EP 659: Dr. Smith on Why PAE is the BEST KEPT SECRET in Urology

In this episode, Dr. Mistry and Donna Lee are joined by interventional radiologist Dr. Preston Smith of Summit IR to discuss Prostate Artery Embolization. PAE is a cutting-edge, minimally invasive, and mostly permanent treatment for an enlarged prostate (also known as BPH). The process of embolization shrinks the prostate by cutting off its blood supply by blocking an artery. Embolization is also 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.

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Phone: (512) 238-0762

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Transcript

Speaker 1 0:00

<silence>

Speaker 2 0:07

Welcome to the Armor Men's Health Show with Dr. Mystery and Donna Lee.

Speaker 3 0:15

Hello and welcome to the Armor Men's Health Show. I'm Dr. Mystery , your host, always joined by my co-host, Donnel Lee .

Speaker 4 0:22

Hi. Welcome everybody. Welcome back to the Shoe .

Speaker 3 0:24

This show is brought to you by NAU Urology Specialists, the urology company that I started in 2007. We have four offices. We have seven medical doctor providers. Mm-Hmm . And we have so much to offer our patients. Donna, how do people get ahold of us? That's

Speaker 4 0:41

Right. You can call us to learn more about our providers at 5 1 2 2 3 8 0 7 6 2 and check out our website, armor men's health.com. Like Dr . Mystery said, we're all over the place. We're worldwide. Dr . Mystery,

Speaker 3 0:51

Worldwide when it comes to men's health, prostate health and urinary health is a big deal.

Speaker 4 0:57

It is a big deal.

Speaker 3 0:59

And when men are confronted by BPH or enlarged prostate with urinary issues such as slow flow, urinary hesitancy, and problems with urgency Mm-Hmm. <affirmative> , they're given a a lot of different options. Yep . And if you have a urologist out there, or your primary care doctor is taking care of you, you may be given options. And so we'd love to talk about some options that we offer that are different. And we are gratefully joined by one of our amazing partners here, Dr. Preston Smith. Welcome Dr. Smith. Hey,

Speaker 5 1:29

How you doing Preston ?

Speaker 3 1:30

You're amazing. <laugh> .

Speaker 4 1:32

So engaging right off the bat . <laugh> ,

Speaker 3 1:35

He , he's so engaging. You know , uh, uh, interventional radiologists and urologists have a love-hate relationship. Do they? They do. Oh , because

Speaker 4 1:43

They're both nodding. So that must be true

Speaker 3 1:44

Because we need them to do things in the hospital. Mm . And oftentimes they don't do it.

Speaker 4 1:49

Why? I don't know .

Speaker 3 1:50

Why

Speaker 4 1:50

Don't they do it, Dr. Smith?

Speaker 5 1:52

Well, that's a, that's a whole, that's a whole long story that I don't want to get into right now.

Speaker 3 1:57

<laugh> , there's a lot of like, jealousy on their part.

Speaker 4 2:00

Oh, no.

Speaker 3 2:00

Because urologists are good looking . Oh, smart. Oh, my

Speaker 4 2:04

Intelligent didn't have big hands. Both.

Speaker 3 2:06

And we have humongous hands. Oh boy . And luckily Preston was, you know, birthed with small hands.

Speaker 5 2:13

<laugh>, you need small hands to do the fine, you know, the fine work that I do. You're

Speaker 4 2:20

Saying he's a better doctor than you are, Dr . <inaudible> ?

Speaker 3 2:22

No, no . Small hands.

Speaker 4 2:23

<laugh>. He's more precise with this now.

Speaker 3 2:27

Yeah , perhaps. Um, so interventional radiology is a field of medicine that does what Dr. Smith.

Speaker 5 2:34

We do minimally invasive image-guided procedures, and many of them are replacements or alternatives to traditional open surgical techniques.

Speaker 3 2:45

So, as we talk in our first segment about what you do , uh, perhaps you could tell me the breadth of all the different procedures that you offer within our practice to help patients improve their life.

Speaker 5 2:58

So the two main ones that we do within this urology practice are prostate artery embolization and varicose embolization. And we do the, each of these procedures for several different things. Prostate embolization is most often used for shrinking down and large prostates and relieving the symptoms that they cause. And vari cil embolization is done for several reasons. Uh, first we do it for pain and maybe we wanna talk about what a vari CIL is in a little bit. Yeah . And then second we do them for fertility issues. Both of these are outpatient procedures. And we do both of them using live x-ray guidance, which is also called fluoroscopy.

