Trans urethral electric vaporisation of prostate as an alternate to trans urethral resection in benign prostatic hyperplasia

BACKGROUND

There is an impression that trans urethral electric vaporisation of prostate (TUEVP) is a relatively safe surgical procedure for obstructing benign prostates, however before considering it an alternative to Trans urethral resection (TURP) in our setting. we conducted this study to assess its safety. convenience and especially cost effectiveness in our practice.

METHODS

Fifty patients with signs of benign prostatic enlargement causing acute urinary retention were selected and divided into two equal groups A and B. Patients of group A underwent TURP while the group B patients had TUEVP. Postoperative follow up to assess the results of the surgeries, including noting the complication rate, began 24 hour after the catheter was removed, continuing during postoperative visits of the patient at 2 weeks, 3 months and finally 6 months.

RESULTS

For approximately same size prostate, the mean operation time was less for TUEVP as compared to the TURP. The mean volume of irrigating fluid used and the number of blood transfusions required was also less in the TUEVP patients. In addition. TURP patients were also noted to have slight postoperative hyponatraemia. Clot retention was more frequent in the TURP group than the TUEVP group. Urethral catheters were required for longer duration (mean duration 74.88 hrs vs 24hrs, p=0.0001) and so was the hospital stay (mean duration 6.25 days vs 4.4 days. p=0.0046) in the TURP group patients. Total mean cost of treatment was also higher in the patients undergoing TURP. Among the complications, only the peroperative blood transfusion rate was higher in the TURP patients as noted above.

CONCLUSIONS

The TURP has slightly higher morbidity and is costlier than TUEVP but its results in terms of relieving outflow obstruction are significantly better than TUEVP. It is therefore concluded that TURP is a more effective procedure but TUEVP with lesser morbidity and cost, is more suitable for relatively lesser obstructions in our setting.

Cost aspects of transurethral resection of the prostate, contact laser prostatectomy, and electrovaporization

OBJECTIVES

To compare the costs of transurethral resection of the prostate (TURP), contact laser prostatectomy (CLP), and electrovaporization in men with lower urinary tract symptoms associated with benign prostatic hyperplasia.

METHODS

We conducted a randomized controlled trial that included men with lower urinary tract symptoms who met the criteria of the International Scientific Committee on benign prostatic hyperplasia. Subjective changes were quantified using questionnaires validated by the American Urological Association. The maximal free urinary flow rate was estimated. Morbidity and mortality were registered. These parameters were measured at regular intervals for up to 1 year and once during long-term follow-up. A cost analysis together with a sensitivity analysis was performed on the basis of a follow-up of 12 months.

RESULTS

A total of 50 men were randomized to TURP, 45 to laser treatment, and 46 to electrovaporization. The subjective and objective changes were very similar during the 12 months of follow-up. The costs were highest for CLP (1885 dollars), followed by TURP (1707 dollars), and were lowest for electrovaporization (1489 dollars). However, the length of hospital stay decreased during the trial more for CLP and electrovaporization than for TURP. Recalculations demonstrated almost equal costs for CLP and TURP (1697 dollars and 1643 dollars, respectively) and the lowest costs for electrovaporization (1386 dollars).

CONCLUSIONS

Electrovaporization has a better cost-effectiveness than CLP and TURP in patients with lower urinary tract symptoms associated with benign prostatic hyperplasia. CLP and TURP showed very similar cost-effectiveness ratios.

The cost of feedback microwave thermotherapy compared with transurethral resection of the prostate for treating benign prostatic hyperplasia

OBJECTIVE

To compare the efficacy of a new microwave thermotherapy for treating benign prostatic hyperplasia (BPH), the ProstaLund Feedback Treatment (PLFT, ProstaLund Operations AB, Lund, Sweden) and transurethral resection of the prostate (TURP) in a clinical trial to their effectiveness in clinical practice over 1 year, to estimate their cost over 1 year, and to evaluate the cost of re-interventions over a longer period (2-3 years).

