Cardiovasc Intervent Radiol (2020) 43:176–185

[Link]

CIRSE STANDARDS OF PRACTICE

CIRSE Standards of Practice on Prostatic Artery Embolisation

Francois H. Cornelis1 • Tiago Bilhim2 • Nigel Hacking3 • Marc Sapoval4,5,6 •

Charles R. Tapping7 • Francisco Cesar Carnevale8

Received: 19 June 2019 / Accepted: 14 November 2019 / Published online: 2 December 2019
 Springer Science+Business Media, LLC, part of Springer Nature and the Cardiovascular and Interventional Radiological Society of Europe
(CIRSE) 2019

Abbreviations QOL Quality of life

BPH Benign prostatic hyperplasia TURP Transurethral resection of the prostate
CBCT Cone-beam CT
IIEF International Index of Erectile Function
IPSS International Prostate Symptom Score
LUTS Lower urinary tract symptoms
PAE Prostatic artery embolisation
PErFecTED Proximal Embolization First, Then
Embolize Distal Rationale of PAE
PSA Prostate-Specific Antigen
PVR Post-void residual volume Epidemiology Including Clinical Features

Benign prostatic hyperplasia (BPH) is a benign prolifera-

Electronic supplementary material The online version of this tion of stromal and epithelial cells combined with
article ([Link] contains sup- decreased programmed cell death [1], leading to both
plementary material, which is available to authorized users.
fibroadenomatous hyperplasia and an increase in the
& Francois H. Cornelis glandular part of the prostate, and thus eventually an
[Link]@[Link] enlarged overall prostate volume [2]. BPH produces lower
1 urinary tract symptoms (LUTS), which include an irritative
Department of Radiology, Tenon Hospital, Sorbonne
University, Paris, France micturition syndrome in the storage phase: increased nyc-
2 turia, frequent urination of small amounts, involuntary urge
Department of Interventional Radiology, Saint Louis
Hospital and Centro Hospitalar Universitário de Lisboa to urinate and dysuria, but also bladder outlet obstruction
Central, Nova Medical School, Lisbon, Portugal during the emptying phase: delayed start of micturition,
3
Clinical Radiology, Southampton University Hospitals, prolonged micturition time, weakening of the urinary
Southampton, UK stream and a feeling of incomplete emptying of the blad-
4
Vascular and Oncologic Interventional Radiology der. Prostate size and symptoms are not necessarily cor-
Department, Georges Pompidou European Hospital, Paris, related. BPH is highly prevalent, affecting up to 50% of
France males at the age of 50 years and 90% of males over
5
Faculty of Medicine, Paris Descartes University, Paris, 80 years. It is estimated that symptomatic BPH needing
France treatment is present in 50% of men with an enlarged
6
INSERM U970, Paris, France prostate [3].
7
Department of Radiology, Churchill Hospital, Oxford, UK
8
Department of Radiology, University of Sao Paulo Medical
School, São Paulo, Brazil

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F. H. Cornelis et al.: CIRSE Standards of Practice on Prostatic Artery Embolisation 177

