Introduction to PAE. Rational / Animal. Francisco Cesar Carnevale MD, PhD. University of Sao Paulo Medical School - Brazil

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1 Introduction to PAE Rational / Animal Francisco Cesar Carnevale MD, PhD University of Sao Paulo Medical School - Brazil

2 Francisco Carnevale, M.D. No relevant financial relationship reported

3 Bladder Outlet Obstruction Evolution of the Bladder Catheter

4 Bladder Outlet Obstruction Enlarged-Prostate (BPH) Lower Urinary Tract Symptoms Clinical BPH Prevalence 26% by the 50 s 46% by the 60 s 75% one symptom by 70 s Platz EA et al., 2002; McVary KT, 2006

5 4,400,000 Benign Prostatic Hyperplasia Economic Consequences ~38,000,000 3,900,000, , ,000 Wei JT et al., 2005; Saigal CS, Joyce G, 2005

6 Benign Prostatic Hyperplasia Medicare (USA) TURP Laser TUMT Malaeb BS, 2012

7 Benign Prostatic Hyperplasia Medicare (USA) TURP Laser TUMT Malaeb BS, 2012

8 Benign Prostatic Hyperplasia Clinical Implications of Current Treatments Blood transfusion 7% Retrograde ejaculation 50% Urethral stricture 9% Urinary incontinence 40% Reoperation 5% Urinary tract infection 8% Impotence 5% Burnett AL, 2006 Rassweiler J et al., 2006

9 Urological Interventions Familiar Concept to IRs Amplatz, K. Catañeda, W. Hunter, D. Is there any role for Interventional Radiology related to benign prostatic hyperplasia?

10 Is Prostate Embolization for BPH New? What has been published?

11 Prostate Embolization for BPH

12 Prostate Embolization Rationale BPH = Hypervascular Condition Embolization Ischemia Size Tissue change Hormonal action Urethral Decompression Smooth Muscle Tonus Disease Progression Medication Effects Improvement of Urinary flow / Symptoms / QoL

13 Prostate Embolization Pre-clinical Investigation Animal Model Harvard, Boston - USA

14 Prostate Embolization Pre-clinical Investigation - Results Feasibility and safety of PAE in dogs 40% prostate reduction with CT Pathological and imaging correlation

15 Prostate Embolization Pre-clinical Studies

16 History of Prostate Embolization First Clinical Experiences The first intentional treatment in a patient confirming the safety and efficacy of PAE for BPH June 19 th 2008 (With permission)

17 History of Prostate Embolization First Clinical Experiences Portugal Group

18 Prostate Embolization Technique 2013/ Nathan F, Carnevale FC, et al. American Journal of Roentgenology, MRI findings after prostatic artery embolization for treatment of benign hyperplasia

19 Prostate Embolization Anatomy Garcia-Monaco R et al. J Vasc Interv Radiol, 2014

20 Incorporating Technology Cone-Beam CT 2013/ Sagittal Axial right lobe Axial left lobe Bagla S et al., 2013 Bagla S., Sterling KM, 2014 Carnevale FC et al., 2014

21 PAE in the World Publications and Presentations ClinicalTrials.gov 19 studies

22 PAE Related Publications

23 Prostate Embolization Evidenced-Based Medicine Systematic Reviews Randomized Controlled Trials Cohort Studies Case-Control Studies Case series / Case Reports Editorials / Expert Opnion

24 Society Statements

25 Society Statements Brazilian Federal Council of Medicine PAE is a new indication for BPH High risk and complexity Performed by Interventional Radiologist Multicentric study with 2-5 years for final approval National REGISTRY

26 The Rise and Fall of Surgical Technique Optimal alternative of treatment Encouraging reports After more and doubtful results Only in highly specialized circumstances Modified, Scott JW, 2001

27 Prostate Embolization for BPH Unanswered Questions How can we improve the technique? What is the best model to compare? Should we treat all BPHenlarged prostates? How long What about does PAE patient s wish...? last? and hope?

28 Prostate Embolization Considerations and Limitations New indication for a familiar concept procedure performed by IRs Many centers in the world performing PAE Demanding embolization procedure More publications with higher scientific level of evidence are necessary There s no way to block PAE (why???)

29 Prostate Embolization Everyone wants Quality of Life