Prostatic artery embolization

[akuko2]

What do you think of the current data on PAE? Do you think it could ever cut into the bottom line/current practice of urologists, and further do you see any other interventional procedures that may take specific therapies out of the hands of urologists.

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[DoctwoB]

Current data is relatively unimpressive. Limited efficacy compared to TURP, takes a while to work, but favorable risk profile, limited availability as not many IRs do it and it is technically complex. It does spare ejaculatory function which is a plus. However nowadays urologists also have Urolift and rezum to give equivalent or better efficacy in the office or under Mac while also preserving sexual function. Hard to see it really catching on, especially since Urologists drive referrals and BPH surgeries are our bread and butter.

My view of the role for it is I use it in men with very large glands (>100gm so not good urolift candidate) who aren’t candidates for Holep, simple prostatectomy, or TURP. I also use it in men with refractory prostatic bleeding who aren’t TURP candidates or who are post TURP.

Our current guidelines say it shouldn’t be done as primary treatment outside of trial setting.

 

[cpants]

Agree with above wholeheartedly. Considered experimental in new AUA guidelines, so very limited insurance coverage for this modality at this point. Definitely has a role for bleeding patients, huge glands in poor surgical candidates.

It's not a straightforward procedure at all. Usually 2-3 hours on table, and requires very skilled interventionalist.

Not ready for prime time in my opinion.

 

[akuko2]

Thanks guys, while I’m on my IR kick any thoughts on varicocelectomy vs varicocele embolization?

 

[DoctwoB]

Varicocele Embolization has the problem of 5-25% rate of technical failure (inability to perform procedure), especially if bilateral, and higher recurrence rates then lap or microsurgical varicocelectomy. One could make an argument for it over lap or macroscopic open varicocelectomy (lower complication/hydrocele rate) but it’s a tough sell in the era of microscopic varicocelectomy, which has higher success rates, lower recurrence rates, and similar complication rate.

 

[mestielest]

I never tried in the primary settings. However, I used pre-surgery embolization in two patients who were recommended to undergo surgery while on ASA and Klopidogrel. Both of them were open prostatectomy candidates. With bilateral prostate embolization both surgeries were uneventful. Thanks God.

 

[NDcienporciento100]

Current data is relatively unimpressive. Limited efficacy compared to TURP, takes a while to work, but favorable risk profile, limited availability as not many IRs do it and it is technically complex. It does spare ejaculatory function which is a plus. However nowadays urologists also have Urolift and rezum to give equivalent or better efficacy in the office or under Mac while also preserving sexual function. Hard to see it really catching on, especially since Urologists drive referrals and BPH surgeries are our bread and butter.

My view of the role for it is I use it in men with very large glands (>100gm so not good urolift candidate) who aren’t candidates for Holep, simple prostatectomy, or TURP. I also use it in men with refractory prostatic bleeding who aren’t TURP candidates or who are post TURP.

Our current guidelines say it shouldn’t be done as primary treatment outside of trial setting.

Full disclosure, I’m biased since I just matched into IR. Could you provide me a Trial comparing outcomes between the two PAE vs TURP that validates your statement that efficacy is low compared to TURP? Ambitious IR’s in several parts of the country are starting to do PAE a lot University of Miami, Mount Sinai New York, Detroit Medical Center just being 3 examples. The places that PAE is being performed a lot is actually Europe where the procedure is becoming huge especially England, probably because the financial incentive to do TURP is not there in England like it is in the US. To your comments on three hours table time, that would be the absolute longest case scenario, your probably looking at under 1.5 hrs which is better then a realistic possibility of a lifetime of sexual dysfunction seen in TURP. Also PAE does not limit options for TURP down the road but if you went with PAE first the vast majority of your pts symptoms would resolve and your TURP RVUs would go down. PAE has only been available to the public for a short period of time (relatively) but a comparable procedure uterine fibroid embolization has been around longer and is becoming more and more popular as a first line tx and I suspect PAE will follow the same course because you can’t keep a really good procedure down lol. The more IRs start to go to family practice physicians and educate them on PAE (which is where Urologist get there referrals) the faster this procedure will catch on. I can’t prove this statement but I’m going to make it anyway, if urologist could perform PAE it would already be mainstream first line tx but they can’t so unfortunately pts that could benefit but don’t know won’t get this great tx.