Eligibility and Results of Surgical Approaches embolisation’’, ‘‘prostate’’, ‘‘embolisation’’. The defined
time period included articles published between January
Indications for treatment are based on the symptoms and 2010 and August 2019. Original articles were selected by
their impacts on quality of life or the presence of compli- the Writing Group based on their clinical relevance. Cited
cations [1, 4, 5]. Important diagnostic predictors are age references from selected articles were analysed to find and
(C 60 years), urodynamic examinations including peak include significant papers previously excluded from the
urinary flow rate (Qmax, uroflowmetry), post-void residual search or that did not come to initial attention.
volume (PVR) and the determination of the prostate vol-
ume via ultrasound (transrectal or abdominal) or MRI [2].
The severity of symptoms should be estimated quantita- Definitions
tively using the International Prostate Symptom Score
(IPSS) questionnaire. The therapeutic strategy is incre- Symptom Scores and Specific Measures
mental from lifestyle modification, to medical treatment of Assessment
(a1-adrenoreceptor antagonists which relax the smooth
muscles of the bladder neck, the prostate, and the urethra The severity of symptoms of BPH can be estimated
and/or 5a-reductase inhibitors to reduce the glandular quantitatively using the following scores (Level 1a):
volume), to invasive options [1, 3]. If the patient is
• The International Prostate Symptom Score (IPSS)
refractory to medical treatment, invasive methods are
questionnaire includes seven questions on symptoms
generally considered. The gold standard is the transurethral
and one question regarding quality of life (QoL) [4, 5].
resection of the prostate (TURP) for prostates up to 80 mL,
Based on this self-evaluation by the patient on a scale
but laser methods (holmium laser enucleation) or vapori-
of 35, a total point value \ 8 corresponds to minimal
sation of the prostate can also be performed [6]. Open
symptoms, 8–19 to moderate symptoms, and 20–35 to
prostate adenoma enucleation is still performed for larger
severe symptoms.
volumes (over 80 mL), even though laser enucleation
• The International Index of Erectile Function (IIEF-5)
allows treating larger sized prostates [3]. Open prostatec-
provides a broad measure of erectile function and
tomy usually requires longer hospitalisation time.
detects treatment-related responses in patients with
erectile dysfunction.
Strategy of Interventional Techniques
• Urodynamic testing or urodynamics is a study that
assesses how well the bladder and urethra store and
Prostatic artery embolisation (PAE) can be performed as an
release urine [4, 10–12]. It represents two possible
alternative to surgical options in patients with a pros-
methods: a simplified Flow max measurement and full
tate [ 30–50 mL without an upper size limit [7]. Some
urodynamic study which requires simultaneous urinary
patients may have comorbidities (for instance, patients
and rectal catheter placement.
undergoing continuous anticoagulation or antiplatelet
• The PSA (prostate-specific antigen) value evaluates the
therapy), and surgical methods may be associated with an
risk of prostate cancer, although BPH and age result in
increased risk of postoperative bleeding, in particular in
normal increase in the PSA value.
patients with a prostate volume [ 65 mL [8]. Moreover,
• The Charlson score predicts 10-year survival in patients
PAE may be suited to younger, sexually active patients
with multiple comorbidities.
who have concerns about retrograde ejaculation (a frequent
consequence of TURP in over 75% of patients), erectile
dysfunction or urinary incontinence [7]. The rationale of Complications (Minor/Major)
PAE is supported by the prostate volume and tissue stiff-
ness reductions observed after treatment [9], although the The description of adverse events following PAE can fol-
mechanism of action in reducing LUTS is likely low the modified Clavien classification [13] (Level 1a).
multifactorial.

Pre-treatment Imaging
Methods
• Ultrasound easily assesses prostate volume and PVR
The PAE working group operated under the purview of the (Level 1a)
CIRSE Standards of Practice Committee. A systematic • CT angiography (CTA) can be proposed to assess
MEDLINE/PubMed literature search was performed with vessel patency/course and collaterals (Level 2b)
different combinations of terms, such as ‘‘prostate [14, 15].

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178 F. H. Cornelis et al.: CIRSE Standards of Practice on Prostatic Artery Embolisation

• MRI is performed to assess prostate volume and (MDT). Only in rare cases, PAE can be performed in
anatomy to serve as the baseline for follow-up (Level elderly patients with positive biopsies to reduce LUTS,
2b) [4]. after curative cancer options have been ruled out in
MDT [20], or in advanced cancer [21].

