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BackTable / VI / Article
Prostate Artery Embolization Procedure
Dr. Chris Beck • Updated Jan 2, 2024 • 2.8k hits
Prostate artery embolization is a minimally invasive procedure used to treat symptoms of benign prostatic hyperplasia (BPH), such as urinary difficulties, in men. The procedure involves the selective blockage of the arteries supplying blood to the prostate, causing a reduction in its size and alleviating symptoms. Performed by interventional radiologists under imaging guidance, prostate artery embolization offers a safe alternative to traditional surgery, with a shorter recovery time and minimal discomfort. This procedure is an effective solution for patients who have not responded to medications or prefer to avoid invasive surgery, providing long-lasting relief from BPH symptoms and improving quality of life.
Table of Contents
(1) Pre Prostate Artery Embolization Procedure Prep
(2) Prostate Artery Embolization Procedure Steps
(3) Post Prostate Artery Embolization Procedure
Pre Prostate Artery Embolization Procedure Prep
Indications
• Benign prostatic hypertrophy (BPH) with lower urinary tract symptoms (LUTS)
• Intractable hematuria
Patient Population
Treat patients with moderate to severe LUTS.
Patients who have failed or cannot tolerate conservative medical management:
• Hypotension
• Retrograde ejaculation
• Decreased sexual drive
Surgery:
• Patients often concerned about potential morbidity or complications
• Contraindication to surgery related to patient comorbidities
Prostate size > 40
Workup
IPSS:
• Many agree with an International Prostate Symptom Score (IPSS) < 8, PAE not indicated
• Quality of Life (QoL)
• IPSS a a good survey for assessing LUTS
Urodynamics:
• Specialized test to assess detruser strength
• Can discern between neurogenic bladder and bladder outlet obstruction
• Neurogenic bladder can be seen in spinal cord injury, MS, diabetics.
Uroflowmetry:
• Qmax: > 10 mL/s unlikely to benefit from PAE
• If Qmax > 10 mL/s, consider other causes of LUTS
Labs:
• PSA
• BMP
• Urinalysis:
Imaging:
• Ultrasound: can evaluate prostate size and evaluate bladder for post void residual (PVR) volume.
• CTA or MRA: can estimate prostate size and potentially evaluate prostate arteries
• MR: can evaluate prostate size and underlying neoplasm. Can compare pre MRI with post MRI to assess change in volume and enhancement
In Summary:
• Recommend consistent preprocedural workup for patients
• Use IPSS
• Need basic understanding of uroflowmetry and post void residual volume
• Need algorithm for prostate cancer evaluation
• Preprocedural imaging can range from basic to complex
• LUTS are not always secondary to BPH
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Prostate Artery Embolization Procedure Steps
Antibiotic
• 400 mg Ciprofloxacin IV preprocedure
• Continue 500 mg Ciprofloxacin PO BID x 5-7 days following procedure
Outpatient Procedure
• Sedation: ranges from local to MAC
• Foley helpful especially when starting out, but try to avoid as comfort level and experience increase
• BB marker on base of penis also helpful when starting out
Prostate Artery Embolization Procedure Summary
• Access: radial vs femoral
• Catheterize left internal iliac artery (IIA)
• DSA: 45° ipsilateral oblique
• 2.1 or 2.4-Fr microcatheter for prostate artery
• Confirm placement with DSA
• Confirm placement and potential non-target embolization with cone-beam
• 100 mcg nitroglycerine into prostate artery before embolization
• Many choices for embolics. Sizes range from 100-500 μm
• Endpoint: stasis or near stasis
• Repeat for contralateral prostate artery
Radial
• Good vector to catheterize the internal iliac arteries
• May have challenges for cone-beam CT
Femoral - sometimes bilateral access needed
Catheterize IIA
• Depends on tortuosity
• Can start with basic C2 catheter if using femoral approach
For femoral access and ipsilateral IIA:
• Can pull reverse curve catheter like Sos into the IIA
• Waltman loop or RUC helpful to access anterior division of IIA
Identify Prostate Artery
Consider cone beam CT at beginning of procedure with flush catheter in aorta:
• Gives nice overview of anatomy
• Can observe anatomic variants