 

[irwarrior]

There is a growing amount of short term and intermediate term data suggesting the safety and efficacy of prostate artery embolotherapy as an adjunct to pharmacologic adjuncts . We have had several patients self refer for this procedure. We educate them that the historic gold standard was TURP and there are many MIST.

We have them do a urine log, check meds (ie diuretics), adjust their fluid intake and education about alcohol and caffeine intake etc. Then often we place them on an alpha reductase inhibitor and alpha blocker (if not already on). We also get a uroflow and in the initial stage urodynamics. We also get a PSA (if they don't have it already) and a prostate MRI. Then if deemed a candidate based on uroflow, how bothered they are by it we will proceed to therapy. We do educate them that it will take a bit longer for full effect. Patients are either sent home same day or admitted for 23 hr observation. We typically see them in the office for follow up in 4 to 6 weeks and then 3 to 6 months and then yearly. The RCT data is certainly growing (Gao et al) and UK ROPE registry has resulted in it getting NICE approval. Now, they are going to do an RCT comparing it to a sham procedure.

It is technically challenging and the anatomy is complex, so not every VIR physician should be doing this. But, I do think there will likely be a growing role for this minimally invasive role. Patients will be asking for it and PCP s and Urologists should identify a vascular interventionalist who they trust that can identify the ideal candidate and who has the clinical and technical expertise to tackle this patient population.

 

[DoctwoB]

Full disclosure, I’m biased since I just matched into IR. Could you provide me a Trial comparing outcomes between the two PAE vs TURP that validates your statement that efficacy is low compared to TURP? Ambitious IR’s in several parts of the country are starting to do PAE a lot University of Miami, Mount Sinai New York, Detroit Medical Center just being 3 examples. The places that PAE is being performed a lot is actually Europe where the procedure is becoming huge especially England, probably because the financial incentive to do TURP is not there in England like it is in the US. To your comments on three hours table time, that would be the absolute longest case scenario, your probably looking at under 1.5 hrs which is better then a realistic possibility of a lifetime of sexual dysfunction seen in TURP. Also PAE does not limit options for TURP down the road but if you went with PAE first the vast majority of your pts symptoms would resolve and your TURP RVUs would go down. PAE has only been available to the public for a short period of time (relatively) but a comparable procedure uterine fibroid embolization has been around longer and is becoming more and more popular as a first line tx and I suspect PAE will follow the same course because you can’t keep a really good procedure down lol. The more IRs start to go to family practice physicians and educate them on PAE (which is where Urologist get there referrals) the faster this procedure will catch on. I can’t prove this statement but I’m going to make it anyway, if urologist could perform PAE it would already be mainstream first line tx but they can’t so unfortunately pts that could benefit but don’t know won’t get this great tx.

All well and good, but the problem is that many equivalent or better therapies exist, and not just TURP. Here is the comparison based on current data

TURP
IPSS reduction of ~15 points
Requires general or spinal
OR time ~90 min
requires catheter, typically 1 day, sometimes longer
done either same day or 1 night hospital stay
lifetime of "sexual dysfunction" as you put it. To elaborate on this the sexual dysfunction is retrograde ejaculation, meaning they have erections, orgasm normally, just don't see ejaculate. For most men at the age where they are receiving a TURP this is a non-issue. For those whom it is a concern, other options exist. It is just a matter of patient selection and counselling.

PAE
IPSS reduction 6-12 points depending on the study
5% technical failure rate (inability to perform procedure) even at index centers developing the procedure. Likely higher in community. Technically complex.
Procedure time ~90min at index centers
30 minutes of fluoro time (I don't know how that compares for IR procedures, but I can do 100 ureteroscopies with less radiation)
Done under local or sedation
some men require catheter, variable percentage
no sexual side effects
limited follow up data

Urolift:
IPSS reduction 10-12 points
done in office under local or in ASC under mild sedation
procedure time ~5-10 minutes, technically simple.
minimal bleeding risk
~90% of men catheter free
no sexual side effects
downside: limited data in prostates > 80gm and more technically difficult if large median lobe present

Rezum:
IPSS reduction 10-12 points
done in office under local or ASC under mild sedation
procedure time ~5-10 minutes, technically simple.
minimal bleeding risk
no sexual side effects
downside: limited data in prostates > 80gm and some irritative LUTS post procedure, most men will have a catheter for a brief duration

