Men on active surveillance for prostate cancer often experience symptomatic BPH and may be offered BPH procedures with the goal of improving quality of life through treatment of LUTS/BPH.482, 483 The BPH treatment selected should not hamper future prostate cancer treatment. Clinicians should recognize that BPH procedures may impact PSA levels; therefore, pre-procedure and post-procedure PSA should be evaluated. Resective technologies such as TURP, simple prostatectomy, AEEP, RWT, and PVP will result in a greater decline in PSA. Bâcle et al. evaluated 310 patients on active surveillance for prostate cancer and compared those who underwent HoLEP for symptomatic BPH to a control group that did not have surgical intervention.484 PSA and PSA density were significantly lower in the HoLEP group (2.0 ng/mL versus 7.7 ng/mL; p<0.0001 and 0.06 ng/mL2 versus 0.14 ng/mL2; p<0.0001, respectively). Compared to the control group, the rate of discontinuation of active surveillance was much lower in the HoLEP group (18% versus 56%; p<0.01). On multivariate analysis, HoLEP was identified as a predictive factor for continued active surveillance (hazard ratio [HR]=0.231; p<0.0001). BPH procedures that produce a pathologic tissue specimen may have further benefit in evaluating patients on active surveillance for prostate cancer when higher grade prostate cancer is detected and results in a change in prostate cancer treatment.485, 486 While other minimally invasive surgical therapies (i.e., PUL, WVTT, TIPD, PAE, IPDCB) have been used to treat symptomatic BPH in men on active surveillance for prostate cancer, their impact on PSA and subsequent prostate cancer treatment is not well characterized. Clinicians should recognize that those with implantable components such as PUL may affect the interpretation of imaging modalities used in active surveillance protocols such as mpMRI of the prostate. Benidir et al. reported that 40% of prostate MRIs in patients with prior PUL were limited by poor quality and/or moderate artifact.352