PATIENTS AND METHODS

In a large randomized international 1-year clinical trial PLFT was as effective as TURP in improving symptoms of BPH and urinary flow. Because PLFT is an outpatient procedure it was less costly than TURP. However, the cost-effectiveness of the new procedure depends on its long-term effectiveness in clinical practice. All 146 patients in the randomized clinical trial were included in the present analysis. The outcome was based on the International Prostate Symptom Score (IPSS) and the bother score, and costs were estimated from treatment-related adverse events and hospitalization. To validate the estimates based on the clinical trial 1-year data on effectiveness and complete resource use in clinical practice were collected in a retrospective observational study from hospital charts and patient questionnaires of 88 patients who had undergone either TURP or PLFT. To assess the number of re-interventions after TURP after the first year information was obtained from hospital and surgical procedure data in the Swedish inpatient registry. The 3-year data for a total of 52,010 patients who had an index hospitalization for TURP between 1990 and 1995 were available for the analysis. The estimate of long-term consequences of PLFT was based on complication and re-intervention data for 87 patients who had undergone PLFT between 1997 and 1999.

RESULTS

The mean 1-year costs in the clinical trial were estimated at [symbol: see text] 1763 for PLFT and [symbol: see text] 3209 for TURP. When all treatment-related resource use in clinical practice for 88 patients was included the costs were estimated at [symbol: see text] 1924 and [symbol: see text] 3264 for PLFT and TURP, respectively. The IPSS and bother scores were not significantly different between the groups in both datasets. Using the registry data the cost of TURP including re-interventions (TURP and bladder neck incisions) was estimated at [symbol: see text] 3159 over 2 years and [symbol: see text] 3185 over 3 years; the respective costs for PLFT were [symbol: see text] 2121 and at [symbol: see text] 2151.

CONCLUSIONS

In the 1-year clinical trial PLFT was as effective but less costly than TURP, but long-term data are still lacking. However, the preliminary analysis over 3 years indicates that the average cost of the procedure remains lower than the total cost of TURP for the same period.

Interstitial laser photocoagulation for treatment of benign prostatic hypertrophy: outcomes and cost effectiveness

BACKGROUND

We examined the efficiency and cost effectiveness of a temperature feedback diode-laser system in the treatment of benign prostatic hypertrophy (BPH).

METHODS

One hundred twenty patients with symptomatic BPH were included in this study between October 1997 and January 1998. Sixty of them were treated by transurethral resection of the prostate (TUR-P), and 60 patients were treated by temperature feedback interstitial laser coagulation (ILC). Direct and indirect cost parameters, such as operative time, operation-related consumables, duration of hospitalization, and amount of medication used were compared between the 2 groups.

RESULTS

All subjective and objective urinary parameters exhibited significant improvement 12 months after ILC. A reduction of 26.8% (46.6 to 34.1 ml) of the pretreatment prostate volume was observed at 12 months following ILC. The duration of hospital stay, operative time, and postoperative medications were significantly lower for those receiving ILC (5.9 to 2.5 days, p < 0.001) than for those who underwent TUR-P. The variety of laboratory tests needed for preoperative evaluation was no less when ILC was chosen for treating BPH (p = 0.849). Indirect costs, such as investment in laser equipment and laser accessories were higher in the ILC group (p < 0.001).

CONCLUSION

The low morbidity profile, particularly the absence of retrograde ejaculation, makes ILC a valuable and attractive option for treatment of BPH patients who wish to retain their ejaculation ability, who have serious underlying diseases, or who have surgical risks for TUR-P or other invasive modalities.

Quality and cost between transcervical and transurethral prostatectomy

Although transurethral resection of the benign prostate (TURP) is a popular technique, it is not without problems. The average postoperative morbidity could be up to 50%. Therefore the quality of life and the total cost have been evaluated in this study, since the incidence of re-TURP was reported to be as high as 25% in 8 years period. This was attributable to incomplete resection, in that only about 40% of the prostatic tissue being resected by this technique. In contrast, transcervical prostatectomy (TCP) performs a total enucleation of the gland. It seems to be cost effective, in that the postoperative urethral catheter is removed routinely on the second day and the patients are discharged home on the fourth day routinely. The total incidence of morbidity, by contrast, was less than 5% and that of mortality under 1%. The initial cost for the primary operation would not be much difference between the these two techniques, but the average cumulative cost per TURP would be expensive, if all the expenses incurred for the treatment of postoperative complications are added together. It would be between pounds sterling 2574.00 and pounds sterling 2434.00, for the primary operation. But the cumulative cost for TURP would be pounds sterling 4333.00 and for TCP pounds sterling 2580.00. The true cost for the operation of TURP could be as high as pounds sterling 10720, compared to pounds sterling 2434.00, being the operation charge for TCP, if all expenses have to be paid by the patient.

