Current Controversies in Prostatic Artery Embolization w/ Dr. Sam Mouli | BackTable Podcast Ep. 280

In this episode, host Dr. Michael Barraza interviews interventional radiologist Dr. Samdeep Mouli about controversies in prostate artery embolization, including technique, durability, and how we can leverage the data to unite IRs and establish PAE as standard of care.
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SHOW NOTES
Dr. Mouli discusses his role as director of translational research in interventional radiology at Northwestern. He reviews the most recent major data on PAE. There have been two major papers, one from a Portuguese group and another from a Brazilian group. The take home points from these papers are regarding the durability of symptoms and the safety profile of PAE. The biggest positive of PAE is that it is the safest among all minimally invasive surgeries. Dr. Mouli argues that PAE should be pursued as first line treatment for benign prostatic hyperplasia (BPH) with lower urinary tract symptoms (LUTs). Another upside of PAE is that it doesn’t prevent patients from undergoing any other medical or surgical intervention in the future.
One of the barriers to PAE becoming first line therapy is that there is currently no standardization among operators. Everyone still does it differently, whether by using different microcatheters, particle sizes, or other technical factors. This gives urologists ground to stand on when they argue against PAE. Dr. Mouli feels IRs should approach BPH with the same rigor that urologists do. He believes we need to use the long-term data to prove that PAE is safe, durable and yields better sexual outcomes than TURP or other minimally invasive surgical procedures. This can be accomplished via publishing guidelines for IRs. He believes a good starting place is to only use 300-500 micron particles for de-novo PAE cases. It has been proven this size is safe and results in very low non-target embolization compared to the 100-300 micron size, which more commonly causes this complication and results in more sexual dysfunction.
Dr. Mouli says urologists are pushing for surgical intervention before exhausting medical management and argues that IRs should do the same. He believes offering PAE early is in the best interest of patients, because waiting to fail medical management can cause further complications. Dr. Mouli does not get pre-procedure vascular imaging or MRI. This is because he uses intra-procedure cone beam CT. He does this as part of his procedure to map out collaterals and other blood supply to the prostate. He then targets these arteries with coils before using particle embolization on the prostate gland itself. He does this because his goal is to match the 5 year success rate demonstrated in recent studies of over 80 percent, with a less than 20% recurrence rate. He ends by stating that the long-term data show a 10-30% re-treatment rate across all treatment modalities. Knowing this, he feels even stronger that PAE should be the first line therapy, considering it is the least invasive option, it is safe and has the lowest rates of sexual dysfunction. If patients prefer more invasive procedures in the future, they can still go that route, or they can elect for repeat PAE as needed.
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RESOURCES
Triago Bilhim Paper:
link.springer.com/article/10....
Francisco Carnevale Paper:
pubmed.ncbi.nlm.nih.gov/33308...
UK-ROPE Study:
pubmed.ncbi.nlm.nih.gov/29645...
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[@Queenfan1961]

I just had a PAE 40 days ago. The procedure was uneventful except that laying on my back for >2 hours was excruciating. I had a urolift but experienced a recurrence of LUTS 8 months later. Both sides of prostate were embolized. The post treatment meds were antibiotics, steroid pack & Pyridium. Other than feeling like I had a goose egg up my bum the first afternoon, I had zero issues after that. I never used Perydium for urinary symptoms. No blood, retrograde ejaculation or anything concerning. I was back in the gym one week later. However is riding a bike an issue??? I ride stationary bike 20 mins 4x week. Of note, my insurance was billed >$24,700, ouch! Outpatient 2 hr procedure.

[@user-bf2ht3ly3y]

it cost me $3,000 in New Delhi. Just had it done 3 days ago.

[@garlandetheridge9902]

Excellent presentation!!

[@mstack1949]

How do I vet or what questions should I be asking a doctor that does PAE? I fear a poor or new "provider" who is not experienced enough. At what point or how many procedures should the doctor perform before they are considered experienced? Excellent information - thanks!

