What are the indications for prostate artery embolization (PAE) in patients with benign prostatic hyperplasia (BPH)?

Prostate Artery Embolization Indications

Prostate artery embolization (PAE) is NOT recommended for routine treatment of lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH) and should only be performed within clinical trials. 1

Current Guideline Position

The American Urological Association explicitly states that PAE for LUTS secondary to BPH is not supported by current data and trial designs, with unclear benefit-to-risk ratio. 1 This represents an Expert Opinion level recommendation from the most recent 2020 AUA Guideline Amendment. 1

Evidence Quality Issues

The guideline panel identified critical deficiencies in PAE research that preclude routine clinical use: 1

• Lack of randomization in most studies 1
• High susceptibility to multiple biases including selection, detection, attrition, and reporting biases 1
• Substantial heterogeneity between trials (I²=90%) making pooled results unreliable 1
• Inconsistent inclusion criteria and outcome definitions across studies 1
• Limited follow-up duration with most data only extending to 12-24 months 1

Potential Clinical Scenarios (Research Context Only)

While not approved for routine use, research literature suggests PAE has been studied in specific populations: 2, 3, 4

High-Risk Surgical Candidates

• Patients with significant medical comorbidities making them poor candidates for general or spinal anesthesia 2, 4
• Those at high bleeding risk who cannot safely undergo TURP or other surgical procedures 2, 4
• Patients on anticoagulation that cannot be safely discontinued 2

Large Prostate Glands

• Prostate volumes ≥80-120 mL where minimally invasive transurethral procedures may not be feasible 2
• Situations where only holmium laser enucleation, thulium laser enucleation, or open prostatectomy would otherwise be options 2

Refractory Cases

• Medication-refractory LUTS in patients who refuse or cannot tolerate surgical therapy 3, 4
• Refractory urinary retention requiring indwelling catheter in high-risk patients 4
• Recurrent hematuria from BPH when other options are contraindicated 2

Critical Caveats

Do not offer PAE as a standard treatment option. The AUA guideline is unequivocal that this procedure lacks sufficient evidence for routine clinical practice. 1

If considering PAE in exceptional circumstances:

• Must be within an IRB-approved clinical trial 1
• Patient must understand this is investigational with unclear long-term outcomes 1
• Alternative proven therapies (TURP, laser enucleation, open prostatectomy) should be exhausted or contraindicated 2, 3
• Requires multidisciplinary evaluation by both urology and interventional radiology 2

Comparison to Established Therapies

When PAE was compared to TURP in limited RCTs, quality of life improvement was reported in only 87% of PAE patients versus 100% in TURP patients. 1 This inferior outcome, combined with the low quality of evidence, reinforces why PAE cannot be recommended outside research protocols. 1

For patients requiring treatment of LUTS/BPH, established options with proven efficacy should be prioritized: TURP, HoLEP, ThuLEP, PVP, Aquablation (for prostates 30-80g), prostatic urethral lift (for prostates <80g without median lobe), or water vapor thermal therapy (for prostates <80g). 1