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Cost Analysis of Surgical Approaches for Bladder Outlet Obstruction: Laser Versus Loop
Samuel H. Eaton, MD1, Lori B. Lerner, MD2.
1Boston Medical Center, Boston, MA, USA, 2VA Boston Healthcare System, Boston, MA, USA.

Background: While outcomes of Holmium Laser Enucleation of the Prostate (HoLEP) have been shown to be equivalent or superior to Transurethral Resection of the Prostate (TURP), no American study to date has attempted to directly analyze differences in cost between these modalities. We performed an internal quality review to evaluate cost differentials one year after purchase of the 100 watt holmium laser.
Methods: All patients undergoing TURP or HoLEP at VA Boston Healthcare System from 2007 through October 2008 were identified. Patients who had a diagnosis of prostate cancer, had simultaneous procedures at the time of their TURP or HoLEP, or had prior prostate/urethral procedures were excluded from analysis. All costs from the day of surgery to 6 months post-operatively were captured. Only costs directly related to operative, post-operative, and urologic follow-up were included in the analysis. Costs were calculated by the Department of Decision Support Services (DSS) and represent actual costs to VA Boston.
Results: Sixteen patients who underwent HoLEP and 21 who underwent TURP met inclusion criteria. Patient characteristics were compared and are represented in Table 1. The two groups were comparable with regard to PSA (a surrogate for prostate size) and age. However, patients undergoing HoLEP had statistically higher American Society of Anesthesia (ASA) classification status, signifying a higher risk patient population. Average length of hospital stay was 0.5 days for HoLEP and 1.3 days for TURP (P <0.05). Cost comparisons are represented in Table 2. The total cost of HoLEP was significantly higher than that of TURP (an average dollar cost of $4566.55). Perioperative costs were not statistically different, but trended in favor of HoLEP largely due to decreased length of hospital stay.

Comparison of Patient Characteristics
HoLEP (SD)TURP (SD)P-value
Age (years)66.0 ± 1.968.8 ± 2.00.33
Prostate Tissue Weight (grams)18.4 ± 2.215.8 ± 2.10.40
PSA (ng/ml)3.2 ± 0.53.2 ± 0.50.86
ASA3.2 ± 0.22.8 ± 0.10.02

Cost Comparison
Total Cost (SD)Operative Cost (SD)Perioperative Cost (SD)
HoLEP$14,369.25 (3,696.42)$11,783.38 (3,180.37)$2,585.88 (1,191.44)
TURP$9,802.70 (4,637.56)$6,476.85 (3,622.33)$3,325.85 (1,414.58)
P-Value<0.05<0.050.10

Conclusions: The cost of HoLEP was significantly higher than that of TURP secondary to higher intraoperative costs. This is likely due to longer operative times from increased surgical complexity, less institutional familiarity with equipment involved, resident teaching, and lack of restrictions on resection time due to use of saline. Additionally, medically complex patients (including those on anticoagulation) were more likely to be selected for HoLEP, as reflected in higher ASA scores. These higher costs must be weighed against the benefits of HoLEP, which include less morbidity, shorter hospital stays and faster recovery times.
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