Prostatic Artery Embolization in Treatment of Benign Prostatic Hyperplasia: Outcome and Efficacy in Medium Sized Compared to Large Prostates

Prostatic Artery Embolization in Treatment of Benign Prostatic Hyperplasia: Outcome and Efficacy in Medium Sized Compared to Large Prostates | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Prostatic Artery Embolization in Treatment of Benign Prostatic Hyperplasia: Outcome and Efficacy in Medium Sized Compared to Large Prostates Noha Elghitany, Osama Hetta, Ahmed Hussein, Allam Allam This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5373074/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 23 Jun, 2025 Read the published version in Egyptian Journal of Radiology and Nuclear Medicine → Version 1 posted You are reading this latest preprint version Abstract Background: Prostate artery embolization (PAE) is a minimally invasive procedure commonly performed to treat lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia. International Prostate Symptom Score (IPSS) is a validated patient questionnaire quantifying LUTS, Quality of Life (QOL) and postvoiding residual volume (PVR) were used for patient selection for PAE. Prostate volume is an easily estimated objective parameter across multiple imaging modalities specially with ultrasound. We are comparing the result of embolization by comparing it in large (over 80 mL) and medium sized prostates (from 51 to 80 mL) volume. We looked at a sample of 88 cases performed at a large teaching hospital between January 2022 to August 2024 with 6 months follow up. Embospheres between 300/500 microns were injected into the prostatic arteries bilaterally (if technically feasible). Ultrasound were used to measure to estimate prostatic volume. N = 42 had an estimated volume (range 51-80 mL) and N=46 had an estimate volume> 80 mL. IPSS, QOL, PVR and PV were assessed before and at 1-, 3- and 6-months post-procedure were collected. The aim of this study is to compare efficacy and outcome of PAE in medium sized prostate in comparison to the large prostates. Results: Both medium-sized and large prostate groups showed statistically significant reductions in prostate volume, IPSS, QoL, and PVR over time (P-value <0.001). However, while the percentage reduction in prostate volume was comparable between the two groups across all follow-up points (e.g., 56.42% vs. 60.71% at 6 months, p=0.055, NS), the large prostate group had significantly greater reductions in PVR at 1, 3, and 6 months (e.g., 77.46% vs. 63.22% at 6 months, p<0.001). Conversely, the medium-sized group demonstrated significantly greater improvements in IPSS at 1 and 3 months (e.g., 65.02% vs. 59.45% at 3 months, p=0.004), but these differences were not significant by 6 months. QoL improvements were similar between the groups throughout the study. No major complications were recorded. Conclusion: Our results suggest that prostate volume should not be used to exclude patients for PAE. Prostate artery embolization Prostate size Prostate volume Lower urinary tract symptoms Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Figure 9 Figure 10 Figure 11 Figure 12 Introduction Benign prostatic hyperplasia (BPH) is the most prevalent benign tumor in ageing men, and its prevalence rises with age, reaching 8% in the fourth decade and up to 90% in the ninth [ 1 ]. Medically refractory lower urinary tract symptoms (LUTS) like sensation of incomplete emptying of the urinary bladder, hesitancy, weak urinary stream, increase in frequency, nocturia and urgency that are caused by benign prostatic hyperplasia (BPH) is a remarkably common concern in men older than 50 years old. Although the latest gold standard method of treatment, transurethral resection of the prostate, is effective, it results in increased morbidity rates than wanted. This is the reason why a high demand of new minimally invasive means to be available as treatment options for BPH, one these techniques is prostate artery embolization (PAE) [ 2 – 4 ]. Despite the fact that BPH is not a fatal disease, it still poses a huge burden on the lives of patients by causing distressing urinary symptoms. On top of that, the side effects of BPH expands beyond the horizons of physical symptoms as it is accompanied with high financial costs due to frequent clinical visits and prolonged sick leaves [ 3 ]. PAE and (TURP) transurethral resection of the prostate have showed similar results in the rate of subjective improvement in the symptoms that is reported by patients(i.e. International prostate symptom score IPSS, IPSS-QoL, and International Index of Erectile Function (IIEF-5)).On the other side, although PAE has a longer procedure time, it has reported outstandingly fewer side effects and shorter hospital stays in comparison to TURP [ 5 ]. Despite TURP being the first line of treatment for patients refusing or having contraindications to surgery, PAE could serve as an alternative treatment as it is performed under local anesthesia which is safer for vulnerable patients [ 6 ]. New procedures have been developed to overcome the symptoms of BPH that aren’t controlled with medical therapy or for patients who can’t tolerate side effects of some of the medical treatments [ 7 ]. It was proven that PAE is an effective method in reducing the BPH symptoms with avoiding the unwanted side effects of surgery such as urinary incontinence or sexual dysfunction [ 8 ]. According to the society of Interventional Radiology Multi-society Consensus has strongly recommended that “the PAE is an acceptable minimally invasive treatment option for appropriately selected men with BPH and moderate to severe LUTS” and moderately recommended that “PAE can be considered as a treatment option in patients with BPH and moderate to severe LUTS who have very large prostate glands (> 80 cm3), without an upper limit of prostate size” [ 9 ]. Medically refractory lower urinary tract symptoms (LUTS) like sensation of incomplete emptying of the urinary bladder, hesitancy, weak urinary stream, increase in frequency, nocturia and urgency that are caused by benign prostatic hyperplasia (BPH) is a remarkably common concern in men older than 50 years old. Although the latest gold standard method of treatment, transurethral resection of the prostate, is effective, it results in increased morbidity rates than wanted. This is the reason why a high demand of new minimally invasive means to be available as treatment options for BPH, one these techniques is prostate artery embolization (PAE) [ 2 – 4 ]. Despite the fact that BPH is not a fatal disease, it still poses a huge burden on the lives of patients by causing distressing urinary symptoms. On top of that, the side effects of BPH expands beyond the horizons of physical symptoms as it is accompanied with high financial costs due to frequent clinical visits and prolonged sick leaves [ 3 ]. PAE and TURP have showed similar results in the rate of subjective improvement in the symptoms that is reported by patients (i.e. International prostate symptom score IPSS, IPSS-QoL, and International Index of Erectile Function (IIEF-5)).On the other side, although PAE has a longer procedure time, it has reported outstandingly fewer side effects and shorter hospital stays in comparison to TURP [ 5 ]. Despite TURP being the first line of treatment for patients refusing or having contraindications to surgery, PAE could serve as an alternative treatment as it is performed under local anaesthesia which is safer for vulnerable patients [ 6 ]. New procedures have been developed to overcome the symptoms of BPH that aren’t controlled with medical therapy or for patients who can’t tolerate side effects of some of the medical treatments [ 7 ]. It was proven that PAE is an effective method in reducing the BPH symptoms with avoiding the unwanted side effects of surgery such as urinary incontinence or sexual dysfunction [ 8 ]. According to the society of Interventional Radiology Multi-society Consensus has strongly recommended that “the PAE is an acceptable minimally invasive treatment option for appropriately selected men with BPH and moderate to severe LUTS” and moderately recommended that “PAE can be considered as a treatment option in patients with BPH and moderate to severe LUTS who have very large prostate glands (> 80 cm3), without an upper limit of prostate size” [ 9 ]. According to The European Association of Urology (EAU) 2020 guidelines on non-neurogenic male LUTS recommend that “Despite PAE remains still “under investigation” it is the only minimally invasive treatment besides prostatic urethral lift that is supported by the EAU guidelines at present in selected patients [ 10 ]. PAE acts as a safe and effective method that provides a new pathway in the treatment of BPH other than formal surgical intervention. Even in the world of other minimally invasive techniques, PAE is still found to be more distinctively advantageous due to its endovascular approach rather than transurethral approach. Not only is PAE done with local anaesthesia and allows patients to stay on anticoagulant medications, but also has no maximum prostate size [ 10 ]. In addition to the decrease in the prostate size and resolution of the bladder outlet obstruction, it also causes a destruction in the receptors and nerves that is responsible for the urinary symptoms causing improvement of the LUTS that is secondary to the benign prostatic obstruction (BPO) [ 10 ]. In spite the fact that PAE in smaller sized prostates is not as beneficial as in larger ones and it’s harder to expect its clinical outcome, some patients with smaller glands have great outcomes [ 10 ]. Materials And Methods Study Population From April January 2022 to August 2024 at a single institution, a total of 88 consecutive patients. mean age of patients was significantly higher in the large prostate group (70.5 ± 6.83 years) compared to the medium-sized prostate group (65.05 ± 8.21 years, p = 0.001) diagnosed with severe LUTS due to BPH that was refractory to medical treatment underwent PAE. Of the 88 patients, 46 patients (52.2%) were with a prostate volume > 80 mL (mean, 133 mL); and the remaining 42 patients (47.7%) were with a prostate volume of 50–80 mL (mean,62.6 mL). This prospective study comparing efficacy and outcome of PAE in medium sized prostate to the large prostates. this technique was approved by the Ethics Committee of Ain Shams University Hospital. Patients were required to read and sign an informed consent prior to the procedure. Patients All undergoing PAE from January 2022 to August 2024. Inclusion criteria were (a) Male