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good evening, everyone, and work with Thio. I have a bike at this evening session is one prostate artery embolization. And if you're watching this live than, I hope you enjoy it. But for those watching on capture up a swell If you watch over 80% of the content, you'll get a certificate at the end at evidence your attendance and I'll pass over now to his mom, My who is an ST six by our base in for me. Um and he's not giving us talk deceiving on course they are three embolization. So without further ado, because, man, I would like to take it away. Sure, thank you very much, Chris, for the invitation to teach on this great initiative education initiative set up by our juniors and going through the search the interventional radiology curriculum for medical students. So that's me as Christmas and on by no means an expert in this field. However, for my limited experience with senior colleagues on being involved in a number of cases on going through literature, I'll like Teo present Teo prostate artery embolization. So as it is already being mentioned, that this is the curriculum that we're trying to go through in this Siris off talks. Uh, this is the developed by, sir. See? So what is prostate Artie embolization and what we're going to cover during this talk clinical presentation, including classifications imaging findings before intervention. I are treatment options on clinical care and follow up. It's the same format for eat in the way they've done it through the curriculum. So clinical presentation, including classification. So the points to cover here. So men with BPH present with lower urinary tract symptoms which will cover in a bit more detail, will go through the IPT I pss scoring system. So background wise anatomy. So the prostate is a walnut sized organ at the base of the urinary bladder. So you got a flat it Here I'm be anatomical astray. Shins date back to the 16th century. It's just a bit of history there in terms of anatomically describing the prostate prostate, it was initially thought to be in lobes. However, this could not be defined by the section, and so the MacNeil classifications of three distinct areas into nonglandular fibers, fiber stroma to glanders regions well developed, is currently used in practice. I'd like Teo mention the central zone there and Fruitful Zone. But one. Our area of focus is predominately on the transitional zone, which is around the urethra. It's only a small part of the prostate, approximately 5% even 10% in some. Some place that says Ah, and why is that important? It's the principle site for benign prostatic hyperplasia, so Nodular expansion occurs. It compresses the urethra and results in bladder obstruction, which is often partial. And that's why they present, you know, but can also present with your new retention. So in terms off histology and gross anatomy, we could see that the transitional zone hairs there's nodular enlargement of the transition is there in this correlates on, um on histological side slides in terms of terminology. Yes, it might seem a bit damn tick, but it's quite important to cover so benign. Prostatic hyperplasia is a histological diagnosis. What was CNN Clinic is benign prostatic enlargement. There is this other small, intimate entity, which again it's probably a little bit sketchy, but essentially is benign prostatic obstruction, which means that prostate is not enlarged, but they are still experiencing symptoms. So what happens in BPH as well? Just touched on it briefly nodule a multi nodular involvement and adenoma. Marta's an adenoma itself is a benign growth, non malignant growth. And you could see from this illustration that where the benign groups and we're prostatic enlargement, uh, happens. It can result in a structure in off the off the wreath right, resulting in the symptoms I mentioned dynamic in terms of the prostrate smooth muscle on the tension. Because some of the medical therapies are based on that with regards to a judge, BPH is common so on autopsy data. About 50 to 60% of patients who are in the sixties have BPH on this. Increases when patients go into their seventies were on 80 to 90% off people. Men who have benign prostatic hyperplasia. Again, this is what we're focusing on bladder outlet obstruction, and we'll go through some of the symptoms which relate to bladder, ultra outlet obstruction and where prostate artery embolization has a role again, as it's it's a focus on on the medical student curriculum would just go through basics of presentation. When the patient presents you take a history, we go through some examination, investigations and management. So how do these patients present well. They'll present initially to the general practitioner and refer to urologist. And if they do require interventional radiology therapy, they will be then referred to us. Now. I just wanted to emphasize on this point that multi disciplinary team approach is is very important here. PA is one of the options where used in management of BPH is not the soul an exclusive option. But it's one of many options that are available on there for a multi disciplinary. A team approach is of importance, so lower urinary tract symptoms just briefly have just put it down as lots. So we got stories symptoms of put down. Funny is one way to remember. It's no actually fun for the patient so they can experience frequency, urgency and nocturia. And then we've also got voiding symptoms here ahead Tennessee Intermittent urinary stream terminal black