CONCLUSION

Transcervical Prostatectomy compares favourably with TURP in every aspect, apart from the skin cut in the lower abdomen.

Transurethral resection vs microwave thermotherapy of the prostate: a cost-consequences analysis

OBJECTIVE

To compare the costs and outcome of high-energy transurethral microwave thermotherapy of the prostate (HE-TUMT) with transurethral resection of the prostate (TURP), as the former is considered to be the best minimally invasive method for managing lower urinary tract symptoms (LUTS) suggestive of benign prostatic hyperplasia (BPH).

PATIENTS AND METHODS

Between January 1996 and March 1997, 144 patients were randomized to treatment with HE-TUMT (78) using the Prostatron device and Prostasoft 2.5 software (EDAP Technomed, Lyon, France), or TURP (66). At baseline and during the annual follow-up, patients were evaluated by the International Prostate Symptom Score and uroflowmetry (maximum flow rate and postvoid residual volume). Kaplan-Meier survival analyses were used to calculate the cumulative risk of re-treatment. A cost-consequences analysis was performed based on the prospective measurement of healthcare use, with costs expressed as Netherland guilders (NLG).

RESULTS

During a 3-year follow-up period, the mean (95% confidence interval) risk of re-treatment was 22.9 (12.5-33.2)% and 13.2 (4.5-21.9)% for HE-TUMT and TURP, respectively (P = 0.215). The mean direct cost of treatment was 3450 (3444-3456) and 6560 (5992-7128) NLG for HE-TUMT and TURP, respectively. The mean total (including re-treatments), discounted (4%) 3-year cost for the HE-TUMT and TURP group was 5300 (4692-5908) and 7800 (7118-8482) NLG, respectively.

CONCLUSIONS

In this prospective randomized trial, HE-TUMT and TURP had a comparable 3-year risk of re-treatment. Healthcare expenditure on HE-TUMT, mainly because it is an outpatient treatment, was significantly lower than for TURP.

Application of External Microwave Thermotherapy in Urology: Past, Present, and Future

The excellent clinical results of transurethral microwave thermotherapy (TUMT) for the treatment of symptomatic benign prostatic hyperplasia (BPH) gave to TUMT the leading position among the microwave thermotherapy modalities available for the treatment of different urologic conditions. Research in TUMT has focused on operating software, temperature monitoring, intraprostatic heat distribution, cell-kill calculations, and correlations with clinical variables. Randomized comparisons of TUMT with other established therapies for BPH, including transurethral resection, have facilitated the evaluation of the clinical outcome, durability, morbidity, and costs of the treatment. The applications of microwave thermotherapy in other urologic diseases are also presented in this review.

The cost of bladder tumour treatment and follow-up

OBJECTIVE

To evaluate the costs of bladder tumour treatment and follow-up.

MATERIAL AND METHODS

The incidence of bladder tumours, both new and recurrences, and the cost of bladder tumour treatments with curative intent were registered during a 4-year period (1994-97).

RESULTS

The incidence of new tumours varied from year to year, in contrast to the number of recurrent tumours, which remained remarkably stable. The total cost of bladder cancer diagnosis, treatment and follow-up was almost 7,000,000 SEK per year (2,800,000 SEK per 100,000 inhabitants per year). The number of therapeutic events per year remained stable at 256 +/- 17 (102 per 100,000 inhabitants per year). Cystectomies were responsible for 34% of the expenditure and transurethral procedures for 40%. Follow-up cystoscopies accounted for only 13% of the total cost. One-third of the routine follow-up cystoscopies resulted in a therapeutic procedure. The cost of transurethral resections and extirpations was approximately five times higher when performed with the patient hospitalized compared to when performed as day-care surgery.

CONCLUSIONS

A reduction in the number of follow-up cystoscopies will only produce marginal economic savings. Further savings could be made if more transurethral resections and extirpations/fulgurations were performed on an outpatient basis. Another important goal is to reduce the median cost per cystectomy.

[Clinical studies on TUR-P using clinical path: report of 50 cases and review of literature]

PURPOSE

This study was undertaken to clarify the usefulness and problems involved in the clinical path of transurethral prostatectomy (TUR-P) in hospital.

