P-A-E (Prostatic Artery Embolisation)

At a glance

• What it is: Prostatic artery embolisation, often shortened to PAE or searched as P-A-E, is a minimally invasive procedure for selected men with urinary symptoms from benign prostatic hyperplasia (BPH). A catheter is guided through the arteries and tiny particles are used to reduce blood flow to the prostate, causing it to shrink gradually.^1,2
• Who performs it: PAE is an interventional radiology procedure, not a urological operation. The radiologist uses X-ray imaging to map and treat the prostate arteries. Urology NSW's role is to assess the prostate and bladder symptoms, review alternatives, and discuss referral when PAE is a reasonable option.^1,2,3
• Who it may suit: Selected men with bothersome lower urinary tract symptoms from BPH, especially where medication has not helped enough or where avoiding a transurethral operation is a priority. Suitability depends on prostate size, urinary retention history, bladder function, vascular anatomy, and the need to exclude prostate cancer or bladder problems.^2,3,4
• What the evidence shows: PAE can improve urinary symptoms and quality of life in selected men. Compared with TURP and other tissue-removing BPH operations, symptom improvement may be smaller and retreatment may be more likely, but PAE usually has a shorter catheter and recovery profile and a lower risk of ejaculatory side effects.^3,4,5,6
• Where it fits: PAE sits alongside medication, UroLift, Rezum, iTind, HoLEP, TURP, GreenLight laser and simple prostatectomy. It is one option in a shared decision about prostate size, symptom severity, risks, sexual side effects, and how durable the treatment needs to be.^3,4

What is PAE?

PAE is a catheter-based treatment for benign prostate enlargement. Under local anaesthetic and sedation, an interventional radiologist passes a fine catheter into an artery, usually from the wrist or groin, and uses X-ray guidance to reach the small arteries supplying the prostate. Tiny embolic particles are then injected to block selected prostate artery branches.^1,2

The aim is to reduce the prostate's blood supply so that the gland shrinks over the following weeks to months. As the gland volume falls, pressure on the urethra may reduce and urinary flow may improve. Unlike TURP, HoLEP or GreenLight laser, PAE does not pass a telescope through the urethra and does not remove prostate tissue directly.^1,3

Because the treatment target is the blood supply rather than the inside of the prostate, careful imaging is central to the procedure. The interventional radiologist needs to identify the prostate arteries and avoid non-target embolisation to nearby structures such as the bladder, rectum or penis.^1,2

How is PAE different from urological BPH procedures?

The main difference is the route and mechanism. Urological BPH operations such as TURP, HoLEP and GreenLight laser treat the obstruction from inside the urethra by cutting, enucleating or vaporising prostate tissue. Mechanical and thermal minimally invasive options such as UroLift, iTind and Rezum also work through the urinary channel.^3,4

PAE is performed through the arteries. There is usually no urethral instrument, no prostate tissue specimen, and no cavity inside the prostate that needs to heal. This can make PAE attractive for men who place a high value on avoiding transurethral surgery or preserving ejaculation, provided they understand the trade-off that urinary-flow improvement may be less marked than with tissue-removing surgery.^3,5,6

What the evidence and guidelines say

The National Institute for Health and Care Excellence (NICE) states that evidence on the safety and efficacy of PAE for benign prostatic hyperplasia is adequate to support use with standard arrangements for clinical governance, consent and audit. NICE also states that patients should be selected by a urologist and an interventional radiologist.¹

The American Urological Association guideline says PAE may be offered for lower urinary tract symptoms attributed to BPH, and that it should be performed by clinicians trained in the interventional radiology procedure after discussion of risks and benefits.⁴ The European Association of Urology guideline notes that PAE is less effective than TURP at improving symptoms and urodynamic measures, but may be associated with fewer peri-operative complications and shorter recovery in selected patients.³

In practical terms, PAE is not a universal replacement for TURP, HoLEP or other BPH surgery. It is a reasonable discussion point for selected patients, especially when the anatomy, symptom pattern and personal priorities fit the procedure.

Who may be suitable?

