The 73-year-old patient had a history of worsening urinary symptoms including treatment for urinary retention. He received an embolization of both prostate arteries using a balloon occlusion microcatheter in a successful non-surgical treatment for BPH.
We have a 73 year old gentleman here with bph. And urinary retention. Ah he has been on Flomax and finasteride for many years. However his lower uterine tract symptoms have worsened in the past six months significantly since november. His symptoms include weak to moderate stream knocked urea frequency every few hours, some urgency, hesitancy straining. Um He has no gross crematoria and uh he does have a history of a. U. T. I. Has been treated with antibiotics in the past. However recently it was supposed to undergo a cornea surgery max was um discontinued for temporarily and during that time he went into acute urinary retention and had to get a fully catheter placed and has failed multiple child avoids since then. His other past medical history and surgical history include Bph glaucoma, macular degeneration in England, a hernia repair. Next slide. His adjusted P. S. A. Back in february was 6.2 which was slightly increased since 2017 which was 5.24 back then. He also has had two prior negative prostate biopsies for the elevated P. S. I. At that time he had a renal ultrasound back in november which demonstrated Mark thickening in mural to speculations of the urinary bladder wall with diverticular, he had a post void residual at that time of 354 ml. Prior to the urinary catheter placement. His I. P. S. S. Score was 25. He had A. Q. L. Q. O. L. Of two and a shim score of six. Next slide. He most recently uh underwent an M. R. I. Prostate which demonstrated that his prostate volume was approximately 150 CCs and there were no focal lesions. Alright so we sort of just got started here because I think the the radioactive be straightforward first run that we did in the artery um a little bit of an angular asian but it wasn't challenging to get down and that's for the advantage doing this technique as opposed to up and over particularly in the the aortic valve applications that are um And then we did a little posterior to look at the iliac and the yeah and then we have a DS today run. Sure. Okay so not a challenging case from you know from an atomic perspective but I wanted to show you guys we have set up right now. We can do that on the list. That would be great. Yeah. Did you guys see the red? Yeah. There we go. In the risk in the risk. We have a my friends uh pray with an ideal city and then through that we have 1 30 the number of black And we have a flow 32 e. Which doesn't have a side for keep giving us a lot of room for our micro castor Micro Catholic that we chose today is the 150 centimeter sniper Catherwood. We're going to probably talk about when we get started here. I know there's a lot of a lot of people that want to comment. Um But let's start off with the anatomy here. I think this is pretty straightforward. Let's show the live feed and let's put a smart mask up there. Good. But I got it. Okay beautiful. We see very clearly on this image if you handle the uh superior particular um I don't see an operator on this image. You guys see it anybody. And also. Okay so we're lucky we have a nice big big artery. You can see there's branches to the median lobe which I think in this case is going to be probably the most important thing that we get a lot of symbolic into that. So we haven't done a lot of radio case. I think it's a nice approach. My my comment in this case it looks like a Type 4% the artery. Can you hear me? Yeah I can hear you yeah. So it looks like a type form the percentage arteries arising from the internal Belinda artery. It is a big prostate. 150. So one comment is with that. Once we don't see the the arbitrator artery in this program it is really important to understand and use convinced C. T. I think you will convince ct to identify if you have any other additional branch. So once you categorize this artery would it be important to understand all the feeding branches that you could have in the prostate. So jeremy. Just calculated it looks like the trunk here. We're gonna take a we're gonna do a quick picture and see where we're at and what branches are coming off, see if there's any rectal branches. So what we're gonna do now is uh we're gonna do a run with the balloon down, then we're gonna put the balloon up and we're gonna see if we can get a change in flow. So jeremy's going to inject um you know the way that we've always injected the prostate? And this is the way that Francisco sort of taught us seven years ago, is to go very slow in the beginning, try to capture the flow in the vessel and then more aggressive sort of at the end of the injection to see the collateral, this looks like a perfect spot. So we'll see what we we pick up here. I would be totally fine analyzing from here without the balloon up. And so sometimes what I'll do is I'll inject two CCS of particles, then inflate the balloon. And so Francisco, in my mind, this the balloon cat, they're sort of helps guide the embolization and more of a perfected technique without actually having to move the castle the disco because you can do uh well, you know what you described as proximal first. Uh and then disposed. And so the disciples sort of similar to what the effect that you would get with the balloon inflated, but we'll see if it changes and then we can always take the balloon back down and then start immobilized. Well I typically use the same particle size because at the end of the cases I've been you know depending with the balloon I don't think that there's really that much