PATIENTS AND METHODS

The subjects consisted of 50 patients, for whom the Department of Urology, Jikei Medical University Hospital introduced its own clinical path and performed TUR-P during a period of 9 months from July 1999 to March 2000. The mean length of hospital stay, rate of postoperative complications, and the medical insurance claims made by these patients were clarified and compared with those of 73 patients before introduction of the clinical path.

RESULTS

With the introduction of the clinical path, the length of hospital stay decreased by an average of 3.4 days and the total medical insurance claims decreased by an average of 18.5%. The rate of postoperative complications before and after introduction was almost equal.

CONCLUSION

Our clinical path for TUR-P was well accepted by both patients and comedicals. However, the present medical treatment system in Japan is not as yet prepared to promote the introduction of this clinical path, and it will take some time before this clinical path is introduced on a full scale.

TUNA of the prostate in an office setting: nursing implications

Transurethral needle ablation is a minimally invasive treatment for benign prostatic hyperplasia. The procedure, with emphasis on patient selection, preoperative preparation, nursing role during the treatment, as well as postoperative care and assessment, is discussed.

Transurethral prostate resection, noncontact laser therapy or conservative management in men with symptoms of benign prostatic enlargement? An economic evaluation

PURPOSE

We evaluated the cost-effectiveness of noncontact laser therapy compared with transurethral prostate resection and conservative treatment in men with symptoms associated with benign prostatic enlargement.

MATERIALS AND METHODS

A total of 340 men with uncomplicated lower urinary tract symptoms participated in a large multicenter pragmatic randomized trial called the CLasP (Conservative management, Laser therapy, transurethral resection of the Prostate) study. Costs to the United Kingdom National Health Service and patients were determined from the time of randomization to the 7.5-month followup. Incremental cost-effectiveness ratios using conservative management as the base case were calculated for certain trial outcomes, including International Prostate Symptom Score (I-PSS), I-PSS quality of life score, maximum urinary flow, post-void residual urine volume, quality adjusted life-years and a composite measure of success based on I-PSS and maximum urinary flow. One-way sensitivity analysis of the basic costs and incremental cost-effectiveness ratios were done from the NHS viewpoint.

RESULTS

Mean costs per patient were greatest for noncontact laser therapy and least for conservative management. The incremental cost-effectiveness ratios showed that transurethral prostate resection was more cost-effective than noncontact laser treatment for all primary trial outcomes. The incremental cost-effectiveness ratios of transurethral prostate resection compared with conservative management were pound 81 per unit decrease in the I-PSS score and pound 1,338 per additional successful case per 100 patients. Sensitivity analysis showed that the initial results were robust.

CONCLUSIONS

Noncontact laser was the mostly costly treatment option. Transurethral prostate resection was more cost-effective than noncontact laser therapy in terms of symptomatic improvement. In men wishing to delay treatment conservative treatment appears to provide a cost-effective alternative in the short term.

Transurethral prostate resection, noncontact laser therapy or conservative management in men with symptoms of benign prostatic enlargement? An economic evaluation

PURPOSE

We evaluated the cost-effectiveness of noncontact laser therapy compared with transurethral prostate resection and conservative treatment in men with symptoms associated with benign prostatic enlargement.

MATERIALS AND METHODS

A total of 340 men with uncomplicated lower urinary tract symptoms participated in a large multicenter pragmatic randomized trial called the CLasP (Conservative management, Laser therapy, transurethral resection of the Prostate) study. Costs to the United Kingdom National Health Service and patients were determined from the time of randomization to the 7.5-month followup. Incremental cost-effectiveness ratios using conservative management as the base case were calculated for certain trial outcomes, including International Prostate Symptom Score (I-PSS), I-PSS quality of life score, maximum urinary flow, post-void residual urine volume, quality adjusted life-years and a composite measure of success based on I-PSS and maximum urinary flow. One-way sensitivity analysis of the basic costs and incremental cost-effectiveness ratios were done from the NHS viewpoint.

RESULTS

Mean costs per patient were greatest for noncontact laser therapy and least for conservative management. The incremental cost-effectiveness ratios showed that transurethral prostate resection was more cost-effective than noncontact laser treatment for all primary trial outcomes. The incremental cost-effectiveness ratios of transurethral prostate resection compared with conservative management were pound 81 per unit decrease in the I-PSS score and pound 1,338 per additional successful case per 100 patients. Sensitivity analysis showed that the initial results were robust.

