What is the role of prostate artery embolization (PAE) in treating benign prostatic hyperplasia (BPH)?

From the Guidelines

Prostate artery embolization (PAE) is a recommended treatment option for benign prostatic hyperplasia (BPH) in men who have failed medical therapy or are not candidates for surgical intervention, as it has been shown to reduce lower urinary tract symptoms by 50-80% in most patients, with improvements in urinary flow and quality of life 1.

Key Points

• PAE involves the insertion of a catheter through the femoral or radial artery under imaging guidance, followed by injection of embolic particles to block blood flow to the prostate, causing it to shrink over time.
• The procedure typically takes 1-3 hours and is performed under local anesthesia with moderate sedation.
• Most patients can return home the same day with a recovery period of about 1 week.
• PAE has fewer sexual side effects and lower risks of urinary incontinence compared to surgical options like TURP, though it may be slightly less effective for severe obstructions.
• Potential complications include temporary burning during urination, blood in urine or semen, and rarely non-target embolization affecting other tissues.
• PAE is particularly suitable for men with very large prostates (>80g), those on blood thinners, or those wishing to preserve sexual function.

Benefits and Risks

• Benefits: reduction in lower urinary tract symptoms, improvement in urinary flow and quality of life, fewer sexual side effects, and lower risks of urinary incontinence.
• Risks: temporary burning during urination, blood in urine or semen, and rarely non-target embolization affecting other tissues.

Patient Selection

• Men who have failed medical therapy or are not candidates for surgical intervention.
• Men with very large prostates (>80g).
• Men on blood thinners.
• Men wishing to preserve sexual function.

Current Guidelines

• The American Urological Association (AUA) recommends PAE as a treatment option for BPH in men who have failed medical therapy or are not candidates for surgical intervention 1.
• The AUA also recommends that patients be informed of the benefits and risks of PAE and that the procedure be performed by experienced physicians in a facility with appropriate equipment and personnel.

From the Research

Prostate Artery Embolization (PAE) for Benign Prostatic Hyperplasia (BPH)

• PAE is a minimally invasive treatment option for BPH, which has shown to be effective in reducing lower urinary tract symptoms and improving quality of life 2, 3, 4, 5.
• The procedure involves embolizing the prostatic arteries to reduce blood flow to the prostate, thereby decreasing its size and alleviating symptoms 2, 3.
• PAE has been shown to be a safe and effective option for patients with medication-refractory urinary obstructive symptoms who are poor surgical candidates or refuse surgical therapy 4, 5.

Indications and Patient Selection

• PAE is typically offered to patients with moderate to severe lower urinary tract symptoms and depressed urinary flow due to bladder outlet obstruction 2, 3.
• Proper patient selection and meticulous embolization are critical to optimize results, and interventional radiologists must have a detailed understanding of the pelvic arterial anatomy 2, 3.

Outcomes and Complications

• Studies have demonstrated that PAE can deliver excellent clinical outcomes in terms of International Prostate Symptom Score, quality-of-life score, maximum urinary flow rate, post-void residual, and prostate volume reduction 5, 6.
• The medium- and long-term clinical success rates of PAE have been reported to be 81.9% and 76.3%, respectively, with minimal complications 6.
• Major complications are rare, and PAE has been shown to have a low complication profile compared to other minimally invasive techniques 5, 6.

Technical Considerations

• PAE requires a detailed understanding of the pelvic arterial anatomy, and several anatomic variants and pelvic anastomoses must be considered to avoid nontarget embolization 2, 3.
• Adequate pre- and postprocedural evaluations with clinical examinations and questionnaires, laboratory tests, and urodynamic and imaging examinations are essential to achieve successful treatment 3.