PAE is an endovascular approach to treat men with LUTS/BPH. Interventional radiologists use fluoroscopy, contrast, and microcatheters to select the prostatic arteries and then embolizes the prostate with microparticles. This embolization results in localized ischemia and hypoxia, triggering apoptosis and necrosis causing fibrosis and atrophy, leading to a decrease in prostate volume.388, 389 This reduction in prostate volume thereby improves patients’ LUTS. There is accumulating evidence that demonstrates PAE’s ability to improve LUTS/BPH. Comparative studies that looked at PAE versus TURP have all shown IPSS improvements with PAE; however, these results were variable with either similar or inferior symptomatic improvements when compared to TURP.390-393 The effectiveness of PAE was recently evaluated by a Cochrane review that looked at six RCTs comparing PAE to TURP and one RCT comparing PAE to sham.394 Symptomatic improvement in LUTS, as defined by changes in IPSS, demonstrated similar IPSS improvements in both the short-term follow-up outcomes (≤12 months) and long-term follow-up outcomes (up to 24 months); however, IPSS improvements favored TURP.394 Sexual dysfunction comparisons suggest that ejaculatory disorders may be less with PAE but with little to no improvement in erectile function.394 In a comparison of PAE to sham, PAE demonstrated a clear improvement in IPSS and quality of life when compared to sham; however, no sexual dysfunction comparisons were addressed.394 The Cochrane review did not evaluate functional outcomes (i.e., urinary flow rates, PVRs). They assessed retreatment rates and found that PAE was associated with increased retreatment rates compared to TURP.394 Functional outcomes were evaluated with a recent RCT comparing PAE to OSP in patients with prostates >80 cc. Despite equal improvements in IPSS, OSP was superior in improving functional measures (i.e., Qmax and UDS) than PAE, with 82.6% of PAE patients remaining obstructed despite similar improvements in both PVR and IPSS.343 Studies such as these underscore the need to continue to follow patients after PAE despite clinical improvements.  PAE improvement over medical management has been assessed in two small clinical trials, PARTEM395 and P-EASY trials.396 Both studies evaluated PAE as an alternative to combined medical therapy (0.5 mg dutasteride/0.4 mg tamsulosin hydrochloride per day) in men with prostates ≥50 cc who failed AB therapy (PARTEM) or who had moderate-to-severe LUTS due to BPH. Both trials demonstrated that PAE outperformed combined medical therapy with improvements in quality of life in both IPSS and IIEF-15 metrics.  Prostate volume should be considered in patients for PAE. Studies comparing PAE to sham, drug, and TURP were performed in patients with prostates ≥50 cc.394-397 Thus, in patients with prostates <50 cc, the expected outcomes for PAE may not be as robust as those seen in the literature. This highlights the need for involvement of a urologist during pre-PAE assessment to confirm that a patient’s LUTS are secondary to BPH.  In appropriately selected patients, the ideal PAE candidate is a patient who has moderate-to-severe LUTS, failed or is not tolerant to medical therapy, has hematuria due to prostatic origin (regardless of size), or is a nonsurgical patient. In addition, a patient’s age, comorbidities, and/or coagulopathy should be taken into account.398 Relative contraindications to PAE are the inability to perform PAE such as severe atherosclerotic disease and inability to receive contrast due to severe contrast allergy. Other relative contraindications to PAE are largely based on PAE’s lack of surgical removal of tissue and include UTI, LUTS not secondary to BPH, detrusor dysfunction, large bladder diverticula, and/or large bladder stones. Integrating both urologists and interventional radiologists ensures appropriate patient selection and optimize PAE outcomes. PAE post-procedure expectations are different from surgical techniques. PAE demonstrates a lower adverse event rate than TURP (per Clavien-Dindo Classification) with no reports of strictures or incontinence and less EjD.390, 394, 399, 400 PAE adverse events include post-embolization syndrome and non-target embolization. Post-embolization syndrome is characterized by transient worsening of LUTS, pain, and low-grade fever. Post-embolization syndrome lasts approximately seven days and is managed conservatively.401 Non-target embolization includes embolization of the bladder, rectum, and/or penis, and although rare (less than 1%), it too can be managed conservatively with symptomatic care. Finally, the technical success (i.e., bilateral embolization of the prostatic artery) is approximately 85-90%, with one study reporting a rate of 75%.390 Although unilateral PAE still results in improvements, recurrence rates are higher in this patient population and patients should be informed of this risk.402 The observed rate of bilateral embolization may be a key component for the recurrence rate of 20-30% that is observed with PAE. The PAE trials that informed this Guideline recommendation have been conducted using particle embolics. There is growing interest in the use of liquid or “glue” embolic PAE. However, at this time, there is limited quality prospective evidence on the use of liquid embolic PAE, and its efficacy and safety remain unknown.