patient not fit for surgery (b) Prostate volume > 50 gm (c) Diagnosis of BPH with moderate to severe LUTS refractory to medical treatment for at least 6 months (International prostate symptom score (IPSS) > 18 and/or quality of life(QOL) > 3) or under acute urinary retention refractory to medical therapy. Exclusion Criteria were (a) Patients with proven prostatic malignancy (b) prostatic biopsy to exclude malignancy, if the Prostate-specific antigen (PSA) level is greater than 4 ng/mL or transrectal ultrasound scan (TRUS) findings are suspicious(c) Patients with large bladder diverticula, renal insufficiency, active urinary infection, neurogenic bladder (d) Unregulated coagulation parameter (e) contrast allergy. Patient evaluation All patients were evaluated by clinical observation. Efficacy variables of IPSS (Table 1), QoL (Table 2), PVR, and PV were assessed before PAE and at 1, 3 and 6 months after the procedure. PSA was assessed before PAE. The PV was measured by Ultrasonography. The PV was determined using the standard ellipsoid formula: lengthÅ~widthÅ~heightÅ~0.52 Either by the CT (Fig. 1a-b).or US images (Fig. 2) Table (1): International prostate symptom score (IPSS) a b a. Pike et al. [ 11 ] b. All information was self-reported. Table (2) Quality of life aspect of the international prostate symptom score ab a. Pike et al. [ 11 ] b. All information was self-reported. Figure (1) a showing the prostate directly after embolization with (white arrow showing contrast seen inside the prostate of the right prostatic gland) and blue and yellow lines measuring (1 length 2 width 3 height) using the equation (length Å~widthÅ~heightÅ~0.52) reaching volume of 62 gram) Figure (2) Showing the prostate volume measuring yellow asterisks with automatic volume measuring using the same equation (lengthÅ~widthÅ~heightÅ~0.52) Embolization technique The patient lies in supine position wearing the hospital gown. Sterilization of the right groin is done. Puncture of the right femoral artery using a puncture set after local anesthesia.6F vascular sheath, then a 5F Cobra head catheter is introduced in right femoral artery to catheterize one of the Internal Iliac artery then catheterizing its anterior division. First, we do diagnostic angiographic using digital subtraction angiography (DSA) by a 5F cobra catheter at left side then right side,(Fig. 3) and the tube been angled at ipsilateral anterior oblique of 30 to 50 degrees with cranio-caudal angulation of 10–15 degrees for better visualization of the prostatic artery origin, then we selectively catheterize the prostatic artery using a 2.4F -2.7F Progreat micro catheter. Then we inject contrast to do selective prostatic artery angiogram (Fig. 5a &b) in different views (Fig. 3a &b) for assessment of its course, related anastomosis and prevention of non-target embolization, if non target embolization is noted we used to coil the artery supplying the non-target organ to avoid non-target embolization, in other situations we advance the micro catheter tip distally to bypass the anastomosis point and also target embolization achieved. In our study we don’t depend on cone beam Computerized tomography (CT) as a regular method for assessment of prostatic artery. It is important to catheterize posterior division of internal iliac and external iliac artery if we cannot visualize prostatic artery, or suspecting additional supply but not routinely done. Injection of 3ml of contrast through micro catheter to ensure the micro catheter position and no reflux occurs. After that we start embolization of prostate bed using microspheres (300 to 500 µm) mixed with contrast and saline in ratio 1:1 till we visualize stasis at the PA. We start by the left side then we catheterize the ipsilateral side by same Cobra catheter by Waltman loop from the same femoral puncture. (Fig. 4) Then femoral sheath is removed, and manual compression applied to the groin for almost 10 minutes till homeostasis achieved. Usually, patient is discharged post procedural on prophylactic antibiotics, and analgesics for one to two weeks, then follow up clinical improvement after four weeks, then three months and six months at the clinic. Figure (3) Showing (a)oblique and (b) AP views for assessment of the prostatic artery course, related anastomosis and prevention of non-target embolization with (yellow arrow) showing of contrast filling of the contralateral prostatic artery through the inter-prostatic anastomosis (white arrow) Figure (4) Showing Waltman loop at the anterior division of the right IIA (white star) with its branches showed in the image (a) yellow arrow showing the prostatic artery type III image (b) originating from the upper third of obturator artery (white arrow) in the same side of puncture right femoral artery Figure (5) Showing selective catheterization of both prostatic arteries (white star) showing tortuous angled “corkscrew” appearance which may help with identification during catheter angiography) using the microcatheter (white arrows) showing the right and left prostatic gland blushes (yellow arrow). Interpretation of Results Technical success with percutaneous embolization is defined as stasis in the prostatic artery with no contrast uptake in control images as demonstrated by intra-operative imaging. Follow up of prostatic size by ultrasound, PVR and IPSS and QOL score at 1, 3, 6 month. Statistical Analysis: The collected data was revised, coded, tabulated and introduced to a PC using Statistical package for Social Science (SPSS 27). Data was presented and suitable analysis was done according to the type of data obtained for each parameter. Descriptive statistics: Mean, Standard deviation (± SD) and range for parametric numerical data. And Frequency and percentage of non-numerical data. Analytical statistics: Student T Test was used to assess the statistical significance of the difference between two study group means, and Fisher’s exact test was used to examine the relationship between two qualitative variables when the expected count is less than 5 in more than 20% of cells. P- value: level of significance, P > 0.05: Non significant (NS) and P < 0.05: Significant (S). Results Prostate Volume Reduction Both the medium-sized and large prostate groups exhibited significant reductions in prostate volume from baseline through all follow-up assessments. Importantly, there was no statistically significant difference in the reduction rates between the two groups, indicating comparable efficacy of the treatment. Figure (6) Shows the prostate volume at different time points of the groups of prostate size. Table (3) Comparison of prostate volume over 6 months by Prostate size in each group IPSS Improvement The International Prostate Symptom Score (IPSS) demonstrated significant improvement in both groups over the 6-month period. While the large prostate group showed greater symptom relief at the 1-month and 3-month follow-ups, this difference was not significant by the 6-month follow-up, suggesting that both groups ultimately experienced similar benefits in symptom management. Figure (7) Shows IPSS at different time points by prostate size. Table (4) Comparison and IPSS by Prostate Size. Quality of Life (QoL) At baseline, the QoL scores were lower in the large prostate group. However, improvements in QoL were comparable between both groups from the 1-month follow-up through to the 6-month assessment, indicating similar efficacy in enhancing quality of life. Figure (8) Shows QoL at different time points by prostate size. Table (5) Comparison of QoL by Prostate Size Post-Void Residual (PVR) Significant improvements in PVR were observed in both groups at the 1-month, 3-month, and 6-month follow-ups. The large prostate group exhibited a more pronounced reduction in PVR at the 1-month and 3-month assessments; however, by the 6-month follow-up, the difference was not statistically significant, reinforcing the comparable efficacy of the treatment across both groups. Figure (9) Shows PVR at different time points by prostate size. Table (6) Comparison of PVR by Prostate Size Overall Findings Both groups demonstrated statistically significant reductions in prostate volume, IPSS, QoL, and PVR over the study period (p < 0.001). While the percentage reductions in prostate volume were similar between the groups (e.g., 56.42% vs. 60.71% at 6 months, p = 0.055, NS), the large prostate group achieved greater reductions in PVR at all follow-up points (1, 3, and 6 months) (e.g., 77.46% vs. 63.22% at 6 months, p < 0.001). Conversely, the medium-sized group showed more significant improvements in IPSS at the 1-month and 3-month follow-ups (e.g., 65.02% vs. 59.45% at 3 months, p = 0.004), though these differences were not maintained by the 6-month assessment. These findings highlight the effectiveness of the intervention in both groups, with varying degrees of efficacy observed at different time points. Table (7) Comparison of reduction rate (%) in prostate volume and symptom score by Prostate Size. Discussion Prostate size is a critical consideration in the evaluation of various treatments for lower urinary tract symptoms (LUTS). Transurethral resection of the prostate (TURP) has long been regarded as the gold standard surgical intervention over the past three decades. However, its effectiveness diminishes in patients with prostate volumes exceeding 80 mL, primarily due to the associated intra-operative and postoperative morbidities. Open prostatectomy (OP) remains the conventional standard for treating larger prostates, as it offers the most effective and durable outcomes. Nevertheless, OP is characterized by a high morbidity rate, substantial blood loss, extended recovery times, and significant patient burden. In response to these challenges, several minimally invasive techniques have been developed as alternatives to OP for the management of enlarged prostates. These include plasmakinetic bipolar resection (PKRP), greenlight photoselective vaporization (PVP), holmium laser enucleation (HoLEP), and thulium laser resection. Notably, the 2013 European Association of Urology guidelines recommend HoLEP as a suitable option for men with prostate volumes greater than 80 mL, with studies affirming its efficacy across varying prostate sizes. Despite its advantages, HoLEP necessitates specialized laser equipment and is accompanied by a steep learning curve, which hinders its widespread adoption, particularly in developing countries. These limitations underscore the need for alternative treatments for benign prostatic hyperplasia (BPH) that address these shortcomings. Prostate