So looking at that, why should I refer to IR for PAE on most patient's when I could do a procedure that is equally or more efficacious, faster, technically simpler with a comparable risk profile either in the office or under mild sedation without radiation exposure? Meanwhile, both Rezum and Urolift have long term, sham-controlled data, which PAE lacks currently. Alternatively, If I want the most effective results, I'll do a TURP, HoLEP (if I have the skillset), or simple prostatectomy in very large prostates. As I wrote above, I do see a niche for PAE as primary therapy, namely in patients whose prostates are too large for rezum/urolift but aren't good candidates for or don't want a simple prostatectomy or HoLEP, or those with refractory prostatic bleeding

As for your last statements, they’re somewhat ridiculous. Even if PAE was done by Urologists, it wouldn’t be first line. Why? In addition to lack of data, as mentioned we already have faster procedures with more robust data and equivalent or better outcomes. Next you’re advocating for direct referral from pcp to IR. How should a pcp know who is a good candidate for medical therapy vs MIST vs PAE vs TURP vs simple prostatectomy? How will they even know if patients symptoms are from outlet obstruction vs detrussor overactivity vs detrussor failure? Maybe they should refer the patient to an expert in the medical and surgical management of urologic disease?

If you want to pick a fight between Urology and IR you’d be better off arguing about ablation for cT1 renal masses.

 

[NDcienporciento100]

All well and good, but the problem is that many equivalent or better therapies exist, and not just TURP. Here is the comparison based on current data

TURP
IPSS reduction of ~15 points
Requires general or spinal
OR time ~90 min
requires catheter, typically 1 day, sometimes longer
done either same day or 1 night hospital stay
lifetime of "sexual dysfunction" as you put it. To elaborate on this the sexual dysfunction is retrograde ejaculation, meaning they have erections, orgasm normally, just don't see ejaculate. For most men at the age where they are receiving a TURP this is a non-issue. For those whom it is a concern, other options exist. It is just a matter of patient selection and counselling.

PAE
IPSS reduction 6-12 points depending on the study
5% technical failure rate (inability to perform procedure) even at index centers developing the procedure. Likely higher in community. Technically complex.
Procedure time ~90min at index centers
30 minutes of fluoro time (I don't know how that compares for IR procedures, but I can do 100 ureteroscopies with less radiation)
Done under local or sedation
some men require catheter, variable percentage
no sexual side effects
limited follow up data

Urolift:
IPSS reduction 10-12 points
done in office under local or in ASC under mild sedation
procedure time ~5-10 minutes, technically simple.
minimal bleeding risk
~90% of men catheter free
no sexual side effects
downside: limited data in prostates > 80gm and more technically difficult if large median lobe present

Rezum:
IPSS reduction 10-12 points
done in office under local or ASC under mild sedation
procedure time ~5-10 minutes, technically simple.
minimal bleeding risk
no sexual side effects
downside: limited data in prostates > 80gm and some irritative LUTS post procedure, most men will have a catheter for a brief duration

So looking at that, why should I refer to IR for PAE on most patient's when I could do a procedure that is equally or more efficacious, faster, technically simpler with a comparable risk profile either in the office or under mild sedation without radiation exposure? Meanwhile, both Rezum and Urolift have long term, sham-controlled data, which PAE lacks currently. Alternatively, If I want the most effective results, I'll do a TURP, HoLEP (if I have the skillset), or simple prostatectomy in very large prostates. As I wrote above, I do see a niche for PAE as primary therapy, namely in patients whose prostates are too large for rezum/urolift but aren't good candidates for or don't want a simple prostatectomy or HoLEP, or those with refractory prostatic bleeding

As for your last statements, they’re somewhat ridiculous. Even if PAE was done by Urologists, it wouldn’t be first line. Why? In addition to lack of data, as mentioned we already have faster procedures with more robust data and equivalent or better outcomes. Next you’re advocating for direct referral from pcp to IR. How should a pcp know who is a good candidate for medical therapy vs MIST vs PAE vs TURP vs simple prostatectomy? How will they even know if patients symptoms are from outlet obstruction vs detrussor overactivity vs detrussor failure? Maybe they should refer the patient to an expert in the medical and surgical management of urologic disease?

If you want to pick a fight between Urology and IR you’d be better off arguing about ablation for cT1 renal masses.

