Benign Prostatic Hyperplasia - New Treatment - Questions and answers

What is the prostate?

The prostate is a gland of the male reproductive system, whose function is to produce a liquid that helps maintaining the sperm’s viability in the vagina after ejaculation. It is located beneath the bladder and the urethra passes through it, which explains why the increase in this gland’s volume causes problems concerning urination.


What is Benign Prostatic Hyperplasia?

The Benign Prostate Hyperplasia (BPH) is the most common prostate disease, very common in middle-aged and elderly men, with many symptoms that affect quality of life. It may affect 70% of men over 65 years old, 80% between 70 and 80 years, 90% over 80 years and almost every man with 90 years. It is a benign enlargement of the prostate volume, which can obstruct the lower urinary tract. There may be no symptoms for some time. If you do not have any symptoms, you do not need any treatment.


What are the most common symptoms?

Symptoms are usually due to urethral obstruction.

These can be:

– Increased frequency of urination with elimination of small amounts of urine;

– Increased frequency of urination during the night;

– Weak and interrupted urine jet;

– Feeling of uncompleted emptying of the bladder after urinating;

– Urgency – difficulty in holding urine;

– Inability to urine to flow with urinary retention, leading to bladder catheterisation;

– Hesitation – difficulty starting urination;

– Impotence caused by medication;

– Blood in the urine;

These symptoms may occur individually or in combination. They can be mild, moderate or severe. There are acute conditions such as urinary retention that bring the patient to the hospital for introducing a probe into the urethra to empty the bladder.

As the diagnosis of BPH is done?

To diagnose BPH a medical history is needed to classify the patient in short, mild or very symptomatic. A detailed physical examination including a digital rectal examination (digital examination through the anus) is performed in the same manner. The prostate-specific antigen (PSA) is of vital importance to the assessment, as it allows early detection of prostate cancer. Other laboratory tests are usually ordered, including urine, Blood Glucose, Cholesterol, Triglycerides, haemogram, Creatinine and Urea. The patient must also make urinary flow chart, the bladder residue post-micturition and in some cases the urodymamic study. Possible imaging tests are pelvic and endo-rectal ultrasound probe for measuring 3 diameters and prostate volume. These exams should be accurate, to rigorously evaluate the percentage of reduction in prostate volume. For this reason, they should always be taken in the same offices. The angiogram obtained by CT allows the observation of the anatomy of the pelvic vessels and their involvement by atherosclerosis. This is very important because it indicates or excludes the possibility of embolization.


How can it be treated?

There are several therapeutic options depending on the severity of symptoms. The mildly symptomatic patients will be followed clinically, under observation. The current medical treatment involves alpha1 antagonists (alfasusina and tamsulosin) and inhibitors of 5 alpha reductase inhibitors (finasteride and dutasteride).

In severely symptomatic patients or those who, for whatever reason, can not take medication, surgery is recommended. This may be prostatectomy by open surgery or transurethral resection of the prostate (TURP). There are many other surgical methods (laser surgery, thermotherapy, etc.), though not being comparable with classical surgery results. Surgery may be associated with bleeding, requiring blood transfusion, sexual dysfunction and retrograde ejaculation. The TURP can also be associated with retrograde ejaculation in most cases. Untreated BPH can lead to serious complications: urinary retention, urinary tract infections, bladder stones and kidney failure.

What does PAE involve?

PAE involves partial block of the blood to the prostate.

Please look at the videos to understand the procedure and see all the steps.



Do you treat the root of the problem?

We do not treat the root of the problem. We treat the symptoms of BPH. Only radical prostatectomy can treat the root of the problem but with many complications.


May PAE stop the enlargement of prostate?

We may or may not stop the enlargement of prostate. It is changeable from patient to patient. In 90% of cases the prostate reduces in size however in some patients after some years it may increase in size again.


Do we predict how much the prostate will shrink?

We can not predict how much the prostate will shrink.


Does the middle lobe of prostate shrink?

Yes the middle lobe may shrink.


May we stop the enlargement or recurring in the future?

It is changeable from patient to patient. We may or may not stop the enlargement and recurring in the future. We can not predict what happens to every patients.

Can we predict when does the shrinkage of prostates Stop?

No one can not predict, and it changeable from patient to patient.

What are the riskd of PAE?

Major complications are very rare, the patients do not get worse, altought in a small percentage, they may not improve.


What is Embolization?

