Évaluation prospective des coûts directs de l’énucléation prostatique par le laser HoLEP ® pendant la courbe d’apprentissage

Comparison of Cost and Perioperative Outcomes Among Patients Undergoing Simple Prostatectomy and Laser Enucleation of the Prostate

Introduction: Simple prostatectomy (SP) and laser enucleation of the prostate (LEP) are treatments for symptomatic benign prostatic hyperplasia (BPH) in men with large glands (e.g., >80 g). The decision between the two operations is often dependent on surgeon preference/experience and equipment availability. As the use of minimally invasive techniques, such as robotic-assisted simple prostatectomy, has increased for the treatment of large gland BPH, studies comparing the outcomes and cost of these modalities in a contemporary cohort are lacking. Methods: All-payer data from Healthcare Cost and Utilization Project State Databases from Florida, New York, California, and Maryland from 2016 to 2018 were used to identify adults who underwent SP or LEP for BPH. Patient demographics, facility characteristics, revisit rates, and cost of the index hospitalization were examined. Multivariable logistic and gamma generalized linear regression models were utilized to compare predictors of the operation performed, 30-day revisits, and index hospitalization cost among the two operations. Results: Of the 2032 patients in the cohort, 1067 (46.4%) underwent LEP and 965 (41.9%) underwent SP. On multivariable logistic regression analysis, SP patients were younger, had higher comorbidity scores, and were more likely to be uninsured compared with LEP patients. Thirty-day revisit rates among the operations were equivalent (odds ratio 0.89, 95% confidence interval 0.63-1.27, p = 0.05). The mean adjusted cost of the index hospital stay for LEP was significantly greater than that of SP ($7291 vs $6442, p = 0.04). However, our sub-group analysis examining high-volume centers revealed no significant differences in cost ($6184 vs $5353, p = 0.1). Conclusions: Across the four states examined, SP and LEP were performed with comparable volume and had similar rates of 30-day revisits. The SP was less expensive than LEP overall; however, among high-volume facilities, the cost of both operations was reduced, such that they were equivalent.

Economic Evaluation of 1470 nm Diode Laser Enucleation vs Bipolar Transurethral Resection of the Prostate

Purpose: Large meta-analyses demonstrate the noninferiority of laser enucleation to transurethral resection of the prostate (TURP) with regard to long-term efficacy and reoperation rate. Although the 1470 nm diode laser enucleation of the prostate (DiLEP) is superior in hemostasis and surgical visibility, its complexity and associated longer operative time limit its widespread usage. The objective of this study was to generate long-term cost estimates for bipolar TURP and DiLEP, taking into account perioperative and adverse event costs. Materials and Methods: This is a retrospective review of patients who underwent DiLEP (n = 114; November 2016 to February 2020) or TURP (n = 194; January 2016 to December 2018). A decision analysis model was constructed to compare costs of the primary procedure and subsequent complications taking into account disposable costs, operating room time, length of stay, reoperation rates, and readmissions. Costs were estimated from internal data, published literature and Medicare procedure costs. Markov modeling was used to create cost projections up to 10 years. Results: DiLEP was associated with shorter length of stay and fewer total complications, but longer operative times and greater initial costs. Cost were recuperated at 8 years postoperatively. At 10 years postoperatively, DiLEP represented approximately $664 cost savings per patient over TURP. Conclusions: DiLEP is a cost-effective alternative to TURP for the treatment of benign prostatic hyperplasia in the properly selected patient. DiLEP has greater initial costs due to longer operative times. Costs are recuperated by 10 years postoperatively due to higher rate of same-day discharges, and lower complication and reoperation rates, incurring a $664 cost savings per patient treated by DiLEP relative to TURP.

Mind the Gaps: Adoption and Underutilization of Holmium Laser Enucleation of the Prostate in the United States from 2008 to 2014

Purpose: There is increasing recognition of the advantages of holmium laser enucleation of the prostate (HoLEP) for benign prostatic hypertrophy (BPH) treatment in the United States but relatively little is known about the extent of HoLEP adoption over time. This study aims to assess national HoLEP adoption rates and regional trends from 2008 to 2014. Methods: We retrospectively analyzed a data set of 100% Medicare claims to determine the rate of U.S. HoLEP adoption in 2008, 2011, and 2014. Rates were adjusted by age and race and stratified by hospital referral region (HRR). Linear and logistic regression models were used to assess for trends in HoLEP adoption over time. Results: Total U.S. BPH cases decreased 24% from 2008 to 2014 and HoLEP cases increased significantly from 1086 (2008) to 3368 (2014). Despite this, HoLEP accounted for just 4% of total BPH cases in 2014. In 2008, 28/306 (9%) of HRRs recorded >10 HoLEP cases per year. This increased to 89 HRRs (29%) in 2011 but stabilized at 94 HRRs (31%) in 2014. In 2014, over 50% of states still had only 0 to 1 sites doing 10+ HoLEP cases per year. Conclusions: Based on this 100% sample of Medicare claims from 2008 to 2014, surgical BPH treatment volume has decreased, while HoLEP volume and regional adoption have tripled. However, rates of HoLEP remain extremely low at just 4% of all BPH procedures in 2014, and large regional gaps in care exist. These data indicate that HoLEP remains substantially underutilized and the majority of regions still lack access to centers performing >10 HoLEP cases per year.