Alright here we go, I will address all of the comments from the top down and post my resources. So let’s begin…..
“TURP”
Side affects- Retrograde ejaculation (65%), Impotence (strait from Cleveland Clinic website, the best urology department in country its rare but it does occur), recurrent post-surgical urinary tract infections, Post-surgical bleeding requiring transfusion, Hematuria, urethral stricture, Urinary incontinence (incidence post surgically is extremely high > 25% most cases will improve over time but long term incontinent patients is 2-5%), need for surgical revision (between 5-15% within 5 years of surgery), transurethral resection syndrome 1-2% (rare but when it occurs it’s a life threatening condition), Need for post-surgical catheter( all patients for multiple days rarely extending into weeks post surgery). References 1-6 below
IPSS reduction 15 (and for the high likelihood of developing at least one of the side affects above it better be)
“PAE”
Side affects- very few, and even fewer that are long lasting, <0.5% require blood transfusion post procedure, <0.5% sepsis, <1% had a nontarget embolization, 0% sexual dysfunction, 0% required post procedure catheter (you said in your statement that some pts require post procedure catheters secondary to the procedure, please provide a resource stating that to be the case),
IPSS Reduction 10-12, when comparing IPSS and QoL there was difference between TURP and PAE
5% technical failure rate and this number continues to improve as the technical aspects of the procedure continue to improve.
mean radiation dose in the PAE group 305.1 cGy/cm2 (about as much as a barium meal required to look at the esophagus, stomach and small intestines)
Long term (>5 years) data is lacking due to the relative young nature of this procedure but there is good data going out 2 years and what it shows is that at 6 months the IPSS Scores are about 1 point in favor of TURP at 12 months its about 0.5 points in favor of TURP, and 24 months its 0.3 points in favor of TURP, so at 6 months there is an insignificant difference especially when combined with QoL parameters.
Very good for large prostates.
FDA Approved, UK National Health Service approved
American Urological Association does not recommend it at this time, but they are extremely biased.
Does not limit your options for TURP down the road
References 7-9
“Urolift and Rezum”
Both great options, however both carry not insignificant risks of bleeding and need for post procedure catheter, and perhaps the biggest point not as good for large prostates.
“Simple Prostatectomy’s” carry most of the same if not greater risks of side effects as TURP.
Urologist are the foremost authority on this matter but PCP’s tx BPH all the time medically with good results and in the areas of the country that PAE has started to gain ground it’s there referrals that helped with that. And the reason they keep referring is because their patients told them they where happy with the results.
My biggest argument was and is that TURP carries a relatively high risk of adverse side effects that I highlighted above that far exceeds the risks seen in PAE and that presently far less patients that could benefit from PAE are being informed of this option and are instead going strait to TURP and the high possibility of adverse side effects that come with it.
Your last point “ablation for cT1 renal masses”
Interventional Radiologist already have these, most busy IR departments get multiple a week, and there is no argument ablation for these lesions carry the same long-term recurrence results as surgery, but there is a few upsides 1 being you don’t have to be cut open!!!! (always a good thing), but for the unfortunate patient with a cT1 lesion that walks into the wrong urologist office that does not inform the patient of the complete risks, Benefits and ALTERNATIVES, they will still get cut open for no reason.
I am highly respectful of your specialty, but I feel that Interventional Radiology provides in some cases better options and I feel that patients are not adequately informed of these options in some cases.
Cheers!

• Benign Prostatic Enlargement (BPH) Management and Treatment | Cleveland Clinic
• Predictive risk factors of postoperative urinary incontinence following holmium laser enucleation of the prostate during the initial learning period
• Morbidity, mortality and early outcome of transurethral resection of the prostate: a prospective multicenter evaluation of 10,654 patients. - PubMed - NCBI
• Transurethral resection of the prostate (TURP) - Mayo Clinic
• An update on transurethral surgery for benign prostatic obstruction
• The Effect of Modified TURP (M-TURP) in Intra and Postoperative Complications
• Efficacy and safety of prostate artery embolization for benign prostatic hyperplasia: an observational study and propensity-matched comparison with... - PubMed - NCBI
• https://pubs.rsna.org/doi/full/10.1148/radiol.13122803
• https://www.jvir.org/article/S1051-0443(19)30211-8/fulltext

 

[DoctwoB]

I'm not going to delve too deep here because it's quite clear to me your set in your convictions. You are quoting a lot of inaccuracies by copy pasting from the internet. A few examples: the rate of TUR syndrome with bipolar TURP is 0. 0.000% if you want to be more precise. You also cite a 0% rate of catheterization for PAE. Note the most common adverse event was urinary retention with a rate of almost 1/3. How do you think we treat urinary retention?