need to switch. If I have a straight and home micro catheter I may use the two fifties um if I go more distal for example I don't want to get uh non target with the smaller particles. But I think when you have a very good balloon occlusion like we do in this case I think it's pretty safe to to use these particles assuming we're watching for collateral ization which we're doing you know as we're injecting obviously. What do you guys think now? I mean that that to me looks like all prostate but then you start to see the collaterals at the end there. Yeah. Hey Ari and Aaron do you guys think that curiosity when you didn't have your balloon up you had much better glandular profusion. So um realizing Aaron with the blue and up or down right now it's right now it is up. But um I agree with you. So what I do in a lot of these cases I'll start the embolization with the balloon down sort of like a modified perfected technique and then when I start to see some reflux then I'll inflate the balloon. But I really don't see I mean it took a lot of injection to get the collaterals to fill here. And so I still feel very comfortable immobilizing in this spot even with the balloon up. But you know I've used this balloon quite a bit so I I sort of know how it behaves. Um But I think if you haven't used it a lot you probably should start with it down for a bit and then inflate it towards the end. Unless you're trying to reverse the potential collateral and then you obviously have to leave it up the whole time. You are just joining us. We're on the right prosthetic artery. We finished the left um We did about eight ccs of 100 mbas seen before we do this run. I'm gonna show you the last few runs uh and then we put into the room O. C. X. Coils 12 by six and then another two by 63 by eight. So I'm gonna show you guys that that's the final run on the on that side. After the coil we had a little bit of an acute angle uh the internal iliac on this side. But again I think the radio access gives us an advantage when we're trying to calculate these angles. Uh you can see here we were a little more distal. Then we pulled back uh and there's the angle right there. We just used a glide wire and we got down into the internal iliac actually. No we didn't use the glide wire let me show you what we did use. We tried a glide wire that didn't work. So then we used a um this is a fathom wire. So I took the fathom wire out of the micro catheter and I put a really big curve on it and I find this works quite well. And you can sometimes track The four French catheter over the fathom and then that way you have easy access without having to use an 035 stiffer wire. Um and sometimes that's lots better than, let's say like a Benson for example, but very similar to the other side. We have a very ah very easy to identify prosthetic artery at the end. But I like you guys to see how we do spin radio because I think it's important for prostate because this can be very challenging. It could be the hardest part of the procedure, especially in tall patients. So, if we look at the way that the II is angular did here, it's in a propeller trajectory as we're, as we're injecting the symbolic here, we can talk. Um we're gonna go back to a little bit more ap but uh, if it reaches the pelvis, which it which it can we can do a full spin and I I will use spins if I'm confused. I use Ember guide quite a bit. I think it's very important for people that don't have a lot of prostate experience to use cone beam ct in almost every case art and I have a lot of experience doing these together and individually. So we feel very comfortable not using it in some cases. Um But I like to use it at the end using a non contrast because I do like to look for non target embolization and you can get a good sense of how well you profusely the prostate with beads. Sometimes you see more beads in the median lobe or less for example and you can some ways predict response that way. I also look for beads and the seminal vesicles to predict uh complications the patient may have being in the rectum for example even in the in the penile branches if we don't like to see that. But if you do identify it you may be able to counsel the patient as to what they may experience post operatively. We're gonna put a coil in here to include the artery. Um This is a como si X. Coil. This is ah What size is this 24? We're gonna put this in uh to finish off and then we'll go over how we exit out of the artery in a second. You know this is uh we're we're distal to that capsule er branch here. So we're gonna drop the coil here. Um We're not coiling a collateral, this is the main prostatic artery. And so this is something that you know we've been debating and looking at over the last few months. Art loves this technique clear. You're going to coil the main prostatic artery on the way out to be very clear. That's exactly what we're gonna do. So okay, so just off the cuff granted I'm about to scrub into a case too. But I I I want I find this a little bit uh atypical, let's say to say the least. Um a couple of reasons why. One is, I would say in our experience we probably repeat about 10% of P. A. S. Um And if you look at the Portuguese experience, it's roughly about 10% of their experience as well when these patients are followed very closely and repeat mobilisations have a very high success rate. And oftentimes we'll go back into that native artery to perform an embolization. Not always, but often times and in performing a, you know, permanent coil embolization. Obviously you will be caging yourself out from that vessel in future and when you have to go back via umbilical collaterals or internal financial collateral. So