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Prostate Artery Embolization (PAE), a non-surgical procedure using interventional imaging systems to shrink an enlarged prostate or Benign Prostatic Hyperplasia (BPH), is gaining momentum. Informed patients are requesting PAE due to the lower complication risk of alternative invasive options, and busy NHS hospitals are seizing the opportunities of freeing up beds, lowering cost per treatments and cost per patient stay.
Traditionally, BPH patients would be referred by an urologist for a transurethral resection of the prostate (TURP), a surgical procedure that involved cutting away a section of the prostate. This would involve a general or spinal anaesthesia and a 2–3 day recovery stay in hospital.
Today, hospitals such as The Christie NHS Foundation Trust in Manchester, have protocolised same day, minimally invasive PAE using Interventional Radiology (IR). This is helping to free up hospital beds and enable patients to get back to their normal daily lives quicker.
A simple switch from left to right-sided patient access
“Studies have proven Prostate Artery Embolization, PAE, has similar outcomes to TURP. Patients now have the option of a minimally invasive alternative which would favour those who are not suitable for or prefer not to have invasive surgical treatment” states Dr Pavan Najran, Consultant Interventional Radiologist at The Christie NHS Foundation Trust. “An enlarged prostate (benign prostatic hypertrophy) is a common problem for men who suffer from lower urinary tract symptoms which can be debilitating. Men now actively seek alternative treatment options which includes PAE to help resolve such severe symptoms.”
“The shift to same-day treatments was accelerated during the Covid years as we had to limit the use of inpatient beds. PAE was protocolised as a day case with discharge of patients the same day. This was made possible by having a ceiling-mounted interventional imaging system giving us the ergonomic flexibility to switch to transradial access (TRA) via the patient’s wrist on the left side rather than transfemoral access (TFA) via the groin on the right. TRA is known to have fewer complications at the access site and is more comfortable for the patient, so it aided the confidence in decision making to speed up our discharge rates.”
Dr Pavan Najran, Consultant Interventional Radiologist at The Christie NHS Foundation Trust
Dr Najran continues, “It sounds like a small point when focusing on big clinical issues, image quality and low dose, but the ergonomics of an IR system are essential. You need to be able to walk 360 degrees around your patient or swing the C-arm around. Floor mounted or fixed robotic systems create physical barriers to getting to the top end of the patient to place jugular lines or orientate larger teams in a small space.”
The importance of high image quality & low dose management
PAE is typically a two-hour procedure involving an interventionist and radiographer technician team. Image quality for navigation accuracy and decision certainty is vital, as is a dose management system to safeguard the patient throughout the procedure and control cumulative dose management for clinical operators.
Dr Najran explains, “Cone Beam CT is essential for PAE as we need to confirm vessel certainty in supplying the prostate. Traditional angiography in this region isn’t conclusive as there are small vessels that you may not identify on an Anterior Posterior, AP-image. Therefore, Cone Beam CT on the IR system can identify very small vessel branches that supply areas at the base of the penis, bladder or rectum. This insight helps with decision making to either embolise or identify an alternative embolization point.”
“Dose reduction is also essential to manage the cumulative dose for the operators working in the room. We need to conserve the dose as much as possible and it was one of the factors in our system selection,” he adds.
An imaging partnership putting patient needs first
The Christie NHS Foundation Trust is the largest single site cancer centre in Europe treating more than 60,000 patients a year. Based in Manchester, it serves a population of 3.2 million people across Greater Manchester and Cheshire with a quarter more patients also referred from across the UK.
“As a cancer centre we try and promote a relaxed atmosphere with a holistic philosophy to reduce the anxiety patients may potentially feel. Whilst the PAE procedures are for benign conditions, it is still our aim to provide the highest level of choice and a calm environment. Canon Medical worked closely with us at the start of our PAE journey, it helped us gain timing accuracy for contrast delivery with the Cone Beam CT. This resulted in defining a PAE protocol,” explains Dr Najran.
