Evaluation of Private Payer and Patient Out-of-Pocket Costs Associated With the Surgical Management of Benign Prostatic Hyperplasia.

OBJECTIVE: To evaluate and compare the financial burden of various surgical interventions for the management of benign prostatic hyperplasia (BPH). METHODS: We identified commercially insured men with a diagnosis of BPH who underwent a procedure of interest (simple prostatectomy (SP), transurethral resection of the prostate (TURP), holmium laser enucleation of the prostate (HoLEP), photovaporization of the prostate (PVP), prostatic urethral lift (PUL), or water vapor thermal therapy (WVTT)) between 2015 and 2021 with the OptumLabs Data Warehouse. Primary outcome was total health care costs (THC) which included both patient out-of-pocket (OOP) and health plan paid costs for the index procedure and combined follow-up years 1-5. A generalized linear model was used to estimate adjusted costs controlling for demographic and clinical characteristics. Patients undergoing WVTT were excluded from extended follow-up analyses due to limited data. RESULTS: Among 25,407 patients with BPH, 10,117 (40%) underwent TURP, 6353 (25%) underwent PUL, 5411 (21%) underwent PVP, 1319 (5%) underwent SP, 1243 (5%) underwent WVTT, and 964 (4%) underwent HoLEP. Index procedure costs varied significantly with WVTT being the least costly [THC: $2637 (95% confidence interval (CI): $2513-$2761)], and SP being the costliest [THC: $14,423 (95% CI: $12,772-$16,075)]. For aggregate index and 5-year follow-up costs, HoLEP ($31,926 [95% CI: $29,704-$34,148]) was the least costly and PUL ($36,596 [95% CI: $35,369-37,823]) was the costliest. CONCLUSION: BPH surgical treatment is associated with significant system-level health care costs. The level of impact varies between procedures. Minimally invasive options, such as WVTT, may offer initial cost reductions; however, HoLEP and SP are associated with lower follow-up costs.

Is Race Associated with the Surgical Treatment for Benign Prostatic Hyperplasia? An Analysis of 30,000 Medicare Lives.

BACKGROUNDS: With an increased prevalence and burden of benign prostatic hyperplasia (BPH), effective and equitable treatment is a priority. Limited data exist evaluating treatment disparities for patients with BPH by race. This study examined the association between race and BPH surgical treatment rates among Medicare beneficiaries. METHODS: Medicare claims data were used to identify men newly diagnosed with BPH from January 1, 2010 through December 31, 2018. Patients were followed until their first BPH surgery, a diagnosis of prostate/bladder cancer, termination of Medicare enrollment, death, or end of study. Cox proportional hazards regression compared the likelihood of BPH surgery between men of different races (White vs. Black, Indigenous, and People of Color (BIPOC)), controlling for patients' geographical region, Charlson comorbidity score, and baseline comorbidities. RESULTS: The study included 31,699 patients (13.7% BIPOC). BIPOC men had significantly lower BPH surgery rates (9.5% BIPOC vs. 13.4% White; p=0.02). BIPOC race was associated with a 19% lower likelihood of receiving BPH surgery than White race (HR, 0.81; 95% CI 0.70, 0.94). Transurethral resection of the prostate was the most common surgery for both groups (49.4% Whites vs. 56.8% BIPOC; p=0.052). A higher proportion of BIPOC men underwent procedures in inpatient settings compared to White men (18.2% vs. 9.8%; p<0.001). CONCLUSIONS: Among a cohort of Medicare beneficiaries with BPH, there were notable treatment disparities by race. BIPOC men had lower rates of surgery than White men and were more likely to undergo procedures in the inpatient setting. Improving patient access to outpatient BPH surgical procedures may help address treatment disparities.

From Consensus to Validation: A Multicenter Study for Design and Development of a Holmium Laser Enucleation of the Prostate Hydrogel Simulation Platform.

