Perioperative and economic analysis of surgical treatments for benign prostatic hyperplasia: A study of the French

(1)

Disponibleenlignesur

ScienceDirect

www.sciencedirect.com

ORIGINAL ARTICLE

Perioperative and economic analysis of surgical treatments for benign prostatic hyperplasia: A study of the French

committee on LUT

Analyse du coût et des résultats périopératoires des traitements chirurgicaux de l’hypertrophie bénigne de prostate : une étude du Comité des troubles mictionnels de l’homme de l’association franc ¸aise d’urologie

R. Mathieu

^a^,∗

, S. Lebdai

^b

, J.N. Cornu

^c

, A. Benchikh

^d

, A.R. Azzouzi

^b

, N.B. Delongchamps

^e

, O. Dumonceau

^f

, A. Faix

^g

, M. Fourmarier

^h

, O. Haillot

ⁱ

, B. Lukacs

^j

, V. Misrai

^k

, A. de La Taille

^l

, G. Robert

^m

,

A. Descazeaud

ⁿ

aServiced’urologie,hôpitalPontchaillou,CHUdeRennes,2,rueHenri-Le-Guillou,35000 Rennes,France

bServiced’urologie,CHUd’Angers,49933Angers,France

cDepartmentofUrology,RouenUniversityHospital,76031Rouencedex,France

dServiced’urologie,hôpitalBichat-Claude-Bernard,groupedeshôpitauxuniversitaires Paris-Nord-Val-de-Seine,universitéDenis-Diderot,Paris-VII,75018Paris,France

eServiced’urologie,CHUCochin,Assistancepublique—HôpitauxdeParis,75014Paris,France

fServiced’urologie,CliniqueTurin,9,ruedeTurin,75008Paris,France

gCliniquemutualisteBeausoleil,34070Montpellier,France

hServiced’urologie,centrehospitalierAix-en-Provence,13616Aix-en-Provence,France

iServiced’urologie,CHUdeTours,37044Tours,France

jServiced’urologie,hôpitalTenon,universitéParisVI,Assistancepublique—Hôpitauxde Paris,75020Paris,France

kServiced’urologie,cliniquePasteur,40,avenuedeLombez,31300Toulouse,France

lServiced’urologie,CHUMondor,Assistancepublique—HôpitauxdeParis,75000Paris,France

mServiced’urologie,CHUdeBordeaux,universitédeBordeaux,33000Bordeaux,France

∗Correspondingauthor.

E-mailaddress:romainmath@yahoo.fr(R.Mathieu).

(2)

nServicedechirurgieurologique,hôpitalDupuytren,CHUdeLimoges,2,avenue Martin-Luther-King,87042Limoges,France

Received6February2016;accepted30March2017 Availableonline8May2017

KEYWORDS Benignprostatic hyperplasia;

Openprostatectomy;

Photoselective vaporizationofthe prostate;

Holmiumlaser enucleation;

Transurethral resectionofthe prostate;

Costanalysis

Summary

Purpose.—Toevaluate perioperativecost relatedtosurgicaltreatmentsofbenignprostatic obstruction(BPO):photoselectivevaporizationoftheprostate(pvp),holmium/thulliumlaser enucleation(HoLEP/ThuLEP),transurethralresectionoftheprostate(TURP)andopenprosta- tectomy(OP).

Materialandmethods.—Weretrospectivelycollecteddatafrom237patientswhoconsecutively underwentasurgicaltreatmentforBPHbetweenJanuary2012andJune2013atnineinstitutions inFrance.Aneconomicsimulationmodelwasconstructedtoestimatethecostofhospitalization relatedtosurgicalprocedurefromthehospitalperspectiveandacostminimizationanalysis wasperformed.

Results.—TURP,OP,HoLEP/ThuLEPandPVPwereperformedin99(42%),23(10%),64(27%) and51(21%)patients,respectively.Formenwithprostatesize<80mL:meanoperativetime wasshorterwithmTURPandPVPthanHoLEP/thuLEP(P<0.001);Meanpostoperativelength ofstaywere 1.9,3vs.3.4 days,for HoLEP/Thulep,PVPandTURP respectively(P=0.006);

Costsofﬁrsthospitalizationwere comparablebetweenHoLEP/ThuLEPandTURPbuthigher withPVP(P<0.001).Formenwithprostatesize≥80mL:ComparedtoPVPandHoLEP/ThuLEP, OPwasassociatedwithshorteroperativetime(P<0.001)butlongerlengthofstay(2.4,4.2vs.