• Can be helpful when choosing an obliquity for IIA DSA to identify origin of prostate artery
• Potential cone beam protocol: 6 mL/s for 42 mL (allows for 2 seconds to fill artery and a 5 second spin)
• Dilute contrast: 1:1 ratio of contrast to saline
DSA in IIA:
• Helpful to access anterior division of IIA
• 45° ipsilateral oblique
• Prostate artery crosses main trunk of obturator artery (if present) > 95% of time
• Obturator easy to identify with distal fork
• Recommend looking at lots of angiograms prior to first case
• Understanding branches of IIA will help identify prostate artery
Catheterize Prostate Artery
• Many different techniques and tools
• Average diameter 1.6 mm
• Artery prone to spasm
• Recommend starting with 2.1-Fr microcatheter
• Preshaped microcatheters can be helpful
• Shapeable microwire usually fine
• 0.016" double angle Glidewire GT (Terumo) helpful
Confirm placement and evaluate for non-target embolization with cone-beam CT:
• Many protocols
• Consider 0.5 mL/sec for 8 mL with 8 second delay (will obtain arterial information and parenchymal filling)
Potential Non-Target Embolization
• Often easiest maneuver is to advance microcatheter distal to potential non-target branch
• Embolize with non-target vessel with Gelfoam or coils
• Larger particles (300-500 μm) may reduce chance of end tissue necrosis
Post Prostate Artery Embolization Procedure
Prostate Artery Embolization Complications
Non-target embolization: rectum, bladder and penis
Urinary retention
• Up to 8%
• More likely with larger volume prostates
• Treated with 1-2 weeks of indwelling Foley catheter
• Some operators will tell patients with > 150 g prostates to expect to go home with Foley
Minor prostate artery embolization complications:
• Hematuria
• Hematospermia
• Pain
Post-Procedural Care
• Can be discharged day of procedure
• 1-3 hour prostate artery embolization recovery time
• Discharge pain regimen to include anti-inflammatory, opioids for break through pain, antiemetics
Follow-Up
• 1, 3, 6 and 12 month visits
• IPSS at each visit
• Similar to UFE, maximal benefit between 3-6 months
• Post procedure imaging and urodynamics usually reserved for troubleshooting
Outcomes at 12 Months
• IPSS improved by 20 points
• QoL improved by 2.5 points
• PVR decreased by 86 mL
After 2 years, IPSS, Qol and urinary flow similar. TURP better at reducing prostate size
Additional resources:
[1] Moradzadeh N, Ranade A, McWilliams J. Angiographic features to aid identification of the prostatic artery during prostatic arterial embolization [abstract]. In J Vasc Interv Radiol. 2019;30(3):Supplement, Page S59. Abstract No.126.
[2] Bagla S, Isaacson AJ. Tips and Tricks for Difficult Prostatic Artery Embolization. Semin Intervent Radiol. 2016;33(3):236‐239. doi:10.1055/s-0036-1586145
[3] Carnevale FC, Iscaife A, Yoshinaga EM, Moreira AM, Antunes AA, Srougi M. Transurethral Resection of the Prostate (TURP) Versus Original and PErFecTED Prostate Artery Embolization (PAE) Due to Benign Prostatic Hyperplasia (BPH): Preliminary Results of a Single Center, Prospective, Urodynamic-Controlled Analysis. Cardiovasc Intervent Radiol. 2016;39(1):44‐52. doi:10.1007/s00270-015-1202-4
[4] Uflacker A, Haskal ZJ, Bilhim T, Patrie J, Huber T, Pisco JM. Meta-Analysis of Prostatic Artery Embolization for Benign Prostatic Hyperplasia. J Vasc Interv Radiol. 2016;27(11):1686‐1697.e8. doi:10.1016/j.jvir.2016.08.004
[5] Gao YA, Huang Y, Zhang R, et al. Benign prostatic hyperplasia: prostatic arterial embolization versus transurethral resection of the prostate--a prospective, randomized, and controlled clinical trial. Radiology. 2014;270(3):920‐928. doi:10.1148/radiol.13122803
[6] Martins Pisco J, Pereira J, Rio Tinto H, Fernandes L, Bilhim T. How to perform prostatic arterial embolization. Tech Vasc Interv Radiol. 2012;15(4):286‐289. doi:10.1053/j.tvir.2012.09.002
[7] BackTable, LLC (Producer). (2017, November 27). Ep 17 – Prostate Artery Embolizations [Audio podcast]. Retrieved from https://www.backtable.com/shows/vi
Podcast Contributors
Cite This Podcast
BackTable, LLC (Producer). (2025, February 18). Ep. 518 – Long-Term Outcomes of Prostatic Artery Embolization (PAE) [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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