Background: Holmium laser enucleation of the prostate (HoLEP) has emerged as a new gold standard for treatment of benign prostatic hyperplasia; however, its steep learning curve hinders generalization of this technique. Therefore, there is a need for a benchtop HoLEP simulator to reduce this learning curve and provide training. We have developed a nonbiohazardous HoLEP simulator using modern education theory and validated it in a multicenter study. Materials and Methods: Six experts established key components for a HoLEP simulator through a Delphi consensus over three rounds including 250 questions. After consensus, a digital design was created and approved by experts, then used to fabricate a physical prototype using three-dimensional printing and hydrogel molding. After a process of iterative prototype testing, experts completed a survey assessing the simulator with a 5-point Likert scale for final approval. The approved model was validated with 56 expert and novice participants at seven institutions using subjective and objective performance metrics. Results: Consensus was reached on 85 of 250 questions, and experts found the physical model to adequately replicate 82.5% of required features. Objective metrics were statistically significant (p < 0.0001) when comparing experts and novices for enucleation time (37.4 ± 8.2 vs 16.7 ± 6.8 minutes), adenoma weight (79.6 ± 20.4 vs 36.2 ± 9.9 g), and complications (6 vs 22), respectively. Conclusion: We have effectively completed a multicenter study to develop and validate a nonbiohazardous benchtop simulator for HoLEP through modern education theory. A training curriculum including this simulator is currently under development.

Neuromuscular Paralysis is not a Barrier to Same Day Catheter Removal After HoLEP.

OBJECTIVE: To determine if same day catheter removal is feasible in a population of holmium laser enucleation of the prostate patients who received paralysis and if bladder pressure monitoring could predict successful catheter removal. METHODS: From February 2021 to February 2022, we evaluated same day catheter removal for patients undergoing holmium laser enucleation of the prostate. Criteria for proceeding with same day catheter removal included: an uncomplicated procedure, continuous bladder irrigation weaned within 120 minutes of arrival to PACU, minimal postoperative hematuria and a bladder pressure over 30 cmH20 as measured using the VP Test device (SRS Medical). RESULTS: One hundred and eight patients were enrolled, with a median age of 68 years (IQR: 62.0-73.0) and prostate volume 80.8cc (IQR: 64.8-112.3). Criteria for catheter removal was met by 83/108 (76.9%) patients. Of those that attempted a trial of void, 69/83 passed for an effective pass rate of 83.1%. Median maximum detrusor pressure for those that passed and failed were 51.0 cmH20 (IQR: 40.5 -68.0) and 48.0 cmH20 (IQR: 38.8-61.8) [P = .53], respectively. Intraoperative Lasix administration was associated with a higher rate of trial of void (TOV) success and preoperative PVR was associated with lower TOV success, with OR (95%CI) of 5.8 (1.4, 29.5) [P = .02] and 0.6 (0.4, 0.9) [P = .01], respectively. CONCLUSION: Same day catheter removal is feasible in those who receive neuromuscular paralysis, with a success rate >80%. Bladder pressure monitoring did not assist with differentiating which patients will pass or fail a trial of void. Intraoperative Lasix administration may be helpful in increasing success for same day catheter removal while elevated preoperative PVR was associated with TOV failure.

Evaluation of the Cost-Effectiveness of Surgical Treatment Options for Benign Prostatic Hyperplasia.