artery embolization (PAE) emerges as a promising minimally invasive option that may fulfill this requirement. Assessing prostate size prior to PAE may serve as a useful predictor of clinical outcomes. A study by Wang et al. [ 12 ] demonstrated significant clinical improvements in both medium and large prostate groups in terms of the International Prostate Symptom Score (IPSS), maximum urinary flow rate (Qmax), post-void residual (PVR), and quality of life (QoL), with results comparable to previous reports. Existing literature supports the efficacy and safety of PAE for large prostates (> 80 grams); however, few studies have investigated its effectiveness in medium and smaller-sized prostates. Notably, only four studies have compared the prostate volume as a predictive factor for PAE outcomes [ 12 – 15 ]. Additionally, Zhang et al. (2018) explored MRI changes post-PAE, revealing that both moderate (50–80 mL) and severe hyperplasia (> 80 mL) groups experienced substantial volume reductions after twelve months, demonstrating significant differences from pre-embolization volumes. From an anatomical and pathological perspective, larger prostates tend to have larger-caliber target arteries with hypervascular lesions, allowing for more embolic agents to be injected, which can induce greater ischemia and infarction. Consequently, one might anticipate more substantial prostate volume reductions and improved clinical outcomes, as suggested by Maclean et al. [ 14 ]. Current evidence remains conflicting regarding the role of baseline prostate volume as a predictor of clinical outcomes following PAE. Maclean et al. [ 14 ] conducted a single-center study involving 86 patients, identifying a modest correlation between baseline total prostate volume (TPV) and symptomatic improvement at twelve months (r = 0.324, p = 0.002). This correlation suggested that approximately 10% of the variation in IPSS improvement post-PAE could be attributed to baseline TPV. Furthermore, Abt et al. [ 10 ] found significant correlations between baseline TPV and improvements in IPSS and Qmax in a cohort of 48 patients with moderate to severe LUTS. Conversely, some studies reported contradictory findings. Wang et al. [ 12 ] observed no significant differences in baseline IPSS or Qmax between large-volume (TPV > 80 mL) and medium-volume (TPV 50–80 mL) groups, yet noted greater reductions in IPSS and increases in Qmax at twelve months for the large-volume group. Hacking et al. [ 16 ] corroborated this relationship, confirming a higher IPSS reduction in larger TPVs, though they found no significant differences in Qmax changes. In contrast, Bagla et al. [ 13 ] reported no significant differences in American Urology Association (AUA) symptom scores across small ( 80 mL) prostate groups, suggesting that prostate size alone may not reliably predict PAE success. Of note, their study was limited by a small sample size and high dropout rates at 6-month follow-ups for example, 47.2% (17/36) in large-volume group and 46.2% (12/26) in medium-volume group [ 17 ]. Maclean et al. [ 14 ] indicated greater IPSS improvements in larger prostates based on regression modeling, consistent with findings by Wang et al. [ 12 ] Nonetheless, our study revealed statistically significant reductions in prostate volume (e.g., 56.42% vs. 60.71% at 6 months, p = 0.055, NS), IPSS, QoL, and PVR (e.g., 77.46% vs. 63.22% at 6 months, p < 0.001) over time for both medium and large prostate groups, with comparable percentage reductions in prostate volume. While the large prostate group exhibited greater reductions in PVR, the medium-sized group demonstrated significantly improved IPSS at earlier follow-ups (e.g., 65.02% vs. 59.45% at 3 months, p = 0.004), though these differences diminished by six months. Furthermore, the recent study by Xu et al. [ 6 ] found no correlation between baseline prostate volume and LUTS recurrence rates, emphasizing the need for further investigation into the predictive capacity of baseline TPV. Notably, most studies to date have predominantly involved patients with large prostate volumes, with limited exploration of outcomes in those with smaller prostates. Bagla et al. [ 13 ] uniquely compared outcomes in patients with prostates above and below 50 mL involving 78 patients, finding no significant differences across size categories as measured by the American Urological Association (AUA) symptom index. This suggests that prostate size alone may not be a reliable selector of PAE success. The latest research by Wise et al. [ 15 ] aligns with our findings, demonstrating no statistically significant differences in IPSS improvement between small ( 51 mL) prostates. These results suggest that small prostate volume should not be viewed as a contraindication for PAE and advocate for the removal of prostate volume criteria from best practice guidelines. Future studies should aim to identify other clinical, imaging, and angiographic variables that more accurately predict IPSS improvement. In our study, the mean age of patients was significantly higher in the large prostate group (70.5 ± 6.83 years) compared to the medium-sized group (65.05 ± 8.21 years, p = 0.001). This observation aligns with Wang et al. [ 12 ] who found age differences between groups impacting symptomatic outcomes. However, Maclean et al. [ 14 ] reported no significant correlation between age and IPSS changes, prompting the inclusion of age in regression analysis in future studies. Limitations of the Wise et al. [ 15 ] study included a relatively small sample size (n = 65), whereas our study involved 88 patients. The variability in embolic particle sizes used also posed a challenge, as preferences among radiologists differed, particularly in earlier cases. Our study addressed this limitation by consistently employing 300–500 µm embospheres for the procedure. This 73 year old patient came complaining of Hesitancy, urine drippling, Urination every 1 hour and not responding to medications (Tamsulin), pre prostatic artery embolization size was 95 cc, IPSS score of 22, QOL of 5 and PVR volume of 100 cc (Fig. 10 ), after the 6 month follow up marked improvement of the symptoms with IPSS score of 7, QOL 0 of and PVR volume of 42 (Fig. 12). Figure (10) Pre-embolization volume measured by US Figure (11) After 1 month follow up with prostatic volume of 70 cc, IPSS score of 12, QOL of 2 and PVR volume of 67 cc. Figure (12) After 6 month follow up volume measured by US conclusion PAE can lead to significant improvements in IPSS, QoL, Qmax, PVR, and prostate volume for both medium and large prostate groups compared to baseline measures. Long-term follow-up will be essential to evaluate the durability of these early and mid-term outcomes. Our findings, consistent with other studies, raise questions about the utility of prostate volume as a sole criterion for selecting candidates for PAE. Future research should focus on identifying technical factors that may serve as more reliable indicators for successful outcomes, such as severe vascular calcification, small vessel size, and vessel tortuosity, which are known to complicate the procedure. While prostate volume remains an easily measurable parameter, its predictive value regarding patient satisfaction and outcomes is likely limited.</p Abbreviations AUA American Urology Association BPH Benign Prostatic Hyperplasia BPO Benign Prostatic Obstruction CT Computerized Tomography DSA Digital Subtraction Angiography EAU European Association of Urology HoLEP Holmium Laser Enucleation IIEF-5 International Index of Erectile Function IPSS International Prostate Symptom Score LUTS Lower Urinary Tract Symptoms NS Non Significant OP Open Prostatectomy PAE Prostate Artery Embolization PKRP Plasmakinetic Bipolar Resection PSA Prostate-Specific Antigen PVP Photoselective Vaporization PVR Postvoiding Residual Volume QoL Quality of Life QOL Quality of Life TPV Total Prostate Volume TRUS Transrectal Ultrasound Scan Declarations Author Contribution N.E. wrote the main manuscript text , collected the cases , done the statistics and prepared the figures. A.A. helped in collecting the cases , revised the statistics , revised every and each part of manuscript. O.H. the main operator of the PAE cases , choose the title of the manuscript A.H. helped in choosing the title of the manuscript All Authors reviewed the manuscript References Langan RC. Benign prostatic hyperplasia. Primary Care: Clinics in Office Practice. 2019 Jun 1;46(2):223-32. Grosso M, Balderi A, Arnò M, Sortino D, Antonietti A, Pedrazzini F, & Arena G. (2015). Prostatic artery embolization in benign prostatic hyperplasia: preliminary results in 13 patients. La radiologia medica, 120, 361-368. Young S, & Golzarian J. (2019). Prostate embolization: patient selection, clinical management and results. CVIR endovascular, 2, 1-7. Jung JH, McCutcheon KA, Borofsky M, Young S, Golzarian J, Kim MH, & Narayan VM. (2020). Prostatic arterial embolization for the treatment of lower urinary tract symptoms in men with benign prostatic hyperplasia. 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Factors predicting a good symptomatic outcome after prostate artery embolisation (PAE). Cardiovascular and Interventional Radiology, 41, 1152-1159. Wise R, Fu H, & Tapping CR. (2024). Prostate volume: does it predict patient outcomes following prostate artery embolisation? A retrospective cohort study. CVIR endovascular, 7(1), 51. Hacking N, Vigneswaran G, Maclean D, Modi S, Dyer J, Harris M, & Bryant T. (2019). Technical and imaging outcomes from the UK registry of prostate artery embolization (UK-ROPE) study: focusing on predictors of clinical success. Cardiovascular and interventional radiology, 42, 666-676. Sun F, Lucas-Cava V, & Sánchez-Margallo FM. (2020). Clinical predictive factors in prostatic artery embolization for symptomatic benign prostatic hyperplasia: a comprehensive review. Translational Andrology and Urology, 9(4), 1754. Tables Tables are available in the Supplementary Files section. