Interventional radiologist Ari J. Isaacson, MD, and urologist Matthew C. Raynor, MD, who work together at UNC Health, have collaborated on a program that offers prostate artery embolization (PAE) to treat benign prostatic hyperplasia (BPH). In this partnership profile, IR Quarterly spoke with Drs. Isaacson and Raynor about their program, its challenges and the benefits it holds to patients.
How did the PAE collaboration between IR and urology begin?
Ari J. Isaacson, MD, and Matthew C. Raynor, MD.
Ari J. Isaacson, MD: When it began, PAE was entirely research. The therapy was very early in the development process, and I was interested in working in a burgeoning field. It was important to me that we approached the study from a collegial perspective. Of all the urologists, I knew Matt the best because I’d trained at UNC and knew him as an attending and a nice guy. I knew Matt would be reasonable and interested, so I said, “This is just research, but we want to evaluate the efficacy of PAE. Would you be willing to be a co-investigator?”
Matthew C. Raynor, MD: From my point of view, urology and IR are natural collaborators. There are many areas urology works in which overlap with IR: percutaneous access to kidneys, stone treatments, management of small kidney tumors with ablation, angio and embolization for kidneys, and angiomyolipoma. Because there is a lot of overlap, there is a natural base for collaboration. Our PAE program stems from that. Our collaboration allowed us to evaluate PAE patients the way we wanted and enabled us to offer different options and build up PAE. It has really exploded since then and has been quite successful.
AI: Once our study demonstrated that PAE was safe and efficacious, we transitioned it to clinical practice. I spoke at urology grand rounds a few times to give our results, and I think approaching it like that from the beginning—starting with research and asking for buy in, instead of just coming in and saying it worked and asking for patients—was the right way to go.
It sounds like the UNC urology department was very supportive. Is the rest of the specialty generally supportive as well?
MR: Back then, the answer would have been “no.” Every urologist I knew of, even at UNC, was not a fan of PAE. But being at an academic center, we’re open to trying new things and we’re all about testing hypotheses and seeing what works and what doesn’t. This is a new technology that was going to happen regardless of whether urology was involved or not, so I wanted to get involved in some good trials and studies that would determine if it is effective and where it fits in the armamentarium of treating BPH. We now know that the technology works, and many urologists are starting to incorporate PAE into their practices. There are still naysayers, but we now mostly recognize that the procedure is effective, so it is now about finding where it fits and how best to coordinate with IR.
Dr. Raynor mentioned that IR and urology have natural collaborations. What makes PAE different?
AI: I think a lot of the collaboration you see between urology and IR is when we need the other to do something that we don’t do, whether it’s placing a nephrostomy tube or embolizing a bleed after a renal biopsy.
With PAE, however, we’re treating a disease state that is entirely treated and owned by urology. It’s as if urologists started treating hepatocellular carcinoma or something that we consider part of the IR domain. But PAE is different because there’s a bit of a turf battle, and I don’t blame them. Urologists have been studying and thinking about this disease state for years and here we are butting our heads in and saying we have a solution. I think the challenge for urologists is to step back and look objectively at how PAE can help their patients.
To be frank, there’s also underlying financial elements. The same patients who would go for urology now go to IR. The issue with PAE is that we’re competing for the same patients and IR is entering a space that has been owned by urology.
MR: You can draw parallels between other disease states in urology as well, like kidney cancer. A percentage of our patients are managed by IR with embolization. It started laparoscopic and then transitioned to IR in most places. And for a good reason, because they do it all the time.
Another disease state I think about is prostate cancer. Back in the day it was all urology. You either had a radical prostatectomy or you went on androgen deprivation therapy. Then radiation came into the fold and is now a large part of prostate cancer management, either as a primary treatment or as a secondary salvage radiation with or without surgery.
So urology has taken a multidisciplinary approach for other disease states we’ve owned and I think we’re just seeing that process early on with PAE for BHP. There has been a little bit of a turf war over the last few years, but that will change as more evidence arrives. It’s the natural cycle of medical innovation.
Do you have any advice for other IRs or urologists on collaborating with each other?
MR: It’s about communication. I had a good relationship with Ari already, but it’s crucial to communicate and make clear to your partners that the goal is not to steal patients. If you look at urology’s BPH volume since we’ve started this collaboration, it’s only gone up. Working together has benefitted both of us. There are patients who will not be great candidates for PAE, and urology can offer them a better option. The rising tide of our collaboration really has lifted all boats. Working together will not be a detriment to your BPH practice, and it will only enhance it.
AI: I would add that both parties approaching the decision with humility helps. From an IR standpoint, you can’t go to the urology group and say that PAE is going to be the best for all patients. You can’t dismiss all the urology procedures, because they have value and will be best for certain patients. If you approach with humility, say that you have a procedure you think could benefit some patients and ask the urologist to work with you on it, and you welcome questions and feedback, then things will work out great. Collaboration breaks down when egos get in the way.