CONCLUSIONS

Noncontact laser was the mostly costly treatment option. Transurethral prostate resection was more cost-effective than noncontact laser therapy in terms of symptomatic improvement. In men wishing to delay treatment conservative treatment appears to provide a cost-effective alternative in the short term.

Cost-effectiveness of new treatments for benign prostatic hyperplasia: results of a randomized trial comparing the short-term cost-effectiveness of transurethral interstitial laser coagulation of the prostate, transurethral microwave thermotherapy and standard transurethral resection or incision of the prostate

OBJECTIVES

To compare the short-term cost-effectiveness of ILC and TUMT with that of transurethral resection or incision of the prostate in patients with symptomatic benign prostatic hyperplasia.

MATERIAL AND METHODS

One hundred and eighteen patients were randomized to ILC, TUMT and TUR-P/TUI-P in 2:2:1 fashion. The use of resources within the first 6 months of follow-up were measured and the cost of treatment for each patient were calculated. A few parameters, primarily related to the time spent by the staff, were measured only in a subgroup of patients. A cost-effectiveness analysis was performed based on the average calculated cost and change in I-PSS found in each group. For costly resources a sensitivity analysis was performed.

RESULTS

At 6 months the cost was lowest in the TUMT group and highest in the ILC group. The cost-effectiveness ratio (C/E) was 763 DKK/point reduction in I-PSS in the control group and 1.200 and 938 in the ILC and TUMT group, respectively. An incremental analysis demonstrated that TUR-P/TUI-P dominated ILC. In a similar comparison of the TUMT and the TUR-P/TUI-P group an incremental ratio of 170 DKK/extra point of reduction in I-PSS was found in the TUR-P/TUI-P group.

CONCLUSION

In the short-term TUMT and TUR-P has comparable cost-effectiveness. TUR-P was slightly more effective than TUMT, but the cost was also slightly higher. In our set-up of ILC the short-term cost-effectiveness of ILC was inferior to that of TUR-P. Conclusions should be made with caution, since the follow-up at present is short.

[Economic evaluation of treatment for benign prostatic hyperplasia--transurethral resection vs thermotherapy vs laser vaporization]

OBJECTIVE

Cost containment has become an important issue in medical practice because of recent bad economic conditions. We analyzed the cost of benign prostatic hypertrophy (BPH) patients and cost-effective analysis was carried out comparing transurethral resection of prostate (TURP), visual laser ablation of the prostate (VLAP) and transurethral microwave thermotherapy (TUMT).

MATERIALS & METHODS

Our series consists of 95 BPH patients treated with TURP, VLAP and TUMT between January 1, 1994 and March 31, 1997. The cost for each patient was calculated (46 were treated with TURP, 31 with VLAP and 28 with TUMT). Considering the clinical outcome, cost-effectiveness was compared in 3 groups retrospectively.

RESULTS

The median level of total charges (insurance points) was 59,395 points for the TURP group, 66,784 points for the VLAP group and 14,927 points for the TUMT group. The median follow-up period was 12.4 months, 46.7 months and 14.4 months, respectively. Several patients needed medication after operation in the VLAP group. In the TUMT group, 3 patients needed re-operation and 5 other needed an alternative surgical method (TURP or transurethral needle ablation) and 1 needed both methods.

DISCUSSION

TUMT is the most cost-effective method, however the recurent rate is highest in the follow-up period among the three groups. The costs of recurent cases were most expensive. We should select surgical treatment for BPH very carefully.

Changes in medicare reimbursement: impact on therapy for benign prostatic hyperplasia

Medicare spending accounts for 17% of all health spending and therefore exerts a significant influence on health care spending policies. Medicare policies such as Diagnostic Related Groups and the Resource Based Relative Value System have resulted in profound changes in health care delivery in the United States. These resource-allocation methods are one of the major sources of controversies between managers, doctors, politicians, and social scientists. Financial disincentives associated with these resource-allocation policies have effectively rationed select therapies, particularly transurethral resection of the prostate (TURP). As a consequence, TURP, once the second most common surgical procedure billed to Medicare and comprising 38% of major surgical procedures performed by urologists, is increasingly challenged by medical therapy and minimally invasive surgical therapies that may be associated with lower efficacy and durability. This article examines the history of Medicare policies and their influence on TURP.

