Prostate artery embolization (PAE) for BPH: what the evidence shows

Who PAE is for

Benign prostatic hyperplasia (BPH) is an age-related enlargement of the prostate. It can cause a weak stream, frequent urination, getting up at night and a feeling of not emptying the bladder. Medication is usually the first step, and the trials below enrolled men whose symptoms had not settled with medicines or who preferred not to take them ^{[2, 3, 5]}.

For those men the usual next step is a surgical procedure such as transurethral resection of the prostate (TURP). Prostate artery embolization (PAE) is a gentler option for selected men. A thin catheter is guided to the arteries that feed the prostate, and tiny particles are released to reduce the blood flow so the gland shrinks gradually and urinary symptoms ease.

Why men choose PAE

Men who look into PAE usually want relief from urinary symptoms without an operation on the prostate. Here is what draws them to it.

• No cutting or removal of prostate tissue, and local anaesthesia in the randomised trial ^[2].
• Fewer adverse events than TURP in that trial: 36 events against 70 ^[2].
• Proven beyond placebo: symptom scores improved by about 13 points more than with a sham procedure ^[3].
• Lasting relief: in 630 men, 81.9% had a good result at 1 to 3 years and 76.3% beyond 3 years, with no urinary incontinence or sexual dysfunction reported ^[5].
• A route for large prostates: in men with prostates over 100 mL, clinical success was 90% at one month and 72.4% out to 5.5 years ^[6].
• A quick recovery. At Clinic Seven, most patients are back to normal activity within a few days.

Advantages over surgery: what you can avoid

Compared with TURP and other prostate operations, PAE lets you avoid several of the burdens of surgery. These are the main ones.

• Spinal or general anaesthesia. PAE was performed under local anaesthesia in the randomised trial ^[2].
• Cutting and removal of prostate tissue through the urethra. PAE works from the arteries and removes nothing.
• A higher burden of adverse events: 36 events after PAE against 70 after TURP in the 12 weeks following treatment ^[2].
• Retrograde ejaculation. In one review TURP was associated with retrograde ejaculation in 50% to 70% of men, while PAE limits the rate ^[7].
• Concerns about sexual function and incontinence. No urinary incontinence or sexual dysfunction was reported in 630 men followed for up to 6.5 years ^[5], and PAE appeared to improve erectile function relative to open prostatectomy ^[4].

PAE compared with TURP

TURP removes prostate tissue through the urethra and is the traditional surgical operation for BPH. PAE offers a different route. In a randomised trial of 103 men in Switzerland, PAE was done under local anaesthesia, while TURP needed spinal or general anaesthesia ^[2].

How much relief to expect

In the Swiss randomised trial, the average symptom score fell by 9.23 points after PAE at 12 weeks, and PAE was associated with fewer adverse events than TURP (36 events against 70) ^[2]. In an earlier randomised trial of 114 men, symptoms, quality of life, urine flow and prostate volume all improved significantly after PAE at every follow-up point up to 24 months ^[1].

Does PAE work better than a placebo?

Yes. In a sham-controlled randomised trial of 80 men with severe symptoms despite medication, half of the men had a sham procedure with no embolization. At six months the PAE group had a 13.2-point greater improvement in symptom score and a clearly better quality-of-life score. Men in the sham group improved by 13.6 points once they went on to have PAE ^[3]. The authors concluded that the benefits are far greater than a placebo effect ^[3].

Results over the longer term

One large series followed 630 consecutive men for up to 6.5 years. The technical success rate was 98.1%, cumulative clinical success was 81.9% at 1 to 3 years and 76.3% beyond three years, and there were 2 major complications without lasting effects. No urinary incontinence or sexual dysfunction was reported ^[5]. In a separate series of 152 men with prostates larger than 100 mL, who would often be offered open surgery, clinical success was 90% at one month and 72.4% out to 5.5 years ^[6].

Where PAE fits among your options

A systematic review of seven studies with 810 patients concluded that PAE is an emerging treatment option for men with symptomatic BPH who cannot undergo surgery or whose medical therapy has failed. PAE had fewer adverse events overall, and it appeared to improve erectile function relative to open surgery ^[4].

In short, PAE is a well-studied option for men who want relief of prostate symptoms through a gentler procedure that needs no cutting.

Who tends to suit which option

These are patterns from the studies, not rules. The right choice follows your symptoms, prostate size, scans and health.

• PAE is often discussed for men who want to avoid surgery or general anaesthesia, are less suited to an operation because of other medical conditions, or want to protect sexual function ^{[2, 4, 5]}.
• Your specialist will review your prostate size, scans and symptoms to confirm whether PAE or another approach is best for you.
• Medication and monitoring remain appropriate for men with milder symptoms.

Questions to ask at your consultation

Bring your prostate ultrasound or MRI, PSA result and a list of your current medicines, and ask:

• Is my prostate size and anatomy suitable for embolization?
• How much improvement in symptoms is realistic for me, and how soon?
• How does PAE compare with TURP or other surgery for my situation?
• What is the plan if my symptoms do not settle?
• What follow-up and tests will I need afterwards?