7.8days,respectively,P<0.0001);Costsofﬁrsthospitalizationweresigniﬁcantlyhigherwith OPthanHoLEP/ThuLEPorPVP(P<0.001).

Conclusions.—PVPandHoLEP/ThuLEPwereassociatedwithashorterLOSthanTURPandOP.

ThisbeneﬁtsuggeststheseprocedurescouldbemorecosteffectivethanOP,butstillnotcheaper alternativestoTURP.

Levelofevidence.— 5.

MOTSCLÉS

Hypertrophiebénigne deprostate;

Photovaporisation prostatique; Énucléationaulaser holmium/thullium; Résection

transurétraledela prostate;

Adénomectomievoie haute;

Analysedescoûts

Résumé

Objectif.—Évaluer les coûts périopératoires de traitementschirurgicaux de l’hypertrophie bénigne de prostate (HBP) : photovaporisation prostatique (PVP), énucléation au laser holmium/thullium(HoLEP/ThuLEP),résectiontransurétraledelaprostate(RTUP)etadénomec- tomievoiehaute(AVH).

Matérieletméthodes.—Lesdonnéesde237patientstraitéschirurgicalementpouruneHBP entrejanvier2012etjuin2013dansneufcentresfranc¸aisontétérecueilliesrétrospectivement.

Uneestimationducoûtdel’hospitalisationliéàl’interventiondupointdevuedel’institution etuneanalysedeminimisationdescoûtsàpartirdel’Échellenationaledescoûts2010ontété réalisées.

Results.—Autotal,99(42%),23(10%),64(27%) et51(21%)patientsontététraitéspar RTUP,AVH,HoLEP/ThuLEPetPVP,respectivement.Pourlesprostatesavecunvolume<80mL: letempsopératoiremoyenétaitinférieuraveclaTURPetlaPVPcomparéàl’HoLEP/thuLEP (p<0,001);laduréemoyenned’hospitalisationétaitinférieureavecl’HoLEP/ThuLEPcomparé àlaPVPetàlaRTUP(1,9,3vs.3,4jours,respectivement,p=0,006);Lescoûtsestimésde l’hospitalisation initiale étaient comparablesentre HoLEP/ThuLEPetRTUP, maissupérieurs avec la PVP (p<0,001). Pour la prostate avec un volume≥80mL : comparée à la PVP et àl’HoLEP/ThuLEP, l’AVHétait associée àunedurée opératoireplus courte(p<0,001),une duréed’hospitalisationpluslongue(2,4,4,2vs.7,8jours,respectivement,p<0,0001)etune augmentationdescoûtsestimésdel’hospitalisationinitiale(p<0,001).

(3)

Conclusions.—PVPet HoLEP/ThuLEP sont associés à une diminution de la durée moyenne d’hospitalisation.Danslemodèleéconomiqueutilisé,cettediminutionpermettraitdediminuer lecoûtd’hospitalisationcomparéàl’AVH,maisnepermettraitpasàcesprocéduresd’êtreplus avantageusesquelaRTUP.

Niveaudepreuve.— 5.

Introduction

With a high prevalence in industrialized countries, lower urinary tract symptoms (LUTS) due to benign prostatic obstruction (BPO) is a major public health concern [1].

Transurethral resection of the prostate (TURP) and open prostatectomy(OP)arestandardproceduresrecommended by the European Association of Urology (EAU) for the surgicaltreatmentofBPO[2].Duringthelastdecade,mini- mallyinvasivesurgicaltechniques,includingphotoselective vaporizationofthe prostate(PVP),holmium laserenucle- ation(HoLEP)andthulliumlaserenucleation(ThuLEP)have beenintroducedasalternativestoTURPandOP.Numerous studieshaveestablishedthatthesetechniquesaresafeand effectivebasedonmidtermfollow-up[3].

Newtechniquesmaybeassociatedwithanincreasedcost intermsofequipmentandconsumablesuse.However,these additionalcostsmay bebalanced by shorter hospitalstay andotherimprovements inperioperativecare.Costeffec- tivenessofthesenewtechniquesstillremainsquestionable andisacriticalissueinaneraofcostsavingsforhealthcare systems.

The objectiveofthisstudy wastoassessperioperative costrelatedtosurgicaltreatmentofBPO.

Methods

Study design and population

NineacademicorprivateinstitutionsinFranceparticipated inthisretrospectivestudy.Ineachcenter,datafrom20to 30consecutivepatientswhounderwentasurgicaltreatment for LUTS relatedto BPO between January 2012 and June 2013were collected.All patients metcriteriafor surgery accordingtotheguidelinesoftheEAUortheFrenchAsso- ciationofUrology[2,4].Patientswithaneurogenicbladder orpasthistoryofurethralstrictureorprostatecancerwere excluded.