Indications for Treatment and Contraindications

Patient Preparation
Indications
Pre-procedural Laboratory and Clinical Assessment
Indications for PAE [16–19] are: (Scores), and Urodynamic Work-up
• Patients with moderate-to-severe LUTS (Level 1a):
Qmax is measured at the baseline (patients without
IPSS C 8; QoL C 3; prostate volume [ 30–50 mL; a
indwelling catheter) and after the intervention, as well as
urine peak flow less than 5 mL/s at micturition volume
IPSS, patient’s QoL, reduction in prostate volume, sexual
of minimum 150 mL; postvoid residual volume (only
function by IIEF, PSA and PVR, satisfaction of the patient
monitoring, no upper or lower limit); and prostate
with the operation and adverse events related to study
volume of less than 50 mL are possible candidate for
procedure [4, 5].
PAE, but the results of PAE are less favourable and the
technique is more complex;
Standard preparation for angiographic procedures
• Patients with symptomatic BPH who have already
undergone failed medical (Level 1a);
PAE can be performed on an outpatient basis. PAE is
• Patients suffering from urinary retention due to BPH
performed under local anaesthesia at the femoral or radial
without an upper limit of prostate size (Level 1b);
puncture site. In some situations (5%) a bilateral puncture
• Patients with BPH and acute or chronic urinary
is needed. Pain is infrequently reported and is controlled
retention but with preserved bladder function as a
with oral medication only (Level 2a). Antibiotics (cipro-
method of achieving catheter independence (Level 2b);
floxacin or cefazoline) are recommended due to the risk of
• Patients with BPH and moderate-to-severe LUTS who
urinary tract infections, as in any prostate intervention
wish to preserve erectile and/or ejaculatory function
(Level 5). A urinary catheter partially filled by contrast
(Level 2b);
media (10–20%) may be inserted and used for orientation
• Patients with haematuria of prostatic origin, as a
during PAE. It may also make the intervention more tol-
method of achieving cessation of bleeding (Level 2b);
erable for the patient, by allowing unobstructed urine flow
• Patients with BPH and moderate-to-severe LUTS who
(Level 2b). The balloon can be removed soon after PAE.
are deemed not to be surgical candidates for any reason,
Many centres do not, however, insert a urinary catheter and
including patients presenting with advanced age, mul-
instead use a cone-beam CT (CBCT) to confirm prostate
tiple comorbidities, coagulopathy, or inability to stop
artery localisation (Level 2a) [22].
anticoagulation or antiplatelet therapy (Level 2b); and
• Patients refusing surgery.
Equipment Specifications: DSA Equipment
Relative Contraindications (Level 1a) and CBCT

• Patients with severe atherosclerosis and/or tortuosity of To identify the anatomical vascular conditions, one can use
the vessels depicted with CTA may be excluded. Pre- CBCT angiography scan with the catheter tip in the distal
operative imaging with a pelvic MRI and/or CTA or abdominal aorta to visualise both sides with a single
MRA assessing pelvic vasculature is recommended in injection, or with the diagnostic catheter at the internal iliac
severe atherosclerotic patients [14, 15]. artery (Level 2a) [22, 23]. The rotation CBCT angiography
• Other exclusion criteria are bladder diverticuli size [ scan of the pelvic arteries is typically acquired with a total
2 cm, bladder stone, detrusor hyperactivity or of 30–40 mL of a contrast agent, an injection rate of
hypocontractility, neurogenic bladder and renal 2–6 mL/s (800–900 psi), and an X-ray delay of 2–4 s using
insufficiency. contrast agent with an iodine concentration of at least
• In case of PSA level above 4 ng/mL, prostate biopsies 250–320 mg/mL. Using and comparing the 3D recon-
have to be discussed before the procedure in a struction as maximum intensity projections (MIP) of
multidisciplinary disease management team meeting CBCT, the origin of the prostate artery is identified.

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F. H. Cornelis et al.: CIRSE Standards of Practice on Prostatic Artery Embolisation 179

