What are the surgical steps of prostatic artery embolization (PAE) for benign prostatic hyperplasia (BPH)?

Surgical Steps of Prostatic Artery Embolization (PAE)

Prostatic artery embolization (PAE) is not recommended for the treatment of LUTS/BPH outside the context of a clinical trial according to current American Urological Association guidelines. 1

Patient Selection for PAE

Before discussing the surgical steps, it's important to note the appropriate patient selection criteria:

• Male patients aged >40 years
• Prostate volume >30 cm³
• Moderate to severe LUTS refractory to medical treatment for at least 6 months (IPSS >18 or QoL >3)
• Patients at high risk for surgery and/or anesthesia 2, 3

Exclusion criteria:

• Prostate malignancy
• Large bladder diverticula or stones
• Chronic renal failure
• Severe tortuosity/atherosclerosis of iliac or prostatic arteries
• Active urinary tract infection
• Unregulated coagulation parameters 3

Pre-Procedure Preparation

1. Imaging workup:

   • CT angiography to evaluate pelvic vascular anatomy, identify prostatic arteries, and assess for atherosclerosis/tortuosity 3
   • MRI to determine prostate volume and rule out malignancy

2. Laboratory tests:

   • PSA measurement
   • Coagulation parameters
   • Renal function tests 3

Surgical Steps of PAE

1. Patient positioning and preparation:

   • Patient placed in supine position
   • Sterile preparation of access site (typically right femoral or radial artery)
   • Local anesthesia at access site 4

2. Arterial access:

   • Femoral or radial artery puncture
   • Placement of vascular sheath (typically 5-6 French) 4

3. Angiography and arterial mapping:

   • Advancement of catheter to internal iliac arteries
   • Angiography to identify prostatic arteries
   • Identification of potential anastomoses with rectum, bladder, or penis to avoid non-target embolization 4

4. Selective catheterization:

   • Use of small-diameter hydrophilic microcatheters (mandatory)
   • Selective catheterization of prostatic arteries bilaterally
   • Confirmation of catheter position with angiography 4

5. Embolization procedure:

   • Administration of embolic material (typically biosphere particles 300-500 μm)
   • Embolization continued until stasis or near-stasis is achieved in the prostatic arteries
   • Procedure repeated on contralateral side 2, 4

6. Completion angiography:

   • Final angiography to confirm adequate embolization
   • Verification of absence of non-target embolization 4

7. Closure and hemostasis:

   • Removal of catheter and sheath
   • Hemostasis at access site
   • Application of pressure dressing 4

Post-Procedure Care

• Monitoring for post-embolization syndrome (pain, fever, nausea)
• Pain management as needed
• Typically performed as an outpatient procedure with same-day discharge 3
• Follow-up at 1,3, and 9 months with assessment of symptoms, uroflowmetry, and prostate volume 2

Potential Complications

• Post-embolization syndrome (most common)
• Hematoma at access site
• Non-target embolization (bladder, rectum)
• Transient urinary symptoms
• Acute urinary retention (may require temporary catheterization) 2, 4

Clinical Considerations

Despite the technical description provided, it's important to note that PAE remains an experimental procedure according to the American Urological Association. The AUA does not recommend PAE for treatment of LUTS/BPH outside clinical trials due to limited high-quality evidence and methodological limitations in existing research 1. For patients with moderate to severe LUTS, established surgical options like TURP remain the gold standard, with HoLEP, PVP, or ThuLEP recommended for patients at higher bleeding risk 5, 1.