The following data were collected in a computerized database:

• age;

• ASAscore;

• prostatevolumeontransrectalultrasound(TRUS);

• urinaryretentionbeforesurgery;

• co-morbiditiesandanticoagulationtherapy.

Weevaluatedperioperativeparametersincludingoper- ative time, length of hospital stay (LOS) and intra and postoperativecomplications(graded accordingtoClavien- Dindo’sclassiﬁcation).Complications weredeﬁned asany

abnormalmedicalorsurgicaleventoccurringwithin30days aftersurgery[5].

Procedures

TURPwasperformedusingmonopolartechnology.PVPwas performed usingaGreenlight^® laser180W-XPS(AMS,Min- netonka, MN, USA) with a moxy fiber. Sodium chloride solution(0.9%)wasusedasirrigationfluid.Generatorwas usuallyprovided for freetothe institution. Duringproce- dure,overcostcomparedtoTURPwasconsideredtobethe use of a singlemoxy fiber; 700 D per procedure accord- ingtothe manufacturercharge policy. ThuLEPandHoLEP were performed usingthe 100W holmiumlaser generator manufacturedbyLumenis^TM andthePiranha^TMmorcellator manufacturedby RichardWolf^TM.Sodiumchloridesolution (0.9%)wasusedasirrigationfluid.Generatorsandmorcella- torswereusuallyprovidedforfreetotheinstitution.During procedure, overcostcomparedtoTURPwasconsideredto betheuseofareusablelaserfiberandbladesofthemor- cellator;70D perprocedureaccordingtothemanufacturer chargepolicy.OPwasperformedineachinstitutioneither byretropubicortransvesicalapproach.

Cost analysis

For modelization purposes, we assumed that short-term functionalresultsaftereach procedurewereentirelysim- ilar, based on available data from the literature. We performedaminimizationcostanalysis.

Theoutcomeofeachtechniquewasassessedintermsof costfromtheinstitutionalperspective.Short-termhospital costswereevaluatedforeachprocedureusingtheNational costsstudy2010fromFrenchtechnicalagencyofinforma- tiononhospitals(ATIH;Agencetechniquedel’information sur l’hospitalisation) database. The National costs study (NCS) defines for different procedures and groups of patients(groupeshomogènesdemalades[GHM]),variables costs andfixed costsrelated totheLOS. Inourstudy,for each hospitalization, variables costs were conserved and fixedcostswererecalculatedbytheratiobetweenobserved LOS and mean national LOS. In NCS, only cost relatedto OPandTURP areconsidered.ForPVP andThuLEP/HoLEP, weconsideredvariablesandfixedcostsusedforTURP.Cost ofequipmentandsingle-usedisposalrelatedtoinnovative techniques wereestimatedaccordingtothemanufacturer chargepolicy.UsingthemethodofreadjustedNCSbasedon LOS:totalcostofhospitalization=variablescosts+(fixed costs×[LOS‘‘study’’/MeanLOS‘‘NCS2010’’])+overcost of consumablesspecifictoalternativetechnique.

(4)

Table1 Practiceandcharacteristicsoftheinstitutionsenrolledinthestudy.

Institution 1 2 3 4 5 6 7 8 9

SurgeonsforproceduresrelatedtoBPO 6 7 5 3 3 8 6 4 3

Practice Public Public Private Public Public Public Public Private Public

NumberofBPOproceduresin2012 179 188 146 113 298 450 235 240 160

Technique

mTURP 76% 45% 41% 60% 45% 85% 22% 23% 90%

OP 24% 20% 3% 5% 40% 10% 3% 2% 10%

PVP — 30% — — — 5% 75% 75% —

HoLEP/ThuLEP — 5% 56% 35% 15% — — — —

Other — — — — — — — — —

mTURP:monopolartransuretralresectionoftheprostate, PVP:photoselectivevaporisation oftheprostate; HoLEP:holmiumlaser enucleationoftheprostate;ThuLEP:thulliumlaserenucleationoftheprostate;BPO:benignprostaticobstruction.

Statistical analysis

² tests were performed to compare groups for non- parametric numerical data. Means from three or more groups were compared using the analysis of variance (ANOVA).AP-value<0.05wasconsideredstatisticallysignif- icant.Relationshipsbetween complicationsandpatientor treatmentparameterswereﬁrstanalyzedusingunivariate regressionlogisticanalysis.Multivariableanalysesincluded covariateswithaP-value<0.05 inunivariableanalysis.All statisticalanalyseswereprocessedusingSTATA11.0.