The embolization of the hypogastric arteries has been attempted and described to treat conditions secondary to uncontrollable bleeding, prostatic or bladder oncological conditions or surgery. We ourselves have published in 1989 in the American journal “Radiology” its achievement in uncontrollable bleeding of the pelvis due to tumors. The supraselective arterial embolization for the treatment of urinary symptoms secondary to BPH was the technique used in a patient with persistent hematuria, described by DeMeritt in 2000. The embolization of prostatic arteries (EAP) in the Treatment of Benign Hyperplasia is an innovative technique, minimally invasive and reliefs symptoms. It is held at the St. Louis Hospital. It has a lower risk than surgery and good preliminary results. Its purpose is to interrupt the blood flow that supplies the prostate, solving the problem and preserving the prostate. No blood flow to the prostate causes its atrophy and symptoms improve or disappear.

The team of the Hospital Saint Louis Interventional Radiology, after making successful embolization in over eighteen hundred patients with uterine fibroids, is now performing embolization in benign prostatic hyperplasia. In our country, it is held at the Hospital Saint Louis, since March 2009 and over 1000 patients have already been treated.

Anywhere in the world, the embolization is carried out by an Interventional radiologist, a doctor who is specially trained to carry out this and other types of minimally invasive techniques, without any incision and leaving no scar.


How is embolization performed?

Under local anesthesia, and no loss of blood, a small hole of 1.5 mm diameter in the groin is maden, through which a thin plastic tube, catheter, is introduced. By a sophisticated digital X-ray monitoring apparatus, the catheter is led into the prostatic arteries. Embolizing small particles are then injected in the prostate arteries, clogging the branches that supply this gland, but saving the internal pudendal artery, so that the patient can still keep erectile function.

Embolization is then repeated on the opposite prostatic artery, through the same hole and through the same catheter.

The technique usually lasts from 2 to 3 hours, while the patient is conscious and may even display the television monitor that shows the treatment in vivo. After the procedure, manual compression is carried out for about 5 minutes and a small compressive dressing is placed and maintained until the next morning. Two hours after embolization, the patient should be able to get up and urinate.

The Hospital St. Louis is the only center in the world where the embolization is performed as a routine treatment in BPH. For this reason, some foreign doctors (to date 92 medical visits) have traveled to Portugal to watch and learn the technique, as well as some patients to be treated.

Hospitalization only lasts a few hours and almost all patients go home after dinner, if the blood pressure is normal or even if they live several hundred kilometers away from Lisbon. In this period, there will be a permanent contact with the medical team to assess complains or clarify any doubts.


How did the embolization start?

For years, I thought about the embolization as a treatment of benign prostatic hyperplasia. In this sense, over the years, I contacted some urologists in order to carry out the technique in patients with contraindication for surgery.

In October 2007 my brother passed away after surgery for benign prostatic hyperplasia. This has increased my interest in performing embolization.

In March 2009 I was contacted by a friend of 78 years with benign prostatic hyperplasia, bladder catheter for 6 months, and major depression. He refused surgery, as he had suffered a lot the three times he had submitted to it. After exclusion of malignancy and explanation of the technique and risks, he was treated successfully, with withdrawal four days later. He began to urinate without any difficulty, got out of depression and his sexual activity improved considerably. Six months later his girl friend was pregnant.

Given the success of this technique and the absence of complications, I began performing embolization in patients refusing surgery with symptoms of benign prostatic hyperplasia.


What tests need to be runned before embolization?

You need to make a pelvic ultrasound via rectum to evaluate the prostate volume. In order to ensure quality, these examinations are always obtained in the same office and the same doctor. The patient must also make PSA to exclude malignancy, flowmetry, post-voiding bladder residue and routine blood tests (blood count, cholesterol, triglycerides, creatinine and urea). Finally, if you have indication for treatment, you will have to perform a CT angiography to study the pelvic vessels. However, this test is not completely accurate, because only embolization can show other lesions of the vessels, that are impossible to be seen by Angio TAC.


What is the success rate of embolization?

From over 1000 treated patients at the Hospital Saint Louis, improvement was observed in about 850 patients. 110 patients were with bladder catheter before de procedure, withdrawing it a few days after embolization. Nowadays, all patients, except three, urinate without any difficulty and without any medication. Long term results are even better.

What are the risks associated with embolization?

