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Rena Malik, MD Podcast
Moment: Top 5 Common Side Effects After Prostate Artery Embolization [And How to Manage Them]
00:20:21
In this episode, Dr. Rena Malik, MD sits down with Dr. Aaron Fischman to explore prostate artery embolization as a treatment for enlarged prostate. They discuss what patients can expect during recovery, potential risks, and the importance of finding an experienced specialist, offering listeners a clear guide to this minimally invasive procedure.
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- [00:00]
A
Our radiologists will often prescribe some anticholinergic or medication to relax the bladder after prostate artery embolization. Do people expect to have an increase in sort of worsening of symptoms during that first two weeks?
- [00:12]
B
There's another analogy I like to use for this. If you have a surgical procedure, not an embolization, it sort of feels like you have an injury. The equivalent is like, if you have an injury, it takes a little while to rehab it. Embolization is different. It's sort of like if you go to the gym and you have a really tough workout. So how long does it take to recover from that? Usually a few days. Most people have about a week of symptoms where they feel worse, and so all of their urinary symptoms get worse for about a week. The prostate gets a little angry after you cut off its blood supply, so you do have to be aware of that. So they get some pelvic pressure. They do feel like they have to pee a lot more frequently. Some people describe getting up even more frequently in the night, and it lasts about a week, and then they start to feel a lot better after that.
- [00:56]
A
Yeah. I used to do the water vapor therapy procedure, the resume. And I would tell my patients, you're gonna hate me for about two weeks, and then you're gonna love me. But in the beginning, you're gon. It's going to be a lot worse.
- [01:05]
B
Yeah. No, I mean, some people do hate me, but I. But I tell them, you're going to hate me for two weeks, maybe less, and then you're going to feel a lot better.
- [01:12]
A
Yeah. And then what about, you know, downtime after the procedure? Return to sexual function. Are there any limitations?
- [01:18]
B
You know, there really aren't that many limitations. It's really what the patient wants to do. They'll get up, they'll walk out of the procedure room. They have a band aid on their wrist. They go home. They feel those symptoms at home. But they can work, they can do all their normal activities. They can go to the gym. We usually ask them not to lift heavy weights for about 24 hours because of the puncture we put in the artery. But they can do whatever they want. They can go out with friends, but they're going to be peeing a lot. I mean, if they're playing golf, as an example, the next day, they're going to be peeing much more frequently than they would otherwise. But these are. Most of the men that I see are so in tune with their bodies that they. That they understand that this is going to Be, you know, a short period of time where they have to just take it easy, but they can do whatever they want.
- [01:57]
A
So I read this study that looked at readmission rates, and it was actually in New York. It looked at 30 day readmission rates, 90 day readmission rates after prostate artery embolization, a transure urethral resection of the prostate and prostate urethral lift. And it was an interesting study because there wasn't that many prostate artery embolizations. So I'll be honest, there are limitations in the study, but it saw that the readmission rate was significantly higher after prostate artery embolization for symptoms like abdominal pain. Is that something that you see typically or.
- [02:26]
B
No? I think this gets back to what we were talking about before. It's about preparing the patient for these things. And if, if, if you tell somebody that they're going to walk out of the procedure room and, and feel like nothing happened, that's not really the case. You know, coming back to the hospital is almost unf. Unheard of. And we manage all of these symptoms at home with medications. And almost all my patients have my cell phone. They call me and I text them and see how they're doing. And my nurse practitioners do the same thing. So it's all about preparing. If you, if you know what you're about to get into, it's much easier. You just don't want to be surprised, you know, the next day that you're, you know, you're peeing every, every 10 minutes.
- [03:00]
A
You know, you think something went wrong.
- [03:01]
B
You think something went wrong, but you know, it definitely didn't. It just means it's working.
- [03:04]
A
So maybe those were just earlier, doing these procedures earlier and not knowing what was sort of expected.
- [03:10]
B
Yeah, I think that's right. Okay.