Results

Institutional characteristics

Table1shows practiceat thenineinstitutionsinvolvedin this study.Mean number of BPH procedures per year and institution was223. None of these institutionsperformed bipolarTURPbutsevenproposedanalternativetostandard treatments (PVP or Holep/Thulep). Overall, 55% and 14%

of the patients underwent a monopolar TURP (mTURP) or an OP, respectively. A PVP or an HoLEP/ThuLEP were performedin22%and9%ofcases,respectively.Theuseof asurgicalalternative intheinstitutionwasnotassociated

witha signiﬁcantdecrease intheuse ofOP(21% and27%

respectively,P=0.23).

Patients’ characteristics

Atotalof237patientswhounderwentsurgeryforBPHwere includedinthisstudy.Patients’characteristicsaresumma- rizedin Table2and groupedbytechnique. Meanage was 71.7±9.8years.Meanprostatevolumewas65.5±39.3mL and70patients(30%)hadaprostatevolume≥80mL.Mean prostate volumewas higher in thegroup of patients who underwentOP ascompared to other surgical alternatives (124.3 vs. 65.5mL, respectively). Fifty-six patients (24%) had a urethral catheter at the time of surgery. Sixty- four patients (27.7%) were receiving platelet aggregation inhibitorsororalanticoagulationbeforetheprocedure,with a higher ratio in the groups of PVP and HoLEP/ThuLEP (41%and36%respectively,P=0.001).Groupswerecompa- rable regarding age, ASA score and history of urinary retention.

Operative and postoperative characteristics

Perioperative characteristics are described in Table 3. In prostate of less than 80mL, mean operative times per gram of tissue were 1.17, 1.29, and 1.69min per mL of

Table2 Patientcharacteristics.

mTURP Openprostatectomy HoLepThuLep PVP Pvalue

n 99 23 64 51

Meanage,years(SD) 71.1(±9.6) 72.7(±6.8) 71(±11) 71.8(±9.6) 0.84 Prostatevolume,mL(SD) 49.5(±25) 124.3(±43.2) 64.9(±36.8) 68.8(±36.6) <0.0001

ASAScore 0.09

1—2(%) 80% 91% 77% 69%

3—4(%) 20% 9% 23% 31%

Urinaryretention(catheter preoperatively)(%)

26% 22% 14% 31% 0.15

Plateletaggregationinhibitor oranticoagulation(%)

18% 4% 36% 41% 0.001

SD:standarddeviation;mRTUP:monopolarRTUP;PVP:photoselectivevaporisationoftheprostate;HoLEP:holmiumlaserenucleation oftheprostate;ThuLEP:thulliumlaserenucleationoftheprostate.

(5)

Table3 Perioperativecharacteristics.

mTURP Openprostatectomy HoLEP/ThuLEP PVP Pvalue Meanoperativetime,min(SD) 48.1(±17.3) 69.9(±27.5) 82.4(±32.7) 72.5(±40.4) <0.001 Meanoperativetimepergram,min

(SD)

1.10(±0.53) 0.61(±0.28) 1.51(±0.79) 1.17(±0.56) <0.001 Meanlengthofpostoperativestay,

days(SD)

3.4(±2.3) 8(±3.8) 2.6(±2.5) 2.8(±2.9) <0.001

Medianlengthofstay,days 4 8 3 3

Prostate<80mL,meanlengthof postoperativestay,days(SD)

3.4(±2.5) — 1.9(±1.3) 3(±3.5) 0.006

Prostate≥80mL,days,mean lengthofpostoperativestay, days(SD)

— 7.8(±3.8) 4.2(±2.7) 2.4(±1.4) <0.001

mRTUP:monopolarRTUP;PVP:photoselectivevaporisationoftheprostate;HoLEP:holmiumlaserenucleationoftheprostate;ThuLEP:

thulliumlaserenucleationoftheprostate.

prostate with TURP, PVP and HoLEP/thuLEP respectively (P<0.0001).Inprostate≥80mL,meanoperativetimeswere 0.60,0.96,and1.04minpermLofprostatewithOP,PVP,and HolepLEP/ThuLEP(P<0.0001).MeanLOS was3.5±3days.

In prostate≥80mL, OPwas associated witha longer LOS thanHoLEP/thuLEPandPVP(7.8,4.2and2.4respectively, P<0.0001).Formenwithprostatevolumeslessthan80mL, mean LOS with alternative surgical treatment were also shortercomparedtoTURP(P=0.001).

