Current considerations in prostate artery embolisation

BACKGROUND: Prostate artery embolisation is an increasingly common, minimally invasive procedure performed for lower urinary tract symptoms caused by benign prostatic hyperplasia, with numerous systematic reviews and meta-analyses concluding that PAE is safe and effective. Despite mounting evidence supporting its role in treating BPH, variability and debate exist across various practical and technical factors associated with PAE. MAIN BODY: PAE requires the use of a permanent embolic, typically microparticles or a liquid embolic, to induce ischaemia within the transitional zone of the prostate and shrink hyperplastic nodules. Microparticles have a large body of evidence that has established them as safe and effective. Liquid embolics can reduce procedure time and radiation dose but require operator experience with preparation and delivery. Pre-procedural CTA and cone beam CT are useful in defining anatomy and identifying non-target vasculature with the aim to reduce procedure time and risk of non-target embolisation but are associated with increased radiation dose. PAE can be safely performed from either a femoral or radial approach. Femoral access may be associated with higher rates of local complications and radial access is generally preferred by patients, although patient anatomy should be considered when selecting the site of access. There is recent evidence supporting the use of PAE as first-line therapy for BPH or as an adjunct prior to surgical intervention. CONCLUSION: Prostate artery embolisation is an important treatment option within the algorithm for managing BPH, and has matured into a credible, evidence-based option alongside surgery and medications. While the efficacy and safety of PAE are well established, varied technical considerations exist regarding embolic choice, access route, imaging adjuncts and the procedure's role within the treatment sequence. Current data supports a pragmatic, anatomy-driven approach that prioritises procedural precision, embolic control, and patient-centred decision-making over adherence to a single technique.