What is the role of prostate arteries embolization (PAE) in treating a male patient in his 50s with benign prostatic hyperplasia (BPH) or prostate cancer and severe lower urinary tract symptoms who has not responded to medical therapy, including medications such as alpha-blockers or 5-alpha-reductase inhibitors?

Prostate Artery Embolization for BPH

Prostate artery embolization (PAE) should NOT be offered for treatment of lower urinary tract symptoms attributed to benign prostatic hyperplasia outside of an IRB-approved clinical trial. 1, 2

Guideline Position

The American Urological Association explicitly states that PAE lacks sufficient evidence for routine clinical practice and maintains an unequivocal position against its use outside research protocols. 1, 2

Key Reasons for Non-Recommendation

• Evidence quality is critically deficient: The AUA guideline panel identified lack of randomization, high susceptibility to multiple biases (selection, detection, attrition, reporting), substantial heterogeneity between trials, inconsistent inclusion criteria, and limited follow-up duration. 2

• Unclear benefit-to-risk ratio: Current data and trial designs do not support PAE as a standard treatment option, representing an Expert Opinion level recommendation from the 2018 AUA Guideline and reaffirmed in the 2019 amendment. 1, 2

• Inferior outcomes compared to established therapies: When PAE was compared to TURP in limited RCTs, quality of life improvement occurred in only 87% of PAE patients versus 100% in TURP patients. 2

Proven Alternative Treatments to Prioritize

For this patient with severe LUTS refractory to medical therapy, the following evidence-based options should be offered instead:

First-Line Surgical Options

• Holmium laser enucleation (HoLEP) or Thulium laser enucleation (ThuLEP): Prostate size-independent options with Moderate Recommendation, Evidence Level Grade B. 1

• Photoselective vaporization (PVP): Established efficacy with proven outcomes. 1, 2

• Transurethral resection of the prostate (TURP): Remains the gold standard comparator with 100% quality of life improvement rates. 1, 2

Additional Proven Options

• Aquablation, prostatic urethral lift, or water vapor thermal therapy: All have superior evidence compared to PAE. 2

• For patients on anticoagulation: HoLEP, PVP, and ThuLEP are specifically recommended as they have lower bleeding risk (RR: 0.20 for transfusion with HoLEP vs TURP). 1

Critical Clinical Caveats

• PAE is investigational only: Patients must understand this is an experimental procedure with unclear long-term outcomes. 2

• Alternative proven therapies must be exhausted or contraindicated: Before even considering PAE within a clinical trial, all established treatment options should be evaluated. 2

• No role in prostate cancer: PAE has no established role in treating prostate cancer; this patient population requires standard oncologic management. 3

If Patient Insists on PAE (Research Context Only)

Should the patient qualify for and insist on enrollment in an IRB-approved PAE clinical trial, the following research-based criteria have been used:

• Age >40-50 years, prostate volume >30-45 cm³, moderate to severe LUTS (IPSS >18), failed medical therapy for ≥6 months, or acute urinary retention refractory to medical therapy. 3, 4, 5

• Exclusion criteria include: prostate malignancy, large bladder diverticula/stones, chronic renal failure, severe iliac or prostatic artery atherosclerosis/tortuosity on CTA, active UTI, unregulated coagulation. 3

• Technical success rates of 93-100% have been reported in small series, with IPSS reductions of 6.5-12 points and prostate volume reductions of 26.5-28.9 mL at short-term follow-up. 4, 5, 6

• Complications in research series include transient post-procedural fever, and one reported bladder wall ischemia (1.5 cm²). 5, 6

Bottom Line Algorithm

1. Confirm medical therapy failure: Ensure adequate trial of alpha-blockers and 5-alpha-reductase inhibitors (if prostate >30cc or PSA >1.5 ng/mL). 1

2. Offer proven surgical options: TURP, HoLEP, ThuLEP, PVP, or other established minimally invasive therapies based on prostate size, patient comorbidities, and anticoagulation status. 1, 2

3. Do NOT offer PAE as standard treatment: Only discuss PAE if patient is enrolled in an IRB-approved clinical trial. 1, 2

4. Document informed consent: If PAE is performed within a trial, strongly reinforce the investigational nature, uncertain clinical outcomes, and availability of proven alternatives. 2, 3