[@hawaiiangunner]

Depends what Clinic you're in. But most clinics do not let a doctor perform this until they have had at least 50 to 100 procedures under their belt. It just depends on the hospital and what their standards are. But no less than 50

[@DougCragoe]

A doctor has to start somewhere. So somebody is going to be patient #1 and so on till he does it 50 times. Then after the 50 procedures he has some experience. But he can't do 50 procedures on a practice dummy. @@hawaiiangunner

[@jacquesbeliveau8531]

Do you mind cutting out on the BS and promotion... Get on with the title of your podcast....wake up.

[@steves916]

Great information helps me understand the risk profile of the procedure before my initial consultation, note i'm another self referral post urological assessment

[@user-hs8vj6vu2i]

Had PAE yesterday 12/19.No pain at all and no sidafects. As someone else posted was 2 hours on your back.

[@TheJoncic]

How are you now?

[@tsabo8227]

Very informative. Thank you. Had a urolift about 4 years ago. Simple. After 4 years just ok. Did tons of research. Decided to go w/aquablation. 7 days out? Happy to report am peeing like a 20 year old again... So far so good. I am looking down the line ten years, and most likely would Pae, if there are unified standards... Just a an additional note... Stayed one night in hospital after aquablation, and they run about 20 to 30 bags saline solution thru ones catheder, which wasnt real fun, but overall would definitely do it again. Imp. No heat generated using aquablation, and perameters setup beforehand by doctor, than button pushed and the robotic portion does the rest...

[@andrewfrench8100]

Can the procedure be done if there is prolonged infection in the prostrate?

[@umakantgairola9422]

Appears to be better therapy. What type of neno particles are used for embolization ...??

[@searover83]

my issue is mostly in the medial lobe.. This was not mentioned in your lecture.. Can you please comment?

[@user-eg1sw7kd6g]

Can PAE successfully target large median lobes? History: UroLift 2 years ago (intact and working) . No improvement with UroLift. New Doc. discovered high bladder neck and large median lobe. prostate size 55g. Lobe is where all my issues are stemming from. Want to preserve current Sexual level. On daily coumadin ( heart valve). I've not had much luck finding out if a median lobe can be treated successfully with PAE. Closest IR who does PAE is Jacksonville FL, about 5 hours one way.

[@jaypeters2518]

I am puzzled by the fact that nowhere in the podcast is it mentioned how much the prostate was reduced I was told it was going to be 50% , ended up being 15%

[@user-eg1sw7kd6g]

If not a urologist, what specialty doctor does this procedure? i'm located in north FL, near Panama City. I had a EURO lift about 1.5 years ago. Results are frustrating. Occasional full flow on the 2nd or 3rd void only when I wake to Urinate at night, never during the day. Starting a flow is extremely difficult. Typically, its go to the urinal and wait for 3 - 10 min for the flow to start. Bladder function, kidneys all check good. Scoped a couple of times following the EURO Lift procedure, but nothing found. I'm starting to wounder if I have some variation of detrusor -- spincter dyssynergia, I don't fit the bill in regards to a spinal injury, I'm physically in good health, but the occasional full flow and the fact that starting is so difficult, makes me wonder if the prostate is the real issue.

[@garlandetheridge9902]

Interventionalist Radiologist

[@sailwinds69]

Try PAE.

[@sailwinds69]

I found CIc in Reno that did it. They also have offices in

[@eugenebdotson7363]

It's to late for the patience when they find out that they can't ejaculate after the procedure, THE doctor expects the tissue to be passed when you pee, you need to have suction to remove the discarded tissue, I had the Rezume procedure and followed all the recommend instructions, now I have to rethink my direction !

[@monroetinker9844]

Great lecture. I am a provider and I think a lot more education needs to be done for the patients on all the various treatments pros and cons so that they can make a better informed decision. I like the idea of having some place to go in the future if this minimally invasive procedure is done early on. A lot of time treatments are bridge to nowhere.

[@beboboymann3823]

AwesOme report! Why would insurance companies not pay for this treatment? Looking at the possibilities of serious issues with invasive treatments this procedure makes sense.