Just a few words of guidance. Stop the crusade, start your training and see the procedures for yourself, and not just the procedures but the patients pre and post operatively. Many of them. Many other therapies for BPH (prostatic stents, TUNA, etc.) have sounded like the greatest thing since sliced bread if you only read the trials. It was only in widespread clinical practice their failures became more readily apparent. PAE may end up in that category, or it may withstand the rigors of widespread use. Time will tell.

You're also making the wrong comparison. PAE, both in terms of efficacy and risk profile is much more alike with MIST (minimally invasive surgical therapies) such as prostatic urethral lift (urolift) or Rezum then it is with TURP. That is the area that PAE will live or die in. I'm guessing it will end up as AN option within that landscape with a specific niche (note that current guidelines recommend against it outside the research setting), rather than THE option. Who knows? In 10 years BPH patients may mostly be treated with waterjet ablation done by a robot (see aquablation, WATER 1 and 2 trials). It's best not to be married to a specific technique and go where evidence and experience dictate. Which is why the BPH patient is best served in the hands of individuals trained and experienced in its management.

 

[NDcienporciento100]

We could go back and fourth all day but that would accomplish nothing. The Number requiring catheters is much much lower and yes close to 0% depending on the institutional, the 1/3 is from and older trial. Do you realize In saying that it should only be done in clinical trials that you are quoting the major urology association which represents the people like you doing TURP and none of there constituents can perform PAE, so it’s very unlikely they would endorse PAE hence why I said in my last post there biased. I agree, look at the evidence and data for everything and I will continue to do so on PAE and other procedures. Let’s rehash this in 10 years, my prediction is PAE will be far more popular then it is today.

 

[cpants]

Full disclosure, I’m biased since I just matched into IR. Could you provide me a Trial comparing outcomes between the two PAE vs TURP that validates your statement that efficacy is low compared to TURP? Ambitious IR’s in several parts of the country are starting to do PAE a lot University of Miami, Mount Sinai New York, Detroit Medical Center just being 3 examples. The places that PAE is being performed a lot is actually Europe where the procedure is becoming huge especially England, probably because the financial incentive to do TURP is not there in England like it is in the US. To your comments on three hours table time, that would be the absolute longest case scenario, your probably looking at under 1.5 hrs which is better then a realistic possibility of a lifetime of sexual dysfunction seen in TURP. Also PAE does not limit options for TURP down the road but if you went with PAE first the vast majority of your pts symptoms would resolve and your TURP RVUs would go down. PAE has only been available to the public for a short period of time (relatively) but a comparable procedure uterine fibroid embolization has been around longer and is becoming more and more popular as a first line tx and I suspect PAE will follow the same course because you can’t keep a really good procedure down lol. The more IRs start to go to family practice physicians and educate them on PAE (which is where Urologist get there referrals) the faster this procedure will catch on. I can’t prove this statement but I’m going to make it anyway, if urologist could perform PAE it would already be mainstream first line tx but they can’t so unfortunately pts that could benefit but don’t know won’t get this great tx.

Some of your comments remind me a lot of the rad onc guys. Bitter that you don't get to direct the patients to your treatment modality. Overstating benefits and downplaying side effects.

What you don't realize is that for every guy that needs a TURP (or PAE for that matter) we are managing a dozen other guys with medications -- think yearly PSA and rectal exams, frequent patient phone calls, episodes of UTI and urinary retention, etc. As a radiologist, I think you would be very foolish to start trying to medically manage BPH, and frankly it would be foolish to be doing PAE's without the patient having a urologist to provide appropriate workup and manage potential complications.

I highly doubt that the PCP's are going to start bypassing urology to send IR PAE patients. We already have relationships, and they trust us to know how to manage these patients. What's the upside to them?

If PAE is so great, I'm sure you guys won't have trouble producing the data to show it. In the meantime if it's just as effective as a Urolif,t then it is a way worse option for the patient.

 

[NDcienporciento100]

Some of your comments remind me a lot of the rad onc guys. Bitter that you don't get to direct the patients to your treatment modality. Overstating benefits and downplaying side effects.