dribbling, so least have hair prostatism. It's got an old turn on what we just referred to these groups. Symptoms is pretty much just known as lots. Now the IPSS. It's a year. It's old urinary symptoms, so seven questions each one. It's a scoring of 0 to 5 on the maximum points of 35 this broad classifications of them into mild, moderate and severe. It's quite brought. It's it's been set up in a way which, ah, it's accepted. Now this is an example off the IPSS, um, scoring system. So give you a brief moment to go through. Go through that essentially bladder outlet obstruction. So the story symptoms you mentioned of frequency, urgency and nocturia. And so the voiding symptoms are pretty much the rest of off the symptoms there and again, those are the The voiding symptoms is where patients, you know, experiencing bladder outlet obstruction. So this is scored out of 35 in and cast if I was mild, moderate or severe. And the reason that's important is because pft is often, you know, treatment for BPH is warranted. Flotation. So, you know, considered should be considered by patients. A zoo connected decision for patients who have moderate to severe scoring system. There's also additional question on quality of life or do to the urinary symptoms. I'm not sure how this like it scales come about, but essentially means if they're delighted, um, down too terrible. There is also on I i E f international index of erectile function, and then I've put there beside it. I I I i e f five because now a compact five question with regards to erectile function there, I mean the quite intimate questions. And again, the IPSS is, uh, you know, the complete compliance. But the response rate to that is probably more accurate with regards to the I I. Yes, again, it's been more intimate questions, but it is off use. Clinical examination eso Often seen by a GP or urologist, they may have a palpable bladder from bladder outlet obstruction right. The role for the digital rectal examination is to look for whether it's a benign feeling, smooth prostate or is there a regularity or nodularity might be concerning for cancer blood test, which can be done things that renal function to investigate other causes off lots on the pier See could be elevated, but it's not specific. Furthermore, euro dynamic the flow studies can also be performed, which will help in patients election. So now, moving swiftly onto imaging, Um, as you know, a talk on interventional radiology and then you know the radiology bit. It is something that we've got a deeply understand and it plays a huge role in identifying suitable patients. Feet p A. So the point from the curriculum, which we're just going to cover here. Imaging modalities includes ultrasound and MRI to determine gland size and lack of malignant features. M R, A or CT A. Helps assess the variable prostatic vessel anatomy before the procedure, so each in turn ultrasound. It's a quick examination can be done in the clinic. Doesn't involve radiation. You know you can get a volume measurement. You can use the calculator. Anything greater than 30 mills is usually considered as an enlarged prostate. Why do we do MRI? Well is to further evaluate, particularly in those patients where they have, you know, risk factors for malignancy, and you want to rule out cancer. It's a better investigation. Investigation. It is, doesn't have any radiation. However, it's longer. MRI sequences can take longer can be quite uncomfortable for some of the patients, particularly with this kind of being quite noisy. Contraindications. Just this image off. You know, putting metal by a magnet doesn't work. So again, there'll be some patients who cannot have MRI scan for a particular reason. How it does allow you to assess volume quite accurately. Ultrasound is very operated, dependent on can be quite subjective. On the also, the role for cancer is also there. So an important tour in ah, work up of a patient with BPH or working up for P. A. This is an emery picture off BPH, and we've got actual sagittal on da Corona low T two slices, which showed an enlarged prostate. As you can see, the median lobe is going up into the bladder. In fact, this patient with this medium lobe so abutment off the bladder they may not necessarily be suitable for Pa, but the features here just are benign prostatic hyperplasia on imaging on Ah, you know, again, it's pretty much not sure it will. There's no malignant features, and again, that's probably where the role of MRI ah lies with regards, Teo computer tomography and geography. CT A. It's important on it was important in terms off planning. Um, it's basically ah, a doughnut, and some may call it on. Dad is why I've got that there. So it does involve radiation, however, it's relatively quick, but it does allow good um, demonstration or vascular anatomy. You could arguably calculated volume from the CT A. But main thing here is vascular anatomy on the prostate. Artery is very small, talking literally Millimeter two millimeters on for us to see it better on a CT. A imaging. We can give a bit of GTM, which will dilate the vessels on allow them to manifest better on a CT scan and eight for planning. So why, it else is, Ah, ct. A important you can plan for access how you're gonna plan the procedure. You look for atheroma. That may preclude you from getting to the prostate artery. And, you know, um, a patient therefore may not be suitable for a prostate artery embolization. I can't emphasize this point enough in the sense that it's very important to look for the anatomy. I put