What are the mandatory and desirable preoperative assessment tests for Prostate Artery Embolization (PAE)?

Preoperative Assessment Tests for Prostate Artery Embolization

For PAE candidacy, you must obtain: prostate volume measurement (ideally >30 cm³), International Prostate Symptom Score (IPSS >18 or QoL >3), PSA with digital rectal exam and transrectal ultrasound to exclude malignancy, CT angiography to assess vascular anatomy, basic coagulation parameters, renal function tests, and screening for active urinary tract infection. 1, 2

Mandatory Tests

Prostate-Specific Assessment

• Prostate volume measurement via transrectal ultrasound (TRUS) or other imaging modality—PAE is typically indicated for glands >30 cm³, with particular benefit for larger glands (≥80-120 mL) where surgical options become more limited 1, 2
• International Prostate Symptom Score (IPSS) to objectively quantify lower urinary tract symptoms—should be ≥18, or quality of life score >3, indicating moderate to severe symptoms 1, 2
• Digital rectal examination and TRUS to evaluate for prostatic malignancy 1
• Prostate-specific antigen (PSA) measurement—serves dual purpose of cancer screening and has prognostic value, as baseline PSA inversely correlates with symptom recurrence (higher PSA associated with lower recurrence rates) 1, 3

Vascular Anatomy Assessment

• CT angiography (CTA) of the pelvis is mandatory to evaluate prostatic arterial anatomy, identify variant origins, assess for severe tortuosity or advanced atherosclerosis of iliac and prostatic arteries that would preclude safe catheterization 1, 4, 5
• CTA helps correlate with digital subtraction angiography during the procedure to facilitate identification of prostatic arteries, which have highly variable origins and collateral circulation 4, 5

Laboratory Tests

• Coagulation parameters (PT/INR, aPTT) to ensure safe arterial access and embolization 1
• Renal function tests (creatinine, eGFR) to assess kidney function adequacy for contrast administration and to exclude chronic renal failure 1, 2
• Urinalysis and urine culture to exclude active urinary tract infection, which is an absolute contraindication 1

Physical Examination

• Vascular access site evaluation (femoral pulses, peripheral vascular disease assessment) to determine candidacy for angiography 2

Desirable Tests

Urologic Evaluation

• Uroflowmetry to measure maximum urinary flow rate (Qmax) as an objective baseline parameter 3
• Postvoid residual volume measurement to quantify bladder emptying efficiency 3
• Cystoscopy in select patients to evaluate for bladder pathology (large diverticula, bladder stones) that would be contraindications, or to assess prostatic urethral anatomy 1, 2
• Urodynamic studies in patients where the etiology of LUTS is unclear or when neurologic disease may be contributing to bladder dysfunction 2

Additional Imaging

• MRI of the prostate can provide detailed anatomic information about gland size, zonal anatomy, and help exclude malignancy, though not mandatory if adequate TRUS and PSA evaluation performed 2

Critical Exclusion Criteria to Screen For

• Prostate cancer—requires negative digital rectal exam, TRUS, and appropriate PSA with biopsy if indicated 1
• Large bladder diverticula or stones on imaging 1
• Severe vascular tortuosity or atherosclerosis on CTA that would prevent safe catheterization 1
• Active urinary tract infection on urinalysis 1
• Uncontrolled coagulation parameters 1

Common Pitfalls

The most critical pitfall is proceeding without adequate vascular imaging—approximately one-third of initially consulted patients are excluded after full evaluation, often due to unfavorable vascular anatomy discovered on CTA 1. Bilateral embolization is essential for optimal outcomes, as unilateral PAE is associated with significantly higher symptom recurrence (42% vs 21%) 3. Failure to exclude malignancy preoperatively can lead to delayed cancer diagnosis, so the combination of DRE, TRUS, and PSA with biopsy when indicated is non-negotiable 1.