What you don't realize is that for every guy that needs a TURP (or PAE for that matter) we are managing a dozen other guys with medications -- think yearly PSA and rectal exams, frequent patient phone calls, episodes of UTI and urinary retention, etc. As a radiologist, I think you would be very foolish to start trying to medically manage BPH, and frankly it would be foolish to be doing PAE's without the patient having a urologist to provide appropriate workup and manage potential complications.

I highly doubt that the PCP's are going to start bypassing urology to send IR PAE patients. We already have relationships, and they trust us to know how to manage these patients. What's the upside to them?

If PAE is so great, I'm sure you guys won't have trouble producing the data to show it. In the meantime if it's just as effective as a Urolif,t then it is a way worse option for the patient.

-Rad Onc pays forward and incredible service to the care for patients, so I feel that your comments on them are disrespectful and I feel they would agree.
-You (meaning urologist) are the foremost experts in managing complications of the urogenital system and are not replaceable as a specialty both from a medical and surgical management standpoint.
-Haveing a urologist available to help manage complications that would result from PAE I feel would be great, medicine is a team sport, just like I think that if a urologist has a complication during a procedure in which they would require for example a general surgeon to help manage that complication. So I think haveing “backup” is a great/essential/not a new idea.
-PCPs already send IRs PAE referrals, last week I was with an IR when he got a call from a PCP to talk about a possible patient. It’s not widespread because unfortunately most PCPs don’t know it exists, but that’s changing.
-“The upside” to PAE is the potential to manage very large prostates with the risk of serious, lasting adverse affects being very low.
-Urolofift is great for small prostates.
-PAE data has already been shown to be very affective, and I will continue to evaluate the data as it comes in with scrutinizing eyes, and if some of the data changes and shows PAE to not be a good option for select pts then I’m sure I can speak for other IRs as well We will throw in the towel. You should always do what is best for the patient.

Look I think PAE is a good option for pts with large prostates that would like to try and avoid some of the very serious complications of TURP or prostatectomy.

 

[NDcienporciento100]

Transurethral Resection of the Prostate (TURP) Versus Original and PErFecTED Prostate Artery Embolization (PAE) Due to Benign Prostatic Hyperplasia (BPH): Preliminary Results of a Single Center, Prospective, Urodynamic-Controlled Analysis - CardioVas

Purpose To compare clinical and urodynamic results of transurethral resection of the prostate (TURP) to original and PErFecTED prostate artery embolization (PAE) methods for benign prostatic hyperplasia. Methods We prospectively randomized 30 patients to receive TURP or original PAE (oPAE) and...

link.springer.com

https://www.ncbi.nlm.nih.gov/m/pubmed/24943914/

 

[mestielest]

Some of your comments remind me a lot of the rad onc guys. Bitter that you don't get to direct the patients to your treatment modality. Overstating benefits and downplaying side effects.

What you don't realize is that for every guy that needs a TURP (or PAE for that matter) we are managing a dozen other guys with medications -- think yearly PSA and rectal exams, frequent patient phone calls, episodes of UTI and urinary retention, etc. As a radiologist, I think you would be very foolish to start trying to medically manage BPH, and frankly it would be foolish to be doing PAE's without the patient having a urologist to provide appropriate workup and manage potential complications.

I highly doubt that the PCP's are going to start bypassing urology to send IR PAE patients. We already have relationships, and they trust us to know how to manage these patients. What's the upside to them?

If PAE is so great, I'm sure you guys won't have trouble producing the data to show it. In the meantime if it's just as effective as a Urolif,t then it is a way worse option for the patient.

I suppose there is a problem about the piece of cake the IR colleagues are eating in every branch. The fluid loaded heart failure to cardio; the elective angio to IR. Acute stroke to the IR; coma to neuro. Alpha blocker non-responded BPH to IR; all night bladder irrigation to uro. Goes like that...

 

[NDcienporciento100]

Ohh I seeeee! So you are trying to say that IR does all the yummy cases while the people of that core specialty are getting dumped on, I feel sooooo baddddd for you!!! Next time you sit at your robot for surgery I want you to think about how bad you have it Lol!! I completely get where you are coming from especially because it was vascular surgery who was the first to do ballon angioplasty, and it was cardiology who invented the stent, and it was neurosurgery that developed coils, wait........ No it wasn’t!!! Interventional Radiology developed all those! Lol

I suppose there is a problem about the piece of cake the IR colleagues are eating in every branch. The fluid loaded heart failure to cardio; the elective angio to IR. Acute stroke to the IR; coma to neuro. Alpha blocker non-responded BPH to IR; all night bladder irrigation to uro. Goes like that...

