EP 651: Can't Pee? You Need PAE! Dr. Smith of Summit IR on the Miracle of Prostate Artery Embolization
Sep 20, 2023
Dr. Sandeep Mistry and Donna Lee
In this segment, Dr. Mistry and Donna Lee is joined by interventional radiologist Dr. Preston Smith of Summit IR. One of the most common procedures Dr. Smith performs is prostate artery embolization, which shrinks an enlarged prostate by cutting off its blood supply. PAE is well-known as a minimally invasive and mostly permanent treatment for BPH. The process of embolization, or blocking an artery, has also been used to treat a variety of conditions from uterine fibroids to arthritic knees--but it's not for everyone. Dr. Smith and Dr. Mistry explain why this procedure is amazingly safe and effective for patients who have been deemed good candidates for PAE. Tune in to learn more about how interventional radiology and whether PAE is right for you! Visit Summit IR online or call 512-828-4300 today!
Voted top Men's Health Podcast, Sex Therapy Podcast, and Prostate Cancer Podcast by FeedSpot
Dr. Mistry is a board-certified urologist and has been treating patients in the Austin and Greater Williamson County area since he started his private practice in 2007.
We enjoy hearing from you! Email us at armormenshealth@gmail.com and we’ll answer your question in an upcoming episode.
In this segment, Dr. Mistry and Donna Lee is joined by interventional radiologist Dr. Preston Smith of Summit IR. One of the most common procedures Dr. Smith performs is prostate artery embolization, which shrinks an enlarged prostate by cutting off its blood supply. PAE is well-known as a minimally invasive and mostly permanent treatment for BPH. The process of embolization, or blocking an artery, has also been used to treat a variety of conditions from uterine fibroids to arthritic knees--but it's not for everyone. Dr. Smith and Dr. Mistry explain why this procedure is amazingly safe and effective for patients who have been deemed good candidates for PAE. Tune in to learn more about how interventional radiology and whether PAE is right for you! Visit Summit IR online or call 512-828-4300 today!
Voted top Men's Health Podcast, Sex Therapy Podcast, and Prostate Cancer Podcast by FeedSpot
Dr. Mistry is a board-certified urologist and has been treating patients in the Austin and Greater Williamson County area since he started his private practice in 2007.
We enjoy hearing from you! Email us at armormenshealth@gmail.com and we’ll answer your question in an upcoming episode.
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Speaker 1:
<silence>
Speaker 2:
Welcome to the Armor Men's Health Show with Dr. Mystery and Donna Lee.
Speaker 1:
Hello
Speaker 3:
And welcome to the Armor Men's Health Show. This is Dr. Mystery , your host, board certified urologist, and happily joined by my wonderful co-host, Donna Lee. That's
Speaker 4:
Right. Welcome everybody. Look , thanks for listening to the show.
Speaker 3:
I have to be nice to you because our listeners like you more than me.
Speaker 4:
That is true.
Speaker 3:
You are a , uh, a professional comedian and right.
Speaker 4:
I am. I have a show . Are
Speaker 3:
You voted?
Speaker 4:
Oh, I am the seventh funniest mom in America per nick at night
Speaker 3:
In , uh, circa 1998.
Speaker 4:
1987. Oh , <laugh> . No, I'm kidding. <laugh> . When I was in high school. No, it was a long time ago. Yes. You don't have to go that route, but I still have , I have street cred and there you go. I
Speaker 3:
Have no comedian or comedian kind of awards, so. That's right. We are a awarded urology practice, though. N a u Urology Specialist. Mm-hmm . <affirmative> , the practice that I started in 2007 is what brings you this show. We would love to see you for any consultation between the nipples and the knees. Donna, how do people get ahold of us and how do people set us questions? That's right . If
Speaker 4:
You wanna learn more about your favorite holistic urology group, call us at (512) 238-0762. You can visit our website, armor men's health.com. And uh, we're located in Round Rock, north Austin. South Austin in Dripping Springs. And I've had two people tell me I talk too fast. Was that okay?
Speaker 3:
That was great. Okay, good.
Speaker 4:
I need to slow down. <laugh> .
Speaker 3:
We are joined today by one of my favorite people on this earth, Dr. Preston Smith. Dr. Preston Smith. Welcome today. That's
Speaker 4:
Nice.
Speaker 5:
Hey, thanks for having me on. I like that introduction.
Speaker 3:
<laugh>. Dr. Smith is an interventional radiologist, which is usually the sworn enemy of the urologist. However, we have joined forces and we are now taking over the world.
Speaker 5:
It's like pinky in the brain.
