Prostatic artery embolization (PAE) could become an alternative to transurethral resection of the prostate (TURP) for treating lower-urinary-tract symptoms secondary to benign prostatic hyperplasia (BPH-LUTS), but further study is needed, a new Swiss study suggests
"The improvement in lower urinary tract symptoms secondary to benign prostatic hyperplasia seen 12 weeks after PAE is close to that after TURP. PAE is associated with fewer complications than TURP but has disadvantages regarding functional outcomes, which should be considered when selecting patients," researchers write in The BMJ, online June 19.
"Further comparative study findings, including longer follow-up, should be evaluated before PAE can be considered as a routine treatment," added Dr. Dominik Abt of St. Gallen Cantonal Hospital in St. Gallen and colleagues.
The team conducted a non-inferiority trial at one medical center, randomizing 103 men 40 and older with refractory BPH-LUTS to receive either PAE performed with 250-400-mcm microspheres under local anesthesia or monopolar TURP performed under general or spinal anesthesia.
From baseline to 12 weeks, international prostate symptoms score (IPPS) dropped 9.23 points after PAE and 10.77 points after TURP, but PAE non-inferiority could not be established (P=0.17).
At 12 weeks, PAE was significantly less effective than TURP in changing the maximum urinary flow rate (5.19 vs. 15.34 mL/s), postvoid residual urine (−86.36 vs. −199.98 mL), prostate volume (−12.17 vs. −30.27 mL) and pressure flow (56% vs. 93% shift towards less obstruction). However, significantly fewer adverse events followed PAE than TURP (36 vs. 70 events).
Dr. Ronald M. Benoit, director of general urology at the University of Pittsburgh School of Medicine in Pennsylvania, told Reuters Health by email, "TURP remains the gold standard for the treatment of lower-urinary-tract symptoms."
"I disagree with the conclusion of this study that the data demonstrate that PAE is a valuable alternative to TURP," Dr. Benoit added. "The primary concern is the short follow-up. Before declaring prostatic artery embolization to be a reasonable alternative to TURP, its durability needs to be demonstrated. Twelve weeks does not meet this standard."
Dr. Benoit is also concerned about the adequacy of the TURP procedures. "Many studies suggesting the equivalence between minimally invasive treatments for LUTS and TURP may be due to the decreased quality of TURPs performed in recent years as fewer TURPs are done in training. These studies may, therefore, be finding equivalence between minimally invasive procedures and less-than-adequately-performed TURP."
"The study finds relatively equivalent outcomes in terms of subjective voiding symptoms 12 weeks after treatment," Dr. Benoit said. "However, more objective measures, such as post-void residual, flow rate, and pressure-flow parameters, demonstrate a significant advantage for TURP. I strongly believe prostatic artery embolization should still be considered an experimental treatment," he concluded.
Dr. Shahin Tabatabaei, director of the Prostate Health Program at Massachusetts General Hospital in Boston, told Reuters Health by phone, "This study has a fantastic approach, and I applaud the authors for trying to do this. The authors were very careful in their data analysis and impartial in their conclusion and results. Unfortunately, they suggested that they were not able to prove that PAE is equal to TURP."
"Most symptoms with BPH, even with placebo, respond within the first three months, then the symptoms return," added Dr. Tabatabaei. "Following patients for only 12 weeks is suboptimal and does not show the long-term results."
"PAE is completely investigational in the United States, and we use it on a case-by-case basis for patients who have no other options," he said. "But for healthy gentlemen who require prostate treatment, it is too premature to recommend PAE as a standard treatment."
"We are all waiting for the long-term effects of PAE technology, which could potentially help a subset of patients," Dr. Tabatabaei noted. "I encourage clinicians and patients to look at these data with caution. This is promising, it's a good step, but it does not suggest that the treatment is ready for prime time."