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5373074","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":374552176,"identity":"84e4f049-69df-467b-a327-9a7cad418d40","order_by":0,"name":"Noha Elghitany","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA5klEQVRIiWNgGAWjYFACHiCukGDm528+AGRJyBCp5YwFu+SMYwkgLTzEaWFsq+A3OJBjADMBPzBn7z34gYFNQtrgwJnPr27UWPAwsB8+ugGfFsuec8kSDDwSxpKHe7dZ5xwDOownLe0GPi0GN3IMJBgkJJL5DpzdZpzDBtQiwWNGSIvxDwYDifqGAznPjHP+EafFTIIhQYJZ4EAO8+PcNmK0nDljZpFwQIIZGMhmzLl9EjxsBP1yvMf4xsd/daCofPw551udHD/74WN4tYBBAoRikwCTBJUjAeYPpKgeBaNgFIyCkQMAo1pFaIwXztMAAAAASUVORK5CYII=","orcid":"","institution":"Ain Shams University Hospital","correspondingAuthor":true,"prefix":"","firstName":"Noha","middleName":"","lastName":"Elghitany","suffix":""},{"id":374552177,"identity":"977b21a8-ff52-4a4c-a671-2875f502a289","order_by":1,"name":"Osama Hetta","email":"","orcid":"","institution":"Ain Shams University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Osama","middleName":"","lastName":"Hetta","suffix":""},{"id":374552178,"identity":"a0ce0c38-8a9f-481a-8620-46d48f65ab78","order_by":2,"name":"Ahmed Hussein","email":"","orcid":"","institution":"Ain Shams University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ahmed","middleName":"","lastName":"Hussein","suffix":""},{"id":374552179,"identity":"6d900723-5dfe-4212-8062-30aca5c9c8cf","order_by":3,"name":"Allam Allam","email":"","orcid":"","institution":"Ain Shams University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Allam","middleName":"","lastName":"Allam","suffix":""}],"badges":[],"createdAt":"2024-11-01 11:53:22","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5373074/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5373074/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s43055-025-01497-y","type":"published","date":"2025-06-23T15:57:05+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":70509302,"identity":"2d689595-72e6-44cf-b46a-72a0ac975432","added_by":"auto","created_at":"2024-12-04 00:13:17","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":686518,"visible":true,"origin":"","legend":"\u003cp\u003ea showing the prostate directly after embolization with (white arrow showing contrast seen inside the prostate of the right prostatic gland) and blue and yellow lines measuring (1 length 2 width 3 height) using the equation (length Å~widthÅ~heightÅ~0.52) reaching volume of 62 gram)\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-5373074/v1/82c119f048f572ec037ee28b.png"},{"id":70509788,"identity":"38edf415-7305-4e7d-a7d7-7c16f6c3ef79","added_by":"auto","created_at":"2024-12-04 00:21:17","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":456736,"visible":true,"origin":"","legend":"\u003cp\u003eShowing the prostate volume measuring yellow asterisks with automatic volume measuring using the same equation (lengthÅ~widthÅ~heightÅ~0.52)\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-5373074/v1/17bb90e4a0a735d9001c45a3.png"},{"id":70510278,"identity":"ebc5ceb8-df42-48c3-bb7f-ad2e744c2c1d","added_by":"auto","created_at":"2024-12-04 00:29:17","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":481875,"visible":true,"origin":"","legend":"\u003cp\u003eShowing (a)oblique and (b) AP views for assessment of the prostatic artery course, related anastomosis and prevention of non-target embolization with (yellow arrow) showing of contrast filling of the contralateral prostatic artery through the inter-prostatic anastomosis (white arrow)\u003c/p\u003e","description":"","filename":"floatimage5.png","url":"https://assets-eu.researchsquare.com/files/rs-5373074/v1/b98f6e31cea711bdb73d05c2.png"},{"id":70509304,"identity":"e769c2f1-3a3c-410c-a39e-4d74d061824e","added_by":"auto","created_at":"2024-12-04 00:13:17","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":484790,"visible":true,"origin":"","legend":"\u003cp\u003eShowing Waltman loop at the anterior division of the right IIA (white star) with its branches showed in the image (a) yellow arrow showing the prostatic artery type III image (b) originating from the upper third of obturator artery (white arrow) in the same side of puncture right femoral artery\u003c/p\u003e","description":"","filename":"floatimage6.png","url":"https://assets-eu.researchsquare.com/files/rs-5373074/v1/1ea34d2c05e40b00b9d083ed.png"},{"id":70509791,"identity":"7abdc7c7-02cd-4168-b01c-3c55804e6810","added_by":"auto","created_at":"2024-12-04 00:21:17","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":607577,"visible":true,"origin":"","legend":"\u003cp\u003eShowing selective catheterization of both prostatic arteries (white star) showing tortuous angled “corkscrew” appearance which may help with identification during catheter angiography) using the microcatheter (white arrows) showing the right and left prostatic gland blushes (yellow arrow).\u003c/p\u003e","description":"","filename":"floatimage7.png","url":"https://assets-eu.researchsquare.com/files/rs-5373074/v1/9bf1d46274e4f98c4c1a2903.png"},{"id":70509786,"identity":"476177c2-d20c-4b2f-9ab5-88ae40507608","added_by":"auto","created_at":"2024-12-04 00:21:17","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":58065,"visible":true,"origin":"","legend":"\u003cp\u003eShows the prostate volume at different time points of the groups of prostate size.\u003c/p\u003e","description":"","filename":"floatimage8.png","url":"https://assets-eu.researchsquare.com/files/rs-5373074/v1/05bae7385ddaba5f2c090639.png"},{"id":70509301,"identity":"84bc30e0-55c3-45ae-9b0f-e27d390ddfc5","added_by":"auto","created_at":"2024-12-04 00:13:17","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":58979,"visible":true,"origin":"","legend":"\u003cp\u003eShows IPSS at different time points by prostate size.\u003c/p\u003e","description":"","filename":"floatimage10.png","url":"https://assets-eu.researchsquare.com/files/rs-5373074/v1/83d11c01f3e026ceabcb4a4d.png"},{"id":70509311,"identity":"550b5e34-74ed-49c8-8449-e0c05676fbfc","added_by":"auto","created_at":"2024-12-04 00:13:17","extension":"png","order_by":8,"title":"Figure 8","display":"","copyAsset":false,"role":"figure","size":42898,"visible":true,"origin":"","legend":"\u003cp\u003eShows QoL at different time points by prostate size.\u003c/p\u003e","description":"","filename":"floatimage12.png","url":"https://assets-eu.researchsquare.com/files/rs-5373074/v1/d1d26b9b390f07111ee13c8a.png"},{"id":70510279,"identity":"e9cf06d6-3e43-4bf6-80af-3f89fd507b47","added_by":"auto","created_at":"2024-12-04 00:29:17","extension":"png","order_by":9,"title":"Figure 9","display":"","copyAsset":false,"role":"figure","size":52559,"visible":true,"origin":"","legend":"\u003cp\u003eShows PVR at different time points by prostate size\u003c/p\u003e","description":"","filename":"floatimage14.png","url":"https://assets-eu.researchsquare.com/files/rs-5373074/v1/20ad3aa9100117a9e7d3abfe.png"},{"id":70509305,"identity":"a9a41ce5-b759-4a18-8feb-f98b9399ea6a","added_by":"auto","created_at":"2024-12-04 00:13:17","extension":"png","order_by":10,"title":"Figure 10","display":"","copyAsset":false,"role":"figure","size":435873,"visible":true,"origin":"","legend":"\u003cp\u003ePre-embolization volume measured by US\u003c/p\u003e\n\u003cp\u003e\u003cimg alt=\"Description: A close-up of an ultrasound\n\nDescription automatically generated\" height=\"253\" src=\"file:///C:/Users/kamb13/AppData/Local/Temp/msohtmlclip1/01/clip_image002.png\" width=\"479\"/\u003e\u003c/p\u003e","description":"","filename":"10.png","url":"https://assets-eu.researchsquare.com/files/rs-5373074/v1/c3d517919ce67ec09298c774.png"},{"id":70509313,"identity":"df70b9e3-8fcd-4c86-a560-2b575e8941ca","added_by":"auto","created_at":"2024-12-04 00:13:18","extension":"png","order_by":11,"title":"Figure 11","display":"","copyAsset":false,"role":"figure","size":1143831,"visible":true,"origin":"","legend":"\u003cp\u003eAfter 1 month follow up with prostatic volume of 70 cc, IPSS score of 12, QOL of 2 and PVR volume of 67 cc.\u003c/p\u003e","description":"","filename":"floatimage18.png","url":"https://assets-eu.researchsquare.com/files/rs-5373074/v1/fcc2659456af50af6d46a26f.png"},{"id":70509308,"identity":"536d94a5-4902-4c47-942d-bfde2e28838f","added_by":"auto","created_at":"2024-12-04 00:13:17","extension":"png","order_by":12,"title":"Figure 12","display":"","copyAsset":false,"role":"figure","size":1410356,"visible":true,"origin":"","legend":"\u003cp\u003eAfter 6 month follow up volume measured by US\u003c/p\u003e","description":"","filename":"floatimage19.png","url":"https://assets-eu.researchsquare.com/files/rs-5373074/v1/0ffb1e1f041701ff1f1437f3.png"},{"id":85686105,"identity":"3971d5e0-7467-4a7d-8e41-f4015d6c23fd","added_by":"auto","created_at":"2025-06-30 16:03:05","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":7307104,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5373074/v1/c2fac49c-f880-410a-b529-6a60fea5f9e5.pdf"},{"id":70509789,"identity":"db16cc5c-673d-415a-8be3-adbf6b403934","added_by":"auto","created_at":"2024-12-04 00:21:17","extension":"doc","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":1027584,"visible":true,"origin":"","legend":"","description":"","filename":"Tables.doc","url":"https://assets-eu.researchsquare.com/files/rs-5373074/v1/142a8d385ef50456d86566c1.doc"}],"financialInterests":"No competing interests reported.","formattedTitle":"Prostatic Artery Embolization in Treatment of Benign Prostatic Hyperplasia: Outcome and Efficacy in Medium Sized Compared to Large Prostates","fulltext":[{"header":"Introduction","content":"\u003cp\u003eBenign prostatic hyperplasia (BPH) is the most prevalent benign tumor in ageing men, and its prevalence rises with age, reaching 8% in the fourth decade and up to 90% in the ninth [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMedically refractory lower urinary tract symptoms (LUTS) like sensation of incomplete emptying of the urinary bladder, hesitancy, weak urinary stream, increase in frequency, nocturia and urgency that are caused by benign prostatic hyperplasia (BPH) is a remarkably common concern in men older than 50 years old. Although the latest gold standard method of treatment, transurethral resection of the prostate, is effective, it results in increased morbidity rates than wanted. This is the reason why a high demand of new minimally invasive means to be available as treatment options for BPH, one these techniques is prostate artery embolization (PAE) [\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite the fact that BPH is not a fatal disease, it still poses a huge burden on the lives of patients by causing distressing urinary symptoms. On top of that, the side effects of BPH expands beyond the horizons of physical symptoms as it is accompanied with high financial costs due to frequent clinical visits and prolonged sick leaves [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePAE and (TURP) transurethral resection of the prostate have showed similar results in the rate of subjective improvement in the symptoms that is reported by patients(i.e. International prostate symptom score IPSS, IPSS-QoL, and International Index of Erectile Function (IIEF-5)).On the other side, although