Speaker 3:
<laugh>. I'm not sure if our listeners are gonna be too young or too old to know that reference. <laugh> , which one's? Pinky? Which one's ? But teenage ages of 40 and 50. You'll know. Pinky in the Brain was all about, well, that
Speaker 4:
Dr . Smith's really young. I'm surprised. He knows . Yeah.
Speaker 3:
So , uh, Preston, why don't you tell our listeners what is the expertise and education of a interventional radiologist and how are they different from a regular radiologist?
Speaker 5:
So back when I trained all of the interventional radiologists trained for a year or two after going through a whole diagnostic radiology program. So I had to suffer in the emergency room just reading x-rays and CT scans, and then after an internship, and then four years after that you could apply to train as an interventional radiologist. Now there is a separate pathway. So interventional radiologist has its own pathway that you can apply to right after medical school. It is much more heavily procedural and medical management based , whereas diagnostic radiology is more of a imaging consultant. I actually got in , in hot water on Twitter recently because I described Oh, no, diagnostic radiology as coaching medicine. Oh , and interventional radiology is actually practicing medicine. Holy, that , that didn't go over well with a bunch of diagnostic radiologists.
Speaker 3:
That's funny . That's funny. Is probably funny . The nerdiest thing I've heard all day. <laugh> . I , I want to thank you for putting half of our listeners to sleep. In simple terms, an interventional radiologist that's funny is someone that uses imaging to do a procedure and that usually involves needles and biopsies and so many cool things that people may not even be aware of. And in urology, we have introduced the interventional radiology component for enlarged prostate management. So, you know, our listeners get to hear me talk about prostate stuff all the time. Preston, why don't you explain to our listeners how you describe enlarged prostate and the interventions that you do for our patients.
Speaker 5:
So I tend to describe a large prostate as something that half the men over 50 and you know, 70% of the men over 70, it just sort of goes up and up and up as you grow older. And one of the most common questions I get from patients is, why is this happening to me? And I say, you know, we don't exactly know, but it's related to your testosterone. And then they say, oh, I have low T and I'm like, well if any t it's related to your testosterone. Mm-hmm . <affirmative> , and this in large prostate problem causes many issues urinating for guys. And there are lots of treatments that urologists have been providing over time, but I can provide a treatment from a totally different avenue. And specifically it is an angiogram where we go into the artery, identify the prostate arteries, and then we drastically or heavily slow down the blood flow , uh, that is supplying the prostate clan. And that signals to the body through sort of a complex series of cell signaling that the prostate needs to get smaller because it's not getting enough oxygen. And then in a controlled fashion, slowly over time after we do this procedure, the prostate will shrink down and the majority of the patients have relief from their urinary symptoms.
Speaker 3:
So prostate artery embolization is this cutting edge type of treatment that not all urology practices will offer. And it is part of our armamentarium for dealing with your enlarged prostate and urinary symptoms. When you come and see us as a patient, you're gonna be given lots of different options for your prostate. Depending on the size and the severity of your symptoms, you may be offered medication. But medication for the long term is something that we tend to wanna discourage. These alpha blockers like Flomax, tamsulosin, fussin , psilocin , they cause your blood pressure to decrease and in the long term can contribute to cognitive decline as well as fatigue. And so we don't like this, you know, especially as you get older. So depending on the size of your prostate, you can be offered a number of maximally or minimally invasive treatments. When it comes to prostate artery embolization, we do this right in the office, right, Dr. Smith?
Speaker 5:
Yes. We have a , a nice cath lab, which is a , a place for us to do live x-ray , uh, built on the backside of the office that is in the north side of Austin. It feels much like a kind of little operating room inside of the office. It's mm-hmm . <affirmative> , brand new shiny,
Speaker 4:
And Dr. Smith likes it to be 60 degrees in there .
Speaker 3:
Yes. It has to be cold and you'll get a little bit of an anesthetic. So a little bit of something to kind of sedate you so you don't move. And then , uh, how , how do you access the arterial system? What, what , what , what's your access method?
Speaker 5:
So back in the day, we used to just kind of feel around for the artery and then access it with a needle. And nowadays we have so , so much better technology than when I first started training. We have ultrasound machines to guide these very small needles in. So it has essentially eliminated any of these complications that you get from just kind of fishing around with a needle trying to get inside of an artery. Mm-hmm . So we mm-hmm . We guide our small artery and then our small access port into the femoral artery is the artery that it people can feel in their groin. Do you like to
Speaker 4:
Say in front of patients? Oh, there it is. <laugh> .
