Francisco Cesar Carnevale, Associate Professor of Medicine, University of Sao Paulo, Brazil, is one of the pioneers in the field of prostatic artery embolization. In this article Dr. Carnevale explains how PAE is positive for both patients and hospitals.
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Dr. Carnevale, why is PAE an attractive alternative to medical or surgical treatment for patients suffering from benign prostatic hyperplasia (BPH)?
Carnevale: PAE is being used all over the world as an attractive alternative to medical and surgical treatments for patients suffering from BPH because it is a minimally invasive procedure, performed under local anesthesia on an outpatient basis, with no reported cases of urinary incontinence, retrograde ejaculation and erectile dysfunction. That is why embolization has gained a lot of support from patients and from medical specialists even outside interventional radiology.
Since the first case was performed by our team in June 2008, we have received recognition and support from the Urology and Radiology Departments at the University of Sao Paulo Medical School in Brazil.
This was vital for clinical research in order to continue to prove that PAE is a safe and effective therapy. From our initial reports, published in 2009 in the journal CardioVascular and Interventional Radiology (CVIR), several studies have been performed to improve the technique and identify the best candidates for the procedure. The fact that other international centres have adopted our PAE technique (the PErFecTED [Proximal Embolization First, Then Embolize Distal] technique) shows that we are moving in the right direction.
In Sao Paulo you have established a “decision board” similar to a multidisciplinary tumour board in order to decide on whether to undertake the surgical vs. minimally-invasive approach. How are patients selected?
Carnevale: Patient selection is crucial for any therapy. In our institution, every single patient who has undergone PAE was discussed with a team of urologists before the procedure. Urologists make the final decision regarding indications and contraindications for treatment. We have received patients from urologists and other medical specialties. Nowadays, the vast majority of patients come directly to the urologist or interventional radiologist, after reading about the procedure on the internet or talking to other patients who have been previously treated. Awareness is essential and patients are usually very satisfied after undergoing PAE.
When looked at from a business perspective, is this treatment appealing for the hospital?
Carnevale: PAE is a very attractive option to hospitals as well. With PAE, a hospital can show that it is up-to-date regarding emerging therapies in modern medicine. They can obtain accolades for pioneering treatments, research and teaching activities. National and international recognition stems from that. PAE is also an outpatient procedure and hospitals are on the lookout for highly complex procedures that do not require patients to be in hospital for long periods in order to have a high rotation of beds. The opportunity to advertise the hospital using a new therapy is also a strong promotion for the hospital.
“With PAE, my hospital can extend the spectrum of BPH therapies. For the best of our patients.”
How do patients receive the treatment?
Carnevale: I have performed PAE all over the world in clinical practice and in teaching and research programmes, and have participated in more than 500 PAE procedures. It has been an amazing experience with patients, physicians and medical institutions. The vast majority of patients have provided positive feedback about embolization. I feel proud to be recognized as one of the fathers of PAE.
How is PAE reimbursed in Brazil?
Carnevale: In March 2016, healthcare authorities in Brazil decided to accept PAE as a treatment alternative to transurethral resection of the prostate (TURP). Obtaining this was like “a war with several battles on many fronts”. We had to compile a range of data from the animal studies performed in 2007 to preclinical and clinical studies carried out at the University of Sao Paulo Medical School. This helped the Federal Council of Medicine in Brazil to approve of and recognize PAE as another treatment alternative for patients with lower urinary symptoms related to BPH. We had strong support from the Urology and Radiology Departments, especially from the respective chairmen, who have been my mentors for the last 10 years, professors Miguel Srougi and Giovanni Cerri. In Brazil, PAE does not yet have a specific code of reimbursement for “BPH embolization”. It is often necessary to deal with individual health insurance companies, but some have approved of and pay for the procedure.
What future trends do you see with respect to minimally invasive treatment of the prostate?
Carnevale: In the last decade, we have observed many new treatment alternatives for symptomatic patients who are suffering from prostate enlargement. Minimally invasive treatments like stents, ablation, vapourisation, lifting and lasers have been offered. Taking a “helicopter view” this offers a chance that any of these therapies could offer patients a good quality of life, as well as be safe and effective. With embolization, we are offering another minimally invasive treatment to patients, one that appears not to put a patient’s sexual life and urinary continence at risk. I believe it is now time to acknowledge PAE and internationally recognize it as a new treatment alternative for these patients.
Dr. Carnevale, thank you for taking the time to talk with us.
About the Author
Urmila Kerslake is a Bristol-based journalist. She is the Digital Education Lead and Senior Editor of the specialist quarterly newspaper, Interventional News, with which the content of this article first appeared as part of a supplement.