Once the prostatic artery is identified on manual over- base of the bladder, especially when a common origin of
view angiography with ipsilateral alignment of the detector the superior and inferior vesical artery and the prostate
of 30–40 ipsilateral anterior oblique and caudocranial artery is present. The central gland of the prostate is typi-
angulation of 10–15, super-selective catheterisation is cally supplied by only 1 main branch of the prostate artery.
then performed using a microcatheter of 1.7–2.4 F, and full Before reaching the prostate, the prostatic artery divides
digital subtraction angiography work-up allows visualisa- into a cranial branch for supplying the central gland part
tion of the characteristic blush of the hemi-prostate (Level and a lateral branch for supplying the peripheral zone.
2a). Alternatively, CBCT may be used for this purpose. In These two branches feeding the prostate may also arise
the prostatic arteries, a flow rate of 0.3–1 mL/s in a total of independently.
3 mL and 600 psi with a 1–2-s delay is recommended.
Having similar performance in terms of detection of Collateral and Anatomical Variation Management
prostate arteries, the use of CBCT during the procedure in
comparison to pre-PAE pelvic conventional CTA results in Anatomical variations are often observed [28]. The most
improved signal-to-noise and contrast-to-noise ratio, using common origin of the prostate artery, in 34% of cases, was
less radiation and less contrast volume [24]. reported in the middle third of the internal pudendal artery
(Fig. 1). A common origin of the prostate artery and the
superior vesical artery was observed in only 20% of cases.
Procedural Features and Variations Independent prostate arteries were observed on each pelvic
of the Technique(s) side in 43% of patients, with an average 2.9 ± 0.9 prostate
arteries per patient. Moreover, small anastomoses or col-
Different Access Routes (Femoral, Radial) lateral vessels from the prostate artery to the middle rectal
artery, internal pudendal artery, or inferior vesical artery
Bilateral embolisation of the prostate arteries is ideally can be observed in approximatively a third of patients.
performed through a single femoral or radial artery punc- Anastomoses to the opposite side of the prostate are also
ture. If the crossover manoeuvre is not successful, a second observed in 20% of patients. Meticulous evaluation of
access can be alternatively created on the contralateral side arterial anatomy before embolisation is therefore required
to again attempt to probe the ipsilateral internal iliac artery. [29].
Femoral approach is more often performed. Transradial Pelvic arterial supply is markedly interconnected by
arterial access also represents a safe and feasible method anastomoses, most of which are characterised by low flow,
for performing PAE (Level 2a) [25, 26]. However, a and are identifiable only on angiogram with pressured
potential challenge is the small diameter of the radial artery injection of contrast media [30, 31]. Some anastomoses,
relative to the diameter of the femoral artery, rendering the however, provide communication between the prostate
procedure more challenging and requiring further training territory and structures of clinical interest including the
for practitioners. Longer catheters and microcatheters are bladder, rectum and penis [30–32]. These anastomoses can
necessary for this approach. be selectively protected with microcoils or gelatin sponge
to reduce the risk of non-target embolisation, especially in
Diagnostic Arteriography Including Common the case of high-flow anastomoses (Level 2a) [33, 34].
Vascular Variants Another possibility in such cases is to navigate the
microcatheter deeper into the prostate and distal to the
Once the prostate artery has been catheterised, 100–200 lg anastomotic origin and perform prostate embolisation
of nitroglycerin may be injected to prevent vasospasm and avoiding reflux of embolic material. On the other hand,
to increase the diameter of the artery to facilitate distal migration of small amounts of embolic agent through
catheterisation. Isosorbide mononitrate (10 mg on each anastomoses involving the obturator territory or other
side) may be used as an alternative drug. The prostate pelvic parietal structures may not lead to clinically relevant
artery has an average diameter of 0.9 mm (range: complications; therefore, there is usually no need for
0.5–1.5 mm) and usually originates from the internal occluding those connections. Likewise, particle reflux or
pudendal artery or from a common origin with the superior migration to seminal vesicle branches does not seem to
vesical artery, obturator, middle rectal and gluteopudendal cause major complications, although it can lead to self-
trunk (medial branches of the internal iliac artery) (Fig. 1) limited haematospermia [29]. It is also common to identify
[27]. Super-selective CBCT may be used when the catheter intraprostatic connections, both ipsilateral-anastomoses
is located in the prostate artery to confirm the adequate between anteromedial and posterolateral prostatic branches
position and avoid non-targeted embolisation. There are of the same side and contralateral anastomoses. Due to the
typically branches to the seminal vesicles and also to the presence of contralateral anastomoses, it can be possible to

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180 F. H. Cornelis et al.: CIRSE Standards of Practice on Prostatic Artery Embolisation

