Comparison of Minimally Invasive Procedures for Benign Prostatic Hyperplasia: A Cost-effectiveness Analysis.

Background Benign prostatic hyperplasia (BPH) is a disease that affects millions of U.S. men and is costly to treat. Purpose To compare the cost-effectiveness of four minimally invasive therapies (MITs) and medical management for the treatment of BPH. Materials and Methods A cost-effectiveness analysis from a payer's perspective with Markov modeling was performed, comparing prostatic artery embolization (PAE), prostatic urethral lift, aquablation, water vapor thermal therapy, and medical management for BPH spanning a time horizon of 5 years. The model incorporated the probability of procedural complications and recurrent symptoms necessitating retreatment, which were extracted from published studies with long-term follow-up. Costs were based on Medicare reimbursements using CPT codes for ambulatory surgery centers. Outcomes were measured using the quality-adjusted life year (QALY), incorporating both life quality and expectancy. Statistical analyses included a base case calculation (using the most probable value of each parameter) and probabilistic and deterministic sensitivity analyses. Results In the base case calculation, outcomes for the strategies were comparable, with a difference of 0.030 QALY (11 days of life in perfect health) between the most (PAE) and least (medical management) effective strategies. PAE was the most cost-effective strategy relative to medical management, with an incremental cost-effectiveness ratio of $64 842 per QALY. Probabilistic sensitivity analysis showed PAE was more cost-effective compared with prostatic urethral lift, aquablation, water vapor therapy, and medical management in pairwise comparisons. In sensitivity analysis of retreatment risk, PAE remained the most cost-effective strategy until its repeat treatment rates exceeded 2.30% per 6 months, at which point water vapor therapy became the optimal choice. PAE was the most cost-effective procedure when its procedural cost was lower than $4755. Aquablation and prostatic urethral lift became more cost-effective when their procedural costs were lower than $3015 and $1097, respectively. Conclusion This modeling-based study showed that PAE appears to be a cost-effective modality among medical management and MITs for patients with BPH, with comparable outcomes to prostatic urethral lift, water vapor therapy, and aquablation at a lower expected cost. © RSNA, 2023 Supplemental material is available for this article. See also the editorial by Gemmete in this issue.

Management of Inverted Papilloma During Holmium Laser Enucleation of the Prostate.

Inverted papilloma of the prostatic urethra is an especially rare finding. A 75-year-old man with urinary retention wished to proceed with a holmium laser enucleation of the prostate (HoLEP) and was found to have a mass arising from his prostate vs bladder on preoperative imaging. Cystourethroscopy revealed the mass arising from the median lobe of the prostate. After transurethral resection and frozen analysis confirmed the benign pathology of an inverted papilloma, the patient subsequently underwent a successful HoLEP during the same surgical setting. Images of this rare prostatic mass are presented to increase urologist recognition and to assist management during HoLEP.

α-Lipoic acid treatment prevents cystine urolithiasis in a mouse model of cystinuria.

Cystinuria is an incompletely dominant disorder characterized by defective urinary cystine reabsorption that results in the formation of cystine-based urinary stones. Current treatment options are limited in their effectiveness at preventing stone recurrence and are often poorly tolerated. We report that the nutritional supplement α-lipoic acid inhibits cystine stone formation in the Slc3a1-/- mouse model of cystinuria by increasing the solubility of urinary cystine. These findings identify a novel therapeutic strategy for the clinical treatment of cystinuria.

Dietary intake of fiber, fruit and vegetables decreases the risk of incident kidney stones in women: a Women's Health Initiative report.

PURPOSE: We evaluated the relationship between dietary fiber, fruit and vegetable intake, and the risk of kidney stone formation. MATERIALS AND METHODS: Overall 83,922 postmenopausal women from the Women's Health Initiative observational study were included in the analysis and followed prospectively. Cox proportional hazards regression analyses were used to evaluate the associations between total dietary fiber, fruit and vegetable intake, and the risk of incident kidney stone formation, adjusting for nephrolithiasis risk factors (age, race/ethnicity, geographic region, diabetes mellitus, calcium supplementation, hormone therapy use, body mass index and calibrated caloric intake; and dietary water, sodium, animal protein and calcium intake). Women with a history of kidney stones (3,471) were analyzed separately. RESULTS: Mean age of the women was 64±7 years, 85% were white and 2,937 (3.5%) experienced a kidney stone in a median followup of 8 years. In women with no history of kidney stones higher total dietary fiber (6% to 26% decreased risk, p <0.001), greater fruit intake (12% to 25% decreased risk, p <0.001) and greater vegetable intake (9% to 22% decreased risk, p=0.002) were associated with a decreased risk of incident kidney stone formation in separate adjusted models. In women with a history of stones there were no significant protective effects of fiber, fruit or vegetable intake on the risk of kidney stone recurrence. CONCLUSIONS: Greater dietary intake of fiber, fruits and vegetables was associated with a reduced risk of incident kidney stones in postmenopausal women. The protective effects were independent of other known risk factors for kidney stones. In contrast, there was no reduction in risk in women with a history of stones.

