How to choose a treatment for benign prostatic hyperplasia (BPH)? A complete comparison of PAE embolization, TURP (electric resection), laser therapy, Rezūm (water vapor), AquaBeam (aquablation), and UroLift (prostatic urethral lift)

When medication options for benign prostatic hyperplasia (BPH) become limited, traditional transurethral resection of the prostate (TURP) is no longer the only treatment choice. Current approaches can be divided into two main pathways: transurethral procedures (TURP, laser, water vapor thermal therapy, aquablation, and prostatic urethral lift) and transarterial procedures that do not go through the urethra, such as prostate artery embolization (PAE). The differences among these six approaches are not about being new or old, but rather their access pathways, anesthesia requirements, recovery processes, and the patient groups they suit best. This article compares all six procedures at once to help you gain a comprehensive understanding before discussing your options with a physician.

When should you consider treatments other than medication for BPH?

Three common situations: urinary symptoms continue to significantly impact your daily life (such as frequency, nocturia, weak stream, or incomplete emptying) even after a period of drug therapy; inability to tolerate medication side effects (such as dizziness, orthostatic hypotension, or decreased libido); or the development of complications like urinary retention, recurrent urinary tract infections, or bladder stones. At this stage, it is worthwhile to understand the differences among various treatment options and make a choice based on your physical condition and personal preferences.

The fundamental difference among the six treatments: Where to access

Transurethral pathway: TURP, laser, water vapor thermal therapy, aquablation, and prostatic urethral lift are all performed by urologists who access the prostate through the urethra using an endoscope to address the prostatic tissue directly. The difference lies in the method used (electric loop, laser light, water vapor, high-pressure water jet, or implants used to bind and lift the enlarged prostate to widen the channel).

Transarterial pathway: PAE does not go through the urethra. The physician inserts a microcatheter into an artery in the wrist or groin, and under angiographic guidance, selectively embolizes the arteries supplying the prostate, causing the gland to naturally shrink due to ischemia, thereby relieving compression on the urethra.

This difference determines several factors: PAE does not touch the urethra or the nerve structures around the prostate, making it a distinct option for those concerned about instruments entering the urethra, those who wish to avoid post-operative urinary catheters, or those worried about retrograde ejaculation and erectile dysfunction. On the other hand, PAE requires angiography equipment and interventional medicine expertise, and symptom improvement occurs gradually as the gland shrinks, rather than immediately after the procedure.

A Comprehensive Comparison of the Six Procedures

PAE (Prostate Artery Embolization)
Access Pathway and Principle: A microcatheter is inserted through the wrist or groin artery to embolize the arteries supplying the prostate, causing the gland to shrink.
Anesthesia and Hospitalization: Mostly performed under local anesthesia; no hospitalization or urinary catheter required.
Key Features and Considerations: Does not go through the urethra; suitable for large prostates, patients on anticoagulants, or those at high risk for general anesthesia; improvement is gradual; requires angiography equipment and MRI evaluation; primarily self-paid.

TURP (Transurethral Resection of the Prostate)
Access Pathway and Principle: Performed transurethrally via endoscope using an electrical loop to scrape away prostate tissue.
Anesthesia and Hospitalization: Spinal or general anesthesia; requires several days of hospitalization.
Key Features and Considerations: A standard procedure practiced for many years, covered by National Health Insurance (NHI); requires attention to complications such as bleeding, retrograde ejaculation, and urinary leakage; patients taking anticoagulants must bear the risk of temporary medication suspension.

Laser Surgery (Vaporization/Enucleation)
Access Pathway and Principle: Done transurethrally using laser light to vaporize or enucleate prostate tissue.
Anesthesia and Hospitalization: Spinal or general anesthesia; hospital stay is shorter than with TURP.
Key Features and Considerations: Less bleeding than with electric loops, suitable for some patients on anticoagulants; laser consumables are mostly self-paid; retrograde ejaculation is still possible.

Water Vapor Thermal Therapy (Rezūm)
Access Pathway and Principle: Performed transurethrally by injecting high-temperature steam through a fine needle to cause tissue necrosis, which is then absorbed by the body.
Anesthesia and Hospitalization: Mild sedation or local anesthesia; most patients return home the same day.
Key Features and Considerations: Short procedure time and minimal impact on ejaculatory function; requires a urinary catheter for a few days postoperatively, with symptom improvement taking about one to three months; fully self-paid.

Prostatic Urethral Lift (UroLift)
Access Pathway and Principle: Tiny implants are delivered transurethrally to hold back the enlarged prostate lobes and pull them to both sides, opening up the urinary channel.
Anesthesia and Hospitalization: Local anesthesia or mild sedation; most patients return home the same day.
Key Features and Considerations: No cutting or heating of tissue, with minimal impact on sexual and ejaculatory function and fast recovery; implants remain in the body; may not be suitable for patients with median lobe hyperplasia or very large prostates; structural changes after the lift can make post-operative MRI evaluation and tracking difficult; self-paid.