PAE may be considered when:

• Symptoms are bothersome enough to consider a procedure after lifestyle measures or medication.
• The prostate is enlarged and the symptoms are likely to be due to benign obstruction rather than bladder overactivity alone.
• The patient wants to avoid a transurethral operation, or has medical factors that make a less invasive procedure worth discussing.
• Preserving ejaculation is an important priority and the patient accepts that symptom improvement may be less predictable than with some tissue-removing operations.^3,4,5

PAE may be less suitable when:

• There is suspected or untreated prostate cancer, bladder cancer, urethral stricture, bladder stone, or another cause of symptoms that needs separate treatment.
• Bladder contractility is poor, meaning the bladder muscle may not be able to empty even if the prostate obstruction is reduced.
• The prostate arteries are too small, tortuous or blocked to treat safely, or vascular anatomy makes non-target embolisation risk higher.
• There is severe urinary retention where a more definitive tissue-removing operation is likely to be needed.

A urological assessment usually includes symptom scoring, urine testing, prostate examination, PSA discussion where appropriate, ultrasound or other imaging, and sometimes cystoscopy or flow testing before deciding whether PAE is a good fit.

How PAE is performed

1. Pre-procedure assessment. The urologist and interventional radiologist confirm that the symptoms are likely to be due to BPH and that other diagnoses have been considered.
2. Imaging and artery mapping. CT angiography or angiography may be used to map the prostate blood supply and identify whether the arteries can be catheterised safely.^1,2
3. Arterial access. The radiologist inserts a small tube through the wrist or groin artery under local anaesthetic and sedation.
4. Selective embolisation. A microcatheter is guided into the prostate artery branches on each side and embolic particles are delivered to reduce blood flow to the gland.
5. Recovery. Many patients go home the same day or after a short observation period, depending on the hospital protocol and the individual's medical situation.^1,2

What to expect after PAE

Improvement is usually gradual rather than immediate. Some men notice change over the first few weeks, with further improvement over several months as the prostate shrinks. Temporary pelvic discomfort, urinary frequency, urgency, burning, blood in the urine or semen, and flu-like symptoms can occur after embolisation.^1,2,3

Follow-up usually includes symptom scoring and assessment of urinary flow and residual urine. Some men still need medication for a period after PAE, and some later choose another BPH procedure if symptoms persist or return.^3,4,6

Risks and limitations

All procedures have risks. With PAE, the risks to discuss include:

• Post-embolisation symptoms such as pelvic pain, urinary burning, urinary frequency, low-grade fever, nausea or fatigue.
• Urinary retention requiring a catheter for a period after the procedure.
• Infection of the urine or prostate, which may require antibiotics.
• Bleeding or bruising at the wrist or groin access site.
• Non-target embolisation, where particles affect nearby tissues such as bladder, rectum or penile blood supply. This is uncommon but is the reason detailed arterial mapping is important.^1,2
• Incomplete symptom relief or retreatment. Some men do not improve enough, or symptoms recur, and another BPH procedure may later be needed.^3,4,6
• No prostate tissue sample. Because no prostate tissue is removed, PAE does not provide pathology. Cancer assessment, when indicated, must be handled separately before or after treatment.

PAE at Urology NSW

Dr Raji Kooner does not perform PAE himself because it is an interventional radiology procedure. Urology NSW can assess men with BPH symptoms, explain how PAE compares with urological options, and arrange referral to an appropriately trained interventional radiologist when PAE appears worth considering.

The recommendation in any individual case is based on symptom severity, prostate size and shape, bladder function, medical history, sexual-function priorities, and the durability expected from treatment. Some men are better served by medication or a minimally invasive urological procedure; others need a more definitive tissue-removing operation such as HoLEP, TURP, GreenLight laser or simple prostatectomy.

Frequently asked questions

Is PAE surgery?

It is not surgery in the usual urological sense. PAE is a minimally invasive radiology procedure performed through the arteries under imaging guidance. It does not involve a telescope through the urethra and does not remove prostate tissue.

Does PAE preserve ejaculation?

PAE is generally associated with a lower risk of retrograde ejaculation than TURP and some tissue-removing procedures, but sexual side effects can still occur and should be discussed with the treating radiologist and urologist.^3,5,6

Is PAE as effective as HoLEP or TURP?

Not usually for maximum urinary-flow improvement. Guidelines and comparative studies generally describe PAE as less effective than TURP at improving objective flow and obstruction measures, while often offering a less invasive recovery profile for selected men.^3,5,6

Can PAE be used for very large prostates?

PAE has been used in men with large prostates, but size alone does not determine suitability. Bladder function, urinary retention, vascular anatomy, bleeding risk, and whether a tissue-removing operation would be more definitive all need to be considered.