Prostate artery embolism is a new alternative for BPH
PAE outperforms medical therapy and has a lower complication rate compared to transurethral resection of the prostate.
The 2023 amendment to the AUA guideline on benign prostatic hyperplasia added a new approach: prostate artery embolism. The concept is simple: Inject an embolic agent into the prostatic arteries to block blood supply, shrinking the prostate to allow better urinary flow.
“PAE is a great example of urology of the future, interventional urology,” said Timothy McClure, MD, assistant professor of urology at Weill Cornell Medicine in New York. “My entire practice is interventional urology.”
Dr. McClure opened the afternoon Plenary on Saturday with an explanation of PAE and some of the clinical trials leading to its inclusion in the AUA guideline. The prior guideline, published in 2021, recommended against PAE for lack of evidence showing more benefit than risk.
PAE is a straightforward interventional procedure. Using cone-based computerized tomography and angiography, the clinician locates the prostatic arteries and threads a 22-French catheter through either the femoral or radial artery into one lobe of the prostate. Once the proper location is confirmed by imaging, an embolic agent is injected into the artery, blocking it. The catheter is repositioned into the other lobe, and the embolization is repeated. Then the catheter is removed, and the procedure is complete.
Interventional procedures are commonplace in radiology, cardiology and other specialties, Dr. McClure said, but have yet to find broad use in urology. He is among the few urologists who are board certified in both urology and interventional radiology with practical experience in urology and vascular and interventional radiology.
Early attempts at PAE had had roughly similar clinical results to transurethral resection of the prostate, with reported complication rates as high as 52%. What were termed complications included clinical failures, while urethral strictures and bladder neck stenosis rates were similar between the two procedures.
As PAE was refined, clinical outcomes for PAE and TURP converged. By 2020, the two procedures showed similar International Prostate Symptom Score improvements with fewer complications for PAE. Current analysis of randomized controlled trials comparing PAE and TURP shows similar improvement for IPSS, although PAE improvement is more variable, and with two times lower complication rates for PAE compared to TURP.
Head-to-head comparison with dutasteride/tamsulosin also showed a clear advantage for PAE. PAE had a 10-point improvement in IPSS and an eight-point improvement in International Index of Erectile Function score over medical therapy.
Duration of IPSS improvement following PAE is still an open question. A trial of PAE versus sham showed clinical improvement for PAE lasting 12 months, but there are few long-term data.
A U.K. study showed a 15-point improvement in IPSS at five years with TURP versus an 11-point improvement with PAE, and virtually identical quality-of-life scores. Nearly half of TURP patients (47.5%) reported retrograde ejaculation versus 24.1% for PAE.
Five-year recurrence for PAE is between 20% and 30%, Dr. McClure reported.
“PAE outperforms medical therapy, has a lower complication rate compared to TURP, improves IPSS similar to TURP and has far lower retrograde ejaculation,” Dr. McClure said. “PAE is not a placebo effect.”