Aquablation
Access Pathway and Principle: Performed transurethrally using a robot-assisted, high-pressure water jet to resect prostate tissue.
Anesthesia and Hospitalization: Performed under anesthesia; requires hospitalization.
Key Features and Considerations: Fast resection speed and precise imaging planning; require careful attention to bleeding control; careful evaluation is needed for patients with large prostates or coagulation disorders; self-paid.

Who is PAE suitable for? Who is it not suitable for?

Suitable groups for PAE evaluation: Patients who are assessed by a urologist as having a prostate volume too large for surgery or who carry high surgical risk; those currently taking anticoagulants or with coagulation abnormalities; elderly patients or those with high anesthesia risks unsuitable for general anesthesia; those who value sexual function and worry about retrograde ejaculation; those who want to avoid instruments entering the urethra, do not want to be hospitalized, or wish to avoid post-operative urinary catheters.

Unsuitable groups or those requiring cautious evaluation: Patients with poor vessel conditions (severe arterial sclerosis or tortuosity, making it difficult for catheters to reach the target); those whose primary cause of symptoms is not prostate enlargement (e.g., bladder function problems); and patients in an acute phase of infection. Suitability must be determined by a physician after evaluating prostate volume and vascular conditions via MRI imaging.

How is PAE performed at Xi-Yi Clinic?

At Xi-Yi Clinic, PAE is performed in our angiography suite using a GE OEC 3D mobile C-arm with cone-beam CT capability. The use of a 3D imaging system during the procedure is necessary to confirm the location of the delicate prostatic arteries, enabling selective embolization and reducing the risk of affecting adjacent blood vessels. In most cases, the procedure is performed under local anesthesia via the wrist artery, leaving a wound about the size of a pinhole. This minimally invasive procedure takes approximately one to two hours, and patients are followed up in the clinic without requiring hospitalization.

Prior to treatment, patients must complete an MRI and clinical evaluation. Symptom improvement occurs gradually as the gland shrinks, generally becoming noticeable within weeks to months after the procedure. The physician will provide a comprehensive explanation of the expected timeline before treatment.

Frequently Asked Questions

Q: Which works better, PAE or TURP?
The two methods use different access pathways and suit different patient groups, so they cannot be directly compared. TURP is a standard procedure with many years of clinical track record; PAE offers alternative path that does not go through the urethra and does not require general or spinal anesthesia. The choice depends on prostate volume, physical conditions, and individual priorities.

Q: Can I still undergo TURP after having PAE?
Yes. PAE does not alter the structure of the urethra and prostate. If surgical treatment becomes necessary in the future, it will not affect subsequent options.

Q: Water vapor thermal therapy claims to preserve most sexual function; how does it differ from PAE?
Different pathways: Water vapor thermal therapy is still performed transurethrally, utilizing thermal energy to cause tissue necrosis and shrinkage, requiring a urinary catheter for a few days postoperatively and taking about one to three months for symptoms to improve. PAE is performed via the arteries, avoids the urethra, and its improvement is also gradual. Both are self-paid procedures with different eligibility criteria, requiring professional evaluation.

Q: How do I choose between UroLift and PAE?

Both aim to minimize treatment impact on sexual function, but their therapeutic principles differ. UroLift involves placing tiny implants transurethrally to hold open and secure the obstructing prostate tissue to both sides, without tissue resection or shrinking the prostate, and symptom improvement generally occurs faster.

PAE, on the other hand, reduces the blood supply to the prostate from the arterial end, causing the enlarged gland to gradually shrink. It does not go through the urethra, leaves no permanent implants in the body, and can also be considered for larger-volume prostates.

The choice between these two treatments requires a physician's evaluation based on factors such as prostate volume, lateral or median lobe morphology, degree of obstruction, vascular conditions, and patient considerations regarding implants and recovery times.

Q: Is PAE covered by NHI?
PAE is a self-paid treatment. The cost depends on the evaluation results and the specific treatment plan, which will be fully explained during your outpatient evaluation.

Q: Where in Taipei can I go for a PAE evaluation?
Xi-Yi Clinic is located at 2F-1, No. 40, Sec. 2, Heping E. Rd., Da’an Dist., Taipei City. We feature specialized outpatient services for male sexual function and cardiovascular health (initial consultation: 1,500 TWD, follow-up: 800 TWD). We operate strictly by appointment, which can be scheduled via LINE or by calling (02) 2366-0186.