PAE has a longer procedure time, it has reported outstandingly fewer side effects and shorter hospital stays in comparison to TURP [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite TURP being the first line of treatment for patients refusing or having contraindications to surgery, PAE could serve as an alternative treatment as it is performed under local anesthesia which is safer for vulnerable patients [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eNew procedures have been developed to overcome the symptoms of BPH that aren\u0026rsquo;t controlled with medical therapy or for patients who can\u0026rsquo;t tolerate side effects of some of the medical treatments [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIt was proven that PAE is an effective method in reducing the BPH symptoms with avoiding the unwanted side effects of surgery such as urinary incontinence or sexual dysfunction [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAccording to the society of Interventional Radiology Multi-society Consensus has strongly recommended that \u0026ldquo;the PAE is an acceptable minimally invasive treatment option for appropriately selected men with BPH and moderate to severe LUTS\u0026rdquo; and moderately recommended that \u0026ldquo;PAE can be considered as a treatment option in patients with BPH and moderate to severe LUTS who have very large prostate glands (\u0026gt;\u0026thinsp;80 cm3), without an upper limit of prostate size\u0026rdquo; [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMedically refractory lower urinary tract symptoms (LUTS) like sensation of incomplete emptying of the urinary bladder, hesitancy, weak urinary stream, increase in frequency, nocturia and urgency that are caused by benign prostatic hyperplasia (BPH) is a remarkably common concern in men older than 50 years old. Although the latest gold standard method of treatment, transurethral resection of the prostate, is effective, it results in increased morbidity rates than wanted. This is the reason why a high demand of new minimally invasive means to be available as treatment options for BPH, one these techniques is prostate artery embolization (PAE) [\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite the fact that BPH is not a fatal disease, it still poses a huge burden on the lives of patients by causing distressing urinary symptoms. On top of that, the side effects of BPH expands beyond the horizons of physical symptoms as it is accompanied with high financial costs due to frequent clinical visits and prolonged sick leaves [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePAE and TURP have showed similar results in the rate of subjective improvement in the symptoms that is reported by patients (i.e. International prostate symptom score IPSS, IPSS-QoL, and International Index of Erectile Function (IIEF-5)).On the other side, although PAE has a longer procedure time, it has reported outstandingly fewer side effects and shorter hospital stays in comparison to TURP [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite TURP being the first line of treatment for patients refusing or having contraindications to surgery, PAE could serve as an alternative treatment as it is performed under local anaesthesia which is safer for vulnerable patients [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eNew procedures have been developed to overcome the symptoms of BPH that aren\u0026rsquo;t controlled with medical therapy or for patients who can\u0026rsquo;t tolerate side effects of some of the medical treatments [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIt was proven that PAE is an effective method in reducing the BPH symptoms with avoiding the unwanted side effects of surgery such as urinary incontinence or sexual dysfunction [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAccording to the society of Interventional Radiology Multi-society Consensus has strongly recommended that \u0026ldquo;the PAE is an acceptable minimally invasive treatment option for appropriately selected men with BPH and moderate to severe LUTS\u0026rdquo; and moderately recommended that \u0026ldquo;PAE can be considered as a treatment option in patients with BPH and moderate to severe LUTS who have very large prostate glands (\u0026gt;\u0026thinsp;80 cm3), without an upper limit of prostate size\u0026rdquo; [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAccording to The European Association of Urology (EAU) 2020 guidelines on non-neurogenic male LUTS recommend that \u0026ldquo;Despite PAE remains still \u0026ldquo;under investigation\u0026rdquo; it is the only minimally invasive treatment besides prostatic urethral lift that is supported by the EAU guidelines at present in selected patients [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePAE acts as a safe and effective method that provides a new pathway in the treatment of BPH other than formal surgical intervention. Even in the world of other minimally invasive techniques, PAE is still found to be more distinctively advantageous due to its endovascular approach rather than transurethral approach. Not only is PAE done with local anaesthesia and allows patients to stay on anticoagulant medications, but also has no maximum prostate size [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn addition to the decrease in the prostate size and resolution of the bladder outlet obstruction, it also causes a destruction in the receptors and nerves that is responsible for the urinary symptoms causing improvement of the LUTS that is secondary to the benign prostatic obstruction (BPO) [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn spite the fact that PAE in smaller sized prostates is not as beneficial as in larger ones and it\u0026rsquo;s harder to expect its clinical outcome, some patients with smaller glands have great outcomes [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e"},{"header":"Materials And Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Population\u003c/h2\u003e \u003cp\u003eFrom April January 2022 to August 2024 at a single institution, a total of 88 consecutive patients. mean age of patients was significantly higher in the large prostate group (70.5\u0026thinsp;\u0026plusmn;\u0026thinsp;6.83 years) compared to the medium-sized prostate group (65.05\u0026thinsp;\u0026plusmn;\u0026thinsp;8.21 years, p\u0026thinsp;=\u0026thinsp;0.001) diagnosed with severe LUTS due to BPH that was refractory to medical treatment underwent PAE. Of the 88 patients, 46 patients (52.2%) were with a prostate volume\u0026thinsp;\u0026gt;\u0026thinsp;80 mL (mean, 133 mL); and the remaining 42 patients (47.7%) were with a prostate volume of 50\u0026ndash;80 mL (mean,62.6 mL).\u003c/p\u003e \u003cp\u003eThis prospective study comparing efficacy and outcome of PAE in medium sized prostate to the large prostates. this technique was approved by the Ethics Committee of Ain Shams University Hospital. Patients were required to read and sign an informed consent prior to the procedure. Patients All undergoing PAE from January 2022 to August 2024. Inclusion criteria were (a) Male patient not fit for surgery (b) Prostate volume\u0026thinsp;\u0026gt;\u0026thinsp;50 gm (c) Diagnosis of BPH with moderate to severe LUTS refractory to medical treatment for at least 6 months (International prostate symptom score (IPSS)\u0026thinsp;\u0026gt;\u0026thinsp;18 and/or quality of life(QOL)\u0026thinsp;\u0026gt;\u0026thinsp;3) or under acute urinary retention refractory to medical therapy. Exclusion Criteria were (a) Patients with proven prostatic malignancy (b) prostatic biopsy to exclude malignancy, if the Prostate-specific antigen (PSA) level is greater than 4 ng/mL or transrectal ultrasound scan (TRUS) findings are suspicious(c) Patients with large bladder diverticula, renal insufficiency, active urinary infection, neurogenic bladder (d) Unregulated coagulation parameter (e) contrast allergy.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003ePatient evaluation\u003c/h3\u003e\n\u003cp\u003eAll patients were evaluated by clinical observation. Efficacy variables of IPSS (Table\u0026nbsp;1), QoL (Table\u0026nbsp;2), PVR, and PV were assessed before PAE and at 1, 3 and 6 months after the procedure. PSA was assessed before PAE. The PV was measured by Ultrasonography. The PV was determined using the standard ellipsoid formula: length\u0026Aring;~width\u0026Aring;~height\u0026Aring;~0.52 Either by the CT (Fig.\u0026nbsp;1a-b).or US images (Fig.\u0026nbsp;2)\u003c/p\u003e \u003cp\u003e \u003cb\u003eTable\u0026nbsp;(1): International prostate symptom score (IPSS) a b\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003ea. \u003cb\u003ePike et al.\u003c/b\u003e [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eb. All information was self-reported.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eTable\u0026nbsp;(2)\u003c/strong\u003e \u003cp\u003eQuality of life aspect of the international prostate symptom score ab\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003ea. \u003cb\u003ePike et al.\u003c/b\u003e [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eb. All information was self-reported.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eFigure (1)\u003c/strong\u003e \u003cp\u003ea showing the prostate directly after embolization with (white arrow showing contrast seen inside the prostate of the right prostatic gland) and blue and yellow lines measuring (1 length 2 width 3 height) using the equation (length \u0026Aring;~width\u0026Aring;~height\u0026Aring;~0.52) reaching volume of 62 gram)\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eFigure (2)\u003c/strong\u003e \u003cp\u003eShowing the prostate volume measuring yellow asterisks with automatic volume measuring using the same equation (length\u0026Aring;~width\u0026Aring;~height\u0026Aring;~0.52)\u003c/p\u003e \u003c/p\u003e\n\u003ch3\u003eEmbolization technique\u003c/h3\u003e\n\u003cp\u003eThe patient lies in supine position wearing the hospital gown. Sterilization of the right groin is done. Puncture of the right femoral artery using a puncture set after local anesthesia.6F vascular sheath, then a 5F Cobra head catheter is introduced in right femoral artery to catheterize one of the Internal Iliac artery then catheterizing its anterior division. First, we do diagnostic angiographic using digital subtraction angiography (DSA) by a 5F cobra catheter at left side then right side,(Fig.