- [03:13]
A
And then what about long term success? So you've alluded to that there is a higher reoperation rate, at least with the particulate matter. And there was a study back in, I think, 2017, so this was years ago. I think prostate artery ovulation has sort of much more evolved since then that showed that there was a significantly higher reoperation rate compared to transurethral resection of the prostate at five years. And so that's, you know, that's a bit concerning now. It may be fine if someone's like, I want to do this now. I'm active, I'm busy, I don't have the time to have surgery. But what are you seeing in terms of reoperation rates?
- [03:43]
B
Great question. I think when you look at the Data, and I trust the data from Brazil. Dr. Carnevale published this 10 year data a few years ago and he was one of the first to do this procedure. I trained with him many years ago and so I know how well he does this and I actually trust his data. And the data is actually very interesting. It's about 20% recurrent symptoms at around 5, 6 years. It's not that dissimilar, something like Urolift or something else transurethral. But 20% recurrence is not ideal. Right. We want to do better than that. And that's really the impetus for us trying these newer embolic materials, like something like glue, because we do think, and it's a little early to tell because we've only been doing this for about four or five, four years, that the recurrence rate should be less. And the scientific reason for that is the arteries become much more damaged, which is what we want. We don't want the prostate to stay alive, we don't want the arteries to reopen. And so that's really the reason why we see that, I think.
- [04:36]
A
Does the prostate form collaterals then?
- [04:38]
B
Yeah, it does, yeah, it does, yeah. We see there's blood vessels inside the prostate and there's blood vessels that are sort of outside the prostate. And so if you can't get the material into the prostate completely, you can imagine that the prostate will find new blood supply. It's actually very, very easy for it to do because there's so many blood vessels in the pelvis. And so one of the challenges is we do these angiograms or these pictures of the blood vessels. We look for all those collaterals, we can see them. And so you find two arteries that go to the prostate. And it's very easy to find the two main arteries. But the real challenge is to find these collaterals. And so one of the things that we think helps as well is to find them during the index procedure. And so you don't have to worry about those reperfusing the plastic. So we do look for those when we do these.
- [05:20]
A
But you don't embolize them at this point in time.
- [05:22]
B
If we see them and they're big enough, we do, but we know based on previous experience where they typically come off of. And so we can go and look for that.
- [05:30]
A
Yeah. I think a lot of people wonder, okay, if I embolize my prostate, am I going to do any harm? Are they going to harm anything? By getting rid of their prostatic, they're shrinking their prostate.
- [05:40]
B
No, I Don't think so. I mean, the prostate is sort of an OR. It's a fertility organ. And when you're 60, 70 years old, you don't really need it anymore. And so we would love to remove the entire prostate, but obviously a prostatectomy is a major procedure, which is why we have all these minimally invasive procedures for prostate. So removing it would be great if we could remove everybody's prostate. I'm sure we would love to do that. It's just not feasible.
- [06:01]
A
Maybe someday.
- [06:02]
B
Yeah, right.
- [06:03]
A
Maybe someday. There was a paper that looked at complications, and again, I don't remember the year of this paper, but it said that there was grade. You know, basically grade one and grade two complications, but they're usually minor. Maybe you need a medication, maybe you need something additional. Range from anywhere from 1% to 67%. So what do you think? I think for people just to understand what are the things that they will really probably deal with.
- [06:29]
B
Yeah, there's. There's expected side effects and there's complications. Complications are exceedingly rare. The side effects are real, and we talked about some of them, but the biggest one is really just frequency, urgency, burning and worsened nocturia or peeing at night. That's. Almost everybody gets one of those symptoms. Yeah, that's not a complication because we know it's going to go away after a few days.
- [06:51]
A
Yeah, yeah. And the dysuria, the pain with urination, that can be really scary for people. But I think if they know it's.
- [06:57]
B
Coming, we treat it with medication. There's very common medications that we use. They don't work amazingly well, but it's just time.