Speaker 5:
They are <laugh> , but believe it, or oops ,
Speaker 4:
As a joke,
Speaker 5:
<laugh> , uh, depending on how sleepy there are, I'll , I'll mess with that . That's
Speaker 4:
True. They're probably
Speaker 5:
Out . But yeah, our, our our , uh, nurse anesthetist is excellent. So we, we have most of the patients very sleepy for the procedure and they don't smart, they don't remember it, you know, after we're done. And how
Speaker 3:
Long does it take?
Speaker 5:
It takes about an hour and 10 minutes.
Speaker 3:
And then , uh, afterwards , uh, when can patients start experiencing some improvement in their urinary symptoms? It
Speaker 5:
Is variable, but generally it will happen somewhere around 10 to 14 days.
Speaker 3:
I mean, it's, it's a revolution when it comes to a very specific type of patient. So, you know, men don't like the idea of having something put in their penis. They don't like the idea of a catheter postoperatively. They want something that's not going to affect their sexual functioning. It almost seems like the perfect kind of confluence of trade-offs is to get this prostate artery embolization. And I think that adding it to the armamentarium is really important, but not all urologists offer it. And , uh, I'd I'd love for you to tell us why
Speaker 4:
<laugh> Oh, money. Oh, I mean, sorry, what?
Speaker 5:
Well, yeah, we're supposed to dance around it and then lead people to the answer. Right. I'll just put that there. In medicine, there are often multiple things that you can do to treat a problem. And sometimes those solutions are proposed by different specialists.
Speaker 3:
So there's turf battles. So, you know, this idea that your prostate would not be treated by urologists seems alien to some, and it kind of in some ways make some urologists feel like it's taking a procedure or money away from their pocket mm-hmm . <affirmative> to be able to do something. But, you know, over the years, so many of my patients have just flat out refused any procedure because they do not want, want a catheter, they don't want an overnight stay. They don't want anything that's gonna cause retrograde, you know, no, no, no, no, no. I'll just live like I am. And so the prostate artery embolization fits a perfect niche for so many of our patients. So, which patients are not going to be great candidates for prostate artery embolization
Speaker 5:
Patients that have, excuse me, I just had a voice crack there. Oh , uh, you're still growing patients <laugh>. Patients that have prostates that are very small may not be as good of candidates. Although if Dr . Mystery shows that they do have en large prostate on a cystoscopy like a , a camera study, then we still may do the procedure. Patients that have severe peripheral artery disease, which is the hardening of the arteries that is caused by high blood pressure smoking and a couple of other things, those patients may develop blockages or narrowings , uh, in their arteries. And that makes it difficult or sometimes impossible for us to do the procedure. But other than that, that's about it. Oh . And patients with , uh, kidney disease that can't get contrast dye because we have to use dye x-ray dye to use the procedure makes ,
Speaker 3:
That's a great one to remember. So we're gonna come back and we're gonna talk more about prostate artery embolization, and if people want to get a hold of you directly, they can call summit ir. What's your phone number? Do you know
Speaker 5:
This happened last time I was on here? I have to , I have to pull out the phone number.
Speaker 3:
You guys are really a piece of work.
Speaker 5:
So our office number is 5 1 2 8 2 8 4300
Speaker 3:
And it's summit-irad.com.com. But you can just contact our office at armor men's health.com and our regular phone number, (512) 238-0762 and we'll get you right over. Hello and welcome to the Armor Men's Health Show. This is Dr. Mystery , your host, board certified urologist men's health expert, joined by my co-host Donnel Lee . Hey
Speaker 4:
Everybody. Welcome back to the show.
Speaker 3:
I heard in your younger years you were also kind of an expert on men's health. Hey . Hey
Speaker 4:
<laugh> . Just the lower regions,
Speaker 3:
Just the lower
Speaker 4:
In college
Speaker 3:
<laugh> . Oh boy. Uh , this is at Men's Health Show. We deal with issues between the nipples and the knees in our practice, n a u Urology specialists, we have an amazing team of physicians and advanced practice providers that are here to take care of you in the most revolutionary and cutting edge way. That's
Speaker 4:
Right. We are available to you all the time if you need anything at all. I would like to reference the previous segment with Dr. Smith that Yes, if you would like for him to insult you on Twitter as well, you can reach out to us at 5 1 2 2 3 8 0 7 6 2 and our website is armor mens health.com.
Speaker 3:
Especially if you are a weak need diagnostic radiologist.