 

[cpants]

I suppose there is a problem about the piece of cake the IR colleagues are eating in every branch. The fluid loaded heart failure to cardio; the elective angio to IR. Acute stroke to the IR; coma to neuro. Alpha blocker non-responded BPH to IR; all night bladder irrigation to uro. Goes like that...

Yea, except I just don't see it happening for PAE. It's not as good as the other options that we have, and the PCP's really just don't want to deal with BPH anymore if the patient doesn't respond well to first line therapy. Time consuming and not in their wheelhouse. Much easier to send them to me and wash their hands of it than send them to IR and then have to deal with catheters, follow ups, etc. Most PCP's don't have bladder scanners, ability to catheterize, uroflowmeters, etc. It's a pipe dream that this med student has that the PCP to IR pathway for BPH would ever be a widespread reality.

The reality is that actual IR docs don't want to deal with these patients either. The guys I send for PAE just go for the procedure and we are expected to manage all postprocedural care (as is appropriate). At least in my area, insurance coverage is now almost nonexistant for PAE following the last AUA guidelines, which is unfortunate because I'd like to have it as an option for nonsurgical candidates with huge glands.

 

[NDcienporciento100]

Yea, except I just don't see it happening for PAE. It's not as good as the other options that we have, and the PCP's really just don't want to deal with BPH anymore if the patient doesn't respond well to first line therapy. Time consuming and not in their wheelhouse. Much easier to send them to me and wash their hands of it than send them to IR and then have to deal with catheters, follow ups, etc. Most PCP's don't have bladder scanners, ability to catheterize, uroflowmeters, etc. It's a pipe dream that this med student has that the PCP to IR pathway for BPH would ever be a widespread reality.

The reality is that actual IR docs don't want to deal with these patients either. The guys I send for PAE just go for the procedure and we are expected to manage all postprocedural care (as is appropriate). At least in my area, insurance coverage is now almost nonexistant for PAE following the last AUA guidelines, which is unfortunate because I'd like to have it as an option for nonsurgical candidates with huge glands.

You know what the great thing about this website is

Yea, except I just don't see it happening for PAE. It's not as good as the other options that we have, and the PCP's really just don't want to deal with BPH anymore if the patient doesn't respond well to first line therapy. Time consuming and not in their wheelhouse. Much easier to send them to me and wash their hands of it than send them to IR and then have to deal with catheters, follow ups, etc. Most PCP's don't have bladder scanners, ability to catheterize, uroflowmeters, etc. It's a pipe dream that this med student has that the PCP to IR pathway for BPH would ever be a widespread reality.

The reality is that actual IR docs don't want to deal with these patients either. The guys I send for PAE just go for the procedure and we are expected to manage all postprocedural care (as is appropriate). At least in my area, insurance coverage is now almost nonexistant for PAE following the last AUA guidelines, which is unfortunate because I'd like to have it as an option for nonsurgical candidates with huge glands.

Yea, except I just don't see it happening for PAE. It's not as good as the other options that we have, and the PCP's really just don't want to deal with BPH anymore if the patient doesn't respond well to first line therapy. Time consuming and not in their wheelhouse. Much easier to send them to me and wash their hands of it than send them to IR and then have to deal with catheters, follow ups, etc. Most PCP's don't have bladder scanners, ability to catheterize, uroflowmeters, etc. It's a pipe dream that this med student has that the PCP to IR pathway for BPH would ever be a widespread reality.

The reality is that actual IR docs don't want to deal with these patients either. The guys I send for PAE just go for the procedure and we are expected to manage all postprocedural care (as is appropriate). At least in my area, insurance coverage is now almost nonexistant for PAE following the last AUA guidelines, which is unfortunate because I'd like to have it as an option for nonsurgical candidates with huge glands.

