Prostatic Artery Embolization (PAE) As Treatment for Lower Urinary Tract Obstruction Due To Benign Prostatic Hyperplasia: An Update of the Literature
Authors: Venyo Anthony Kodzo-Grey 
Published: August 2020

Prostate artery embolization (PAE) as treatment for lower urinary tract symptoms due to benign prostatic hyperplasia (BPH) was first undertaken in 2000 and since then utilization of PAE for the treatment of symptomatic BPH associated with failure of medical therapy or patients not being fit to undergo general anaesthesia or spinal anaesthesia for surgical treatment of the prostate gland has continued to be undertaken by well trained interventional radiologists in various well equipped interventional radiology units globally especially in the developed countries. PAE is a technically demanding procedure which is only undertaken by well trained interventional radiologists. PAE is undertaken under radiology imaging control via the left or right femoral artery or the radial artery under local anaesthesia. Super-selective catheterization of the small prostatic artery is undertaken with the use of fine microcatheters that traverse the pelvic arteries / internal pudendal arteries. The PAE procedure does involve introduction of microparticles to completely block the prostate arteries. The embolization agents include polyvinyl alcohol (PVA) and other synthetic materials including microspheres. Successful PAE does lead to necrosis and shrinkage of the prostate gland. With regard to the technical details of PAE, the interventional radiologist does obtain access into the arterial system by piercing the femoral artery or the radial artery under radiology imaging control including ultrasound scan with utilization of a trocar which is hollow. A guide-wire is threaded through the trocar and trocar is then removed. A cannula is passed over the guide-wire and once the cannula is in place the guide-wire is removed. The cannula does allow a sheath to be inserted into the artery. Contrast material is injected through the sheath under radiology imaging / fluoroscopic control which does allow the anatomy of the pelvic blood vessels to be illustrated including the anatomy of the internal pudendal artery as well as if the anatomy is normal or there is a variation in the anatomy of the pelvic vessels including whether or not there is tortuosity of the pelvic vessels or atherosclerosis of the vessels. The contrast angiography is utilized to guide the interventional radiologist to identify the prostate artery in order to advance the catheter to the ostium of the prostatic artery and this then enables the radiologist to inject polyvinyl alcohol or microspheres into the prostatic artery. The anatomy of the pelvic vessels does vary which is well known by all interventional radiologists. Successful PAE does refer to complete bilateral embolization of the prostatic arteries but at times the radiologist is only able to undertake unilateral embolization of a prostatic artery due to a variant anatomy of the pelvic vessel or tortuosity of the vessel or atherosclerosis. Over the past 18 years various case reports, case series, and studies of PAE either alone or in comparison with trans-urethral resection of the prostate have been reported in various journals. These publications have mostly shown that PAE is safe and efficacious in improving upon the IPSS, QoL, Q-max, Post -void residual urine volume, as well as reduction in the volume of the prostate. Some of the studies have shown almost equivalent in the IPSS improvement in comparison with the IPSS improvement pursuant to TURP. Nevertheless, some of the reported improvements in other functional outcomes have not been as good as that obtained following TURP. Additionally the studies had been reported with short and medium term-follow-up only hence generally one cannot confidently state what the overall long-term outcome of PAE would be. Nevertheless, PAE has be associated with minor complications mainly and not with major complications including major bleeding. TURP tends to be associated with higher incidence of retrograde ejaculation and erectile dysfunction in comparison with PAE in which the sexual function tends to remain stable. PAE tends to be associated with retention of urine / long period of urethral catheterization in comparison with TURP. The overall cost of PAE tends to be much cheaper in comparison with TURP because of the fact that PAE tends to be undertaken as an outpatient procedure without any hospitalization cost. Specific complications which could occur include non-target embolization that could lead to transient rectitis, or penile ulcer, urinary tract infection, and dysuria. PAE may be associated with pelvic and urethral pain of more than 1 to 3 days but PAE is not associated with dilutional hyponatraemia which occasionally occurs following TURP. There is need for more studies to be undertaken on PAE and to be reported with long-term follow-up to enable a consensus opinion to be made about the long term outcome of PAE. Meanwhile PAE could be undertaken on individuals who have failed medical therapy who are not fit to undergo surgery or who do not want to undergo surgery.