[@jjsmnow]

Wrong! They do pay for it. Govt usa regular medicare (not the dam disadvantages plans) payed for it twice in 10 years in my case. Look up Dr Bagla in Virginia or on other videos.

[@sailwinds69]

@@jjsmnow Yes I have a Medicare disadvantage program I'm fighting right now for not paying for my PAE which work for me Great after two months of doing it I highly recommend PAE to any guy with a large prostate insurance companies are totally f*****

[@sailwinds69]

My insurance prominence Medicare disadvantage did not pay for it I had to pay for it and I'm fighting them now about it most insurance companies pay for it there's just a few they're holding out sayings experimental saying it doesn't work saying you're risking your life doing it Total lies Medicare approve this over 5 years ago and they're not following the Medicare rules

[@jimzimmerman5288]

Kaiser said my 30 gram(#might wrong)prostate was really to small for a good out come? Is that true?

[@atomicbrothers8600]

might want to research TUIP Transurethral incision of the prostate (contrasted to TURP transuretheral rescetion)

[@hootowl6354]

There was six and a half minutes of commercials before the episode even started. What the hell is going on with KZbin?

[@roberts.1400]

Get KZbin Premium, not very expensive and you'll never see a commercial or ad again ... Plus, you can share the Premium membership with family or friends at no extra charge. So, if you're watching your pennies maybe get a kickback from someone to help defray the cost would help out ...

[@maheshdadlani9239]

Is cancer screening necessary prior to this procedure? If yes, what needs to be done? Blood work or MRI of the prostate? Kindly advise. Thanks.

[@DnBarPoet77]

Very informative discussion! I'm considering a PAE based on recommendation from urologist.

[@FlaThunderstorm]

Just to clear up any questioning. Retrograde ejaculation occurs when semen enters the bladder instead of emerging through the penis during orgasm. Although you still reach sexual climax, you might ejaculate very little or no semen. This is sometimes called a dry orgasm. Retrograde ejaculation isn't harmful, but it can cause male infertility. I had the same after I had Green Light Laser a few years ago. Never reduced my sexual activity in any way.

[@silaslongshot941]

Since the object of the procedure is to block blood flow to the prostate, what happens to all that necrotic (dead) tissue?

[@nicasietenicasiete7358]

I saw another video say the body absorbs it. Whatever that means.

[@andrewthomson6851]

Had PAE done October 2021, yes body absorbs. Shrink my prostate and like a young man again.

[@nicasietenicasiete7358]

@@andrewthomson6851 After researching this procedure. Its slowly becoming my first choice. I haven't found much statistics on it but it seems like the best. If you have a website or dr name for the procedure it would be very much appreciated.

[@andrewthomson6851]

@@nicasietenicasiete7358 Hello, I’m in Sydney Australia. Are you in the States? We can have it done on our Medicare. I can only say it changed my life and would recommend it highly. I had it done in Sydney at the Northern Beaches Hospital by a Dr. Shawn Quigley. Hope you get it sorted like me. Good luck

[@scubarojo]

@@andrewthomson6851 When you say "like a young man"...how "young" are you now. I'm 74.

[@michaelwesner5753]

I had 2. They don't work.😢

[@Thom3748]

Not one bit of improvement?

[@jaypeters2518]

I had one with minimal results. I'd like to see a distribution of reduction in prostate size.

[@Thom3748]

@@jaypeters2518 I asked my urologist about this procedure and he wasn’t at all thrilled. He said the data is inconclusive. Here is southern California. The procedure is done by radiologist not by urologist. I think that says a lot about where the professionals stand on the efficacy side for the procedure.

[@jaypeters2518]

@@Thom3748 it is a mixed bag. My urologist was all for it like it was a panacea. He was expecting a 50% reduction in prostate size. As as I mentioned earlier, mye reduction in prostate size was only about 15% from 150 g to 125. I did experience severe PAE syndrome, which landed me in the ER for a couple of days. It may have been just my stomach's reaction to Tylenol and an antibiotic. After listenin* to the podcast it was clear that all IRs are not equal. if I had Dr Sam Mouli the results could have been different?