\u0026nbsp;3) and the tube been angled at ipsilateral anterior oblique of 30 to 50 degrees with cranio-caudal angulation of 10\u0026ndash;15 degrees for better visualization of the prostatic artery origin, then we selectively catheterize the prostatic artery using a 2.4F -2.7F Progreat micro catheter. Then we inject contrast to do selective prostatic artery angiogram (Fig.\u0026nbsp;5a \u0026amp;b) in different views (Fig.\u0026nbsp;3a \u0026amp;b) for assessment of its course, related anastomosis and prevention of non-target embolization, if non target embolization is noted we used to coil the artery supplying the non-target organ to avoid non-target embolization, in other situations we advance the micro catheter tip distally to bypass the anastomosis point and also target embolization achieved.\u003c/p\u003e \u003cp\u003eIn our study we don\u0026rsquo;t depend on cone beam Computerized tomography (CT) as a regular method for assessment of prostatic artery.\u003c/p\u003e \u003cp\u003eIt is important to catheterize posterior division of internal iliac and external iliac artery if we cannot visualize prostatic artery, or suspecting additional supply but not routinely done. Injection of 3ml of contrast through micro catheter to ensure the micro catheter position and no reflux occurs. After that we start embolization of prostate bed using microspheres (300 to 500 \u0026micro;m) mixed with contrast and saline in ratio 1:1 till we visualize stasis at the PA.\u003c/p\u003e \u003cp\u003eWe start by the left side then we catheterize the ipsilateral side by same Cobra catheter by Waltman loop from the same femoral puncture. \u003cb\u003e(Fig.\u0026nbsp;4)\u003c/b\u003e Then femoral sheath is removed, and manual compression applied to the groin for almost 10 minutes till homeostasis achieved.\u003c/p\u003e \u003cp\u003eUsually, patient is discharged post procedural on prophylactic antibiotics, and analgesics for one to two weeks, then follow up clinical improvement after four weeks, then three months and six months at the clinic.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eFigure (3)\u003c/strong\u003e \u003cp\u003eShowing (a)oblique and (b) AP views for assessment of the prostatic artery course, related anastomosis and prevention of non-target embolization with (yellow arrow) showing of contrast filling of the contralateral prostatic artery through the inter-prostatic anastomosis (white arrow)\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eFigure (4)\u003c/strong\u003e \u003cp\u003eShowing Waltman loop at the anterior division of the right IIA (white star) with its branches showed in the image (a) yellow arrow showing the prostatic artery type III image (b) originating from the upper third of obturator artery (white arrow) in the same side of puncture right femoral artery\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eFigure (5)\u003c/strong\u003e \u003cp\u003eShowing selective catheterization of both prostatic arteries (white star) showing tortuous angled \u0026ldquo;corkscrew\u0026rdquo; appearance which may help with identification during catheter angiography) using the microcatheter (white arrows) showing the right and left prostatic gland blushes (yellow arrow).\u003c/p\u003e \u003c/p\u003e\n\u003ch3\u003eInterpretation of Results\u003c/h3\u003e\n\u003cp\u003eTechnical success with percutaneous embolization is defined as stasis in the prostatic artery with no contrast uptake in control images as demonstrated by intra-operative imaging. Follow up of prostatic size by ultrasound, PVR and IPSS and QOL score at 1, 3, 6 month.\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis:\u003c/h2\u003e \u003cp\u003eThe collected data was revised, coded, tabulated and introduced to a PC using Statistical package for Social Science (SPSS 27). Data was presented and suitable analysis was done according to the type of data obtained for each parameter. Descriptive statistics: Mean, Standard deviation (\u0026plusmn;\u0026thinsp;SD) and range for parametric numerical data. And Frequency and percentage of non-numerical data. Analytical statistics: Student T Test was used to assess the statistical significance of the difference between two study group means, and Fisher\u0026rsquo;s exact test was used to examine the relationship between two qualitative variables when the expected count is less than 5 in more than 20% of cells. P- value: level of significance, P\u0026thinsp;\u0026gt;\u0026thinsp;0.05: Non significant (NS) and P\u0026thinsp;\u0026lt;\u0026thinsp;0.05: Significant (S).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e \u003cstrong\u003eProstate Volume Reduction\u003c/strong\u003e \u003cp\u003eBoth the medium-sized and large prostate groups exhibited significant reductions in prostate volume from baseline through all follow-up assessments. Importantly, there was no statistically significant difference in the reduction rates between the two groups, indicating comparable efficacy of the treatment.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eFigure (6)\u003c/strong\u003e \u003cp\u003eShows the prostate volume at different time points of the groups of prostate size.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eTable\u0026nbsp;(3)\u003c/strong\u003e \u003cp\u003eComparison of prostate volume over 6 months by Prostate size in each group\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eIPSS Improvement\u003c/strong\u003e \u003cp\u003eThe International Prostate Symptom Score (IPSS) demonstrated significant improvement in both groups over the 6-month period. While the large prostate group showed greater symptom relief at the 1-month and 3-month follow-ups, this difference was not significant by the 6-month follow-up, suggesting that both groups ultimately experienced similar benefits in symptom management.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eFigure (7)\u003c/strong\u003e \u003cp\u003eShows IPSS at different time points by prostate size.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eTable\u0026nbsp;(4)\u003c/strong\u003e \u003cp\u003eComparison and IPSS by Prostate Size.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eQuality of Life (QoL)\u003c/strong\u003e \u003cp\u003eAt baseline, the QoL scores were lower in the large prostate group. However, improvements in QoL were comparable between both groups from the 1-month follow-up through to the 6-month assessment, indicating similar efficacy in enhancing quality of life.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eFigure (8)\u003c/strong\u003e \u003cp\u003eShows QoL at different time points by prostate size.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eTable\u0026nbsp;(5)\u003c/strong\u003e \u003cp\u003eComparison of QoL by Prostate Size\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003ePost-Void Residual (PVR)\u003c/strong\u003e \u003cp\u003eSignificant improvements in PVR were observed in both groups at the 1-month, 3-month, and 6-month follow-ups. The large prostate group exhibited a more pronounced reduction in PVR at the 1-month and 3-month assessments; however, by the 6-month follow-up, the difference was not statistically significant, reinforcing the comparable efficacy of the treatment across both groups.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eFigure (9)\u003c/strong\u003e \u003cp\u003eShows PVR at different time points by prostate size.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eTable\u0026nbsp;(6)\u003c/strong\u003e \u003cp\u003eComparison of PVR by Prostate Size\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eOverall Findings\u003c/strong\u003e \u003cp\u003eBoth groups demonstrated statistically significant reductions in prostate volume, IPSS, QoL, and PVR over the study period (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). While the percentage reductions in prostate volume were similar between the groups (e.g., 56.42% vs. 60.71% at 6 months, p\u0026thinsp;=\u0026thinsp;0.055, NS), the large prostate group achieved greater reductions in PVR at all follow-up points (1, 3, and 6 months) (e.g., 77.46% vs. 63.22% at 6 months, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Conversely, the medium-sized group showed more significant improvements in IPSS at the 1-month and 3-month follow-ups (e.g., 65.02% vs. 59.45% at 3 months, p\u0026thinsp;=\u0026thinsp;0.004), though these differences were not maintained by the 6-month assessment. These findings highlight the effectiveness of the intervention in both groups, with varying degrees of efficacy observed at different time points.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eTable\u0026nbsp;(7)\u003c/strong\u003e \u003cp\u003eComparison of reduction rate (%) in prostate volume and symptom score by Prostate Size.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eProstate size is a critical consideration in the evaluation of various treatments for lower urinary tract symptoms (LUTS). Transurethral resection of the prostate (TURP) has long been regarded as the gold standard surgical intervention over the past three decades. However, its effectiveness diminishes in patients with prostate volumes exceeding 80 mL, primarily due to the associated intra-operative and postoperative morbidities. Open prostatectomy (OP) remains the conventional standard for treating larger prostates, as it offers the most effective and durable outcomes. Nevertheless, OP is characterized by a high morbidity rate, substantial blood loss, extended recovery times, and significant patient burden.\u003c/p\u003e \u003cp\u003eIn response to these challenges, several minimally invasive techniques have been developed as alternatives to OP for the management of enlarged prostates. These include plasmakinetic bipolar resection (PKRP), greenlight photoselective vaporization (PVP), holmium laser enucleation (HoLEP), and thulium laser resection. Notably, the 2013 European Association of Urology guidelines recommend HoLEP as a suitable option for men with prostate volumes greater than 80 mL, with studies affirming its efficacy across varying prostate sizes.\u003c/p\u003e \u003cp\u003eDespite its advantages, HoLEP necessitates specialized laser equipment and is accompanied by a steep learning curve, which hinders its widespread adoption, particularly in developing countries. These limitations underscore the need for alternative treatments for benign prostatic hyperplasia (BPH) that address these shortcomings. Prostate artery embolization (PAE) emerges as a promising minimally invasive option that may fulfill this requirement.\u003c/p\u003e \u003cp\u003eAssessing prostate size prior to PAE may serve as a useful predictor of clinical outcomes. A study by \u003cb\u003eWang et al.