Prostatic Artery Embolization versus Standard Surgical Treatment for Lower Urinary Tract Symptoms Secondary to Benign Prostatic Hyperplasia: A Systematic Review and Meta-analysis

Abstract

Context: Prostatic artery embolization (PAE) has been introduced into clinical practice for the treatment of lower urinary tract symptoms secondary to benign prostatic hyperplasia (BPH-LUTS) despite a lack of high-level evidence. Objective: To perform a systematic review and meta-analysis of clinical trials comparing efficacy and safety of PAE versus established surgical therapies. Evidence acquisition: Medline, Embase, and York CRD were searched up to June 23, 2018. Only comparative studies were included. The risk of bias was assessed by the Cochrane Collaboration tool. Meta-analyses were performed using RevMan 5.3. Evidence synthesis: Five studies including 708 patients met the selection criteria. Risk of bias was rated high for most of the studies. Mean reduction in the International Prostate Symptom Score was lower after PAE compared with standard surgical therapies (mean difference 3.80 points [95% confidence interval: 2.77-4.83]; p < 0.001). PAE was less efficient regarding improvements in all functional parameters assessed including maximum urinary flow, post void residual, and reduction of prostate volume.In contrast, patient-reported erectile function (International Index of Erectile Function 5) was better after PAE and significantly fewer adverse events occurred after PAE. Conclusions: Moderately strong evidence confirms efficacy and safety of PAE in the treatment of BPH-LUTS in the short term. Significant advantages regarding safety and sexual function, but clear disadvantages regarding all other patient-reported and functional outcomes were found for PAE. Large-scale randomized controlled trials including longer follow-up periods are mandatory before PAE can be considered as a standard therapy and to define the ideal indication for PAE in the management of BPH-LUTS. Patient summary: We reviewed the role of prostatic artery embolization (PAE) in the treatment of symptoms associated with benign overgrowth of the prostate. The results suggest that PAE is not as effective as established surgical therapies but has fewer side y These authors contributed equally. * Corresponding author. Kantonsspital St. Gallen,

Outcome prediction of prostatic artery embolization: post hoc analysis of a randomized, open‐label, non‐inferiority trial

“…Because of its efficacy and safety profile, PAE has been suggested as the most appropriate alternative to medical treatment or to other minimally invasive treatments such as Urolift ® or Rezum ® . This study shows that beside the patient's clinical circumstances and expectations, his individual prostate size and zonal anatomy should also be considered in patient counselling; thus, very small prostates are at a higher risk of therapy failure compared to large glands.…”

“…Nevertheless, PAE has come into use over the past years and was recently approved by the National Institute for Health and Care Excellence (NICE) as a minimally invasive approach for LUTS/BPH . Patient‐reported outcomes with PAE are similar to those for established surgical methods, and it has a better side‐effect profile but lower desobstructive efficacy . Because PAE is a very different therapeutic approach, outcome predictors for traditional transurethral surgical approaches are unlikely to be fully applicable to PAE.…”

Position Paper of the German Society for Interventional Radiology (DeGIR) on Prostatic Artery Embolization

“…Bei allen 3 RCTs handelt es sich um monozentrische Studien mit einer nur begrenzten Patientenanzahl. Die Ergebnisse dieser 3 RCTs, einer britischen Registerstudie und einer prospektiven Fall-Kontroll-Studie, ausgewertet mit der "Propensity Score Matching"-Methode (UK-ROPE trial), sind in einer aktuellen Metaanalyse von Zumstein et al aus dem Jahr 2018 zusammengefasst worden [54][55][56]. Hier zeigt sich nach aktueller Studienlage, dass der Einfluss auf den Schweregrad von LUTS, gemessen mit dem IPSS-Fragebogen, bei der PAE im Vergleich zum chirurgischen Standardverfahren signifikant geringer ist (mediane Differenz 3,8 Punkte; 95 %-Konfidenzintervall (KI) 2,77-4,83; p > 0,001).…”

Die Prostataarterienembolisation zur Behandlung des benignen Prostatasyndroms

“…Zumstein et al [20] führten im Jahr 2018 eine systematische Literatur-und Metaanalyse mit insgesamt 708 Patienten, bestehend aus o. g. Studien und einer randomisierten kontrollierten Studie von Carnevale et al [21] von 30 Patienten, durch. Die durchschnittliche Differenz in der Verringerung des IPSS betrug 3,8 Punkte [95 %-KI 2,8-4,8] (p < 0,001) zugunsten der TURP.…”