conventional in inverted commas well later cover prostate artery anatomy on the various types that exist, And so we've got to be careful of variance. So essentially, it's a very important planning to. Here's an example of a CT A. So we can see that. You know, we're trying to get to the small arteries that absolutely tiny, and in this particular case here, you can see that there's some after him and near the origin again. It's something that is very useful for planning on at this point. A patient may also not be suitable for Pa, and then, you know it's not so. You know, you save that step from them attending on the day you're trying to cannulate a very difficult, um or, you know, trying to get access to a very tiny prostate artery. So it's very important in the terms of planning. So we have costed. I are treatment options. Well, there's one. There's prostate artery embolization. However, the point again. Like I said, it's just one selective embolization and prostate got trees with small particles. Efficacy it approximately 80%. And again, that's from the point on the curriculum from Sir. See how I'm just gonna go into a little bit more detail in terms of treatment options in general for BPH, which, although remains the remain off urology, but it's still important to consider again, like I said, is an MD T approach the medical so simple medication, as we mentioned earlier, it can be given the patient's see how they get on. They're surgical options again, remain of urologists. It's terp transurethral exception of the prostate. It's an invasive procedure there. However, less invasive surgical procedures resume your lift and occupation, which also mentioned, however, given a lot that we would still consider the IR option to be minimally invasive and that being prostate artery embolization. So this is what people think of radiologists. I'm not sure how much the experience the audience has had with or dealing with the radiology department or understand what radiology do, but they might think there's somebody sitting in the dark room looking at plain films, however, or they may think we do this and have bit of fun with a kit. But essentially, interventional radiology is a very clinical specialty. We find ourself in a theater type environment with an angio sweet, sterile equipment, you know. Still, everything's been done in a in a sterile fashion but fancy technology. It's very much a clinical specialty and can offer treatments for various conditions. Just a brief history of A. It's a relatively new treatment if you think about it since early 2000, so it's only within this century on. The therapeutic effect was first described around 2000 by this paper due back in in J B I. R. That then followed on with some animal studies is couple of papers here, which should animal studies. The first human treatment, which was intentional for P A as a primary treatment for benign prostatic hyperplasia, was described in 2000 and 10. So not that long. The evidence is, however growing. It's because it's a safe and effective procedure, and there's a lot of work that has gone on over the years describing and these are some of the studies or papers you know came to further, so I'm just going to keep it brief. But the evidence is getting strong. It's building, and you know, there's still a lot of work to do and the lot things that we can learn about prostate artery embolization. It's the more onda lot more work is going on again. Like I said, there's four more people experience in research out of bed and have done some great work, uh, with regards to prostate artery embolization research. So Pa versus other options some of the stuff we can take. It's a safe and effective procedure. It has a similar IPSS reduction compared with it, it's non inferior where it basically, you know, is useful is ejaculated dysfunction with Pa described as having less dysfunction on similarly less bleeding or lower bleeding risk and definitely a short stay with regards to the hospital. So it's a safe and effective procedure which has Bean in the UK approved by Nice. It's 2018. We've also got a certain standard of practice on prosthetic artery embolization, which is from 2020 on. We've also got a multi society consensus position statement on P A, which is quite important. This is these three are quite important references to be aware off on, you know, cover a lot of the evidence base up to up to the point of their publication just a little bit focused on patient selection and considerations. Now, Pa is not necessarily suitable for all patients with BPH. And like I said, I'm just gonna re emphasize it is one of the options and and MDT approach is quite important. With prostate volumes about 30 to 50 mills, you could you could could be said, you know, as it like t r u p and in a surgical treatment is very good for that. However, you know when you're going to higher volumes, particularly towards 100. Uh, Mark, then you know, Pa certainly has a a role with regards to that again. Felt medical therapy. You know, patients was suffering from your attention or the dependent on on catheters. Ah, I'm patients, you know, ultimately refusing surgery. There's quite a long list. I don't want to sort of go into too much detail off them, but they're they're on. You know, we have to also accept that the surgical interventions, whether it be invasive or minimally evasive, still have a role. We got the relative contraindications off p a. Then we just touched on that before, After sclerosis. Very difficult to get into the vessel. Very