- [07:06]
A
What about blood in the ejaculate?
- [07:07]
B
Some people get that it's not. It's not super common, but the blood supply to the seminal vesicle is actually sometimes shared with the prostate artery. And so we many times are embolized in the seminal vesicles, too. So sometimes the patients will get some blood in their semen for a little bit. I usually tell patients to wait about a week before they have sex or to do any sort of masturbation or anything like that. Not everybody listens to me, but it's okay to have any sort of sexual encounter after. It just. It might be, you know, you might not be in the best physical condition to do it, but it's okay. You can do it.
- [07:38]
A
Yeah. Yeah. I think the other thing about hematospermia or blood in the semen is that people don't realize it can last a long time. It really Just depends on how frequently you ejaculate. So for some people, it can make a whole month and they are still seeing blood in their semen. And so I think just not to be alarmed that it's usually, of course, if you had a procedure, it's from that procedure. But even as a urologist, I tell patients most times like, you know, it's a benign cause, as long as it goes away, nothing to really worry about.
- [08:03]
B
Yeah, and hematospermia is something that we've, we treat rarely as the main reason why we do embolization. There's some people that do really well with embolization just specifically for that, that symptom. So we sometimes do that too.
- [08:16]
A
So in terms of risks of radiation, let's just talk about generally, because I think there's a lot of misconceptions in society about radiation exposure, whether it's from a procedure like this, a mammogram, a CT scan. What are the true risks? Like, what should people be looking for in terms of their own health? Like, what is too much?
- [08:35]
B
Well, there's principles in radiology. We use something called Alara, which is as low, as reasonably achievable. That's generally the policy that we follow with all sort of radiation exposure. So what that means is you want to minimize the radiation dose that you're using. That involves not using radiation unless you need it. It involves spending less time on the fluoroscopy pedal or the X ray ped. And it also means using equipment that's good. There's a lot of equipment that people used to use years ago that had a much higher radiation dose. The machines that we use now are so low that the radiation exposure is super low. And like I said, it's similar to what you would get from a CAT scan. So. And many times less. So it's really not a lot of radiation. And I think one of the problems with this procedure early on is it would take operators a long time to do it because they didn't understand the anatomy as well back then. And so now we can do it much faster than we used to, but there are some people that do it rarely and their radiation doses could be a little bit higher. So what I would say to men that are thinking about this is to really do their research and find people that have a lot of experience doing it, they can do it much faster and with much less radiation dose.
- [09:42]
A
And who do you think is the ideal candidate for this procedure?
- [09:45]
B
So the ideal candidate is probably somebody who has a good sized prostate. So what's good size. We say above 60, but you can treat people with smaller prostates too. But I see a lot of patients where their prostate's 150, 200, totally fine. There are limitations with some of the other procedures with larger prostates, but there really is no size limitation with this. People that are, like you said, have a normal bladder function, and we look, we try to determine that ahead of time. People who have moderate to severe symptoms, somebody has mild symptoms, they're not going to get that much better. You know, we like to say people who have failed medication, but there's lots of men that just don't want to take medication. So it's not, it's not like that's like a requirement or anything. But really large prostates, people that have good vascularity in their tissue, so good arteries, you look at their CAT scan or their. You can see that on those images. If the blood vessels are good and robust that go to the prostate. And if you can find a good artery and embolize it, you can do really well.
- [10:37]
A
So if you're looking at people who have, you know, a lot of people fall in that 40 to 60 gram range, do you think they perform, they do less well with prostate area embolization?
- [10:47]
B
Lots of people have been looking at this, and I think a lot of it depends on the operator. The challenge with smaller prostate is the arteries are smaller and harder to find. There's also a challenge that you're not going to shrink the prostate as much if it's on the smaller side. And so percentage wise, you're not going to get as dramatic of a benefit. But the analogy where we squeeze that water out of the sponge, you don't necessarily have to reduce the volume to have symptom relief because you're relieving the obstruction by sort of getting rid of all of that dense fluid in the prostate. It's something that we look for too, on the imaging to try to understand whether the arteries are big enough and robust enough. And so you can have a really small prostate but a beautiful artery, and you'll do really well too.