Speaker 5:
<laugh> . It's not helping <laugh> . This is
Speaker 4:
<laugh> . You know what you told us about it. So
Speaker 3:
Dr. Preston is an interventional radiologist. He is the latest addition to the Jurassic Park that we call n a u urology specialist. He makes a fifth doctor, four urologists and one interventional radiologist. An amazing addition cutting edge . Uh , probably the first one in Texas. I don't know anyone that has an interventional radiology program in the entire state. No, as far as I know. Right . And it's so that we can add to our repertoire the prostate artery embolization procedure. If you wanna learn more about the prostate artery embolization for your enlarged prostate. You know who first talked to me about p a e is my own father. Really? Yes. In Houston. He's in Houston. And he called me 10 years ago and was like, Sonny , where can I get this prostate artery embolization procedure? And I would have patients that left Texas and go to other states in order to get the prostate artery embolization. Wow. And ever since my father shamed me into not knowing enough about that procedure, I have made it my focus and goal to include that as part of our approval . Uh ,
Speaker 5:
Is somebody still looking for
Speaker 3:
Their father's approval? Perhaps <laugh>
Speaker 5:
Daddy
Speaker 3:
Issues? I hope he doesn't hear this . <laugh> can't take . I'm sending it to him. <laugh> . So Preston, why don't you tell us kind of technically what's some of the equipment that you use and what are some of the technical considerations when it comes to, you know, performing the best prostate artery embolization procedure?
Speaker 5:
So we use, first off an X-ray machine. It is a little different than a, a normal, you know, fixed x-ray machine that someone may go get their, you know, let's say they , they broke their forearm like somebody I know I e my girlfriend. But it's a little different than that. It's called a C-arm. So it is, it's mobile and it allows us to see what we're doing inside of your body. We also use what I call a catheter. It can be confusing to some patients because when they hear catheter, they think of a bladder catheter, especially
Speaker 3:
When they're in a urology office. Yes ,
Speaker 5:
Mm-hmm. <affirmative> . So we're really setting them up for getting confused. But , uh, our catheters are angiographic or catheters that are used to do an angiogram, which is a die study of a vessel. So they're much smaller, they're much more like a long iv and they have many different shapes to them. And those catheters will allow us to get inside of arteries that are not just a , you know, a straight highway. So we can get inside curved arteries, double curved arteries, hairpin turned arteries. They are many different catheter shapes. So we use this X-ray machine. This is like F one. That's right, exactly. I know F one
Speaker 3:
For the veins. Arteries. Arteries, sorry.
Speaker 5:
So we use, we use that and then some wires to kind of help snake this catheter inside of arteries. And in this case, we combine all these things together and we will identify by injecting dye through the catheter and then work a catheter into the prostate arteries. And we do all this with the live x-ray machine kind of going as needed. And then once we are in the right spot into the arteries that are feeding the prostate, which is usually one per side , uh, we will drip these small beads, these small medical grade plastic beads into the prostate arteries. And the beads I use , uh, are a little less than a half millimeter in size.
Speaker 3:
Wow. It's funny you, you mentioned that , uh, you know what , I have probably been gifted with some of the most amazingly self-taught patients on earth. They're Google experts. It's Dr . And one of them the other day visited us from outta state and asked me what size bets Wow . You used . I was like, I have no idea. That's a pretty specific question. So , so you , you , you use beads that are about 500 nanometers. They
Speaker 5:
Are 300 to 500 microns. Okay . Those are, those are the microns wow com common size , so 0.3 to 0.5 milli millimeters.
Speaker 3:
Millimeters. Wow. And about how many beads like go into like an artery in case some patient asks me next day <laugh> . Yeah .
Speaker 5:
It's , it's, I , I tell people if, 'cause that's about the size of a grain of sand or a little bigger than grains of sand. So I'll tell people, if you just took , uh, a generous pinch of sand, you know, we will probably use a quarter of that. And , and I mean, just with your fingers, not the palm of your hand, not grabbing it just like mm-hmm . <affirmative> , like a pinch of salt, like a , a big pinch of salt. Mm-hmm. <affirmative> , we probably use half of that or less than half of that , but
Speaker 3:
You're able to check in real time whether or not the blood flow through that artery is being obstructed properly. So you'll use more or less of the beads in order to appropriately occlude that artery. Yeah .
Speaker 5:
It's , it's highly variable. It's generally, so a big pinch of sand is how much comes in like one dose, you know, it's , it's mm-hmm . <affirmative> , it's , it's about two cubic centimeters and it's rare that I'll use the whole thing whenever I'm using the whole thing. I'm like, oh my gosh.
Speaker 3:
So explain to me physiologically, because I know, but our listeners may not know, why don't the beads go anywhere else?