difficult access, which may preclude the procedure. And therefore you can go ahead. Other things are blinded. I particular size of a greater than two centimeters. That's bladder. Did it? I particularly you Get these out pouchings of the bladder from chronic, you know, bladder outlet obstruction on this little point hair where you're just gonna be a bit more cautious. Well, though, that BSA is pointing on specific, but the patient may have to have further work up with regards to Mariah prostate biopsies before proceeding with P. A consent is very important on he's done by the urologist or referred to the ER. Options should be put forward to the patient and including doing nothing. The benefits are well. The benefits of prostate artery embolization is to reduce the volume size and to really release some of the pressure on the urethra again, hopefully with improvement in the bladder outlet obstructive or symptoms in general, risks are these are general risks for an IR procedure. Vascular procedures pain. Uh, were they done under local anesthetic? And most patients tolerate that fine infection risk. Is there again minimal? But we because we're working through minimally invasive um uh, we're using a minimally invasive technique with only a small incision if that in in the and at the access site, bleeding remains a risk from any access site, and that's that's well known specific risks with regards to pee a nontarget embolization. And that's where some of the symptoms or the complications are. Adverse effects off pa. You can take place. You gotta be careful about where the prostate artery may have master most to where it's arising from where it's leading to. In case, you know, you have reflux off Enbrel and Bolic agents into vessels on with regards to associate it, um, adverse effects with the really to a rectal branch or there is going to a penile brahch again they can experience similar. Basically, you may have him at a sperm ear, but again, those are things which may be related to nontarget embolization. It's very, very important to have that clear on on when consenting a patient post embolization syndrome lost a few days, not very long. Picture my field, mild fever, nausea. Ah, bloating. And this is also important is technical failure. You may not be able to still get into despite all that planning may still be able to get into the prostate artery radiation. I mentioned that there it can can be quite a high risk. Oh, no high risk. You can be a high those procedure relatively compared to other procedures. But again, operator experience ast times reduce and access and planning go forward again. Those risks come down quite significantly, so technique. So with any, uh, and the I r. Procedure or I like to think of it is the three s s and that's how I see it myself, is how we're going to start. You're gonna plan your access. Are we gonna go through a femoral artery? Radial artery again, Important to plan where they're going to stop staring and we go back to the CT A to see and what planes we need to in for a Scooby come eat turning oblique. It's electoral by 30 40 degrees Craniocaudal angle again, but then also looking at the vascular anatomy on what catheters wires that we're going to use. Two. Stare away to the prostate arteries before we can and allies the prostate arteries and finally closure and follow up. How are we going to close that vessel? It's very important again. Planning is very important in such procedures. I know is that the overwhelming slide, but prostate oxy anatomy in basic terms, you will be able to come, and I'll actually got internal extent are letting off to the leg. But essentially, it's a branch coming from the internal island. To put it in the basic tubs, we've got the PA coming here. That's a superior Visa bill artery on. You know it's important to recognize other arteries around that before you recognize the possibility of things like the obturator arteries. Important internal potential artery is important and satirically till on the superior vehicle artery. So knowing anatomy off other vessels allow use, then better identification off the prostate artery. As you can see, it has variant origins. Their head's coming of the three is head's coming directly off the internal iliacs again. They classified into these five times coming off the operator, you know, again coming up the internal potential, and you got an accessory vessel there where it could also be a rising from so again go back to the CT A and planning, but essentially to keep it simple is the branching pattern that what you really need to know in terms or as a foundation level, is that it's a branch of the internal iliacs. And then, if you do wish you could go in and learn more about the anatomy and broad blood, they're associating branches. I haven't really gone into other things in terms off. Um, you've got prostate article you got to prostate arteries on both sides. Usually, however, there may be a a crossing branch which connects both sides together, and that will be important that time of procedure. Um, again, you got to look for catheter policemen on positioning to avoid any nontarget embolization. So planning is key. But I hope this doesn't make sense of left it up there, particularly for, you know, for a little while longer. So you can appreciate the anatomy that you may come. Uh, you know, that may come your way. Were to access Femoral is a familiar approach, less tolerated by patients you can imagine. You know, they're having something and they're growing dignity. And