\u003c/b\u003e [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] demonstrated significant clinical improvements in both medium and large prostate groups in terms of the International Prostate Symptom Score (IPSS), maximum urinary flow rate (Qmax), post-void residual (PVR), and quality of life (QoL), with results comparable to previous reports. Existing literature supports the efficacy and safety of PAE for large prostates (\u0026gt;\u0026thinsp;80 grams); however, few studies have investigated its effectiveness in medium and smaller-sized prostates. Notably, only four studies have compared the prostate volume as a predictive factor for PAE outcomes [\u003cspan additionalcitationids=\"CR13 CR14\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Additionally, Zhang et al. (2018) explored MRI changes post-PAE, revealing that both moderate (50\u0026ndash;80 mL) and severe hyperplasia (\u0026gt;\u0026thinsp;80 mL) groups experienced substantial volume reductions after twelve months, demonstrating significant differences from pre-embolization volumes.\u003c/p\u003e \u003cp\u003eFrom an anatomical and pathological perspective, larger prostates tend to have larger-caliber target arteries with hypervascular lesions, allowing for more embolic agents to be injected, which can induce greater ischemia and infarction. Consequently, one might anticipate more substantial prostate volume reductions and improved clinical outcomes, as suggested by \u003cb\u003eMaclean et al.\u003c/b\u003e [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCurrent evidence remains conflicting regarding the role of baseline prostate volume as a predictor of clinical outcomes following PAE. \u003cb\u003eMaclean et al.\u003c/b\u003e [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] conducted a single-center study involving 86 patients, identifying a modest correlation between baseline total prostate volume (TPV) and symptomatic improvement at twelve months (r\u0026thinsp;=\u0026thinsp;0.324, p\u0026thinsp;=\u0026thinsp;0.002). This correlation suggested that approximately 10% of the variation in IPSS improvement post-PAE could be attributed to baseline TPV. Furthermore, \u003cb\u003eAbt et al.\u003c/b\u003e [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] found significant correlations between baseline TPV and improvements in IPSS and Qmax in a cohort of 48 patients with moderate to severe LUTS.\u003c/p\u003e \u003cp\u003eConversely, some studies reported contradictory findings. \u003cb\u003eWang et al.\u003c/b\u003e [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] observed no significant differences in baseline IPSS or Qmax between large-volume (TPV\u0026thinsp;\u0026gt;\u0026thinsp;80 mL) and medium-volume (TPV 50\u0026ndash;80 mL) groups, yet noted greater reductions in IPSS and increases in Qmax at twelve months for the large-volume group. \u003cb\u003eHacking et al.\u003c/b\u003e [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] corroborated this relationship, confirming a higher IPSS reduction in larger TPVs, though they found no significant differences in Qmax changes. In contrast, \u003cb\u003eBagla et al.\u003c/b\u003e [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] reported no significant differences in American Urology Association (AUA) symptom scores across small (\u0026lt;\u0026thinsp;50 mL), medium (50\u0026ndash;80 mL), and large (\u0026gt;\u0026thinsp;80 mL) prostate groups, suggesting that prostate size alone may not reliably predict PAE success. Of note, their study was limited by a small sample size and high dropout rates at 6-month follow-ups for example, 47.2% (17/36) in large-volume group and 46.2% (12/26) in medium-volume group [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cb\u003eMaclean et al.\u003c/b\u003e [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] indicated greater IPSS improvements in larger prostates based on regression modeling, consistent with findings by \u003cb\u003eWang et al.\u003c/b\u003e [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] Nonetheless, our study revealed statistically significant reductions in prostate volume (e.g., 56.42% vs. 60.71% at 6 months, p\u0026thinsp;=\u0026thinsp;0.055, NS), IPSS, QoL, and PVR (e.g., 77.46% vs. 63.22% at 6 months, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) over time for both medium and large prostate groups, with comparable percentage reductions in prostate volume. While the large prostate group exhibited greater reductions in PVR, the medium-sized group demonstrated significantly improved IPSS at earlier follow-ups (e.g., 65.02% vs. 59.45% at 3 months, p\u0026thinsp;=\u0026thinsp;0.004), though these differences diminished by six months.\u003c/p\u003e \u003cp\u003eFurthermore, the recent study by \u003cb\u003eXu et al.\u003c/b\u003e [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] found no correlation between baseline prostate volume and LUTS recurrence rates, emphasizing the need for further investigation into the predictive capacity of baseline TPV. Notably, most studies to date have predominantly involved patients with large prostate volumes, with limited exploration of outcomes in those with smaller prostates. \u003cb\u003eBagla et al.\u003c/b\u003e [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] uniquely compared outcomes in patients with prostates above and below 50 mL involving 78 patients, finding no significant differences across size categories as measured by the American Urological Association (AUA) symptom index. This suggests that prostate size alone may not be a reliable selector of PAE success.\u003c/p\u003e \u003cp\u003eThe latest research by \u003cb\u003eWise et al.\u003c/b\u003e [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] aligns with our findings, demonstrating no statistically significant differences in IPSS improvement between small (\u0026lt;\u0026thinsp;51 mL) and large (\u0026gt;\u0026thinsp;51 mL) prostates. These results suggest that small prostate volume should not be viewed as a contraindication for PAE and advocate for the removal of prostate volume criteria from best practice guidelines. Future studies should aim to identify other clinical, imaging, and angiographic variables that more accurately predict IPSS improvement.\u003c/p\u003e \u003cp\u003eIn our study, the mean age of patients was significantly higher in the large prostate group (70.5\u0026thinsp;\u0026plusmn;\u0026thinsp;6.83 years) compared to the medium-sized group (65.05\u0026thinsp;\u0026plusmn;\u0026thinsp;8.21 years, p\u0026thinsp;=\u0026thinsp;0.001). This observation aligns with \u003cb\u003eWang et al.\u003c/b\u003e [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] who found age differences between groups impacting symptomatic outcomes. However, \u003cb\u003eMaclean et al.\u003c/b\u003e [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] reported no significant correlation between age and IPSS changes, prompting the inclusion of age in regression analysis in future studies.\u003c/p\u003e \u003cp\u003eLimitations of the \u003cb\u003eWise et al.\u003c/b\u003e [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] study included a relatively small sample size (n\u0026thinsp;=\u0026thinsp;65), whereas our study involved 88 patients. The variability in embolic particle sizes used also posed a challenge, as preferences among radiologists differed, particularly in earlier cases. Our study addressed this limitation by consistently employing 300\u0026ndash;500 \u0026micro;m embospheres for the procedure.\u003c/p\u003e \u003cp\u003eThis 73 year old patient came complaining of Hesitancy, urine drippling, Urination every 1 hour and not responding to medications (Tamsulin), pre prostatic artery embolization size was 95 cc, IPSS score of 22, QOL of 5 and PVR volume of 100 cc \u003cb\u003e(Fig.\u0026nbsp;10\u003c/b\u003e), after the 6 month follow up marked improvement of the symptoms with IPSS score of 7, QOL 0 of and PVR volume of 42 \u003cb\u003e(Fig.\u0026nbsp;12).\u003c/b\u003e\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eFigure (10)\u003c/strong\u003e \u003cp\u003ePre-embolization volume measured by US\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eFigure (11)\u003c/strong\u003e \u003cp\u003eAfter 1 month follow up with prostatic volume of 70 cc, IPSS score of 12, QOL of 2 and PVR volume of 67 cc.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eFigure (12)\u003c/strong\u003e \u003cp\u003eAfter 6 month follow up volume measured by US\u003c/p\u003e \u003c/p\u003e"},{"header":"conclusion","content":"\u003cp\u003ePAE can lead to significant improvements in IPSS, QoL, Qmax, PVR, and prostate volume for both medium and large prostate groups compared to baseline measures. Long-term follow-up will be essential to evaluate the durability of these early and mid-term outcomes. Our findings, consistent with other studies, raise questions about the utility of prostate volume as a sole criterion for selecting candidates for PAE. Future research should focus on identifying technical factors that may serve as more reliable indicators for successful outcomes, such as severe vascular calcification, small vessel size, and vessel tortuosity, which are known to complicate the procedure. While prostate volume remains an easily measurable parameter, its predictive value regarding patient satisfaction and outcomes is likely limited.