What is prostatic artery embolization (PAE) used for in patients with benign prostatic hyperplasia (BPH)?

Prostatic Artery Embolization (PAE) for Benign Prostatic Hyperplasia

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

What is PAE?

PAE is a minimally invasive procedure where an interventional radiologist:

• Inserts a catheter into the patient's arterial system
• Injects tiny particles to reduce blood flow to the enlarged prostate
• Causes the prostate to shrink in size, potentially relieving symptoms 2

Current Guideline Recommendations

• The 2018 AUA Surgical Management of BPH Guideline explicitly states that PAE should not be used outside clinical trials 1
• PAE is not included in the standard treatment options for BPH in established guidelines 1
• Traditional surgical options like TURP remain the benchmark for surgical therapies due to published evidence from randomized clinical trials with long-term follow-up 1

Potential Applications of PAE

Despite not being recommended for routine use, research suggests PAE may have potential applications for specific patient populations:

• Patients with very large prostates (>90g) who may not be suitable for traditional surgical approaches 3
• High-risk patients who cannot tolerate surgery or anesthesia 4
• Patients who have failed medical therapy but wish to avoid traditional surgery 5

Comparative Effectiveness

• PAE may improve BPH symptoms and urodynamic measures, but evidence is uncertain whether it achieves better results than TURP 2
• Studies show PAE may result in:
  • Reduced prostate volume
  • Decreased post-void residual volume
  • Enhanced urinary flow 6
  • Fewer adverse events compared to TURP and OSP 2

Limitations and Concerns

• Long-term durability of symptom improvement is not well established 2
• Potential need for reintervention after PAE is not fully characterized 2
• Cost-effectiveness compared to standard treatments remains uncertain 2
• Enormous gaps in knowledge exist regarding its optimal use 1

Alternative Treatment Options

For patients seeking treatment for BPH, established options include:

• Medical therapy with alpha-blockers and 5-alpha reductase inhibitors 1, 7
• Minimally invasive surgical therapies like water vapor thermal therapy 1
• Standard surgical interventions like TURP, laser enucleation (HoLEP, ThuLEP) 1

Conclusion

While PAE shows promise as a minimally invasive treatment option for BPH, particularly in high-risk patients or those with very large prostates, current guidelines do not support its use outside of clinical trials. Patients interested in PAE should be informed about the limited evidence for its long-term efficacy and should consider established treatment options first.