Speaker 3 3:44

So that's like what we do in urology. But we have more things that we do even in urology that you are a part of. So, biopsies of different lesions , uh, including lesions like lymph nodes. You can do biopsies of renal tumors and you can even cure kidney cancer. Is that right?

Speaker 5 4:02

Yes, that's true. Instead of traditional nephrectomy or resection of a tumor that's in the kidney, we can put small needles inside of these tumors and then create what we like to call. 'cause it sounds really cool, is an ice ball and frees the tumors, more balls, they're everywhere. <laugh>.

Speaker 3 4:25

So , um, as a surgeon, I love to cut. Why would a patient want not to be cut on? It seems odd to me .

Speaker 5 4:31

<laugh> . Well, sometimes when you, when you cut, if it's just a small hole, it's, you know, it's no big deal. But if you're gonna remove a kidney, that's a , that's a bigger hole, you know , uh, many times or sometimes, whereas if we go into the kidney and then freeze the tumor, the holes I need to create are only as small as the needles we need to place inside the tumors. So they're, they're very small. Not even requiring a stitch , uh, once we pull the needles out.

Speaker 3 5:01

Mainly because you can sew correct.

Speaker 5 5:04

<laugh> ? Well, I've got these small hands. They're very good for sewing <laugh> .

Speaker 3 5:07

And then sometimes patients come to us with , uh, masses on their kidney that they wanna know if it's cancer or not. And you're able to do a biopsy, correct? Mm-Hmm. <affirmative>, talk us through what that may look like for a patient.

Speaker 5 5:18

So when patients are undergoing biopsies, they come to us for an outpatient procedure. So you don't have to go to a hospital to get this done. Typically, we can see these kidney lesions with one of two imaging modalities, either ultrasound or ct. Um, you can't typically see them with x-rays. And we don't do things under MRIs to the kidneys.

Speaker 3 5:46

'cause they take you long to like process the images. Yeah.

Speaker 5 5:48

It , it would be somewhat impractical. And then there's a whole, you can't use metal things inside of the MRIs. That's special needles.

Speaker 3 5:56

Your needle's gonna fly away. Yeah. <laugh> . And so , um, beyond that we also do uterine fibroid embolization. Can you talk a little bit about

Speaker 5 6:04

That? Yes. Uterine fibroids are benign tumors of the uterus that usually cause lots of bleeding during women's menstrual cycles and sometimes bleeding outside of the cycles. And then they can also grow large enough to where they kind of push on everything else in the pelvis. So that's the bladder, the bowels, sometimes the muscles of the back. And they can cause a lot of different issues. And if they get large enough, women are left with one of two options, either wait around for menopause to happen or get your whole uterus taken out. A lot of women don't like either of those options. So they'll come to us interventional radiologist and ask us to perform a uterine fibroid embolization, which is a procedure where we inject small plastic beads to block off the blood flow to the uterine fibroids and cause them to shrink down. And this will help relieve all of the symptoms that the fibroids cause again, most often bleeding and pain.

Speaker 3 7:07

And so most of our listeners would also not know that a urologist or a interventional radiologist that is a part of a urology practice could take care of knee pain. Can you talk to me about knee pain?

Speaker 5 7:19

Uh , yes. Knee pain, it's interventional radiology taking care of knee pain is, is coming in in vogue right now. Just like some of the other conditions we talked about. Traditionally, if you have very bad osteoarthritis of your knee, which is traditionally thought of as the wear and tear type arthritis, you can manage it with knee injections and some other, some other types of injections that are not , uh, the typical steroids that have been used. Or you can get a knee replacement. There's not like a middle option. Recently interventional radiologists have started embolizing or reducing the blood flow in areas where there is active inflammation due to osteoarthritis of the knee. And this is really good for people who may not be ready for a knee replacement or may not have enough cartilage damage to really warrant a knee replacement, but they still have very significant lifestyle limiting pain. So they're sort of stuck between a rock and a hard place.

Speaker 3 8:20

And so for us , um, we talked a little bit about baric seal embolization. And so I send patients to you that are older, that have significant varicose seals. How do you explain to a patient what a varicose seal is? And then I'll do it.

