Re: Patients with frailty, BPH and indwelling bladder catheter: What are the 1-year outcomes after Rezūm therapy?

To the Editor, I have read the article by Balsamo et al.[1] on the outcomes of Rezūm therapy in frail patients with benign prostatic hyperplasia and indwelling catheters with interest. The authors are to be commended for addressing this high-risk population and providing prospective data on catheter independence and functional outcomes. Here, I highlight 2 methodological considerations regarding the interpretation of their findings. First is potential bias because of the exclusion of patients with missing data. In a hypothetical case-control setting comparing Rezūm-treated frail patients with controls, patients with poorer outcomes may be more likely to be lost to follow-up. Excluding such patients may overestimate the efficacy of Rezūm, as only those who complete follow-up and achieve catheter independence are analyzed. Therefore, inclusion of all treated patients with appropriate sensitivity analyses for missing data would provide a more accurate estimate of the treatment effect. Second is reporting of erectile function outcomes. The International Index of Erectile Function (IIEF) is a widely used tool for assessing erectile function. However, its application in evaluating outcomes post-Rezūm therapy requires careful interpretation. Some studies have reported no significant changes in IIEF scores following treatment,[2] whereas others have observed improvements, particularly in patients with baseline erectile dysfunction.[3] These discrepancies may arise from differences in the study design, patient populations, and follow-up durations. Therefore, although the IIEF provides valuable insights, its results should be considered along with other clinical indicators and patient-reported outcomes to comprehensively evaluate posttreatment sexual function. I appreciate the authors' contribution to the literature on minimally invasive therapies for frail patients. Careful consideration of missing data handling and limitations in sexual function assessments may help guide interpretations and inform future comparative studies.