also in terms off, I mean manual compression at the end, on the groin and lying flat. All those things put together despite the advent off closure device is it's still in a somewhat less tolerated by patient Brady, largely better tolerated by patients. You go from the wrist, it's easier, and a beast patients, you're limited by kids. Sometimes you're limited by their vessel itself. You know you want to have the vessel to be a couple of millimeters at least before you access Another thing, which I've just mentioned here with a question mark in terms of starting is related to pee A. Whether the placement of urinary catheter. Some experience operators will say you don't need it because you know that they planned it. Well, they think the procedure is gonna be a relatively, uh uh, either done in in a timely fashion where patient doesn't need to empty the bladder, but it can be avoided. Um, but in some cases that you're in a catheter on eating place. But again, it's not something pleasant to the patient. Usually so access wise, this is a small revision about slide on, sold in a technique. Who was holding a fish? Interventional radiologist. Interventional radiologist. There I had the first described the technique in 1953. You know, some people talk about doctor and intervention that the SELDINGER technique was 1953. So we're going back a long time. And that technique is still used or modified in current day practice. What does that involve? So initially you're going to get a sharp needle into a vessel. Let's just take this. We're going reiterate access into the common femoral artery. Retrograde meaning against the flow. We put a needle in, you get some blood back. You could insert a wire into the into the vessel. The needle, then comes out and over that you could put a sheet on the tube. Just a Nexium pulse. Often access needle on you can. Also, if you're going into, for example, radio, you could use a smaller needle on a micro puncture access of with the thinner wire examples of feet. Smaller sheets. Useful raedle access. You go more conventional sheets, which you can use in the summer access, but essentially, it's a sheath. Once you've got stable access with Blunt ended, you've got the port. There. You can put some. You can flush it, keep it regularly flashed on the inject contrast in etcetera, and then food the hub of the back. You can pass your your catheter and wire staring, so this is an angiogram. They've got the aorta expects of the common I like arteries and then going into the external internal branches there. So how are we going to get there? So if you're accessing into the common femoral artery, which ideally around the level of phlegm or heads, helps with depression at the end, you need to go up getting into the same side and challenging and similarly going across and again that comes to importance of planning on what catheters are you going to use very sexual shapes and sizes of catheters? And, you know, this is just a brief example of them. Um ah, there wires again. Why has come with different, um, you know, built on basically on different technology. Get hydrophilic softer wiles. You get stiff, stiffer exchange wires. You know you could get micro wise again. There's so much kids out there, but that also makes six specialty. Quite exciting and a skillful specialty in terms off navigating to the target vessel to get over the arch. Commonly used after is the rim catheter bit. Because the prostate artery is tiny, it's a couple of millimeters. You often need a micro caster to go within. The to go within a sort of what we call a parent or mother caster to get to your target vessel. Again, there's a details. At this point, it's very useful to know a variety of kit or a number of catheters, which are are available, and we can allow you to get to your access point. Is that I the diagram off? Ah, the internal I lack artery there loosely could divide it into Nanterre in posterior trunk again. Like I said, that's quite loosely So you've got the branches coming off, but essentially we've got over you Get in my Macracanthorhynchus up to that point, and then you could take specific or dedicated and geography imaging from there to plan further ahead, going back. So once we've come around to that point, we need to send get into the prostate artery, and that's where you have a roll of a micro caster. Here's idea is referred to in this particular, um ah, articles as a suppository prostate artery. You can inject a vasodilator into it, too, to foot for you to dilate it for it to be better scene and allow for much more distal access into the into the vessel. If you can appreciate this, you've got a parent Catherine stuff. But you've got this thinner microcatheter going in, and this is where the prostate artery has been candidate, and once contrast is it being injected into the gland. You can see the right and the prostate with its intense contrast, flush or light up on this particular med ality. So once you've got there into the prostate artery using a parent Castell, Mother Caster and then a micro caster and a soft wire in there. Very careful that that the why could result in the vessel going into spasm. But again, it's very important to know what your embolize ing Priety administrating. Um hum bolic agents, it's very important to Pauls. Stop. Really? Check on honing on to what? Ah, you know which west vessel you actually embolize ing. So here is a more technology, so within the procedure can use CT technology. But within the in the and you're sweet, you can use cone beam