Impact of nutritional factors on incident kidney stone formation: a report from the WHI OS.

PURPOSE: Increased fluid intake, and decreased dietary sodium and animal protein intake are thought to reduce the risk of kidney stones but the role of calcium intake is controversial. We evaluated the relationship between dietary factors and incident kidney stone formation. MATERIALS AND METHODS: Secondary analysis was done of 78,293 women from the prospective WHI OS (Women's Health Initiative Observational Study) with no history of nephrolithiasis who completed the validated food frequency questionnaire. Multivariate logistic regression was used to determine demographic and dietary factors, and supplement use independently associated with incident kidney stones. RESULTS: Overall 1,952 women (2.5%) reported an incident kidney stone in 573,575 person-years of followup. The risk of incident kidney stones was decreased by 5% to 28% (p = 0.01) with higher dietary calcium intake and by 13% to 31% (p = 0.002) with higher water intake after adjusting for nephrolithiasis risk factors. Conversely higher dietary sodium intake increased the risk of nephrolithiasis by 11% to 61% (p <0.001) after adjustment with the most pronounced effect in women with the highest intake. Higher body mass index independently increased the risk of incident nephrolithiasis (adjusted OR 1.19-2.01, p <0.001). Animal protein intake was not associated with nephrolithiasis on multivariate analysis. CONCLUSIONS: This study adds to the growing evidence underscoring the importance of maintaining adequate fluid and dietary calcium intake. Greater dietary calcium intake significantly decreased the risk of incident kidney stones. In contrast, excess sodium intake increased the risk of incident nephrolithiasis, especially in women with the highest intake. Animal protein intake was not independently associated with nephrolithiasis.

Changes in urinary stone risk factors in hypocitraturic calcium oxalate stone formers treated with dietary sodium supplementation.

PURPOSE: We investigated the effects of supplemental dietary sodium on risk factors for urinary stone disease in stone forming patients with hypocitraturia. MATERIALS AND METHODS: Ten patients diagnosed with recurrent isolated hypocitraturic calcium urolithiasis were identified. Baseline 24-hour urinalysis was performed with patients on their regular diet, including citrate replacement with 20 mEq potassium citrate 3 times per day. Strict daily dietary logs were kept for a 7-day period, during which patients had normal oral intake and potassium citrate replacement. Patients then received supplemental sodium chloride for 1 week (1 gm orally 3 times per day), in addition to their regular diets and potassium citrate supplementation. Dietary logs were continued and 24-hour urinalysis was performed at the end of 1 week of supplemental sodium. Risk factors for urinary stone disease were compared using the Student t test and ANOVA. RESULTS: Two patients were unable to comply with sodium supplementation based on 24-hour urinalysis and, therefore, they were excluded from study. The remaining 8 patients were analyzed. Patients on supplemental dietary sodium demonstrated significantly increased mean urinary voided volume (933 ml per day above baseline, p <0.05) and mean urinary sodium excretion (66 mEq per day above baseline, p <0.05). There was no statistically significant change in urinary calcium, oxalate or uric acid. The urinary supersaturation relative risk ratio decreased for calcium oxalate stones (0.93 vs 0.63, p <0.05), while those of brushite, struvite and uric acid were not different before vs after supplemental sodium. CONCLUSIONS: Dietary sodium supplementation resulted in an increased voided urine volume and decreased the relative risk supersaturation ratio for calcium oxalate stones in patients with a history of hypocitraturic calcium oxalate nephrolithiasis. Urinary calcium excretion as well as other urine parameters that are risk factors for nephrolithiasis was not changed. Sodium restriction may be inappropriate in patients with hypocitraturia and recurrent urinary stones. Sodium supplementation may be beneficial in these patients because it results in voluntary increased fluid intake.