[Impact of a clinical pathway in cases of transurethral resection of the prostate]

OBJECTIVE

Because of recent increases in health care costs, cost containment has become a important issue in medical practice. We evaluated the effect on cost and clinical outcome with the implementation of clinical care pathway for transurethral resection of the prostate (TURP) patients.

MATERIALS & METHODS

Our series consists of 69 consecutive patients treated with TURP between June 1, 1999 and March 31, 2000. The patients were divided into two groups at random. Thirty-two patients were treated on the clinical pathway (pathway group) and 37 patients were not placed on the clinical pathway program (non-pathway group). Total hospital charges, average length of stay and clinical outcomes were compared in two groups.

RESULTS

The average of total hospital charges (insurance points) and average length of stay were 48,424.2 point, and 12.7 days for the pathway group, and 55.365.5 point, and 14.7 days for non-pathway group respectively. Postoperative complications and rehospitalization did not differ between two groups.

DISCUSSION

With the implementation of the clinical care pathway, average hospital charges and length of stay were reduced. The clinical pathway program is considered to be a good tool for health care cost management. This methodology can be applied to all patients. However, when we make the clinical pathway program, we take into account the individuality of each patients.

Cost effectiveness of treatment for benign prostatic hyperplasia: an economic model for comparison of medical, minimally invasive, and surgical therapy

PURPOSE

To evaluate the cost effectiveness of minimally invasive therapy relative to medical (alpha-blocker) therapy and transurethral resection (TURP) for patients with moderate to severe symptoms of benign prostatic hyperplasia (BPH).

METHODS

We constructed a decision-analytic Markov model for a hypothetical cohort of 65-year-old men with moderate to severe BPH symptoms. Microwave thermotherapy was selected to represent minimally invasive treatment. Cost-effectiveness analysis was performed with 25 health states using the 3 treatments, 5 short-term clinical events, and 17 possible long-term outcomes. Each health state had an associated cost and utility. Quality of life (QoL) and utility estimates were obtained by interviewing 13 men with BPH symptoms using the standard gamble reference methods. Patients were classified as risk averse (RA) or non-risk averse (NRA) on the basis of their attitudes to risk. We calculated the incremental cost effectiveness of microwave thermotherapy relative to medical therapy and TURP over 5 years after treatment initiation. Event probabilities were obtained from the literature, a consensus panel, and published randomized clinical trials.

RESULTS AND CONCLUSIONS

The utility values generated were internally consistent and externally valid for a hypothetical cohort of 10,000 RA patients. Microwave thermotherapy was preferred by the NRA group, while medical therapy was preferred by the RA group. Surgery was least preferred by both groups. Microwave thermotherapy had a small incremental cost but improved QoL in comparison with medical therapy. Microwave thermotherapy had a higher utility and lower cost than TURP and thus was dominant over TURP. This analytical method can be applied to evaluate the cost effectiveness of any BPH therapy.

Holmium laser resection of the prostate is more cost effective than transurethral resection of the prostate: results of a randomized prospective study

OBJECTIVES

A cost-effectiveness analysis was carried out comparing electrosurgical transurethral resection of the prostate (TURP) with holmium:yttrium-aluminum-garnet laser resection of the prostate (HoLRP).

METHODS

One hundred twenty patients with benign prostatic hyperplasia and urodynamically proved obstruction were randomized to undergo either TURP or HoLRP. Economic and clinical outcome data were recorded prospectively out to 1 year postoperatively.

RESULTS

The HoLRP group experienced fewer complications and had a shorter hospital stay and catheterization time than the TURP group, with equivalent clinical outcomes at 12 months. HoLRP cost 24.5% less (New Zealand dollars $651) than TURP during the first year.

CONCLUSIONS

Because the clinical outcomes out to 1 year were equivalent, HoLRP was more cost-effective than TURP. On the basis of these savings, a minimum of 93 cases per year are required to recover the capital and service costs of the holmium:yttrium-aluminum-garnet laser.