Speaker 5:
So as, yeah. As arteries kind of break into more and more branches and they break into an almost innumerable number of branches by the time you get to the capillaries mm-hmm. <affirmative> , so half of a millimeter in size is way, way higher up in the branching of the tree. So those beads will get stuck, let's say after an artery branches into just eight, eight arteries. And they will get lodged in there. Like I tell 'em , like a fat guy trying to get through a door and they'll get stuck. And so I don't think you can say that anymore. Yeah. I don't, you can't say it . No . Especially
Speaker 3:
When a large
Speaker 5:
Heavy
Speaker 3:
Or a large man man can't say of these things , a big man coming through a tiny cat door
Speaker 5:
<laugh> . Yeah. A small guy or a big guy or , or a , a big guy trying to put on a small coach jacket . There we go, Tommy, Tommy boy, <laugh> . Um, so once those beads get stuck in there, the blood flows in one direction or generally one direction only. So your blood flow is going to be kind of hammering with your pulse, these beads into a smaller than space than they are. And these beads are kind of like rubber bouncing balls. They're a little squishy, so they get like squeezed into whatever space they are and then they're stuck there so they don't wash through and come back out and go somewhere, somewhere else or swim against. They're not salmon, they don't swim against the , uh, the current of your blood . Here's our
Speaker 3:
T-shirt. Another thing
Speaker 5:
People beads are not salmon.
Speaker 3:
Yeah . Another thing that , uh, uh, patients , uh, are frequently concerned about is like this idea that you're cutting blood flow off to an organ. Like doesn't it die? And so I I kind of explain it's a little bit like yeah . You know , uh, uh, choking , uh, <laugh>
Speaker 5:
For those who
Speaker 3:
Like that, for those who like that , uh, it's a little bit of excellent choking , uh, but not completely choking to death because there's other blood flow to the prostate, you know, from the urethra, from the bladder, from the penis. And so the prostate doesn't completely die. Right.
Speaker 5:
It , yeah, it doesn't, it's, I , I mean, they've done studies on this where they, you know, before we tried this out on humans, luckily we have the F D A who says, you gotta show me that this works on something else. So, you know, at the risk of offending peta , I'll tell you they did this on like pigs, you know? Mm . And they embolized the prostate using the same size beets we do, and then they took the prostate out and looked at it and the prostate doesn't die or necros right away. Mm-hmm . <affirmative> , they're tiny areas of it that do just right next to blood vessels, but your body can handle that. But most of the prostate shrinks down and they're like sunny explained, there are two, there are two reasons for that. One, the , the prostate has a bunch of different blood supplies, alternate pathways, and then two, the bigger particles you use . So if we used 500 to 700 or all the way up to a a millimeter in size particles or beads , uh, red blood cells can kind of sneak around these bigger beads. So if we use really small ones, those get stuck much deeper and they kill things, you know, more so the size of the beads we use is very specific
Speaker 3:
Size matters.
Speaker 5:
Yes . Size is what we ,
Speaker 3:
We believe strongly there's , please reference our previous Dr . Dellinger penis enlargement , uh, conversation. So , um, when somebody , uh, is getting this type of procedure done, what do you generally tell them about how quickly they can get back to their normal activity? Because they can get back to golfing pretty quick , right? That's
Speaker 5:
The best part. Mm-hmm . <affirmative> , you know, you , you just have to stay away from heavy lifting for 48 hours. And that's really something that I told people that, you know, in the old days, in older days, yeah. So we surprisingly knock on wood out of like over 250 patients that we've only specifically done prostate embolization to , no one has had a real groin complication, which is pretty unbelievable. And so that means that either means our patients are following their directions Exactly. Which I sometimes don't believe or <laugh> . Um, we could, they could probably do even more. They can pretty much walk out on their own. They have to, yeah. Yeah . They're walking.
Speaker 3:
And a lot of our listeners are gonna go online and see like a company like Austin Radiologic Association or a r a offer, the same prostate artery embolization, but this, these are unsupervised radiologists. You need a urologist that's working with your radiologist to get the best possible outcome. And so I highly discourage people to going just straight to a radiologist to get this done. Even though it's a somewhat unique offering. We take all insurances, we will do a completely thorough evaluation and make sure that your lifestyle and your expectations are met. So , uh, when it comes to prostate artery embolization , uh, urology radiology collaboration is something I cannot emphasize more. Donna, how do people get more information and get ahold of us? That's
Speaker 4:
Right. You can call us at (512) 238-0762 and visit our website, armor men's health.com.
Speaker 2:
The Armor Men's Health Show is brought to you by N a U Urology Specialist. For questions or to schedule an appointment, please call 5 1 2 2 3 8 0 7 6 2 or online at armor men's health.com.