ct, and you can see how, with contrast sedation, you could see that you are in the top of it. But, um, a thing where you're looking here for you looking for any branches which are going down to the rectum or elsewhere. And you're looking for any variant anatomy or nasty. Most is to another vessel, um, prior to embolization and folic agents. So what do you use many EMBOLIC agents out there? You know, temporary agents. You've got more permanent. You know, more prominent agents which can either be in liquid. You put plugs, coils. Lot of people see coils. Metallic spent you see them? A lot of the stuff you don't really tickly see particular focus of it. Attention is here is particles as it's a gland. You want to get deep into the gland in order to shrink the gland is do you know for it to have sufficient and you necrosis of the Christians, the gland and in fortune of the gland to reduce inside. So you really, you know, ideally, want to use use part is too good to get that deep, glandular and symbolization again just bit of a syringe and you know how we prepare it. And it might come in a large vial. Just use these non branded, um, syringes here, but you prepare it and you agitated and this is again a diagram of what particles. But it's small. The key thing is small. And what size do even use before we touch on that will go back. It's the familiar slide in terms off where your catheter is, what's fears you're gonna use and, you know, and how they work with the guards to particles. But now in the PVA embassy is a spirit is very used now, more commonly in prostate artery and is a shin with regards to size again. Different operators have different views on this and from what I've come across. But, you know, some may say you have a combination of migrants for the smaller, um, stairs to go in deep into the gland, uh, you know, again and then also the larger ones for the part of the vessel. Essentially, the main idea off is Stasis. You want to get it bilaterally. You may find that from one side that there's cross feeling and, you know, couple couple majority of the prostate. It might not be technically feasible able to get into the other side. So again, you. But you do want Teo, you want to get, you know as as much Stacy's as possible. And that's where these are more advanced techniques commands and got the perfected techniques. So you have approximate bill is Asian first and then, and allies distantly going. Realization. If there's a there's a matter me and there's a different anastomosis and you want to protect Protect that all you want to avoid nontarget embolization. You can use some of these techniques, so here we go. So we got a micro catheter into the glands so you can see that gives this's part of the perfected techniques approximate bolic Microsoft injection and then followed by bit more selective distal embolization. And this is what you want to get to. You know you wanna have true flow. Stacy's you want to after. It may be a very challenging to get in there, so it's very important that you get adequate, Stacy's and, you know, again resulting in appropriate angina. Chris's in function to reduce that volume on have symptomatic relief from the procedure. Here's some imaging off a gland pre You know, you can see these intense blush of the glands of prostate atrial side preamble ization. If you got to appreciate, you know, we got post Advil is a shin. You could see less of the gland there, and that's ah, Stasis in terms Off the flow is hopefully picture it better in, um or Magda view here. So we've got the left prostate artery. But this intense especially, can see how it's being immobilized, and there's no longer flow to it. So it's very, very important to get, um, adequate. True states is to cluster. So how do we enter how do we stop them? Closure The the closure? The case. So if we've gone in either radially or family, what family apply manual compression with regards to radial access? There are various bands are equal party or Vandals? God. It's basically a compression bandage applied around the wrist on which will allow early mobilization. You could opt for a closure device, although prostate artery embolization could potentially be performed from a very small sheet size where man you compression sufficient put antibiotics here. So it's important patients completely short course of antibiotics, usually ciprofloxacin floxin. From my experience, they're limited experience on, but that's again prevent any UTI is developing. So clinical care and follow up. Um, so looking at clinical care and follow up, it's just a brief point, which I'm going to touch on. The prostate are trimmed, listen, typically form. There's an outpatient procedure so that it can be done as day case versus a surgical intervention where overnight stays required are increased risk of bleeding again. Things can be turned around for the patient as potentially has a day case. The symptoms improved within several months. You've got to give it time for it to work um, you know, early follow up initially at three months just to see how the patients go over the procedure, whether experienced, any early side effects that that affects complications or post embolize a shin syndrome how we're gonna follow them up. We started with imaging. You could follow up with imaging, but does that make much Ah, sense? I mean, if you've reduced the prostate volume, how does that call it? Ultimately, the patient presented with symptoms so it's very important later on, like six months or even 12 months, is to repeat the IPSS