Cost effectiveness of microwave thermotherapy in patients with benign prostatic hyperplasia: part I-methods

OBJECTIVES

To present the method used to evaluate the cost effectiveness, from the societal perspective, of transurethral microwave thermotherapy relative to medical therapy (alpha-blocking agents) and transurethral resection of the prostate (TURP) for a hypothetical cohort of 65-year-old men with moderate-to-severe benign prostatic hyperplasia (BPH) symptoms.

METHODS

We constructed a decision-analytic Markov model with 25 health states describing the 3 treatments, 5 short-term clinical events, and 17 possible long-term outcomes. Each health state had an associated cost and utility. Utility weights, reflecting an individual's preference for a specific health outcome, range from 0, indicating death, to 100, indicating perfect health. Utility estimates were obtained by interviewing 13 men with moderate-to-severe BPH symptoms using the standard gamble preference measurement technique. On the basis of their risk attitudes, the patients were classified as risk averse or non-risk averse. The rates of remission, temporary and permanent adverse events, retreatment, and mortality were obtained from the Targis System (Urologix) randomized clinical trial, published reports, and a consensus panel. The costs during the 5 years after treatment initiation were estimated using national Medicare reimbursement schedules. The costs are reported in 1999 U.S. dollars.

RESULTS

Eliciting utility values from patients with BPH was feasible and generated internally consistent and externally valid measures. In the non-risk-averse group, the utility value for significant remission, moderate remission, no remission, and worsening BPH symptoms without an adverse event was 99.1, 97.1, 94.4, and 87.3, respectively. As expected, the risk-averse individuals (n = 6) exhibited higher utility values than those in the non-risk-averse group (n = 7). In the non-risk-averse group, thermotherapy was the preferred treatment, and in the risk-averse group, medical therapy was preferred. In both groups, TURP was the least preferred therapy. The initial thermotherapy procedure costs without complications were estimated at $2629, and the initial TURP procedure costs without complications were estimated at $4597. Time-dependent probabilities were developed to reflect treatment durability.

CONCLUSIONS

The resulting model parameters appear to be suitable for evaluating the cost effectiveness of thermotherapy relative to medical therapy and TURP in 65-year-old men with moderate-to-severe BPH symptoms.

Cost effectiveness of microwave thermotherapy in patients with benign prostatic hyperplasia: part II--results

OBJECTIVES

To evaluate the cost effectiveness of transurethral microwave thermotherapy relative to medical therapy (alpha-blocking agents) and transurethral resection of the prostate (TURP) for patients with moderate-to-severe benign prostatic hyperplasia (BPH) symptoms.

METHODS

A cost-effectiveness analysis was performed from the societal perspective for a hypothetical cohort of 65-year-old men with moderate-to-severe BPH symptoms. We calculated the incremental cost effectiveness of thermotherapy relative to medical therapy and TURP during 5 years after treatment initiation. Event probabilities were obtained from published reports, a consensus panel, and the Targis System (Urologix) randomized clinical trial. Costs were estimated using the national Medicare reimbursement schedules. Costs are reported in 1999 U.S. dollars. Total thermotherapy procedure costs were estimated at $2629. Quality-of-life and utility estimates were obtained by interviewing 13 patients with moderate-to-severe BPH symptoms. On the basis of their risk attitudes, patients were classified into risk-averse or non-risk-averse groups. The costs and health effects were discounted at 3% annually.

RESULTS

In a hypothetical cohort of 10,000 non-risk-averse patients who were candidates for all three modalities, the 5-year costs were highest for patients undergoing TURP and lowest for those receiving medical therapy ($7334 and $6294, respectively). The thermotherapy group exhibited the highest 5-year utility value (53.52 quality-adjusted life-months). Compared with medical therapy, thermotherapy resulted in an additional 0.23 quality-adjusted life-months, with an incremental cost of $741. This yielded an incremental cost per quality-adjusted life-year gained of $38,664 for thermotherapy compared with medical therapy. Thermotherapy had a higher utility (difference of 1.71 quality-adjusted life-months) and lower cost (difference of $299) compared with TURP and thus was dominant over TURP. The results were similar for a hypothetical cohort of 10,000 risk-averse patients.

CONCLUSIONS

From a societal perspective, thermotherapy appears to be a reasonable and cost-effective alternative to both medical and surgical treatment. However, the actual treatment decision should be based on multiple factors, only one of which is cost effectiveness.