Speaker 5 8:33

So a varicose seal is, it's no different than a incompetent vein or a varicose vein, which is most often found in a patient's thigh. Often in the, the thigh of a , you know, a woman,

Speaker 3 8:47

Those big blue veins that we see in the thigh and the calf.

Speaker 5 8:51

And that vein that we see is usually the result of something deeper upstream. A vein that doesn't have working valves, allowing blood to kind of pool or drain flow in the wrong direction with gravity away from the heart with gravity. So I'll tell the patients that these ropey visible veins can be fixed by fixing the drainage problem, which is upstream.

Speaker 3 9:16

And so in urology we see verica seals commonly in people with left-sided testicular pain, usually a dull ache with continuous standing or , uh, heavy lifting. And then we see it often in people with infertility. And so you can have it surgically repaired by an open incision and a microscope. And we love doing those and we do tons of them. Uh, but you do it in a minimally invasive way. How long does the procedure take

Speaker 5 9:42

A unilateral vari cil embolization? I'll tell patients it's one of the simplest things that I do, you know, the common left sided embolization, because the incompetent vein almost always comes off of the left kidney vein. And if we approach it by getting into that vein from above, which is access in the main vein in the neck, it is almost a straight shot. So it'll take us like 30 minutes, quote unquote , from door to door when we start to, you know, start the clock for the, with the anesthesiologist to when we're rolling outta the

Speaker 3 10:13

Room. That's amazing because it takes me , uh, two hours to do it. And uh, Donna, if people are interested in an interventional radiology or a minimally invasive technique for any of the conditions we talked about today, how do they get ahold of us? You

Speaker 4 10:26

Can call us at (512) 238-0762 our website, armor men's health.com. Send Dr. Smith any questions you'd like and we'll answer them anonymously.

Speaker 3 10:35

Hello and welcome to the Armor Men's Health Show. I'm Dr . Mystery , your host here as always with my wonderful, beautiful co-host Donnelley . Oh.

Speaker 4 10:43

Oh , that's me. <laugh> . You're gonna say something else. Thank you. That's very nice.

Speaker 3 10:47

I've decided to be nicer to you.

Speaker 4 10:49

I like that approach. 'cause you've been mean to me for four years.

Speaker 3 10:51

Yes. It's probably no longer going to get me anything because so many of our patients and so many of our listeners love you more than me. That's

Speaker 4 10:59

Right. And you do need to be nicer to the love to one on the show. That's

Speaker 3 11:02

Correct. That isn't . And so this show was started , uh, by my urology practice. NAU urology specialist , uh, started in 2007. Donna, how big are we?

Speaker 4 11:12

We're so big. We're busting at the seams. And we need another office, Dr . Tory . That's how big we

Speaker 3 11:16

Are. Size does matter. Sometimes it

Speaker 4 11:17

Does matter. We're second largest, but now we're like really large . Second largest. The

Speaker 3 11:20

Second largest urology practice in Austin.

Speaker 4 11:24

That's right. It was a joke before. 'cause we had so few doctors, but now we have too many.

Speaker 3 11:28

We have too many <laugh> . Uh, but we do have availability for you if you want to be seen. Um, and uh , Donna, how do people get ahold of us?

Speaker 4 11:35

Call us during the week. Get 5 1 2 2 3 8 0 7 6 2 in our website, armor men's health.com where you can submit your questions. We'll answer them anonymously. And remember, we have podcasts wherever you listen to free podcasts.

Speaker 3 11:47

What's nice about being big but not too big is that we're not owned by anybody. Mm-Hmm. <affirmative> . We have our own doctor led organization. Right. We really care about patients and their care and we're able to offer state-of-the-art cutting edge technology because I believe in it and our doctors believe in it. And we don't have to worry about a corporate overlord worrying about our decision making . That's

Speaker 4 12:13

Right. And the big group doesn't have what we have.

Speaker 3 12:16

Not yet.

Speaker 4 12:16

That's right. We got Dr. Smith.

Speaker 3 12:18

We got Dr. Smith. Dr. Preston Smith is joining us again. Uh, Dr. Smith, thanks for joining us today.

Speaker 5 12:24

Anytime . So

Speaker 3 12:24

I want to talk , uh, today about prostate artery embolization. So why don't you tell me your talk track or what you tell patients about what symptoms of BPH people can expect to get as they get older?