Embolization is a very safe technique, however, it may associate some risks, as any medical treatment, but they are rare. Currently, most patients do not feel any symptoms after embolization. Some may refer slight pain, heat or burning, which are easily controlled by appropriate medication. The embolization risks are much lower than surgery. In order to avoid risks, patients whose arteries are very atherosclerotic, revealed by the Angio TAC, are excluded. Complications are those of any catheterization, being the most frequent, the hematoma at the puncture site (20 patients), urinary tract infection (16 patients; easily prevented by taking antibiotics started before embolization), urine or sperm with blood and temporary purple colouring of the thigh and abdomen. However, these side effects disappear after a few days without treatment.


Will embolization be painfull?

Embolization does not cause any pain during or after the procedure. Only six of the treated patients reported some pain during and after it.


How long does it take to recover from it?

The day after embolization, the patient should not stay in bed and can, in most cases, get back to his normal life. However, the patient shall not drive. The patient can resume his professional activity usually between 2 to 7 days after treatment.


How are the results of embolization evaluated?

The results are evaluated by embolization flowmetry, post micturition bladder residue, the PSA and prostatic ultrasound carried out 1, 3, 6 and 12 months after embolization. After the first month, a reduction in prostate volume of about 10% to 30% can be observed. The improvement or disappearance of symptoms take place soon after embolization or at the latest after one week week.


May I be treated regardless of the size of my prostate?

Unlike TURP, which can only be performed if the prostate is smaller than 60cc, embolization can be performed even in very large prostates with a volume greater than 400cc.


Is my sexual potency affected?

Unlikely prostatectomy, in which some patients are left with sexual dysfunction, retrograde ejaculation, and TURP, sexual function is not affected in embolizaton.

None of the 1000 treated patients, had sexual function affected.


What happens to the prostate after embolization?

There is a partial interruption of the blood supply to the prostate, resulting in prostate ischemia, or reduction of the blood flow to the vessels. As a result, there is a progressive reduction of prostate size (between 10 and 40%). Hence, the symptomatology decreases or disappears and the prostate stops growing, which is very important for the patient. However, in about 10% of patients prostate size doesn’t reduce despite the improvement in symptoms.


Can I be treated by embolization?

Indications are: severe symptoms with indication for surgery, more than 40 years old and no contraindication.


What are the contraindications of prostatic embolization?

The absence of symptoms is a contraindication. If symptoms are caused by bladder problems, treatment will not cure it. When in doubt, you must perform an urodynamic study.

What to do to be treated?

You must ask for an appointment at the Hospital Saint Louis. You should do prostate ultrasound with rectal probe, PSA, recent flow chart and residue vesical post-micturition.

Before the appointment you must complete international surveys on symptoms, quality of life and sexual function.

The doctor will examine your case and the technique will be explained to you. It may be necessary to run more tests. After this consultation, you must do an Angio CT for evaluation of the pelvic vessels and possible treatment. However, this test has some limitations because some aspects of the vessel’s anatomy can not be detected by CT and only during treatment. An  urodynamic study to antecipate the results of embolization may be needed in some cases. This test should be handed at the Hospital Saint Louis, for analysis and deciding wether embolization should be performed.




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Comentários: 6

  1. daniel J. carroll, jr. says:

    I am a 78 year old, long time sufferer of BPH and would like to travel to Lisbon for the PAE procedure. Could you please provide me with the total cost, if possible, in U.S. dollars.
    I live in New Orleans, Louisiana and have bee afflicted with BPH for approximately 28 years. I have tried all the medications that are normally prescribed for this condition but nothing has helped.
    Thank you for your response. Respectfully, Dan Carroll

  2. daniel J. carroll, jr. says:

    Prof. Martins Pisco, I am interested in undergoing the PAE procedure,. I have been suffering from BPH for many years and desperately need relief. Doctors in the U.S. are not yet performing PAE and it is not known when, if ever, the PAE procddure will be allowed.
    I am soon to be 78 years old and in reasonable good health. I am ready to travel to Lisbon when arrangements can be made. Please provide me with whatever information you can. Respectfully, Dan Carroll

  3. J.T. Miltenberger says:

    I would like to know what Doctors in the Washington DC area perform Prostatic Artery
    Embolization? Does this procedure have fewer complications than either TUNA or TURP? I have already had TURP performed 13 years ago and would prefer a different approach this time.

    Thank You For Your Time

    J. T. Miltenberger

  4. Eric Jones says:

    How do I send you the ultrasound and PSA tests? Can they me emailed/faxed? How long does it take to schedule the procedure, and what is the cost?

  5. elizabetep says:

    You can send your texts by email: or You have to stay in Portugal around 1 week for thr procedure. The cost is 4.300€.

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