[@MrJOHNMICHAELVEGA]

Why didn’t it work ? The radiologist told me he didn’t know!

[@danielriccardi6408]

only reason it wouldnt work is if they do not get the beads into the right artery

[@MrJOHNMICHAELVEGA]

Could you explain this because that would mean Fraud!

[@jonathanbryant9855]

It's so crazy that an organ with no room to grow starts growing. Im glad the brain doesn't do this.

[@scubarojo]

Well lets see what my Doc says about PAE. He's never mentioned it...and he's not a very old doc.

[@user-eg1sw7kd6g]

My urologist didn't mention it either. Coming up on 2 years post op UroLift, with no improvements in my bph. i am going to mention it at my next appt. I found a radiologist locally but i have to have a reference to see him. Not sure why, unless there are some additional tests which need to performed by the Urologist? I've done all the test, meds, natural meds, diet and exercise without any improvements in the last 3.5 years. I hope I don't run into resistance to the point of switching Urologist and starting over again.

[@danielriccardi6408]

yea but they never mention the massive dose of radiation you get with this procedure!

[@Scott-cu4ol]

how long after the procedure before you can resume sexual intimacy?

[@sailwinds69]

Cost 12028 paid Jan 2023 and it worked 2 months after procedure I had prostate that blocked me from urination... now Mar 14 back to normal pee. Thanks PAE

[@glenwoodriverresidentsgrou136]

How dos PAE work on MLE? On a percentage basis, how much does the prostate shrink after treatment?

[@Scott-cu4ol]

@@glenwoodriverresidentsgrou136 i’m not sure but i had my done a little over a month ago and the improvement is remarkable! I would strongly recommend it.

[@robertmahler8894]

@@glenwoodriverresidentsgrou136 30-40%

[@robertmahler8894]

@@sailwinds69, Are you saying the blockage is back? How are you doing NOW!

[@MrJOHNMICHAELVEGA]

I had Prostate Artery Embolization done but it didn’t work. 0 outcome total failure!

[@DeathSentryCoH]

Any info on why it didn't work? was your prostate size within the size specs they indicate? did veins grow back too quickly?

[@danielriccardi6408]

how big was your prostate?

[@dmcarden]

​@@DeathSentryCoHI wonder what keeps the veins from growing back..if anything

[@glgl1472]

I call this whole podcast but the sin of omission not one word about the amount of radiation that a person is exposed to how that is may be standardized or not standardized and what you guys are doing to reduce it that's a huge controversy that's what's keeping me from actually having it and the fact that you didn't even mention it tells me that you're hiding something

[@paulnotdownunder3172]

There is no radiation involved.

[@danielriccardi6408]

I wonder how much radiation are you exposing yourself to?

[@marksakowski9272]

All those procedures are barbaric and stink with the dark ages! The issue is that elderly, non contributing to the wealth $$$$$$$$of the society are the sufferers. More than 90% of men above age of 75 are suffering enlarge prostates but who gives a rat's ass. If it was a problem of young people, in a production age when a enlarged prostate would take them out of the tax paying duties, I bet my balls that a solution to this so medically benign situation was found years ago! A permanent and a good solution.

[@darrellcriswell9919]

You have no idea what you are talking about!

[@garlandetheridge9902]

Although this is the desired procedure, I've heard not all insurances companies pay for this. I hear that the cost is unaffordable to the average man. Not sure of the cost, somewhere between $50.000 and $60.000.

[@sailwinds69]

Cost 12028 just paid and it worked

[@garlandetheridge9902]

@@sailwinds69 Thanks Steve for your reply. Is that 12,028.00?

[@sailwinds69]

Stupid insurance didn't cover avoid prominence medicare advantage. Liars calling procedure experimental

[@sailwinds69]

@@garlandetheridge9902 yes

[@garlandetheridge9902]

Not prohibitive but a lot