Dr. Sabri: I mean improvement in these symptoms and that we mentioned before, which are how often do you go to the bathroom, having a good urine stream, not having to wake up in the bathroom at night, and just improving your quality of life. And, there’s like a survey that we have the patients fill before and after, and we see significant improvement in their quality of life, and that’s something that we focus on, want to make sure the patients feel better, they have without interruption to their daily life, and offer them a minimally invasive outpatient procedure, that they can, you know, see that it’s not interrupting their daily life a lot.
Host: If a person doesn’t seek treatment for an enlarged prostate, what would be some of the complications or side effects of that?
Dr. Horton: Well, the prostate can continue to grow, the side effects get worse. Well, as the prostate enlarges, it can place more pressure on the urinary stream, requiring, at some point, for patients to actually have to self-catheterize themselves in order to go to the bathroom, or a catheter may have to remain within the bladder, you know, for quite some time.
Dr. Sabri: I agree. I mean, that’s one of the issues, that, you know, if you have to leave a catheter in for long-term to be able to go to the bathroom, it can be quite lifestyle limiting for these patients, and, you know, trying to seek medical advice before that happens because if the prostate becomes too enlarged, it becomes really hard for us to do anything about it and the options are very limited outside of an extensive surgery, So, medical therapy can be effective for a lot of patients. The patients that medical therapy does not work for them or they have side effects from medical therapy are the ones that we need to evaluate for some of these other options, but if they seek medical advice really late and the prostate is too enlarged, the options that we have become limited. So, we encourage patients to seek advice when they have issues with their urinary tract, which is issues with urination and the slowing of urination and poor stream and having to go to the bathroom a lot and waking up at night, to seek advice sooner before the prostate gets too enlarged and the options become more limited.
Host: Do you have an examples of patients who’ve had really great success with this treatment?
Dr. Horton: Yes, the majority of patients that we have seen in the past are patients who had large prostates that were able to be a surgical candidate, and the urologist sent them to us, either basically because they had catheters or they were having a lot of bleeding via the penis, and to our knowledge at least 90 percent of those patients had improved symptoms. I had one recently in June in which I can recall in which he had pulmonary emboli, or blood clots to the lungs. And what you do is you treat that with anticoagulations, or blood thinners, the patient developed even more bleeding. He had prostate problems, and so we ended up having to embolize his prostate and then coming back he ended up with blood clots in his legs, which we also treated, so we were able to do quite a bit for him, and I see him in clinic and he is, you know, no catheter, his lungs are fine, his legs are great, he’s very happy.
Host: Thank you very much for joining us today.
Dr. Horton: Thank you for having us.
Dr. Sabri: Thanks for having us.
Conclusion: Thanks for listening to Medical Intel with MedStar Washington Hospital Center. Find more podcasts from our healthcare team by visiting medstarwashington.org/podcast or subscribing in iTunes or iHeartRadio.