What are the effects of a procedure that reduces blood flow to the prostate (called prostatic arterial embolization) in men with symptoms caused by an enlarged prostate?
An enlarged prostate may cause difficulty with urination such as a weak stream or the need to urinate often during the day or at night. This can be treated by medications or by different types of surgery. One main type of surgery is called transurethral resection of the prostate. This involves going inside the urethra through the penis and removing prostate tissue. Prostatic arterial embolization is another form of treatment that works by stopping blood flow to parts of the prostate. We did this study to compare how prostatic arterial embolization compares to transurethral resection of the prostate and other procedures used in men with an enlarged prostate.
We found eight studies that compared prostatic arterial embolization to transurethral resection of the prostate. In six of eight studies, so-called randomized trials, chance decided which group people were in. In the other two studies, the men themselves and their doctors decided. We also included one study that compared prostatic arterial embolization to a sham procedure (men were made to believe that they had received treatment, but in reality, they did not). We found no evidence comparing prostatic arterial embolization to treatments other than transurethral resection of the prostate.
Prostatic arterial embolization compared to transurethral resection of the prostate
Based on up to 24 months' follow-up, prostatic arterial embolization and transurethral resection of the prostate may work similarly well in helping to relieve symptoms. Men's quality of life may be also improved similarly. We are very uncertain about differences in major unwanted effects. Prostatic arterial embolization likely increases the need for being treated again for the same problem. Prostatic arterial embolization may work similarly with regard to erection problems, but may reduce problems with ejaculation.
Certainty of evidence
The certainty of evidence for the outcomes was mainly low or very low. This means that the true effect can be very different from what this review shows. Better designed, larger studies with longer follow-up are needed to answer the question of how prostatic arterial embolization compares to other treatments.
Compared to TURP, PAE may provide similar improvement in urologic symptom scores and quality of life. While we are very uncertain about major adverse events, PAE likely increases retreatment rates. While erectile function may be similar, PAE may reduce ejaculatory disorders. Certainty of evidence for the outcomes of this review was low or very low except for retreatment (moderate-certainty evidence), signaling that our confidence in the reported effect size is limited or very limited, and that this topic should be better informed by future research.
A variety of minimally invasive surgical approaches are available as an alternative to transurethral resection of the prostate (TURP) for management of lower urinary tract symptoms (LUTS) in men with benign prostatic hyperplasia (BPH). Prostatic arterial embolization (PAE) is a relatively new, minimally invasive treatment approach.
To assess the effects of PAE compared to other procedures for treatment of LUTS in men with BPH.
We performed a comprehensive search the Cochrane Library, MEDLINE, Embase, three other databases, trials registries, other sources of grey literature, and conference proceedings with no restrictions on language of publication or publication status, up to 8 November 2021.
We included parallel-group randomized controlled trials (RCTs), as well as non-randomized studies (NRS, limited to prospective cohort studies with concurrent comparison groups) enrolling men over the age of 40 years with LUTS attributed to BPH undergoing PAE versus TURP or other surgical interventions.
Two review authors independently classified studies for inclusion or exclusion and abstracted data from the included studies. We performed statistical analyses by using a random-effects model and interpreted them according to the Cochrane Handbook for Systematic Reviews of Interventions. We used GRADE guidance to rate the certainty of evidence of RCTs and NRSs.
We found data to inform two comparisons: PAE versus TURP (six RCTs and two NRSs), and PAE versus sham (one RCT). Mean age was 66 years, International Prostate Symptom Score (IPSS) was 22.8, and prostate volume of participants was 72.8 mL. This abstract focuses on the comparison of PAE versus TURP as the primary topic of interest.
Prostatic arterial embolization versus transurethral resection of the prostate
We included six RCTs and two NRSs with short-term (up to 12 months) follow-up, and two RCTs and one NRS with long-term follow-up (13 to 24 months).
Short-term follow-up: based on RCT evidence, there may be little to no difference in urologic symptom score improvement measured by the International Prostatic Symptom Score (IPSS) on a scale from 0 to 35, with higher scores indicating worse symptoms (mean difference [MD] 1.72, 95% confidence interval [CI] –0.37 to 3.81; 6 RCTs, 360 participants; I² = 78%; low-certainty evidence). There may be little to no difference in quality of life as measured by the IPSS-quality of life question on a scale from 0 to 6, with higher scores indicating worse quality of life between PAE and TURP, respectively (MD 0.28, 95% CI –0.28 to 0.84; 5 RCTs, 300 participants; I² = 63%; low-certainty evidence). While we are very uncertain about the effects of PAE on major adverse events (risk ratio [RR] 0.75, 95% CI 0.19 to 2.97; 4 RCTs, 250 participants; I² = 24%; very low-certainty evidence), PAE likely increases retreatments (RR 3.20, 95% CI 1.41 to 7.27; 4 RCTs, 303 participants; I² = 0%; moderate-certainty evidence). PAE may make little to no difference in erectile function measured by the International Index of Erectile Function-5 on a scale from 1 to 25, with higher scores indicating better function (MD –0.50 points, 95% CI –5.88 to 4.88; 2 RCTs, 120 participants; I² = 68%; low-certainty evidence). Based on NRS evidence, PAE may reduce the occurrence of ejaculatory disorders (RR 0.51, 95% CI 0.35 to 0.73; 1 NRS, 260 participants; low-certainty evidence).
Long-term follow-up: based on RCT evidence, PAE may result in little to no difference in urologic symptom scores (MD 2.58 points, 95% CI –1.54 to 6.71; 2 RCTs, 176 participants; I² = 73%; low-certainty evidence) and quality of life (MD 0.50 points, 95% CI –0.03 to 1.04; 2 RCTs, 176 participants; I² = 29%; low-certainty evidence). We are very uncertain about major adverse events (RR 0.91, 95% CI 0.20 to 4.05; 2 RCTs, 206 participants; I² = 72%; very low-certainty evidence). PAE likely increases retreatments (RR 3.80, 95% CI 1.32 to 10.93; 1 RCT, 81 participants; moderate-certainty evidence). While PAE may result in little to no difference in erectile function (MD 3.09 points, 95% CI –0.76 to 6.94; 1 RCT, 81 participants; low-certainty evidence), PAE may reduce the occurrence of ejaculatory disorders (RR 0.67, 95% CI 0.45 to 0.98; 1 RCT, 50 participants; low-certainty evidence).