- [11:23]
A
So it's really sort of anatomically dependent on the arteries. Looking ahead, what do you think is going to be the biggest change in terms of how people perceive prostate artery embolization?
- [11:33]
B
I know that when I need a procedure for this, I'm going to have an embolization. All of my family members as well, I would recommend the same thing. And I think as we sort of move through the next couple of years, we know that as the male Population is aging. Pretty much everybody at some point. I mean, we know it's 80% of patients that are 80 years old are going to have some BPH symptoms. Most people are going to want something done. And when you're thinking about what you want to do about it and you're. And you want to do something a little bit more than medication, the decision to do a surgical procedure, I think, is a more difficult one. I think the decision to do this minimally invasive treatment is a little bit easier for men to wrap their head around. And I think it's dramatically increased over the next couple years. There's no question about it.
- [12:14]
A
Do you think there's enough radiologists performing it for that increase in demand?
- [12:19]
B
I don't know if that's the case yet. There are lots of people that do it. The growth in the last couple years has been pretty exponent exponential, but there's probably not enough. And one of the things that I focus on is training. I do a lot of training of my, my residents and my, even my medical students that come in to see how to do it. But ultimately, you know, when we want to teach somebody how to do this, we, we want some sort of visual key. And so we do a lot of training courses where we record live videos and we have technical things that we talk about to other physicians. So you can see some of that stuff on my, on my YouTube channel.
- [12:49]
A
I think the challenge with interventional radiology is you guys do a lot, right. Like you talked about before. So having someone really focus in on the pro. A big ask for something that's probably more challenging than some of the other procedures you guys perform.
- [13:02]
B
Yeah, it's, it's hard because not everybody wants to focus on it. Not everybody has an interest in it. I think the more people that do it and the more people that learn how to do it, I think become more comfortable with it. But when I first started, I didn't have this as my primary focus. It was, it was lots of different things like you said. But as I've advanced through, through my career, it's become something that I focused on. And I think it's really important to have intervention radiologists that are focused on it. And there are many. Is there enough to take care of, you know, all the men in, in the U.S. i don't, I don't know that we have that yet.
- [13:34]
A
Well, I'm not sure that everyone will, you know, there's so much available, but we do need more if we want to utilize it more. Yeah, I think so. In terms of finding an interventional radiologist who might be an expert in this, how do people go about doing that?
- [13:47]
B
I would love to say that there's an easy answer to that question, but there's not. I know from my interactions with colleagues who does it and who does it does it well. So I'm always happy to refer people that live in different states to different people. But people have to just do their own research and ask questions, and they need to speak to their intervention radiologist and say, what's your experience with this? What kind of outcomes do you get? How do you do it? What technique do you use? Do you do radial access? Do you do femoral access? They should ask these questions. If you can't get in touch with a practice or an interventional radiologist that does it, even when you're trying to make an appointment, it may not be the right fit for you. You have to really do your research. That's the key.
- [14:23]
A
I do think expertise really matters because I think we certainly don't see that high of a success rate that you're quoting in our. In our practice. But again, I think it just depends because that's radiology, that. That department that we work with that takes care of a lot of different things.
- [14:38]
B
Yeah. You know, you do have to find somebody that does a high volume, but that's the case with a lot of surgical procedures, not just this.
- [14:43]
A
Is there any other ongoing studies or things that you're excited about that you're working on right now?
- [14:49]
B
You know, the biggest thing that I'm working on right now is really trying to advance the embolic choice that we're using. And I think, you know, my big focus is on using a different type of Embolica, something more of like a liquid. There's different liquids that we have available. And these are the things that I'm most interested in understanding because we really want to get those recurrence rates low. We want the side effects to be lower than they are potentially. And we just think that this procedure is as good as it is, but it could be better. And there's lots of things that we could do technically to make it better, but it does require a fair amount of effort and work to sort of move it forward. But this has been a big passion of mine for the last decade or so.