OBJECTIVE: To compare the cost-effectiveness of surgical interventions for BPH. METHODS: Using a Markov model, a cost-utility analysis was performed comparing HoLEP, B-TURP, WVTT, and PUL for prostate size <80cc (index patient 1) and HoLEP and SP for prostate size >80cc (index patient 2). Model probabilities and utility values were drawn from the literature. Analysis was performed at a 5-year time horizon with extrapolation to a lifetime horizon. Primary outcomes included quality-adjusted life years (QALYs), 2021 Medicare costs, and incremental cost-effectiveness ratios (ICERs) with a willingness-to-pay threshold of $100,000/QALY. Univariate and probabilistic sensitivity analyses were performed. RESULTS: At 5 years, costs per patient for index patient 1 were $3292 (WVTT), $6532 (HoLEP), $6670 (B-TURP), and $10,257 (PUL). HoLEP resulted in the highest QALYs (4.66), followed by B-TURP (4.60), PUL (4.38), and WVTT (4.38). This translated to HoLEP being most cost-effective (ICER $11,847). For index patient 2, HoLEP was less costly ($6,585 vs $15,404) and more effective (4.654 vs 4.650) relative to SP. On sensitivity analysis for index patient 1, B-TURP became most cost-effective if cost of HoLEP increased two-fold or chronic stress incontinence following HoLEP increased ten-fold. When follow-up time was varied, WVTT was preferred at very short follow up (<1 year), and HoLEP became more strongly preferred with longer follow up. CONCLUSION: At 5 years follow up, HoLEP is a cost-effective surgical treatment for BPH- independent of gland size.

Salvage versus primary holmium laser enucleation of the prostate: trends, outcomes and safety analysis.

PURPOSE: To study the safety, efficacy and trends in index procedures leading to salvage holmium laser enucleation of the prostate (S-HoLEP). METHODS: This was a single-institution retrospective review of HoLEPs performed between 2006 and 2020. Patients who underwent S-HoLEP were compared to those undergoing primary holmium laser enucleation of the prostate (P-HoLEP). The endpoint of primary interest were functional outcomes. Changes in index procedures over the study period were analyzed. RESULTS: A total of 633 HoLEPs were performed during the study, with 217 being S-HoLEP. The S-HoLEP cohort was older than P-HoLEP cohort, 71.2 years vs 68.8 years (p = 0.03). All other factors were well matched. The most common index procedures prior to S-HoLEP included transurethral resection of the prostate (TURP) (87, 40.1%), transurethral microwave thermotherapy (TUMT) (44, 20.3%), photoselective vaporization of the prostate (PVP) (24, 11.1%) and prostatic urethral lift (PUL) (24, 11.1%). Preoperative prostate volume, IPSS and Qmax were similar between groups. Intra-operatively, S-HoLEP had longer procedure and morcellation times (p = 0.01 and 0.007). Postoperatively, the S-HoLEP cohort had longer catheter duration and hospitalization (both p < 0.001). Postoperative Qmax, IPSS and 90-day complication rates were similar. On temporal analysis, minimally invasive surgical therapies (MIST) have become more prevalent as index procedures. CONCLUSION: S-HoLEP is safe and efficacious for patients requiring additional BPH surgical intervention. S-HoLEP patients had longer operative times and hospital stays but equivalent postoperative functional outcomes compared to P-HoLEP. As MIST mature and gain traction, it is expected that rates of S-HoLEP will continue to rise.

Travel characteristics and outcomes for patients seeking HoLEP.

INTRODUCTION: Holmium laser enucleation of the prostate (HoLEP) is an effective but underutilized option for the surgical management of benign prostatic hyperplasia (BPH). With low adoption, questions arise surrounding patients access to care. It is unclear whether patients undergoing HoLEP are local or specifically seek care from afar. We looked to determine the proportion of patients who traveled out-of-state for HoLEP treatment and the impact of travel on peri and postoperative metrics. MATERIALS AND METHODS: We performed a retrospective cohort study evaluating patients that underwent HoLEP at a single institution from 2007-2019. Patient demographic, perioperative data, postoperative outcomes, travel distance and income data were compared between those who traveled and did not travel out-of-state for care. RESULTS: From 2007-2019, 1565 patients underwent HoLEP at our institution. The mean age was 70.0 years, average body mass index (BMI) of 27.9 kg/m2, and 91.6% identified as Caucasian; 44.2% of patients traveled from out-of-state for HoLEP care, traveling a median of 597 miles. Patients who came from out-of-state had larger prostates (p = 0.005) and worse preoperative International Prostate Symptom Score (IPSS) total and bother scores (p = 0.002). There was no difference in immediate, 30 or 90 day complications rates. In- and out-of-state patients had similar postoperative urinary and functional outcomes. CONCLUSIONS: A large proportion of patients specifically seek out HoLEP and travel out-of-state for care. The reasons are likely multifactorial -including advanced disease, lack of local care and healthcare consumerism. These results have implications both for those currently providing HoLEP as a treatment option as well as those motivated to start a HoLEP practice.

