Prostatic Artery Embolization for Benign Prostatic Hyperplasia

From "Prostatic Artery Embolization Promising
for Treating Enlarged Prostate",
Radiological Society of North America

Prostatic Artery Embolization (PAE) was first described in the 1970's as a salvage approach for intractable prostatic hemorrhage.  As a secondary effect, patients embolized for bleeding experienced improvement in their lower urinary tract symptoms (LUTS) and objective reduction in prostate volume.[1]

Significant literature exists describing prostatic arterial anatomy and variants.  The preclinical research defining this anatomy was done in a porcine model.[2]  The first report of PAE for benign prostatic hyperplasia (BPH) in the peer-reviewed literature was by Carnevale and colleagues in 2010.[3]  In this initial case series, two patients had significant reductions in prostate volume and improvement in LUTS.

Since then, a number of case series and small studies demonstrate improvements in a number of parameters related to BPH.  However, none of these studies are randomized or controlled, they are often single-institution and may omit one or more meaningful outcome measures.

Pisco and colleagues reported the outcomes of 15 consecutive patients undergoing PAE. [4] Over a median follow-up of 8 months, they demonstrated an improvement in symptoms (mean IPSS decrease 6.5), improved urine flow (mean Qmax increase 3.85mL/s) and decreased prostate volume (mean volume reduction 28.9mL).  Importantly, there were no changes in PSA or erectile function indicating that PAE did not affect the cavernous arteries or nerves that control erections.  Only one patient experienced a complication (bladder wall ischemia) that did require surgical correction.

The same group has now reported (up to) 2 year outcomes for 103 patients undergoing PAE.[5]  They reported promising operative and perioperative outcomes including little reported pain (average visual analog pain score 1.6), a mean procedure time of 83 minutes, mean fluoroscopy time of 24 minutes, improvement in LUTS (mean IPSS decline 13.5 at 2 years) and urine flow rates (mean increase in Qmax 5.7mL/s).  There was no significant change in PSA or prostate volume at the 2 year mark.  

Given the strengths and shortcomings in the data regarding PAE, there is a fair amount of enthusiasm and skepticism for PAE in the urological community.  In a recent editorial in the Journal of Urology, Kevin T. McVary (Associate Editor), Professor and Chair, Division of Urology of Southern Illinois University said,

"If PAE has merit for our patients there will be no avoiding the truth...  the best way to expose it with as little risk to our patients and society is through a properly performed randomized clinical trial."

Stephen Schatz, MD

Johns Hopkins is one of 12 sites worldwide participating in a prospective, randomized trial comparing PAE to traditional transurethral resection of the prostate (TURP) for BPH.  Stephen Schatz, MD, Assistant Professor of Urology has teamed up with Kelvin Hong, MD and Mark Lessne, MD of the Deparment of Vascular and Interventional Radiology to administer the study.  The primary endpoint is the International Prostate Symptom Score (IPSS) at 12 months; and secondary endpoints will include urine flow (Qmax), post void residual, detrusor pressure, erectile function, prostate volume (by MRI) and PSA measurements.

Men interested in participating must:

• be between 50 and 79 years of age
• have an IPSS > 13
• have a prostate volume 50-80 grams
• have failed medical therapy
• be a candidate for TURP
• have no suspicion of prostate or bladder cancer 

Interested patients can call the Brady Urological Institute Clinic 410 955 6100 for an appointment with Dr. Schatz or speak with Elizabeth Fabian, the study coordinator.

This blog was written by Stephen Schatz, MD.


[1] DeMeritt JS, et.al. Relief of benign prostatic hyperplasia-related bladder outlet obstruction after transarterial polyvinyl alcohol prostate embolization. J Vasc Interv Radiol. 2000;11(6):767–770

[2] Sun F, Sánchez FM, Crisóstomo V, et al. Benign prostatic hyperplasia: transcatheter arterial embolization as potential treatment—preliminary study in pigs. Radiology. 2008;246(3):783–789.

[3] Carnevale FC1, Antunes AA, da Motta Leal Filho JM, de Oliveira Cerri LM, Baroni RH, Marcelino AS, Freire GC, Moreira AM, Srougi M, Cerri GG.  Prostatic artery embolization as a primary treatment for benign prostatic hyperplasia: preliminary results in two patients.  Cardiovasc Intervent Radiol. 2010 Apr;33(2):355-61. doi: 10.1007/s00270-009-9727-z. Epub 2009 Nov 12.

[4] Pisco JM, Pinheiro LC, Bilhim T, Duarte M, Mendes JR, Oliveira AG.  Prostatic arterial embolization to treat benign prostatic hyperplasia.  J Vasc Interv Radiol. 2011 Jan;22(1):11-9

[5] Rio Tinto H, et.al., Prostatic Artery Embolization in the Treatment of Benign Prostatic Hyperplasia: Short and Medium Follow-up.  Tech Vasc Interv Radiol. 2012 Dec;15(4):290-3.