Speaker 5 12:36

As you get older, and I know our listeners are, they are very well educated on BPH, but it is a process that we don't completely understand. We know it's testosterone related, and we know that this is at the root of causing the prostate to slowly grow as we enter middle age and later age , uh, later in life. And the prostate as it grows, will many times slowly kind of choke off the exit of urine from the bladder. And that will cause two things. One of them, you, you feel it right away. It's a weak stream or difficulty initiating urination. And then the other one, which is, is what I tell patients, the real problem is that they start holding on to more urine as it gets more difficult for them to urinate.

Speaker 3 13:27

And that's called urinary retention. And urinary retention can cause urinary tract infections, bladder, stone , and even sometimes in drastic fashion. Renal failure. Mm-Hmm. <affirmative> . And so , um, most urologists offer many different ways of treating this and they can include terp , they can include aqua ablation, UroLift, rezum. You may have heard many different terms to fix BPH. And we offer within our office prostate artery embolization. Can you briefly talk about what are the benefits of PAE over traditional ways of dealing with BPH?

Speaker 5 14:07

The benefit of PAE is best ex , I best try to explain it by comparing it to those nasal strips that let people breathe easier. You know, for years there were many different ways that people would try to fix their breathing through their nose. And it always involved blowing balloons up or putting tubes in or doing all kinds of things to the nostrils. And then some smart guy came and said, Hey, how about we put something on the outside of it to just kind of open things up a little bit. And you know, that that guy saved a lot of people because it's a lot easier and it required a lot less kind of , you know, stuff going inside of people's noses.

Speaker 3 14:44

And in this nose and tr um , arena, you can actually go in there and scrape stuff out just like a turp .

Speaker 5 14:49

Right, exactly.

Speaker 3 14:51

And so , uh, in the same way you go , uh, arterially through the vasculature and try to cut off the blood flow to the prostate to shrink it. Mm-Hmm. <affirmative> . Um, what does the procedure look like for our patients?

Speaker 5 15:03

It is, it , it is a, a an angiogram, which is a die study done with live X-ray, where we identify the arteries of the prostate. And then we slowly drip these small beads that are less than a millimeter in size into these arteries. And this chokes off most of the blood flow to the prostate gland without actually, you know, touching the gland physically. And patients undergo this as an outpatient procedure. So they'll come into our office, change clothes, roll back into our live X-ray room, which is called a cath lab, and then undergo this procedure. It takes about an hour and 10 minutes. And then they'll roll back out and recover for an hour. And then we'll get 'em up , make sure they're walking around. Okay. And then they can leave.

Speaker 3 15:50

When can they expect improvement?

Speaker 5 15:52

10 to 14 days after the prostate embolization is the average time for noticing, usually it's first off improvement of urine flow or patients will describe it as things are things are loosening up and I'm able to pee a little easier. Um, and then a lot of the other symptoms which are that silent, you know, the silent symptoms we talked about earlier,

Speaker 3 16:15

Urgency, frequency, nighttime peeing.

Speaker 5 16:18

Yes. Tho those symptoms will begin to improve some somewhat right away with the improved flow. And then they'll continue to improve kind of as the bladder sort of regains its flexibility over the next several months.

Speaker 3 16:31

And I tell patients that you have to wait about 12 weeks before to see maximum improvement. Mm-Hmm. <affirmative> , what do you tell them? Yes.

Speaker 5 16:37

I I tell 'em the same thing. Just because it takes, the prostate will keep shrinking. Although its gains after, let's say eight weeks are not as much, whereas the bladder will keep regaining its flexibility all the way out to three months.

Speaker 3 16:53

So then you have , uh, the lack of a need for a catheter. Correct?

Speaker 5 16:58

Yes. It's a patient's favorite part about see .

Speaker 3 17:00

So nothing in your peepee . Nothing. And that's amazing. And then in terms of sexual function , uh, what do you tell patients in what they can expect for a difference in sexual function?

Speaker 5 17:11

Uh, some patients will actually notice that their sexual function improves. The number is somewhere around 15%. We don't quite understand exactly why this happens, but there are nerves that run along the outside of the prostate gland and through the prostate gland. And if those are left alone during any sort of intervention, then as the prostate shrinks, there is sometimes a chance for improvement.

Speaker 3 17:38

So when somebody gets one of these and if it works, then they can get off their medications and if it doesn't work, does it interfere with any other procedures?