Reimbursement of surgical procedures for benign prostatic hyperplasia: are we disincentivizing complex care?

PURPOSE OF REVIEW: To provide an overview of how surgical benign prostatic hyperplasia (BPH) procedures are compensated in the United States and the implications of the current reimbursement system on the care of patients. RECENT FINDINGS: The resource-based relative value care system is Medicare's current reimbursement model. There is strong evidence that the current system does not adequately account for complex care. Consequently, for BPH surgical procedures, treatment options best suited for complex patients are not adequately reimbursed which may have implications on healthcare delivery and outcomes. SUMMARY: Inadequate reimbursement for certain BPH procedures may disincentivize the care of complex patients. Procedures such a holmium laser enucleation of the prostate are well suited for complex patients but have a steep learning curve. The incentive to learn and offer such procedures to complex patients may be unfairly influenced by reimbursement levels, which in the end penalizes patients and the treatments available to them.

HoLEP: the new gold standard for surgical treatment of benign prostatic hyperplasia.

INTRODUCTION Transurethral resection of the prostate (TURP) was considered the "gold standard" surgical treatment for medication-refractory benign prostatic hyperplasia (BPH) for decades. With the desire to reduce hospital stay, complications, and cost, less invasive procedures gained usage in the 1990's. With the advent of a soft tissue morcellator, holmium laser enucleation of the prostate (HoLEP) was introduced as an efficacious alternative to TURP and due to its advantageous side effect profile compared to TURP, has grown in popularity ever since. HoLEP has become a size-independent guideline endorsed procedure of choice for the surgical treatment of BPH. MATERIALS AND METHODS: We provide a review on the evolution of HoLEP as a gold standard compared to the historical reference procedures for BPH, and provide a review of emerging laser technologies. RESULTS: A growing body of literature has shown HoLEP to be a safe and efficient procedure for the treatment of BPH for all prostate sizes. Long term studies have proven the durability of HoLEP, as a first line surgical therapy for BPH. CONCLUSIONS: HoLEP is a proven modality for the surgical treatment of BPH. It can be performed on patients with high risk for postoperative bleeding, or after previous prostate reducing procedures. HoLEP is the only procedure that is AUA guideline-endorsed for all prostate sizes for the surgical treatment of BPH. Given these considerations, HoLEP has become the new gold-standard for the surgical treatment of BPH.

Morcellation Efficiency in Holmium Laser Enucleation of the Prostate: Oscillating Morcellator Outperforms Reciprocating Morcellator With no Apparent Learning Curve.

OBJECTIVE: To compare the morcellation efficiency of the Wolf Piranha oscillating morcellator with the Lumenis VersaCut reciprocating morcellator. MATERIALS AND METHODS: After institutional review board approval, we conducted a retrospective analysis of patients undergoing holmium laser enucleation of the prostate (HoLEP) for symptomatic benign prostatic hyperplasia. The first 41 cases of HoLEP with morcellation performed with the oscillating morcellator were matched by weight of resected tissue to 41 control patients from our historic data set who underwent morcellation with the reciprocating system. The primary outcome of interest was morcellation efficiency. We also evaluated surgeon experience level to assess for a learning curve with the oscillating morcellator. RESULTS: The 41 patients from each group were comparable in terms of age, prostate size, continuation of aspirin, and catheter status. The oscillating morcellation efficiency was nearly double that of the reciprocating morcellator (8.6 g/min [range: 3.0-18.3] vs 3.8 g/min [range: 0.9-10.1], P <.0001). Mean resected weights for cases with the oscillating and reciprocating instruments were 69 g (range: 17-224 g) and 69 g (range: 17-213 g), respectively (P = .9). The total operative time and complication rates did not significantly differ. For the oscillating system, morcellation efficiency for cases performed by staff alone was 9.8 g/min compared with 8.1 g/min when trainees were involved (P = .2), and there was no correlation between morcellation efficiency and number of cases performed (R = 0.01). CONCLUSION: The oscillating morcellation system resulted in a morcellation efficiency double that of the reciprocating system for tissue retrieval after HoLEP. Achieving efficiency with the oscillating system was not associated with a significant learning curve and was not impacted by trainee involvement.