Fig. 1 Collaterals of internal iliac artery and variation of origin of prostate arteries (left hemipelvis angiogram of the internal iliac artery under
ipsilateral oblique projection)

achieve embolisation of both prostate lobes through depends on the intraprostatic vascularisation and size of the
catheterisation of the prostatic artery on only one side [35]. prostate. If the microcatheter position within the main
For the same reason, embolisation of the first hemilobe of prostatic artery trunk is proximal, premature complete
the prostate may require a larger number of particles than stasis is frequently seen with reflux, not allowing delivery
the second lobe, because the contralateral side is already of more embolic volume. To overcome this limitation and
partially embolised by intraprostatic contralateral commu- although further evaluation is needed, the PErFecTED
nications, especially when using the PErFecTED (Proximal technique or balloon occlusion may be used as options to
Embolization First, Then Embolize Distal) technique. allow for the use of greater embolic volumes while limiting
non-target embolisation and rupture of the small intrapro-
Methods of Embolisation: Conventional, static branches (Level 3b) [41–43].
PErFecTED, Balloon Occlusion

Once the embolisation position is confirmed, slow-flow Medication and Peri-procedural CARE
injection of microspheres (300–500 lm) or polyvinyl
alcohol particles (100–300 lm), highly diluted with con- Patient Monitoring and Analgesia
trast medium (20–40 mL of embolisation solution), is
performed with a complete occlusion as end-point (Level The procedure is performed under local anaesthesia (Level
2a) [36–39]. The procedure is performed bilaterally and 1a) [8]. In general, patients do not experience pain during
unilaterally only in the case of a failure to catheterise 1 or after PAE. If pain occurs, it can be controlled with oral
side. The use of small microspheres (100–300 lm) may medication. The use of smaller microspheres
increase the risk of adverse events [13]. Embolisation of (100–300 lm) has shown higher pain levels, mainly ure-
the prostatic arteries is completed when slow flow or stasis thral burning when urinating [23]. In most cases, the pro-
is observed, with disruption of arterial flow and opacifi- cedure is performed in an ambulatory setting, or with 1
cation of the prostate gland [40]. For complete unilateral night of hospitalisation. Patients usually receive hydration,
embolisation of the prostate artery, less than 0.5 mL of 500 mg ciprofloxacin, phenazopyridine, a non-opioid
microspheres are generally required, but the volume often analgesic and nonsteroidal anti-inflammatory drugs. If

