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.

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.

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.