Interventional radiology is a catalyst for expanding future patient treatment
Expansion of patient services continues. New services treating liver cancer have recently been introduced using the IR system. An example of this includes Chemosaturation procedure which is a complex treatment involving cardiac bypass and administering high-dose chemotherapy directly into the hepatic artery with systemic circulation isolation.
Dr Najran concludes, “Delivering innovative procedures for patients is a key goal for the interventional department at The Christie Hospital. Ergonomic space saving ceiling-mounted interventional imaging equipment helps us deliver personnel heavy procedures allowing us to have up to 14 essential people in the IR suite including – interventionists, cardiac perfusionists, anaesthetists, radiographers and nurses.”
It’s exciting times for interventional imaging. Evolving innovations in image quality, dose and system ergonomics are helping to broaden the range of procedures that focus on minimal invasion. This improves the patient experience and reduces overall cost of treatment, ticking all the boxes of improving quality of care.
Interventional Radiology – Innovations helping to minimise invasive surgical procedures
Interventional Radiology (IR) refers to a range of techniques which rely on the use of radiological image guidance to precisely target therapy. This can include X-ray fluoroscopy, ultrasound, CT or MRI. Most IR treatments are minimally invasive alternatives to open and laparoscopic (keyhole) surgery.[i]
The continued tide of innovation in IR is helping to evolve traditional surgical options by providing alternatives that are less invasive plus speed up procedural and recovery times for patients. Across the clinical specialities, from oncology, cardiology, neurology or urology, there are IR solutions designed to support in the cath lab, hybrid suite or operating room.
Floor and ceiling mounted C-arms support complex interventional procedures with an unprecedented range of patient access and full-body coverage from head-to-toe and fingertip-to-fingertip.
Built-in planning tools allow for quick and intuitive analysis prior to procedures and enable navigation with confidence and accuracy. For example, 3D volume data functionality helps select a tumour and define corresponding feeding vessels with information overlaid to be viewed live during fluoro of the procedure. Visualisation of contrast media helps correspond to arterial, venal and capillary blood flow providing valuable insight in identification or hepatic tumour feeding vessels.
Dose and noise reduction innovations help with creating clinical confidence and patient care. For example, noise reduction technology – to reduce unwanted changes in pixel values – provides cleaner, sharper, more defined images during stent placement, embolisation or ablation procedures at the same time as minimising dose. Dose management tools are also key in modern IR. Advanced hardware significantly reduces patient dose and scatter radiation offering greater protection for the patent and clinical staff. Real-time software tools help further eliminate unnecessary exposure to minimise dose and improve workflow.
Dan Parr, Imaging Systems Business Manager CT/MR/VL/XR/HIT at Canon Medical Systems UK explains, “Our leading IR systems feature a unique ‘Dose Tracking System’ that tracks X-ray beam movement and provides real-time feedback on skin dose information, mapping it visually as a simple, colour-coded visual on the system interface. This advanced warning system gives quick and easy-to-see alerts to operators to adjust C-arm angulation, frame rate settings and collimation to reduce skin dose. This is especially useful to operators undertaking long procedures to avoid regions where dose thresholds have been exceeded. Evaluations suggest the potential for a 50% dose reduction to patients when compared to replaced systems and UK National Diagnostic Reference Levels (NDRLs).”
“The opportunity for IR to support surgical teams and broaden the range of patient services that can be undertaken more minimally is really exciting,” Dan Parr concludes. “There are increasing pressures facing healthcare today from growing numbers of patients and waiting lists. So, by seeking out new ways of working, protocolising same day procedures and bringing in imaging tools that can streamline workflow and bolster clinical confidence is a solid idea. This will not only benefit patient care, but also deliver health economics into the long term.”
[i] British Society of Interventional Radiology, https://www.bsir.org/patients/what-is-interventional-radiology/
Photo Caption 1: Interventional radiology systems are minimally invasive alternatives to open and laparoscopic surgery.
Photo Caption 2: Dr Pavan Najran, Consultant Interventional Radiologist at The Christie NHS Foundation Trust
Photo Caption 3: The Christie NHS Foundation Trust in Manchester has protocolised same day, minimally invasive PAE using Interventional Radiology.