So you are advocating for PAE for the 90 year old wheel chair bound CHF pt with EF of 15% poor surgical candidate as the one that can most benefit from this procedure(PAE) while the 65 year old that walks two miles a day whose only real problem is he has a very large prostate is not a good candidate? So your going to put the 65 year old who has no other medical issues through TURP or Prostatectomy with a very realistic possibility of having to where a diaper the rest of his life or worse, when PAE could be all he needs? And PAE does not limit the options down the road. This line of reasoning is crazy to me! You can make all the Med students comments you want, you give that scenario to an outside unbiased person and ask what would you rather do? Hint 90% not picking TURP/Prostatectomy.

 

[cpants]

You know what the great thing about this website is


So you are advocating for PAE for the 90 year old wheel chair bound CHF pt with EF of 15% poor surgical candidate as the one that can most benefit from this procedure(PAE) while the 65 year old that walks two miles a day whose only real problem is he has a very large prostate is not a good candidate? So your going to put the 65 year old who has no other medical issues through TURP or Prostatectomy with a very realistic possibility of having to where a diaper the rest of his life or worse, when PAE could be all he needs? And PAE does not limit the options down the road. This line of reasoning is crazy to me! You can make all the Med students comments you want, you give that scenario to an outside unbiased person and ask what would you rather do? Hint 90% not picking TURP/Prostatectomy.

Experimental treatments are reserved for patients without other good options. Doesn't necessarily need to be somebody on death's doorstep. I've sent a few patients for PAE with large glands and supermorbid obesity or hostile abdomen from prior surgeries. My preference would be HOLEP for most of these patients, but it's not available in my area.

TURP is time-tested, proven, extremely effective, and has an excellent side effect profile. Significant long-term incontinence is very rare and is treatable. I don't tell my patients that there is a "very realistic possibility of having to wear a diaper for the rest of your life or worse" because that really isn't the case. Incontinence rates are well below 4% in most series for any type of incontinence, and total incontinence requiring a diaper is almost unheard of with proper technique.

Even newer minimally invasive newer technologies like Urolift and Rezum have large, excellent studies describing their efficacy and good side effect profiles.

Get data, then come back. We are the ones you have to convince, not the PCP's. Experimental designation by the AUA is well deserved at this time. PAE is very technically challenging, and my prediction is that when you start getting some large series with community IR docs doing the procedures you are going to see a lot of less selective embolization and much worse risk profile.

 

[mestielest]

Ohh I seeeee! So you are trying to say that IR does all the yummy cases while the people of that core specialty are getting dumped on, I feel sooooo baddddd for you!!! Next time you sit at your robot for surgery I want you to think about how bad you have it Lol!! I completely get where you are coming from especially because it was vascular surgery who was the first to do ballon angioplasty, and it was cardiology who invented the stent, and it was neurosurgery that developed coils, wait........ No it wasn’t!!! Interventional Radiology developed all those! Lol

Unfortunately I don't have a robot now. Even though I have graduated from a clinic that primarily carrying out robotics, I have never been interested in that stuff. I mostly perform pediatric urology, penile reconstruction, and incontinence surgery by now and love this thype of things.

 

[NDcienporciento100]

Let’s talk about “Approved vs Not Approved”
When the Urologist on this thread say that PAE is not approved they don’t mean it in the traditional sense (ex; FDA approves a new drug to treat X disease). They mean one thing it’s not recommended by (AUA) American Urology Association which has no right to approve anything! The AUA gives recommendations, Only 1 problem they are a society that represents urologist meaning that it WOULD NOT BE IN THE AUA’s CONSTITUENTS BEST INTREAST TO APPROVE PAE!

PAE IS WHOEVER APPROVED BY THE FDA.
So when these Urologist say that it is not approved it is grossly misleading.

The UK have also approved in 2018.

I am attaching all links below, and you can even read the reasoning the AUA did not give it there recommendation (notice how I said recommendation, they can’t approve anything).

In 10 years this therapy will be far more widespread and you may even see Urologist try to learn how to perform it. Just my prediction.

FDA approves minimally invasive, cheaper option for prostate surgery

Men who suffer from benign prostatic hyperplasia have a new treatment option, University of California, San Diego researchers announced this July—and it’s one that involves minimal operative pain, fewer out-of-pocket dollars and no hospital stay.

www.radiologybusiness.com

https://www.jvir.org/article/S1051-0443(19)30211-8/fulltext

FDA Will Allow Marketing of First Device for Prostatic Artery Embolization : Hayes, Inc.

www.hayesinc.com