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necessary, corticosteroids and/or opioids can be used for Clinical Efficacy, Scores and Flowmetry (Short-/Mid-/
pain management. Patients are usually discharged 3–6 h Long-Term Results)
post-procedure (Level 2a). Those taking oral medications
for LUTS can continue them for 1–2 weeks post-PAE. Criteria of symptomatic improvement are defined by an
IPSS \ 18 with a decrease of at least 25% and a QoL
Indwelling Urinary Catheter score B 3, with at least a one-point decrease compared to
baseline (Level 2b) [4, 5].
Patients with indwelling catheters due to urinary retention Clinical failure of the procedure is defined as the per-
at baseline usually return at 2 weeks for catheter removal sistence of severe symptoms (IPSS decrease B 25%, IPSS
and, in most situations (80–90%), spontaneous urination is score C 18, QoL score decrease B 1, and a QoL score
restored. In case of failure, additional attempts to remove C 4) (Level 2b).
the Foley catheter are made every week for an additional The success rates at 6 and 12 months are 78% and 75%,
2–3 weeks for patients whose first attempt failed. respectively [45]. At 6 months, mean improvement of the
IPSS, the IIEF-score, the QoL score and the urinary flow
was up to 12.9 points, 1.6 point, 2.8 points and 2.8 mL/s,
Post-procedural Follow-up Care (Including respectively (Level 1a). At 6 months, PSA level and
Imaging) prostate volume mean reductions were of 1.38 ng/mL
(24%) and 16.9 mL (20%). There is no statistical associ-
Clinical follow-up is performed at 3, 6 and 12 months, ation between symptomatic improvement and prostate
including IPSS, IIEF and patient-reported complication volume reduction. However, in patients with prostate vol-
domains (Level 1a) [5]. At 3 and 12 months, additional umes [ 80 mL and Charlson score C 2, the mean IPSS
clinical follow-up is performed with flow studies such as and peak flow were significantly improved at 3 months and
Qmax, and a prostate volume study. MRI and ultrasound 1 year, compared to baseline as well as mean QoL score
may be performed at 3 and 6 months. and post-void residual volume [32, 51, 52]. A significant
decrease in prostate volume (up to 30%) and PSA level was
also reported.
Outcomes
Complications and Their Management
Effectiveness
Adverse events related to PAE are mostly mild and are
Primary/Secondary similar to other endovascular embolisation intervention
[53]. A minor post-embolisation syndrome is frequently
The procedure is considered successful if at least one hemi- observed during the first 3 days following the procedure.
prostate is embolised, but in the vast majority of cases both This syndrome may include nausea, vomiting, slight
sides are embolised (Level 1a) [44]. The success rate hyperthermia, painful urination, pelvic pain, rectal bleed-
defined by the embolisation of at least one hemi-prostate ing and haematuria. Additionally, a few patients report a
ranged from 90 to 98% [45]. Major atherosclerosis, small feeling of slight pressure or minimal pain in the pelvic
diameter of the prostatic arteries and severe artery tortu- region radiating into the perineal region in the first 2 days
osity are reasons for failed catheterisation. after PAE. These issues can be well managed with oral
analgesics. Dysuria (9%) is part of the post-embolisation
Comparison with Conservative Treatment and Surgery syndrome and is not a complication. Other reported com-
plications are urinary infections (7.6%), self-contained
No significant differences are observed in terms of rates of macroscopic haematuria (5.6%), acute urinary retention
clinical failure for TURP and PAE [46–48]. Mean reduc- (2.5%) and rectal bleeding (2.5%) [45]. This is usually an
tion in IPSS from baseline to 3 months is similar [49, 50]. embolisation effect due to the initial stages of necrosis.
However, at 3 months, PAE is less effective than TURP However, it may also be the result of non-target emboli-
regarding changes in Qmax, PVR, prostate volume and sation, but this is rare [54]. Hematospermia (0.5%) should
desobstructive effectiveness according to pressure flow be considered as an adverse event and not a complication.
studies. Fewer adverse events occurred after PAE than after Urinary retentions are treated with transient urinary
TURP. Hospital stay after PAE is significantly shorter than catheterisation, but other complications do not require any
TURP (3 days vs 5 days) [7]. There was no significant specific treatment. Major complications include severe
difference regarding mean operative time between both urinary sepsis that may require readmission for intravenous
groups (80–90 min). antibiotic treatment; bladder ischaemia that could, although

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182 F. H. Cornelis et al.: CIRSE Standards of Practice on Prostatic Artery Embolisation

rare, require a surgical excision of the necrotic area; and Supplementary Material
ischaemia of the glans [55].
A table with Levels of Evidence is available in the online
supplementary material of the article.
Conclusion
Compliance with ethical standards
PAE is an effective method for treating symptoms related Conflict of interest T. Bilhim is on the Advisory Board of Merit
to BPH and is a new minimally invasive alternative to Medical, is a consultant for Terumo, a stock holder in the company
classic urological surgical procedures in patients presenting ‘‘Embolx’’ and has a speaker agreement with Philips. M. Sapoval is a
with a large prostate. However, due to the small diameter consultant for Merit Medical and has received research grants from
BTG and Merit Medical. All other authors declare that they have no
of the prostate artery and anatomical variations as well as conflict of interest.
anastomoses, PAE needs meticulous work-up and should
be performed by a trained IR.
A summary of key recommendations can be found in
Table 1.