\u003c/p"},{"header":"Abbreviations","content":"\u003cp\u003eAUA\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;American Urology Association\u003c/p\u003e\n\u003cp\u003eBPH\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Benign Prostatic Hyperplasia\u003c/p\u003e\n\u003cp\u003eBPO\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Benign Prostatic Obstruction\u003c/p\u003e\n\u003cp\u003eCT\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Computerized Tomography\u003c/p\u003e\n\u003cp\u003eDSA\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Digital Subtraction Angiography\u003c/p\u003e\n\u003cp\u003eEAU\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;European Association of Urology\u003c/p\u003e\n\u003cp\u003eHoLEP\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Holmium Laser Enucleation\u003c/p\u003e\n\u003cp\u003eIIEF-5\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;International Index of Erectile Function\u003c/p\u003e\n\u003cp\u003eIPSS\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;International Prostate Symptom Score\u003c/p\u003e\n\u003cp\u003eLUTS\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Lower Urinary Tract Symptoms\u003c/p\u003e\n\u003cp\u003eNS\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Non Significant\u003c/p\u003e\n\u003cp\u003eOP\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Open Prostatectomy\u003c/p\u003e\n\u003cp\u003ePAE\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Prostate Artery Embolization\u003c/p\u003e\n\u003cp\u003ePKRP\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Plasmakinetic Bipolar Resection\u003c/p\u003e\n\u003cp\u003ePSA\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Prostate-Specific Antigen\u003c/p\u003e\n\u003cp\u003ePVP\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Photoselective Vaporization\u003c/p\u003e\n\u003cp\u003ePVR\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Postvoiding Residual Volume\u003c/p\u003e\n\u003cp\u003eQoL\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Quality of Life\u003c/p\u003e\n\u003cp\u003eQOL\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Quality of Life\u003c/p\u003e\n\u003cp\u003eTPV\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Total Prostate Volume\u003c/p\u003e\n\u003cp\u003eTRUS \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Transrectal Ultrasound Scan\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eN.E. wrote the main manuscript text , collected the cases , done the statistics and prepared the figures. A.A. helped in collecting the cases , revised the statistics , revised every and each part of manuscript. O.H. the main operator of the PAE cases , choose the title of the manuscript A.H. helped in choosing the title of the manuscript All Authors reviewed the manuscript\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eLangan RC. Benign prostatic hyperplasia. Primary Care: Clinics in Office Practice. 2019 Jun 1;46(2):223-32.\u003c/li\u003e\n\u003cli\u003eGrosso M, Balderi A, Arn\u0026ograve; M, Sortino D, Antonietti A, Pedrazzini F, \u0026amp; Arena G. (2015). Prostatic artery embolization in benign prostatic hyperplasia: preliminary results in 13 patients. La radiologia medica, 120, 361-368.\u003c/li\u003e\n\u003cli\u003eYoung S, \u0026amp; Golzarian J. (2019). Prostate embolization: patient selection, clinical management and results. CVIR endovascular, 2, 1-7.\u003c/li\u003e\n\u003cli\u003eJung JH, McCutcheon KA, Borofsky M, Young S, Golzarian J, Kim MH, \u0026amp; Narayan VM. (2020). Prostatic arterial embolization for the treatment of lower urinary tract symptoms in men with benign prostatic hyperplasia. Cochrane Database of Systematic Reviews, (12).\u003c/li\u003e\n\u003cli\u003eKnight GM, Talwar A, Salem R, \u0026amp; Mouli S. (2021). Systematic review and meta-analysis comparing prostatic artery embolization to gold-standard transurethral resection of the prostate for benign prostatic hyperplasia. CardioVascular and Interventional Radiology, 44, 183-193.\u003c/li\u003e\n\u003cli\u003eXu Z, Zhou Z, Mu Y, Cai T, Gao Z, \u0026amp; Liu L. (2021). An updated meta-analysis of the efficacy and safety of prostatic artery embolization vs. transurethral resection of the prostate in the treatment of benign prostatic hyperplasia. Frontiers in Surgery, 8, 779571.\u003c/li\u003e\n\u003cli\u003eBortnick E, Brown C, Simma-Chiang V, \u0026amp; Kaplan SA. (2020). Modern best practice in the management of benign prostatic hyperplasia in the elderly. Therapeutic Advances in Urology, 12, 1756287220929486.\u003c/li\u003e\n\u003cli\u003ePisco JM, Bilhim T, Pinheiro LC, Fernandes L, Pereira J, Costa NV, \u0026amp; Oliveira AG. (2016). Medium-and long-term outcome of prostate artery embolization for patients with benign prostatic hyperplasia: results in 630 patients. Journal of Vascular and Interventional Radiology, 27(8), 1115-1122.\u003c/li\u003e\n\u003cli\u003eMcWilliams JP, Bilhim TA, Carnevale FC, Bhatia S, Isaacson AJ, Bagla S, \u0026amp; Tam AL. (2019). Society of Interventional Radiology Multisociety Consensus Position Statement on Prostatic Artery Embolization for Treatment of Lower Urinary Tract Symptoms Attributed to Benign Prostatic Hyperplasia: From the Society of Interventional Radiology, the Cardiovascular and Interventional Radiological Society of Europe, Soci\u0026eacute;t\u0026eacute; Fran\u0026ccedil;aise de Radiologie, and the British Society of Interventional Radiology: Endorsed by the Asia Pacific Society of Cardiovascular and Interventional Radiology, Canadian Association .... Journal of vascular and interventional radiology: JVIR, 30(5), 627-637.\u003c/li\u003e\n\u003cli\u003eAbt D, M\u0026uuml;llhaupt G, Hechelhammer L, Markart S, G\u0026uuml;sewell S, Schmid HP, \u0026amp; Engeler DS. (2021). Prostatic artery embolisation versus transurethral resection of the prostate for benign prostatic hyperplasia: 2-yr outcomes of a randomised, open-label, single-centre trial. European Urology, 80(1), 34-42.\u003c/li\u003e\n\u003cli\u003ePike JF, Abel WF, Seckel TB, Schammel CM, Flanagan W, \u0026amp; Devane AM. (2021). Prostatic Artery Embolization: An Alternative Treatment for Benign Prostatic Hyperplasia. Journal of Clinical Interventional Radiology ISVIR, 5(02), 091-098.\u003c/li\u003e\n\u003cli\u003eWang M, Guo L, Duan F, Yuan K, Zhang G, \u0026amp; Li K. (2015). Prostatic arterial embolization for the treatment of LUTS due to benign prostatic hyperplasia: a comparative study of medium and large size prostates. BJU Int, 117, 155-164.\u003c/li\u003e\n\u003cli\u003eBagla S, Smirniotopoulos JB, Orlando JC, van Breda A, \u0026amp; Vadlamudi V. (2015). Comparative analysis of prostate volume as a predictor of outcome in prostate artery embolization. Journal of Vascular and Interventional Radiology, 26(12), 1832-1838.\u003c/li\u003e\n\u003cli\u003eMaclean D, Harris M, Drake T, Maher B, Modi S, Dyer J, \u0026amp; Bryant T. (2018). Factors predicting a good symptomatic outcome after prostate artery embolisation (PAE). Cardiovascular and Interventional Radiology, 41, 1152-1159.\u003c/li\u003e\n\u003cli\u003eWise R, Fu H, \u0026amp; Tapping CR. (2024). Prostate volume: does it predict patient outcomes following prostate artery embolisation? A retrospective cohort study. CVIR endovascular, 7(1), 51.\u003c/li\u003e\n\u003cli\u003eHacking N, Vigneswaran G, Maclean D, Modi S, Dyer J, Harris M, \u0026amp; Bryant T. (2019). Technical and imaging outcomes from the UK registry of prostate artery embolization (UK-ROPE) study: focusing on predictors of clinical success. Cardiovascular and interventional radiology, 42, 666-676.\u003c/li\u003e\n\u003cli\u003eSun F, Lucas-Cava V, \u0026amp; S\u0026aacute;nchez-Margallo FM. (2020). Clinical predictive factors in prostatic artery embolization for symptomatic benign prostatic hyperplasia: a comprehensive review. Translational Andrology and Urology, 9(4), 1754.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables are available in the Supplementary Files section.\u003c/p\u003e\n"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Prostate artery embolization, Prostate size, Prostate volume, Lower urinary tract symptoms","lastPublishedDoi":"10.21203/rs.3.rs-5373074/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5373074/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eProstate artery embolization (PAE) is a minimally invasive procedure commonly performed to treat lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia. International Prostate Symptom Score (IPSS) is a validated patient questionnaire quantifying LUTS, Quality of Life (QOL) and postvoiding residual volume (PVR) were used for patient selection for PAE. Prostate volume is an easily estimated objective parameter across multiple imaging modalities specially with ultrasound. We are comparing the result of embolization by comparing it in large (over 80 mL) and medium sized prostates (from 51 to 80 mL) volume. We looked at a sample of 88 cases performed at a large teaching hospital between January 2022 to August 2024 with 6 months follow up.\u003c/p\u003e\n\u003cp\u003eEmbospheres between 300/500 microns were injected into the prostatic arteries bilaterally (if technically feasible). Ultrasound were used to measure to estimate prostatic volume. N = 42 had an estimated volume (range 51-80 mL) and N=46 had an estimate volume\u0026gt; 80 mL. IPSS, QOL, PVR and PV were assessed before and at 1-, 3- and 6-months post-procedure were collected. The aim of this study is to compare efficacy and outcome of PAE in medium sized prostate in comparison to the large prostates.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBoth medium-sized and large prostate groups showed statistically significant reductions in prostate volume, IPSS, QoL, and PVR over time (P-value \u0026lt;0.001). However, while the percentage reduction in prostate volume was comparable between the two groups across all follow-up points (e.g., 56.42% vs. 60.71% at 6 months, p=0.055, NS), the large prostate group had significantly greater reductions in PVR at 1, 3, and 6 months (e.g., 77.46% vs. 63.22% at 6 months, p\u0026lt;0.001). Conversely, the medium-sized group demonstrated significantly greater improvements in IPSS at 1 and 3 months (e.g., 65.02% vs. 59.45% at 3 months, p=0.004), but these differences were not significant by 6 months. QoL improvements were similar between the groups throughout the study. No major complications were recorded.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOur results suggest that prostate volume should not be used to exclude patients for PAE.\u003c/p\u003e","manuscriptTitle":"Prostatic Artery Embolization in Treatment of Benign Prostatic Hyperplasia: Outcome and Efficacy in Medium Sized Compared to Large Prostates","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-12-04 00:13:12","doi":"10.21203/rs.3.rs-5373074/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a9ffba56-c7c2-4bf0-aecd-db4abfcf5b3b","owner":[],"postedDate":"December 4th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-06-30T15:58:50+00:00","versionOfRecord":{"articleIdentity":"rs-5373074","link":"https://doi.org/10.1186/s43055-025-01497-y","journal":{"identity":"egyptian-journal-of-radiology-and-nuclear-medicine","isVorOnly":false,"title":"Egyptian Journal of Radiology and Nuclear Medicine"},"publishedOn":"2025-06-23 15:57:05","publishedOnDateReadable":"June 23rd, 2025"},"versionCreatedAt":"2024-12-04 00:13:12","video":"","vorDoi":"10.1186/s43055-025-01497-y","vorDoiUrl":"https://doi.org/10.1186/s43055-025-01497-y","workflowStages":[]},"version":"v1","identity":"rs-5373074","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5373074","identity":"rs-5373074","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}