Urologist happy to weigh in in your neck of the woods. When the data shakes out (and PAE certainly needs more/longer term), I see it as being A good option in the MIST (minimally invasive surgical therapy) arm, but far from THE option. To help contextualize I can explain how I tend to think about BPH treatments.
First is obviously meds. Combination therapy with alpha blocker and 5-ARI gives you about a 6 point IPSS reduction compared to 3-4 for placebo. So really not that impressive. They're cheap and worth a try because some will have a great response (and a 5ARI will shrink the prostate making other surgical therapies easier), but hardly a slam dunk. TBH my opinion is that meds are oversold, and there are a lot of men getting by on meds whose disease progresses to detrussor failure (or being older and a poor surgical candidate) at which point there is less we can do to help them.
Second is minimally invasive therapies, done in the office or under sedation. Urolift, Rezum, and I'd put PAE in this category as well. In general Urolift and rezum give you a 10-12 point IPSS reduction. PAE 6-12 depending on the series. As an aside I will say I find that variation significant. Why? Because Urolift or rezum are stupid easy for any Urologist. It's one of the technically simplest procedures we do. PAE is technically challenging, and it stands to reason that your results would thus be more dependent on the skills of the operator. Complication rate low, mostly post procedure LUTS and occasional retention. Both urolift and rezum actually have quite mature data, 6 year multi center randomized sham controlled trials. I expect (until the next thing comes out) that Urolift, Rezum, and PAE will all be viable options in this category. This is the category I'd recommend for most men with significant symptoms, but few signs of disease (highly elevated PVRs, urinary retention, UTI, bladder stones, etc.) Why? Because for whatever reason, these treatments are much better at treating subjective symptoms then they are at improving objective parameters like urine flow rates, PVRs, etc. They give 2/3 or more of the symptomatic benefit of TURP, but 1/3 the objective benefit, so not a great option for the 80 year old with catheter dependent chronic retention.
Third you have TURP, PVP, HoLEP, etc. IPSS reduction of 15 points. Much more impressive improvements in objective parameters. Procedures done under general or spinal, often an overnight admission, higher complication rate, though significant complication rate in modern series still very low. For example, having done a couple hundred I've never seen a transfusion, even though historic literature tells you a 3% transfusion rate.
Fourth you have the rare cases, the 200gm glands who need a simple prostatectomy (or HoLEP in very skilled hands). Rare enough to not really enter the discussion, but a potential use case for PAE if you have a guy with a huge gland whose not a great operative candidate
All this aside, to be perfectly blunt I just don't see PAE catching on as more then a niche procedure. The simple truth is that Urologists control those referral patterns, and won't refer away most men who could just as easily get a urolift with similar (better?) benefit. Furthermore it will be some time before most urologists would even have a local IR skilled in PAE. There will always be the guy who asks for it, or the one who really doesn't want a transurethral procedure, or the 200gm gland who can't tolerate general, etc, but on the whole it's hard to see it becoming too main stream when its' success depends on urologists giving away their cases. It's just human nature, I'm not arguing for it, but it is a simple truth. For the same reason I'm not bullish on the long term prospects for female urology vs. urogynecology. In the short term there is plenty of work for both, but if volume gets tight, who do you think the gynecologists (who are the primary referral source) will refer to: the gyn trained urogyn or the urology trained female urologist. Hint: its not us.
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