Preoperative Prostatic Artery Embolization Combined With Transurethral Resection of the Prostate Versus Transurethral Resection of the Prostate Alone in Large Benign Prostatic Hyperplasia: A Systematic Review and Meta-Analysis.

Benign prostatic hyperplasia (BPH) with large prostate volume presents substantial surgical challenges for transurethral resection of the prostate (TURP), encompassing heightened intraoperative haemorrhage risk, prolonged operative duration, and increased perioperative morbidity. Prostatic artery embolization (PAE) has been investigated as a minimally invasive adjunct to reduce prostatic vascularity prior to TURP, potentially optimising perioperative outcomes. This systematic review and meta-analysis evaluated the comparative efficacy and safety of PAE combined with TURP (PAE+TURP) versus TURP alone in patients with large-volume BPH. PubMed (MEDLINE), Embase, Scopus, and Web of Science were searched from inception through January 2026. Randomised controlled trials (RCTs) and cohort studies comparing PAE+TURP with TURP alone in large-volume BPH were eligible. The primary outcome was the International Prostate Symptom Score (IPSS). Secondary outcomes comprised operative time, maximum urinary flow rate (Qmax), and quality of life (QoL). Pooled mean differences (MDs) with 95% confidence intervals (CI) were derived using random-effects models. Three studies (one RCT and two cohort studies) totalling 261 patients (88 PAE+TURP, 173 TURP alone) were included. PAE+TURP yielded significantly greater IPSS improvement than TURP alone (MD=-2.07; 95% CI: -3.15 to -0.99; p<0.001; I²=0%). Subgroup analyses stratified by follow-up duration demonstrated no significant between-group difference in studies reporting three-month outcomes, whereas studies reporting six-month outcomes favoured PAE+TURP. Operative time was significantly shorter with PAE+TURP (MD=-38.7 minutes; 95% CI: -66.1 to -11.3; p=0.01), albeit with substantial heterogeneity (I²=97.8%). Qmax and QoL did not differ significantly between groups (both p=0.08). The single RCT was rated low risk of bias using the Cochrane Collaboration Risk of Bias 2 (RoB 2) tool; both retrospective cohort studies received a good-quality rating on the Newcastle-Ottawa Scale, though residual confounding inherent to observational designs cannot be excluded. Preoperative PAE followed by TURP was associated with shorter operative time and superior lower urinary tract symptom (LUTS) control compared with TURP alone in large-volume BPH. The limited evidence base and methodological heterogeneity across current studies underscore the need for large-scale randomised trials to establish long-term benefits and standardise patient selection criteria.