Another scenario I'm curious about, you know, we know that the, the bigger the gland, the, the easier the embolization, at least in my experience, are there any circumstances where you are getting sent these patients

or considering PAE for smaller glands? So yes, a couple of different things. So first of all, if we're doing it before radiation and men have like a 25 cc gland, for example, right? I'll say, listen, I can try it, but that, that patient might be better served either to have a turp or a mist or something, right? And it'll just depend on what's really happening. 40, 45 cc, I think you can still do the PAE and you'll be all right. On the flip side, when it's chronic prostatitis, I'll try any size gland that you have. So I've done, I think the smallest size I've done is like 23 cc. Yeah, it's really small. And so not the prostatitis patients are never fun. It's a tough procedure. It's not fun. It's like, you're kind of finding a needle in a haystack. It's like, sometimes they'll do well. The prostatitis patients don't have the same high response rate. They also, I couch them and I'm like, you know, it's not a 50, 50, but the data shows, maybe 70, 75% improvement or chance of improvement, I mean. And so, you know, you still got to do the case, but every time I see a prostatitis, a prostatitis patient, I'm like, damn, this is going to suck. But so to your point, if it's new adjuvant, then I would say, you know, 40, 45, I'm happy to do it. And the reason I'll still take it on is because the smaller the gland, the better the radiation and the better the plan for radiation. Got it. So that's, that's the main reason to do it. Okay.

In terms of the technical details is, is there anything different to doing PAE for prostate cancer relative to that for BPH with what's?

Good question. So I believe that if you're going to do it in the neo-adjective setting, you've really got to use the perfect technique. And the reason I say it is because their data is real. You know, Francisco's data, I was talking to him about this at guest last year. And I just kind of started to use it significantly. And I was like, I was still trying to figure out how the hell he does it. And it actually dawned on me when he said it. He was like, yeah, it's different for every patient. I was like, Oh, really? He's like, yeah, of course it is.

I was like, let's do this. Let's, let's, okay. So a lot of our listeners are going to be trainees. You and I are familiar with the perfected technique because I, you know, started doing P like you did. I saw one in training and then really got into it, just reading about it when it was starting to develop. And so I just read everything there was available on my own. And then I was lucky to get to travel and visit. Ari Isaacson, when he was at UNC and he was, you know, really, and he let me spend a day with him watching him do it.

So let's

tell our trainees, what is the perfected technique compared to just doing a routine embolization? Okay.

Sure. So good. That's a good point. So most time our trainees will learn that when you're doing an embolization, you really, uh, you start distal and then you come back proximal, right? And typically you start with the smaller beads and then you size up. So the prox, sorry, the perfected technique stands for proximal embolization first then distal. So what does that mean? So you kind of bait you park your micro catheter proximally in the prostatic artery, you emmilize from there and then you go distal, even though you think they're stasis, you go distal, ideally into each branch. If you can see each branch and you then even give more embolic distally. And the thinking is number one, you can pack in more, which results in more necrosis, but the pathophysiology, my understanding, and this is not my theory. This is what Francisco told me and a couple of other people told me. And what they published is that there's these tiny little collateral pathways throughout the prostate that develop that can still be shut down when you're a little bit further in and you can't see them if you're proximal. So it's the reason that if those are open, you can then go and emmilize more. Now, the other thing that I learned both from him and Chevank in Miami is start with small beads. So once the threes and then use threes to fives later. So what I'll usually do now is once the threes proximally, and of course, this is where Francisco was so key to like kind of helping open my eyes last year when we randomly had this discussion. He was like, yeah, you know, I'll give like three, four, five CCs, depending on the size of the gland of like ones of threes, just depends. And then I'll switch to threes to fives. And him and Chevank both told me this. When you go distal and you stay threes to fives because those collateral pathways, like you just, you don't want them to open up randomly. And if they are open, sorry, you want them to be open, you want to shut them down. You don't want to get through them with the ones of threes because you're really deep into the Oregon. So in fact, it's funny. I'll usually say to my texts or to my, uh, but if you have like, if you can get really far in there, I'll usually joke with my texts and with my fellows, like, Oh yeah, hopefully the catheter is becoming out of the penis sometime soon. That's how they know I'm happy about the case if I say that, but no. So, so basically you start proximally with ones of threes, give a few CCs and then you start, then you give threes to fives, then you go distal and give more threes to fives. And yes, it uses the idea of sizing up. A lot of my fellows will always ask me, well, if you're going distally, shouldn't use ones of threes to pack it in more. And I think the thinking is if there are those collateral pathways that you can't see, you just don't want to,

to mistake them. Right. I'd rather not send 100 to 300 into the pina and rectum and.

