HoLEP vs PAE: comparing treatments for an enlarged prostate

Two treatments that are often compared are prostate artery embolisation (PAE) and holmium laser enucleation of the prostate (HoLEP). They work in very different ways, and understanding the differences can help you have a more informed discussion with your doctor.

Symptoms of an enlarged prostate

Men with BPH may notice one or more of the following:

• a weak or slow urine stream
• needing to urinate often, especially at night
• a feeling that the bladder has not fully emptied
• straining to start urination
• a sudden, strong urge to urinate

Mild symptoms can sometimes be managed with lifestyle changes or medication. Treatment is usually considered when symptoms start to affect daily life, sleep or comfort.

How is an enlarged prostate assessed?

Before recommending a treatment, your doctor will review your symptoms and arrange tests. These commonly include a PSA blood test, a urine test, and an ultrasound or urine flow test. If PAE is being considered, CT angiography is used to map the prostate arteries.

What is prostate artery embolisation (PAE)?

PAE is performed by an interventional radiologist. A thin catheter is guided into the small arteries that supply blood to the prostate, and tiny particles are released to reduce blood flow to the enlarged tissue. Over time, the treated tissue gradually shrinks.

PAE is usually done with local anaesthetic and light sedation, without an incision, and most patients go home the same day.

What is holmium laser enucleation of the prostate (HoLEP)?

HoLEP is a surgical procedure performed by a urologist through the urethra, without an external cut. A laser is used to separate the enlarged prostate tissue that is blocking urine flow, and the tissue is then removed from the bladder. HoLEP is generally performed under general or spinal anaesthetic and usually involves a short hospital stay.

How do PAE and HoLEP compare?

How quickly symptoms improve

Improvement after HoLEP is usually noticed soon after the urinary catheter is removed. After PAE, symptoms tend to improve gradually over several weeks as the prostate shrinks.

Prostate size

HoLEP can be used across a wide range of prostate sizes because the blocking tissue is removed. PAE may also be considered for larger prostates; suitability depends on prostate size, anatomy and the condition of the arteries supplying the prostate.

Longer-term results

Because HoLEP removes the obstructing tissue, the need for further treatment is low. Men who have PAE are more likely to need a further procedure in the years after treatment than men who have surgery. This is worth discussing with your doctor when weighing up your options.

Recovery

PAE does not involve removing prostate tissue, and many men return to light everyday activities within a few days. Mild stinging when passing urine, temporary urinary frequency, and occasional light blood in the urine or semen can occur in the first week.

Recovery after HoLEP usually takes longer. A temporary urinary catheter is needed for a short period after surgery, and your surgical team will advise when you can return to work, driving and normal activity.

Sexual function

HoLEP commonly causes retrograde ejaculation, where semen passes back into the bladder rather than out of the body. PAE generally has a lower risk of affecting ejaculation because prostate tissue is not removed. If this is important to you, discuss it with your doctor when comparing options.

When should you see a doctor?

Speak with a doctor if you notice ongoing urinary symptoms such as a weak stream, frequent night-time urination or difficulty starting urination. Seek prompt medical attention if you are unable to pass urine, notice blood in your urine, or develop fever, chills or severe pelvic pain.