- [15:24]
A
Yeah. Are people doing that same sort of investigation in other embolizations like you mentioned, fibroid or liver?
- [15:30]
B
Yeah, sure. Well, fibroids we've been doing for many, many years. The other procedures that we do that are pretty interesting. The biggest one, I would say, is embolization of the genicular arteries around the knee for patients with osteoarthritis.
- [15:43]
A
Wow.
- [15:44]
B
Osteoarthritis is an. Many times an inflammatory condition where you do get increased blood flow to the, to the structures around the knee, and so you could block those as well. We do that as well. There's patients that have hemorrhoids, we can embolize hemorrhoids now, all sorts of things like that. So there's. There's lots of interest in all. In all the musculoskeletal applications for embolization, too.
- [16:05]
A
That's so cool. I wonder why. I think that radiology is very much a referral dependent field, but I think that there's so much there that could be more direct to patient if it was, you know, really done correctly. Because I think people deserve choices.
- [16:21]
B
Yeah, for sure. I mean, this is the, the beauty of our specialty is that we provide minimally invasive treatments for very complex problems. The biggest problem that I see is that a lot of men and women don't. Don't know what we do. And so that's one of the reasons why I'm here, to sort of get the word out a little bit.
- [16:37]
A
Yeah, no, I think it's important, like I said, I think that if. And you know, you alluded to earlier, like, some people wait till they're 80 and now their bladder is not functioning as well. And I tell my patients, I don't know if you're going to be that guy who At 80, splatter stops functioning. I've had guys where I do a transurethral resection on them, and I'm like, they're definitely not going to do well, but they want it. And we talk about all the risks and benefits and, you know, we do. They don't want to do your dynamics, and they do. Great. And so I can never guess just based on, you know, obviously there's certain things that give us more caution and we'll try to do your dynamics, but ultimately you can't ever really tell who's going to be that guy who's starting to have symptoms in their 50s or 40s even, and which one of those bladders is going to stop working.
- [17:21]
B
Right. You don't know? I wish we knew.
- [17:23]
A
I wish we knew because, you know, it's not always the size of the prostate that matters. Right. It's how it blocks it depends on maybe your baseline bladder function. I mean, there's a lot of factors there. And I think that we have, like, several societies for bph, several in urology, but like very few societies that focus on bladder function. I'm. I'm in. I'm in one of them. And I think that we need to, like, collaborate better and figure, figure these things out. And I hope AI will help with that to some degree.
- [17:46]
B
Yeah, we're working on some other things where we're trying to predict response based on imaging. There's the lobes, the prostate, the left and the right, but there's also the middle lobe. So there's different predictive factors with that. And we're also trying to understand, maybe using AI, if we can detect how vascular the gland is, which is sort of a unique property, you don't really think about that with other surgical procedures. But what we're trying to do is decrease the blood flow. And so if somebody has very little blood flow, they may not be as good of a candidate as somebody that has a lot of blood flow. And so could you determine the blood flow, the flow dynamics, and the prostate ahead of the procedure?
- [18:19]
A
Well, I would wonder about the collaterals. Like, if they have more collaterals, they're probably not going to do as well. They may be very vascularized. Right. But if you have a lot of collaterals that you can't embolize, then.
- [18:28]
B
Well, one of the problems with collaterals is they're very hard to detect on CAT scan ahead of time. And so if you have some. Some sense of what the collaterals would be, you might be able know a little bit more going in. We have new CAT scanners now. They're called photon counting CTs. And so we're doing some preliminary work on trying to understand whether that could detect the collaterals ahead of time as well.
- [18:46]
A
If you like that clip from this episode with Dr. Aaron Fishman, make sure to check out the full episode right here.
- [18:51]
C
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