Table 1 Summary of recommendations

Recommendation Level of
evidence

Indications Patients with moderate-to-severe lower urinary tract symptoms (LUTS) related to BPH may benefit from Level 1a
prostatic artery embolisation (PAE)
PAE can be performed in patients with symptomatic benign prostatic hyperplasia (BPH), in case of Level 1a
failure of medical treatment
PAE can be performed in patients suffering from urinary retention due to BPH without an upper limit of Level 1b
prostate size
PAE can be performed in patients who have comorbidities (for instance, patients using anticoagulation or Level 2b
antiplatelet therapy)
PAE is suited to younger, sexually active patients who have concerns about retrograde ejaculation, Level 2b
erectile dysfunction or urinary incontinence
PAE may be performed in patients with BPH and acute or chronic urinary retention in the setting of Level 2b
preserved bladder function, as a method of achieving catheter independence
PAE may achieve cessation of bleeding in patients with haematuria of prostatic origin Level 2b,
Pre-operative scores International Prostate Symptom Score (IPSS) and urodynamic testing provide a broad measure of the Level 1a
and testing severity of symptoms of BPH. Inclusion criteria for PAE are: IPSS C 8 and/or quality of life score
(QoL) C 3; prostate volume [ 30–50 mL; a urine peak flow less than 15 mL/s; post-void residual
volume \ 200 mL
Contraindications Relative contraindications to PAE are patients with bladder diverticuli size [ 2 cm, bladder stone, Level 1a
detrusor hyperactivity or hypocontractility, neurogenic bladder and severe renal insufficiency
In case of) PSA (prostate-specific antigen level above 4 ng/ml, prostate biopsies must be discussed before Level 1a
the procedure with the referring urologist
Imaging Imaging by ultrasound, CT angiography (CTA) and MRI can be used in combination to assess: prostate Level 1a
volume and post-void residual (PVR); vessel patency/course and collaterals; and serve as the baseline
for follow-up, respectively
Pre-operative imaging with a pelvic MRI and/or CTA or MR angiography scan may assess pelvic Level 2b
vasculature
Patient preparation, Antibiotics (ciprofloxacin or cefazoline) can be used due to the risk of urinary tract infection, as in any Level 5
procedural features prostate intervention
and variations of the Although femoral approach is more often performed, transradial arterial access represents a safe and Level 2a
technique of PAE feasible method for performing PAE
Cone-beam CT (CBCT) angiography may be used to identify the anatomical vascular anatomy of the Level 2a
prostate

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F. H. Cornelis et al.: CIRSE Standards of Practice on Prostatic Artery Embolisation 183

Table 1 continued
Recommendation Level of
evidence

Digital subtraction angiography work-up allows visualisation of the prostate arteries and the Level 2a
characteristic blush of the prostate
If anastomoses with pelvic arteries occur, proximal closure of the anastomoses can be performed using Level 2a
coils to avoid non-target embolisation
Slow-flow injection of highly diluted (20–40 mL solution) calibrated microspheres (300–500 lm) or Level 2a
polyvinyl alcohol particles (100–300 lm) is performed with a complete occlusion as end-point
The procedure is considered successful if at least 1 hemi-prostate is embolised, but in the vast majority of Level 1a
cases both sides are embolised
PErFectED (Proximal Embolization First, Then Embolize Distal) technique and balloon occlusion PAE Level 3b
may be used as options to secure prostate arterial occlusion
Medication and Peri- PAE is usually performed under local anaesthesia as an outpatient intervention Level 1a
procedural Care Pain is infrequently reported and is controlled with oral medication Level 2a
Patients are usually discharged 3–6 h post-procedure. Level 2a
Outcomes Clinical follow-up is performed at 3, 6 and 12 months, including IPSS, international index of erectile Level 1a
function (IIEF) and patient-reported complication domains
Criteria of symptomatic improvement are defined by an IPSS \ 18 with a decrease of at least 25% and a Level 2b
QoL score B 3 with at least 1 point decrease, compared to baseline
Clinical failure of the procedure is defined as the persistence of severe symptoms (IPSS decrease B 25%, Level 2b
IPSS score C 18, QoL score decrease B 1, and a QoL score C 4), or a decrease in the peak urinary
flow
In reporting adverse events following PAE, it is recommended to use the modified Clavien classification Level 1

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