I've gone back through as you know, I am a collaterals. It is a complete pain in the neck. And so I don't really see the need. I think that if there was a need to say, I'm worried about, am I getting a truly um bolic enough effect to cause an infarction. I would make the argument to use something like myself and our um speak for him because I know he scrubbed too Is one of these gel foam paste. So just make your own telephone paste. It acts like a 1-2 millim particle particle. There were once you see medallion and you get a nice sort of like a temporary glue effect. Um, I just, I guess for me, I don't really see the point of calling. Could you maybe expand on what, you know, you know, sonny, I don't disagree with you. Um, I don't do this in every case. This is something that um, we've talked about quite a bit. I think I think my repeat numbers are not high, so I'm not that worried about it when I, when I do it. Um, and I think if you're gonna, if you're gonna get uh, you know, recurrent symptoms, it probably will be through the collaterals and not through the main prosthetic artery. But you know, I've seen both. So it's hard to say. I mean, obviously there's no data to support this. We know that um, we wanted to show this just because we've been debating whether this is something that we should or should not be doing, but we do it and that's why we're talking about it. But I 100% agree with you. Art art, you know, thinks that this may be, well, you can talk about it. You know, this may create a situation where we can get the catheter out sooner sooner and I try not to fail treatment or something else to offer him opportunities. I mean struggled to go back to do a repeat P. A. I think it's a great first step. I can tell you that as a guy I had this is the first I have patients with prostate cancer that we do focal treatments of the tumor to have 100 and 80 grand prostate. These people have been relegated to only prostatectomy. Now we can treat the spot and then I m belies them about a month later after we treat their cancer. So I think there's a lot of opportunities I just think stopping the pressure head helps their symptoms resolve a little quicker and we can get the catheter out sooner. So jeremy just released the coil with what we call the pickle. You guys can see it here the green pickle. Um And so now we're gonna we're gonna finish up now can we get the arm up to do a spin? So we're gonna check the lateral. If you got if you want to zoom out a little bit we can see we're tucking the arm and we're gonna check the lateral. This is a very easy spin to do radio. We do this with all our radio cases. It is a little more challenging. We do prostate obviously because we have to put were you know we have to put the patient's head right up against the C. Arm. We're going to center it a little bit. I think we're able to show you guys the three D. Screen coming up after we do the scan which is going to be on the three D. Workstation. Um And I want to just roll through it really quickly for you just so you can see what I look for on the non contrast cone beam ct. Again we talked about to be able to predict potential non target. I don't think we're gonna have any. But you know, we always want to look the other option that with a with a non non contrast uh cone beam is you can just do it at the end after you take the the sheath out if you want. I mean I love using non contrast cone beam ct. I'm probably the only one. But um I like I like being able to do this uh at the end of the case. So we're all set to go here. We show the three D. Screen billion. Check no non contact. Can you guys see the three D. Screen or No. Yes. So you can see it so very commonly when we do the second side, the contrast is already washed out. Uh Well not completely but you can see the other side still has some retained contrast. I'm looking very closely for non target. I don't see any. We have a lot of uh you know, we can definitely see some contrast in the median lobe there and so this looks like a great embolization. So we're done, we don't want the catheter flicking any of the vessels on the way out. So we remove it with the wire in place like that. Very simple thing to do every radio case. We do it that way. Um And now we're gonna show you guys the band real quick. Can you guys see my finger? Yeah um anywhere. So I like I don't think the style it is a good place to access. The best place to access in general is an inch above the style Oid or so this is about an inch and a half above that. So this is probably about as high as I would go. Uh We we had a let's show the other band for a second. I have a regular size. This is the merit prelude. Yeah but this is this is medium. So this isn't gonna fit. This is a large tr which I think will work well. So we're gonna put that right. You know, jeremy knows where he punctured. It's gonna be right over the puncture site, not the entry into the artery itself or into the skin itself. It's always over the over the arterial me. And so with a higher up puncture. You gotta be very careful how you place the band if you place it over the sheath, you're probably gonna get a hematoma. So it's a it's a subtle point but it's I think it's really important to see how to close these type punctures. Um In terms of the type of bands, all the bands are good. I think we'll show later. We'll show a distal access, hopefully when Darren's here um that you have to, you really used to different. I like the prelude sink, distal or the vessel stat. Those are the two options for that. Um Any other questions before we wrap up? We're done with the P. A. Hey Aaron, I came back if you were talking about taking out the catheter.