Speaker 5 17:47

No, this is, it doesn't take anything else off the table. So I , I try to tell patients it's like going in and getting a haircut right before some really important event. Like let's say you're getting married and you're going to get a haircut the next day or , or the day before, you can always cut off a little more hair. But if you shave your head, you can't add that hair back on before the wedding. So

Speaker 3 18:09

You're not married. Correct.

Speaker 5 18:11

<laugh>? I'm <laugh> , I'm not. I've got long hair not, not cutting it. No

Speaker 4 18:16

Small hands , long hair.

Speaker 3 18:18

It's

Speaker 5 18:18

Okay . It's a great company . He's not,

Speaker 3 18:19

He's not, he's not Mary worthy. But , uh, that's okay .

Speaker 4 18:22

That is not true.

Speaker 3 18:24

It's because he is short.

Speaker 4 18:25

Be nice to our doctors.

Speaker 3 18:27

Anyway. Dr. Smith , uh, so when it comes to recovery, what do you tell your patients in terms of , uh,

Speaker 5 18:33

Recovery? I tell them that it's going to, their only restrictions are two days of no heavy lifting. And then patients will also ask when they can resume any sort of sexual activity. And that's also two days of no heavy lifting. Wink wink. Yeah. Silly .

Speaker 4 18:47

I feel bad. Two days

Speaker 3 18:48

Just stay there. Right ? Just , just lie there. <laugh> .

Speaker 4 18:51

Oh no. I could see a prescription pad going crazy with instructions.

Speaker 3 18:55

And when it comes to payment for this, this is not a cash paste , uh, service that we offer many interest to pay for it. Uh , if somebody had to pay cash, what do we charge?

Speaker 5 19:05

We charge, gosh, I think it's $12,001 million.

Speaker 4 19:09

No ,

Speaker 3 19:09

$1 million. Mm-Hmm .

Speaker 5 19:11

<affirmative> , it's 12 , $12,000. Mm-Hmm.

Speaker 3 19:13

<affirmative> . So that is what our cash pay price is because on this show we always talk about price. So you know what to expect and , but , uh, a lot of insurance pay for it , uh, which ones all

Speaker 5 19:22

Of the major insurances except for Aetna will cover this procedure.

Speaker 4 19:26

So patients just pay a copay? Yes. And they're just gonna have this amazing procedure and their lives are changed

Speaker 3 19:32

And Medicare pays for it. Medicare. Right . Which is very important. And we also use this procedure to downsize a prostate. So if you have a humongous prostate, a normal one is 30 grams. If you have 120 gram prostate, we can downsize it and then maybe make you eligible for a less invasive procedure.

Speaker 5 19:49

Yes. It, it works hand in hand with some of the other minimally invasive interventions that still go through the urethra or through the penis, but cause less issues afterwards. So it's, it's kind of like down staging cancer from a high stage to a low stage. We downstage your prostate , uh, to a smaller size.

Speaker 3 20:09

What kind of diagnostic evaluation would you like to see before you do APAE on a patient?

Speaker 5 20:14

Generally the one number I have to know is the size of the prostate clinic because

Speaker 3 20:19

Really, really small prostates don't do

Speaker 5 20:21

Well. They don't do as well. Yeah.

Speaker 3 20:23

What is your ideal prostate size?

Speaker 5 20:25

Greater than 50 grams is good. Greater than 40 grams is still still okay. Greater than 80 grams is really good. So if everyone had an above 80 gram prostate,

Speaker 4 20:37

How big is an 80 gram? Is that a walnut?

Speaker 3 20:39

It's like a tennis ball . Tennis ball .

Speaker 4 20:42

Oh, that's big. Okay. Right .

Speaker 3 20:43

It's a big prostate

Speaker 5 20:44

Hundred. I forget what grapefruit is. It's like, like 160 or something.

Speaker 6 20:48

That's a big grapefruit baby. That's it. Yeah .

Speaker 3 20:51

Donna, how do people get ahold of us and how do people meet Dr. Smith?

Speaker 4 20:54

You can call Dr. Smith at (512) 238-0762 and visit our website, armor men's health.com. Check out our podcasts wherever you listen to podcasts. Thanks Dr. Smith. Thanks Dr. Mistri .

Speaker 2 21:05

The Armor Men's Health Show is brought to you by NAU 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.