Comprehensive Guide to Prostatic Arterial Embolization (PAE)

What is Benign Prostatic Hyperplasia (BPH)?

Benign prostatic hyperplasia (BPH) is a common condition in older men where the prostate gland enlarges, leading to urinary symptoms such as frequent urination, difficulty starting urination, and a weak urine stream.

What is Prostatic Arterial Embolization (PAE)?

Prostatic Arterial Embolization (PAE) is a minimally invasive procedure designed to reduce the size of the prostate gland. This procedure works by blocking the blood supply to the prostate, causing it to shrink.

How is PAE Performed?

• Digital Subtraction Angiography (DSA): This imaging technique guides the procedure.
• Access Points: The procedure uses femoral or radial arteries to reach the prostate's blood supply.
• Embolization: Tiny particles are injected to block blood flow to the prostate.

Who Should Not Have PAE?

PAE may not be suitable for patients with:

• Atherosclerosis: Hardening and narrowing of the arteries.
• High Tortuosity of Arteries: Excessive twisting of the arteries.
• Adverse Collateral Vessels: Unfavourable alternative blood pathways.

What do Professional Organizations Recommend About PAE?

American Urological Association (AUA)

• Recommendation: Generally advises against PAE due to an unclear balance of risks and benefits for managing lower urinary tract symptoms (LUTS).

European Association of Urology (EAU)

• Recommendation: Suggests considering PAE for patients with prostate sizes of 30-80 mL who can accept potentially inferior outcomes compared to transurethral resection of the prostate (TURP).
• Patient Selection: Should be done by urologists and trained interventional radiologists.

Japanese Urological Association (JUA)

• Recommendation: No specific recommendation on PAE.

What are the Adverse Effects of PAE?

Compared to TURP, PAE may have:

• Similar Risks: Postoperative complications, including acute urinary retention.
• Reduced Catheterization Time: Less time needed with a catheter.
• Shorter Hospital Stays: Reduced length of hospitalisation.

How Effective is PAE?

Study Findings

• Effectiveness: PAE may not improve urinary symptoms or quality of life as effectively as TURP. There is also a higher risk of needing retreatment within 12 months.
• Pain and Urinary Outcomes: PAE may be less effective in reducing pain and improving urinary flow.
• Adverse Events: While PAE may have a lower total number of adverse events, differences in outcomes such as urinary flow rate and prostate volume reduction suggest TURP may be more effective.

Key Study Data

• International Prostate Symptoms Score (IPSS): PAE showed a mean improvement of 9.23 points compared to 10.77 points with TURP.
• Postoperative Pain: Higher in the PAE group (56.3%) compared to the TURP group (31.9%).
• Urinary Flow Rate: Higher in the TURP group (15.34 mL/second) than the PAE group (5.19 mL/second).
• Prostate Volume Reduction: More significant reduction in the TURP group (30.27 mL) compared to the PAE group (12.17 mL).

Is PAE Better Than TURP?

Comparing PAE and TURP

Transurethral Resection of the Prostate (TURP) is a more established surgical procedure for treating BPH. Here’s a comparison:

• Efficacy: TURP is generally more effective in improving urinary symptoms and reducing prostate size. PAE may be considered for patients who prefer a less invasive procedure and can accept potentially inferior outcomes.
• Recovery: PAE may offer a shorter hospital stay and reduced catheterization time, but TURP has a more substantial improvement in urinary flow and symptom relief.
• Risk of Retreatment: PAE has a higher risk of needing retreatment within 12 months compared to TURP.
• Side Effects: Both procedures have similar risks of postoperative complications, but PAE patients may experience more postoperative pain.

Summary

• PAE: Less invasive, shorter recovery time, but potentially less effective and higher chance of needing additional treatments.
• TURP: More effective, longer recovery time, but provides better long-term symptom relief and reduction in prostate size.

What are the Alternative Treatments for BPH?

Aside from PAE and TURP, several other treatment options are available for BPH:

1. Holmium Laser Enucleation of the Prostate (HoLEP): Uses a laser to remove excess prostate tissue.
2. UroLift: Inserts implants to lift and hold the enlarged prostate tissue out of the way.
3. iTind: Temporarily reshapes the prostate to relieve obstruction.
4. Optilume: Uses a balloon coated with a drug to open the urethra and prevent scarring.
5. Rezum: Utilizes steam to destroy excess prostate tissue.
6. Aquablation: Uses a water jet to remove prostate tissue.

Words of Wisdom from a Urologist

Choosing the right treatment for BPH depends on your specific situation and preferences. PAE offers a less invasive option with a shorter recovery time but may not be as effective as TURP. TURP remains the gold standard for significant symptom relief and prostate reduction. Other alternatives like HoLEP, UroLift, and Rezum also provide effective treatments with different benefits and recovery profiles. Discuss with your urologist to determine the best approach for you, considering factors like prostate size, symptom severity, and your overall health. Remember, every patient is unique, and your treatment should be tailored to your needs.