To the Editor: We read with interest the recent article by Drs. Sotimehin, Haile, and Gill regarding the management of benign prostatic hyperplasia (BPH).1 We thank the authors for their evidence-based commentary.

Office-based procedures and the gold-standard surgical technique of transurethral resection of the prostate (TURP) for BPH are limited by prostate gland size.1 For larger prostate glands, surgical techniques such as laser enucleation of the prostate or prostatectomy may be required.2 However, many patients with BPH have contraindications to surgery, including the need for anticoagulant or antiplatelet treatment.

Prostate artery embolization (PAE) is an outpatient procedure performed under moderate sedation by experienced interventional radiologists. Multiple studies have demonstrated that PAE is most effective in large prostate glands, specifically glands with median lobe enlargement. Additionally, because PAE does not require general anesthesia, most medical comorbidities are not a contraindication. The low bleeding risk of PAE also makes it a good option for patients taking anticoagulant or antiplatelet medications.3

Multiple randomized controlled trials have compared the efficacy of PAE and TURP over follow-up periods of up to 24 months. Overall, these trials demonstrated that TURP is superior to PAE in improving clinical outcome parameters such as International Prostate Symptom Score and quality-of-life ratings. However, the differences between PAE and TURP were quantitatively small and were often not statistically significant. These trials also demonstrated a trend toward fewer adverse events with PAE than with TURP, particularly in terms of sexual dysfunction.4,5

The most recent American Urological Association guidelines for the management of lower urinary tract symptoms secondary to BPH include PAE, performed by an experienced physician, as a potential treatment option.2 We agree that PAE can serve as a useful complement to office-based and surgical procedures, and with its addition we are able to offer effective and safe treatment for all patients, irrespective of prostate size, medical comorbidities, or need for anticoagulant or antiplatelet medications.