Outcomes of Holmium Laser Enucleation of the Prostate in the Re-Treatment Setting.

PURPOSE: Holmium laser enucleation of the prostate can also be applied in the re-treatment setting when other benign prostatic hyperplasia therapies fail. We compared outcomes in men who underwent holmium laser enucleation of the prostate in the primary vs the re-treatment setting. MATERIALS AND METHODS: We retrospectively reviewed the records of 2,242 patients who underwent holmium laser enucleation of the prostate at a total of 4 academic hospitals between 2003 and 2015. Patient demographics, and operative and perioperative outcomes were compared between re-treatment and primary holmium laser enucleation of the prostate. RESULTS: Of the 360 of 2,242 men (16%) who underwent re-treatment holmium laser enucleation of the prostate the procedure was done for residual urinary symptoms in 71%. The most common primary procedure was transurethral resection of the prostate in 42% of cases. Mean time between prior benign prostatic hyperplasia surgery and re-treatment was 68 months (range 1 to 444). There were no significant differences in age, prostate size, AUA (American Urological Association) symptom score or average flow rate between the cohorts. Perioperatively, re-treatment holmium laser enucleation of the prostate was associated with significantly shorter operative time, reduced blood loss, lower specimen weight and shorter length of stay. The AUA symptom score improved in both groups, although it remained higher in men who underwent re-treatment (6.5 vs 5.0, p <0.001). The likelihood of clot retention (4.7% vs 1.8%, p = 0.01) and urethral stricture (3.3% vs 1.5%, p = 0.043) was slightly higher in the re-treatment group. CONCLUSIONS: Immediate perioperative outcomes of holmium laser enucleation of the prostate performed in the re-treatment setting were no different from those in the primary setting. While re-treatment was associated with an increased likelihood of clot retention, urethral stricture and higher AUA symptom score, these minimal differences must be considered against the overall favorable symptom improvement across both cohorts.

The impact of training on the perioperative and intermediate functional outcomes after holmium laser enucleation of the prostate.

INTRODUCTION: To systemically measure the impact of trainees' participation on the perioperative and functional outcomes after holmium laser enucleation of the prostate (HoLEP). MATERIALS AND METHODS: Benign prostatic hyperplasia patients who underwent HoLEP at our department between January 2007 and January 2013 were classified based on trainee's level. Perioperative outcomes and complications were collected. Functional outcomes were assessed using the Sexual Health Inventory for Men (SHIM), International Prostate Symptom Score (IPSS), and International Continence Society-Short Form (ICSmaleSF) questionnaires. Voiding and incontinence domains of ICSmaleSF were assessed separately. Patients were divided into group 1 if no trainee participated in the operation, group 2 if a senior trainee performed the operation, and group 3 if a junior trainee participated in the operation. The patient's baseline characteristics, complications, and perioperative outcomes were compared. RESULTS: There were no differences in the baseline characteristics. There were significant differences in overall operative and enucleation time (p = 0.0186, p = 0.0047, respectively) with shorter times noticed with more experienced operators. There were no differences in resected tissue weight, hemoglobin change, and transfusion rates. Postoperatively, all patients had a similar length of stay and catheterization. Complications (graded by Clavien grading system) were not different. All patients were followed up at regular intervals starting at 6 weeks, 3 months , 6 months, 1 year, and every year after that and there were no differences in flow rates or post void residual volumes at any time point. There were no differences in SHIM, IPSS, and ICSmale voiding scale among the groups. However, ICSmale continence scale was significantly different where the highest score seen in group 2. CONCLUSION: Trainee participation in HoLEP in a controlled training environment does not compromise the safety of the procedure.