Correct.

Question for you nine. Are you using 100 or 300 and perfected technique on your routine PAE for BPH in let?

I do now. Yeah. And for chronic prostititis. Yep. I use them for all them if I can. So if, yeah, you know, there's a couple of things to think about there. If for some reason there's like I had one the other day where it was a prostititis case, the guy actually had seeds and so it was like impossible. He probably had 50 seeds in his prostate. I mean, it was frigging. It was just, it sucked and his prostate volume was like 40. So the whole case, and I knew it was going to suck, but he was on, he was on a catheter and he had had post radiation hemorrhagic cystitis. So it had sucked like every which way around, but he, he, he, my, that same urology colleague actually went in and cauterized a bunch of year ago. Uh, he was doing fine and then he ended up going into retention, never had any bleeding, but went into retention. And then he was like, is there anything you can do? And I was like, Oh man, I guess I'm going to have to try PAE. So when I was doing the case on Tuesday, he had like this crazy collateral that went to the penis, intrapastatic, not collateral. And I was way deep in, but for some reason I typically use concertos, the concerto just wouldn't go. It wouldn't make like the final turn. And you know, he had torturous vessels. Everything sucked about it. Well, I, I put in two escoyles because those did go and like it didn't totally shut shut down flow. So flow was like, flow was like really stagnant. And I was like, you know, this guy is miserable. And my fellow, they're like, what are you going to do? And I was like, well, we're going to emblest. He's like, are you serious? I was like, yeah, I was like, the guy is miserable. And trust me, he'll deal with the base of penis that has some, some, you know, ulcers if he needs to, or even tip of penis that has ulcers. And he's already on the catheter. So it's not like I'm going to, like, if we don't fix this, it's not like he's going to have a rectile function to be worried about. So I was like, we're, I, I closed my eyes and just shot and based on 300 to 500. Yeah. So in that situation to your point, I did three survives because I was like, no, I don't know what's happening here. On the other side though, there was good supply. I felt pretty confident and I just see, I started with was the threes and then I used three supplies to finish.

And his penis didn't fall off, did it?

Well, it's only been a week. So let's see. Okay. It's not even been a week. Yeah. As you know, the ulcer situation

takes, it usually happens about a weekend. So I've had a night. I don't, cause I don't get complications.

Then you're not doing enough and you know that like.

Uh, another question for you, nine. So the ones

that you're doing, and if you are doing these for, for, you know, I know it brought up local advances, these, let's say extra prostatic extension or seminal vesicles. Are there any other considerations for, um, doing the amylization on those patients? You know, does it look different? Is there anything else you have to do?

So definitely looks different. Ultimately, no, there's not necessarily anything you do differently. Um, I'll still do the procedure. You know, when I got my ID, a lot of radox and urologists brought up this point that like, how did I know that there was an increased collateral flow? Because the prostate cancers are supposed to be quote unquote hypervascular. This is another project that we, we presented a poster on and I didn't, I couldn't figure out how to write it up. And by the way, for any listeners, if anybody's great at taking these and translating posters to papers, I would love some help. So I'll just put that out there. Feel free to contact me. But it's funny. When you're in the artery, the prostate cancer is actually not as hypervascular as the BPH. I know it sounds crazy. Yeah. On the MRI, they say that it's hypervascular, but I actually think on prostate MRI for anybody that's done any body fellowships or reads prostate MRI, they do like kind of these curves that show the enhancement of the prostate cancer as compared to the rest of the normal prostatic parencoma. I almost feel like it's delayed enhancement and the prostatic parencoma is like early enhancement and not, not to get too geeked out here, but in the pyrods 2.0 and even in the updates, enhancement only really upgrades from like a three to a four if I remember that correctly. So my point is that it's not even really that important. The enhancement of the, of the gland. So my point there is to say most likely, no, you don't need to worry about anything. My second point is to say, just watch out for any possible collaterals because if it is invading like, you know, the rectum or something, of course, like any other part of the body, you know, tumor invading another area could lead to some crazy vasculature. And that's what the radiation oncologist and the, and the urologist who, who approved the IDE brought up as well. Like how did I know? And I was like, well, I published a paper that showed that there was not any untoward situations as far as non-target embolization. So that's the best way that I know. But for the most part, what we found when we did that poster was if anything, the prostate cancer itself is hypervascular. And I did not necessarily see any increased number or frequency of collaterals.

Got it.