Dr. Marc Sapoval, head of the Vascular and Oncological Interventional Radiology Department at the Hôpital Européen Georges-Pompidou in Paris, discusses prostatic artery embolization (PAE), and the training IRs need in order to master this promising procedure.

Dr. Sapoval, you’re recognized worldwide as an innovator and expert in the procedure prostatic artery embolization (PAE). Could you briefly describe PAE for those new to the field?

Put simply, PAE is a minimally invasive endovascular procedure that blocks the blood supply to an enlarged prostate, creating ischemia and gradually reducing its volume. It’s of course more complicated than that. But the main point is that it’s radically less invasive, and proven to be as clinically effective as transurethral resection of the prostate (TURP), the ’gold-standard’ procedure for benign prostate hyperplasia (BPH), a leading cause of prostate enlargement.

And PAE is performed by whom?

Interventional Radiologists (IRs) are the only specialists that are qualified to perform PAE. In fact, it requires skills in pelvic embolization, intra-arterial navigation, image fusion and guidance—so specialist competence is required. But, and I can’t stress this enough, PAE is not a ‘competitive’ procedure to TURP. It’s an extremely promising addition, or complement, to the range of therapies currently available. PAE is especially relevant for men who aren’t viable candidates for TURP or other treatments. So there are compelling medical reasons for urologists to explore the potential of PAE. 

TURP is performed by urologists, how does PAE affect their patient pool?

It may seem as though PAE will take cases away from the urologist, but this is actually not the situation. TURP will still be performed for many patients, yet it is not a suitable procedure for all candidates. In fact offering PAE increases the overall patient pool, as it is suitable for more patients, for example those who do not want invasive surgery. These patients will seldom reach the urologist as they don’t wish to speak about surgery in the first place. Indeed, many would rather continue with their discomfort than undergo surgery. However, they will more likely be ready for PAE if the indication is confirmed by the urologists and IR.

So urologists and IRs should work together?

Yes. They should work as a team to offer this technique. The urologist will always remain the prostate specialist because of his or her specialized background. Moreover, the urologist is the one best qualified to diagnose cancer, to manage the patient overall, and to deal with any complications arising from BPH. IRs can perform embolization and should be part of the decision, because they will meet the patient and explain the intervention, and its results and complications. After PAE, the patient will return to the urologist for long-term follow up, although the IR will see him again to make sure that the clinical results are optimal. 

If we turn to the actual PAE procedure itself, what demands does it place on the IRs performing it?

PAE is a highly and technically demanding intervention. First, mastering the detailed pelvic arterial anatomy is very important. This is because of the variations in the prostatic artery, and the range and variety of possible anastomosis, some of which are potential sources of complications. Then, the catheterization of tortuous and calcified iliac arteries and small arterial branches feeding the prostate is usually quite challenging.

Because of the nature of BPH or of the PAE procedure?

Both. For example, the male pelvic vasculature is complex and highly variable. Correctly identifying the target arteries is a skill in itself. Then there’s the actual procedure. It calls for skillfulness, and a thorough understanding of cone beam computed tomography. Radiation exposure is a general concern but even more so since patients are frequently overweight, with excess weight concentrated around the pelvic area—and of course PAE is a pelvic intervention. This combination of factors, together with the C-arm angle typically required when performing PAE, means IRs must make sure they can use their equipment’s features to limit radiation. Such measures include reducing the fluoroscopy pulse and acquisition frame rate, selective use of come beam computed tomography, and so on. The list of competencies is really quite extensive.   

What profile of IR should start with performing PAE?

IRs with extensive experience, and those trained to do embolization on a regular basis, including trauma and pelvic work—these are promising backgrounds from which to start learning PAE. And of course, all prospective PAE practitioners require dedication and training. The results of PAE have to be worked for!

So what’s available to assist IRs on this steep learning curve?

Well here there has been real progress. The simulation training software from Mentice means IRs have an extremely realistic training tool – it is something I helped design and optimize. Prior to this, there really were no realistic practice environments or tools. Learning was based on observation, slides, videos, films, and closely monitored lab practice.

Will simulation help reduce the learning curve?

Yes, because the scenarios within the training software are based on actual, real-life cases. As an IR you will face some cases that are not so straightforward. In fact, there will be cases you may not encounter until your 50th or even 70th case. By training on a simulator you will be better prepared. Such training can help you reach a point of confidence much faster than traditional training methods. You will be ready to face difficult situations with proficiency and reliability. And obviously, with reliability comes fewer complications. We IRs now have an opportunity to train for these scenarios based on actual cases. We can hone our skills in complete safety: no radiation risks, no patient safety issues, no use of animals. There’s no better way for an IR to prepare for the challenging cases that will inevitably occur. We also need to look forward. How will IRs maintain their PAE skills? How can training centers provide the volume of cases needed to meet demand? The answer in both cases is simulation training. In fact, simulation training is a genuine breakthrough for the breakthrough procedure that is PAE.

Dr. Sapoval, thanks for your time.

Thank you Dominic.

About Dr. Sapoval