questionnaire on the I. I yes. Five question if you can get that with patients to to complete that in order to see if your procedures worked. And so clinical followup is important, particularly off symptoms, and so that also then goes back to in terms of patients. Election. Um, make sure your patients, you know, are adequately worked up. You've selected the patients who are most likely to benefit from the procedure. That's it in summary, in terms off. It's just put this slide in here. So interventional radiology has the role in men's health, particularly with prostate artery embolization, which we've covered in this session. Testicular vein Embolization is another procedure. Um, related Teo, I are in men's health and which we will try and hopefully cover in the latest session. I'd like to take this opportunity again to think ah are genius for allowing me to, uh, vitamin D that I thank you so much as money got better than Yeah. My just means have no stop it. Okay? Yeah. Thank you. Thank you. So I'm sorry about the technical issues at the start, but I think that went okay in the end, Say, and we'll just have a look at the questions dropped in the chat. There was just 11 or two. And so the first one from Darrelle Maloney was regarding ultrasound for prostate. So just to clarify whether that's and abdominal ultrasound or trans rectal And then the second question was, um, from Mohammed, who's asked whether we should be embering embolize ing both branches of the prostate are artery always one enough. So I think if you, um eat yourself again and I've give you a chance that with your stomach, they take it. We were We'll try and address those questions are later dates and whose money is teaching another session later on in the Siris say, Oh, he's back. He's back. Um, so did you understand? Catch? There's two questions. Yes, I did. Okay, Um, in terms off, the first question is abdominal or trans rectal ultrasound. Well, again, it depends on the patient's body. Habitus. It's a very open and examination if you can get good views on, um, ultrasound. The benefit of Transrectal ultrasound is that, you know biopsies could be performed at the same time again. It will be very on patient with regards to embolize in both branch of prostate arteries, or one branch is enough. That's a very good question. Speaking to senior colleagues and having limited experience, it's very important that you try and embolize both branches or, you know, or the both prostate on trees on each side to get adequate. Stacy's having said that only one branch one side may be enough. Um, if you know there's cross feeling, you know, you might get in branch going across both prostates, which will then hopefully allow Ah, again, that's where comb cobine ct may coming. So you may go into one side and you see, actually is covering a large amount of the prostate. And that's where 1 may be enough. So again it goes back to climbing. Your procedure goes the the the use off interpreted your current beam CT and see how much coverage of prostate you're getting. But ideally, yes, you want to cover. Besides, was my chances at your questions, and but we've got a couple more come in. So it was just about feedback months of that. But do you prefer to inject for a pre meal prior to embolization for better Stasis or just the PBA spears I don't seen used? Like I said, it's limited experience that I have. I'm not seen grapple be used. Um, try temple ization for better Stasis. But, um, I've seen a quick, adequate Stasis achieved with PVDs fairs and, you know, again using some of the advanced techniques, typically with lots of perfected, to get to get get, um, out of Stasis cool. I had the answers, the question and say, Just want to thank you again is one apologies for the for the delayed started running for the slight technical issues, but I think we powered on through just one last question. Yeah, well rounded. Sure. Is there a role for Pa in and in other than BPH? Say, for example, prostate cancer? Again, it's a very good question. Ah, in a work in progress, whether you know, you could sort of translate that into chemo embolization, but yeah, you know, we hope that they will be, ah, increasing role in management of prostate cancer. But again, at the moment, my understanding that p a does that how it's license and available as a treatment option is for his reserved for BPH. Well, it was performed back in the time. You know, prior to that in terms off bleeding, you know, you'd still do it as bleeding. But we will hope hopefully there will be a role in terms off, and it will hopefully form part off management off prostate cancer. But we'll watch your space. Yeah, I think that's that kind of exercise. Is the importance of ongoing research really it? You know, we can postulated, potentially, it will be beneficial for prostate cancer as well. We're seeing with more evidence coming out, say that for BPH is potentially better in many ways. Done, you know, traditional approach, which is drudgery full resection of prostate. See, this shows that I are still relatively new feel basically with the and uncle article interventions. So it's quite exciting for, you know, I are. Judy is have Teo be going into a field days. Is Jane you quite rapidly and cool? We'll round off their thank you everyone for watching. They still need to watch the other episodes on capture on there were there are seven more episodes yet to come out of a release. So please to him for those ones as well. All right, we'll finish the recording there. Thank you. Thank you.