Is Prostate Arterial Embolization (PAE) a reasonable treatment option for Benign Prostatic Hyperplasia (BPH) and what are the associated risks, including sexual dysfunction, compared to Transurethral Resection of the Prostate (TURP)?

PAE for BPH: Treatment Recommendation

PAE is not recommended as a standard treatment option for BPH outside of a clinical trial, and TURP remains the superior choice for symptom improvement and durability. 1, 2

Guideline Position on PAE

The American Urological Association explicitly states that PAE should not be offered for LUTS/BPH outside the context of clinical trials (Expert Opinion). 1, 2 This recommendation is based on:

• Insufficient evidence quality: Studies lack proper randomization, have high selection bias, and demonstrate substantial heterogeneity between trials 2
• Unclear benefit-to-risk ratio: The evidence is compromised by detection, attrition, and reporting biases that preclude routine clinical use 2

The 2023 European Association of Urology guidelines similarly note that PAE is inferior to TURP for both symptom improvement and urodynamic parameters. 1

PAE vs TURP: Direct Comparison

Efficacy Outcomes

TURP demonstrates superior clinical outcomes across all major endpoints:

• Symptom improvement: TURP produces a median 15-point IPSS improvement at 12 months versus 10 points for PAE 3
• Urodynamic parameters: TURP shows significantly greater improvements in peak flow rates and post-void residual volumes, particularly at 1 and 3 months 4
• Prostate volume reduction: TURP achieves 44% volume reduction compared to only 31% with PAE at 3 months 5
• PSA reduction: TURP produces greater PSA reductions at all follow-up timepoints 4

The UK-ROPE study, which included 216 PAE patients and 89 TURP patients, found that PAE failed to demonstrate non-inferiority to TURP in propensity-matched analysis. 3

Retreatment Rates

PAE has significantly higher failure and retreatment rates:

• Technical failure: 5-6% of PAE procedures fail technically 4
• Clinical failure: 9.4% clinical failure rate for PAE versus 3.9% for TURP 4
• Reoperation rates: PAE has a 5% reoperation rate before 12 months and 15% after 12 months (20% total), while TURP retreatment rates are favorable 1, 3

Safety Profile

While PAE has some procedural advantages, the complication profile is mixed:

PAE advantages:

• Shorter catheterization time 1
• Shorter hospitalization (71% outpatient/day cases versus 80% of TURP requiring ≥1 night stay) 3
• Less blood loss 1

PAE disadvantages and complications:

• Acute urinary retention: 25.9% of PAE patients 4
• Post-embolization syndrome: 11.1% 4
• Non-target embolization: Penile ulcers in some cases 3
• Groin complications: Arterial dissection and hematomas 3
• One study showed more overall adverse events with PAE (P=0.029) 4

Sexual Dysfunction Risk

PAE appears to have a lower risk of ejaculatory dysfunction compared to TURP, which is its primary sexual function advantage:

• TURP has ejaculatory dysfunction rates of approximately 36-57% 1
• PAE sexual dysfunction data is limited in the guidelines, but the procedure theoretically preserves ejaculatory function better due to its non-ablative mechanism 1
• However, this potential advantage must be weighed against PAE's inferior efficacy and higher retreatment rates 1, 3, 4

For comparison, aquablation shows only 10% ejaculatory dysfunction versus 36% for TURP, making it a better option if preserving ejaculatory function is the priority. 1

Anatomical Considerations for This Patient

Your CTA findings reveal important technical challenges:

• Type IV anatomy on right (inferior vesical artery from internal pudendal): More technically demanding 6
• Severe ostial stenosis of left internal iliac artery: May compromise left-sided embolization success 6
• Moderate arterial calcifications: May increase procedural difficulty 6

These anatomical variants increase the risk of technical failure and incomplete embolization, further reducing the likelihood of successful PAE outcomes. 6

Clinical Algorithm

For this patient, the treatment hierarchy should be:

1. First-line surgical option: TURP (bipolar or monopolar) for prostate 30-80 ml 1
2. If ejaculatory preservation is critical: Consider aquablation (10% ejaculatory dysfunction rate) 1
3. If high bleeding risk: HoLEP, ThuLEP, or GreenLight PVP 1
4. PAE consideration: Only within an IRB-approved clinical trial 1, 2

Key Pitfalls to Avoid

• Do not offer PAE as equivalent to TURP: The evidence clearly shows inferiority in symptom improvement and durability 1, 3, 4
• Do not minimize retreatment risk: 20% of PAE patients require reoperation, which should be disclosed 3
• Do not assume PAE is "safer": While less invasive, PAE has unique complications including post-embolization syndrome and acute retention 4
• Anatomical complexity matters: This patient's Type IV anatomy and iliac stenosis increase technical failure risk 6

Bottom Line

TURP remains the gold standard with proven superior efficacy, lower retreatment rates, and established long-term outcomes. 1 PAE's advantages in hospitalization time and potentially lower ejaculatory dysfunction do not outweigh its inferior symptom improvement, higher failure rates, and investigational status. 1, 2, 3, 4 If this patient prioritizes ejaculatory preservation, aquablation would be preferable to PAE, as it offers both proven efficacy and low ejaculatory dysfunction rates. 1