Prostatic Artery Embolization

Background and indications

Benign prostatic hyperplasia (BPH) affects approximately 50% of men over 50 and up to 80% over 70. It causes obstructive urinary symptoms: frequency, weak stream, nocturia, and incomplete emptying sensation. When medical treatment (alpha-blockers, 5-alpha-reductase inhibitors) becomes insufficient, prostatic artery embolization (PAE) is a minimally invasive alternative to conventional surgical treatments (transurethral resection, laser enucleation, adenomectomy).

PAE is particularly indicated for patients with a large prostate (> 40 mL), high surgical risk, or those wishing to preserve sexual function (no risk of retrograde ejaculation, unlike surgery).

Pre-procedure assessment

Assessment includes a urological consultation with IPSS score (International Prostate Symptom Score), PSA measurement, uroflowmetry (Qmax), prostatic ultrasound with volume measurement, and prostate MRI. A pelvic CT angiography is performed to map the prostatic arteries before the procedure.

Procedure

Under local anesthesia and light sedation, a microcatheter is introduced through the femoral or radial artery at the wrist. Under fluoroscopic guidance, the interventional radiologist selectively catheterizes the prostatic arteries on both sides and injects calibrated microspheres (100-300 or 300-500 µm) that occlude the adenoma's blood supply. The procedure typically takes 1 to 2 hours. Cone-beam CT imaging is performed during the procedure to confirm proper particle distribution and exclude non-target embolization.

Results and scientific evidence

The UK-ROPE trial, a prospective multicenter study of 305 patients, demonstrated significant symptom improvement with a mean IPSS reduction from 24 to 12 points at 12 months (Ray et al., BJU International, 2018; DOI: 10.1111/bju.14249). Maximum urinary flow rate (Qmax) improves by an average of 5 to 7 mL/s and prostate volume decreases by 20 to 30% at 12 months.

Randomized comparative studies (MAP trial, PARERE trial) showed comparable efficacy to transurethral resection (TURP) on IPSS score and quality of life at 12 months, with fewer complications and better sexual function preservation. Technical success rate exceeds 95% and the 5-year reintervention rate is approximately 15-20%.

Risks and complications

Complications are rare and generally minor. Post-embolization syndrome (urinary burning, mild fever, pelvic discomfort) occurs in 10-15% of cases and resolves within days. Major complications (non-target bladder or rectal embolization) are exceptional (< 1%) thanks to selective catheterization techniques and cone-beam CT control.

Recovery

Recovery is rapid: return to normal activities within 2 to 5 days. A urinary catheter is generally not required. Symptom improvement is gradual over 1 to 3 months. Follow-up is scheduled at 1, 3, 6, and 12 months with reassessment of IPSS, Qmax, and prostate volume on MRI.

Practical information

The procedure is performed as an outpatient or short inpatient stay depending on the case. It is performed by a specialized interventional radiologist, in coordination with the treating urologist.