Holmium laser enucleation of the prostate: efficiency gained by experience and operative technique.

PURPOSE: Holmium laser enucleation of the prostate is highly effective for symptomatic benign prostatic hyperplasia. Despite its steep learning curve the procedure is an efficient treatment, especially for large prostate glands. We determined the change in enucleation efficiency with time with increased operative experience and improved technique. MATERIALS AND METHODS: We reviewed the records of all 949 consecutive men who underwent holmium laser enucleation of the prostate between 1999 and 2007. Patients were excluded from analysis when enucleated gm or time was not recorded and enucleated tissue was less than 5 gm. Efficiency was measured in gm enucleated prostate tissue per minute. Descriptive statistics on laser time, gland weight and efficiency were evaluated in an 8-year period. RESULTS: A total of 91 patients met study exclusion criteria, leaving 858 available for evaluation. Mean enucleation time was 94 minutes (range 12 to 485). Mean prostate specimen weight was 77 gm (range 5 to 376). Mean efficiency or enucleation rate was 0.55 vs 1.32 gm per minute in the first 4 vs the last 5 years. Further efficiency improvements were noted in the last 5 years with a mean of 1.57 gm per minute enucleated in the last 2 years. CONCLUSIONS: As experience with holmium laser enucleation of the prostate grows, advances in operative technique have been made. Prostatic enucleation efficiency continues to improve, further strengthening the role of holmium laser enucleation of the prostate for benign prostatic hyperplasia of small and large prostate glands.

Preliminary results of sacral neuromodulation in 23 children.

PURPOSE: Sacral nerve stimulation with InterStim is approved in the United States for use in adults. Limited data on the effectiveness of sacral nerve stimulation in children are available. We report our experience with patients who underwent InterStim placement for the treatment of severe dysfunctional elimination syndrome, which is defined as a constellation of functional urinary and gastrointestinal symptoms in patients without anatomical anomalies or obvious neurological disease, in whom intensive medical and behavioral therapies have failed to improve symptoms. MATERIALS AND METHODS: A total of 23 patients 6 to 15 years old with presenting symptoms of dysfunctional voiding, enuresis, incontinence, urinary tract infections, bladder pain, urinary retention, urgency, frequency, constipation and/or fecal soiling were followed for a mean of 13.3 months after InterStim placement. RESULTS: Of the 19 patients with urinary incontinence 3 (16%) had complete resolution, 13 (68%) had improvement, 2 (11%) were unchanged and 1 (5%) was worse (sign test, p = 0.002). Among the 16 patients with nocturnal enuresis 2 (13%) had resolution, 9 (56%) improved, 4 (25%) were unchanged and 1 (6%) was worse (sign test, p = 0.0063). Of the 15 patients with urinary retention requiring intervention 9 (60%) had improvement and 1 had worsening symptoms (sign test, p = 0.022), while 2 of 6 patients (33%) on intermittent catheterization were able to stop. One patient had development of new incontinence and enuresis. Bladder pain, urgency, frequency and constipation improved in 67% (8 of 12), 75% (12 of 16), 73% (11 of 15) and 80% (12 of 15) of the patients, respectively. Medications required postoperatively decreased by an average of 3 per patient (p < 0.001). The overall patient satisfaction rate was 64%, while that of the caregiver was 67%. Two leads were explanted from the 23 patients. Complications encountered included 1 seroma, 1 episode of skin sensitivity, 2 device failures and 1 lead revision. CONCLUSIONS: Sacral nerve stimulation in children is an option for carefully selected patients who have failed other therapies. Our results show that sacral nerve stimulation was effective in the majority of patients with the dysfunctional elimination syndrome. However, longer followup is needed.