In this interview Dr. Shivank Bhatia, Associate Professor of Interventional Radiology and Urology at the University of Miami Hospital, speaks about Prostatic Artery Embolization, the relatively new minimally invasive procedure to treat benign prostatic hyperplasia. Dr. Bhatia highlights what this new procedure means for interventional radiologists as well as the training aids available to help drastically reduce the learning curve.
Doctor Bhatia, most of the people reading this are already familiar with prostatic artery embolization, or PAE as its commonly abbreviated. But for those new to the topic, could you give a brief description?
Sure. PAE is a relatively new minimally invasive procedure used to treat benign prostatic hyperplasia, or BPH… an enlarged prostate. Performing PAE demands quite advanced skill sets but the thinking behind PAE is simple. Using the femoral or radial artery for access, an interventional radiologist—an IR—introduces a microcatheter through which he or she injects tiny particles that block the blood supply to the prostate, causing it to gradually shrink in size.
And the alternative to PAE… what would that be?
Currently, the procedure most commonly deployed to reduce the size, or more accurately, the volume, of the prostate is transurethral resection of the prostate, or TURP for short. It’s quite a successful procedure, but it’s invasive, requires hospitalization, and can have serious side effects.
Sexual dysfunction, retrograde ejaculation and incontinence are the side effects most commonly associated with TURP.
And how does PAE compare to TURP?
Well, as I’ve already said, PAE is minimally invasive. Most patients can return home after a few hours of recovery. There is ongoing research to evaluate long term efficacy of PAE and compare the outcomes to TURP. However, PAE as we know — and this is crucial — can be performed without the serious side effects I’ve just mentioned.
It’s also important to remember that TURP is an invasive operation. However, many of the patients presenting with BPH are elderly, and often have serious comorbidities that makes them unsuitable for such a drastic intervention. For these patients, PAE could be a very attractive alternative to TURP. In addition, for those with very large prostates, over 80 grams, PAE can be an optimal choice.
You mentioned the need for the IR performing PAE to have advanced skill sets. Could you elaborate?
Sure. PAE is a challenging procedure. The IR uses fluoroscopy to identify the target arterial feeds and to guide the catheter through the patient’s vasculature. So a thorough knowledge of anatomy, imaging equipment with appropriate capabilities, and features such as cone beam computed tomography are a prerequisite.
But it takes another set of skills to actually perform the procedure. IRs must be highly-proficient in choosing and manipulating microwires and microcatheters. They need to have perfected their injection techniques, and need to know how to interpret cone beam computed tomography in order to avoid non-target embolization.
Finally, IRs need to be expert in the complex vasculature of the male pelvic region. This is actually more difficult than it sounds, as the vasculature in question is highly variant. In fact, it takes considerable expertise to correctly identify the prostatic artery.
That’s three distinct groups of skills that have to be mastered. What training aids are out there to help IRs tackle this steep learning curve?
PAE was first presented in 2011, and since then training has been based primarily on the observation-apprentice model. But this doesn’t provide hands-on experience.
Things have now changed radically with the release of the Mentice simulation training software. I’ve been deeply involved in helping to create and develop this software, as has Professor Marc Sapoval from Hôpital Européen George-Pompidou in Paris.
The steep learning curve for this complex procedure would require 15-20 cases for an IR to become comfortable at it, and perform it within a reasonable procedure time. Simulation can drastically reduce this steep learning curve, I feel it will have a significant impact on training IRs for a niche and complex procedure such as PAE.
By using simulation software, IRs have a hyper realistic training environment for PAE. And I mean realistic not only because of the detail and veracity of the simulated fluoroscopy, but also because the training material is derived from real case histories.
When using simulators whilst proctoring, modifications in the procedure can be highlighted, as certain anatomies will require technical modifications.
I’m extremely proud of what we have accomplished.
You mentioned earlier that PAE first appeared in 2011. The procedure seems to have made great strides in such a short period of time. What do you see in terms of its future development?
PAE undoubtedly has great potential. Especially when we bear in mind the huge numbers of men suffering from clinically significant BPH—somewhere in the region of 40-50% of men with histological evidence of BPH. So it really is imperative that hospitals and training centers examine the potential of PAE and their training capabilities for the procedure. And I feel simulation is going to play an integral part of the training and wide spread adoption of PAE.
But TURP and other therapies are destined to be around for the foreseeable future?
Most certainly… and I hope so! PAE is a complement to the range of therapies available to treat BPH. Besides, the mode of therapy used depends on each patient’s very specific conditions. Some patients are better candidates for TURP. Some for open prostatectomy. Some for PAE.
Personally I hope the advent of PAE leads to even closer collaboration and cooperation between IRs and urologists; a pooling of expertise that can only be of benefit to the many men out there suffering from BPH.
Dr. Bhatia, thanks for your time.
Thank you. The pleasure has been mine.
About Dr. Bhatia
Dr. Shivank Bhatia is an Associate Professor of Interventional Radiology and Urology at University of Miami Miller School of Medicine. He has extensive experience with Prostatic Artery Embolization (PAE) and has built a multidisciplinary program with the Department of Urology at University of Miami. Due to his significant collaboration with the Urology Department, he was awarded title of Associate Professor of Urology in 2015. Dr. Bhatia also serves as a Principal Investigator for clinical trials related to evaluate role of PAE in BPH and Prostate cancer.