Per and postoperative complications

Nomajorintraoperative complicationwasreported.Post- operativecomplicationsClavien≥2occurredin52patients (22%). Twenty-six patients (11%) required readmission.

Majorcomplications(grade≥3)werereportedin4patients andincluded hemorrhagiceventswithanewprocedurein 3patientsandamyocardialinfarctinonepatient.Inmulti- variableanalysis,age(P=0.01),prostatevolume(P=0.01) and ASA score (P=0.02) were independent predictors of overall complications while technique (P=0.71) and API (P=0.72)werenot.

Cost analysis

Costs frominstitution perspective according prostate volume and technique are summarized in Table 4. Costs of hospitalization for prostate<80mL were similar between TURP and HoLEP/ThuLEP, but higher with PVP (2168D, 2007D and 2659D, respectively, P<0.001). For larger prostate, PVP and HoLEP/Thulep were associated with cheapercoststhan OP(2501D,2702D and3375D respectively,P<0.001).

Discussion

PVPandHoLEParenowconsideredsafeandeffectivesur- gicalalternativestostandardtreatmentsinBPH[3].These proceduresprovideseveraladvantagesincludingreduction ofbleeding,preventionofTURPsyndromeanddecreaseof hospitalstay [6].Oneotherpotentialmajorbeneﬁtwould

beadecreaseofhealthcarecosts.Evaluationofperioper- ative outcome andcost effectivenessof thesetechniques compared tostandard treatments frommulti-institutional studyisacriticalissue.

OurstudyshowsthatPVPandHoLEPareassociatedwith ashorterlengthofstaythanTURPorOP.Datafromrandom- izedcontrolledtrials,gatheredrecentlyinameta-analysis by Cornu et al., show that compared to TURP, PVP and HoLEPareassociatedwithareductionofhospitalstay(1.4 and1.85 days,respectively).ComparedtoOP, thisreduc- tionreaches a meandifferenceof 4dayswithHoLEP[3].

Alivizatos etal. reported a similarreduction of LOS with PVP[7].Inourstudy,thereductionofLOSislessimportant thanexpected.Itcouldbeaconsequence ofpatients’co- morbiditiesoranticoagulationinthesegroupsbutwedidnot ﬁndsuchadifferenceinouranalysis.Webelieveitreﬂects themanagementofalternative surgicaltreatmentsinfew centersduringtheirinitialimplementationphaseorduring thelearningcurveofsomesurgeons.

Despitetheapparenthigherinitialcosts ofthedevices and consumables, PVP and HoLEP could be cheaper than TURPandOPduetotheirbeneﬁtregardingLOS.Inourstudy, useofanalternativesurgicaltreatmentforprostatelarger than80mLwasassociatedwithahigheroperativetimeper grambutshorterLOS.MeanreductionsofcostwithPVPand HoLEP/ThuLEP were 874D and 673D, respectively. These resultsaresimilartothoseobservedinpreviousstudieswith PVP[8]andHoLEP[9].Raimbaudetal.evaluatedcosteffec- tiveness of PVP and OP in French healthcare system and reportedameanadditionalcostof1450 eurosforOP[8].

WithHoLEP,Saloniaetal.demonstrateda10%reductionof costhospitalization[9].

FewstudiesevaluatedthecosteffectivenessofHoLEPin comparisontoTURPbutallreportedasignificantshort-term benefitforthissurgicalalternative[10,11].Severalstudies havealreadycomparedcostsofPVPandTURP,mostlywith the80Wand120Wtechnologies.Mostofthesestudiescon- cludedtoabenefitforPVP[12—15].Recently,someauthors did notfind any significant differencebetween TURP and PVP[16,17].Armstrongetal.previouslyconcludedPVPwas evenlesscosteffectivethanTURP[18].Toourknowledge, onlyonestudycomparedthelasttechnologyXPS180Wbut

(6)

Table4 Costanalysis.

Prostatevolume<80mL Prostatevolume≥80g

mRTUP PVP HoLEP/ThuLEP Pvalue OP PVP HoLEP/ThuLEP Pvalue

Meancostof hospitalization (D),SD

2168±595.9 2659.2±1397.1 2007.4±546.1 <0.001 3375.2±723.4 2501.4±540.4 2702.2±782.8 <0.001

mRTUP:monopolarRTUP;PVP:photoselectivevaporisationoftheprostate;HoLEP:holmiumlaserenucleationoftheprostate;ThuLEP:

thulliumlaserenucleationoftheprostate;OP:openprostatectomy.

demonstrated asignificant benefitfor PVP, mostly due to thereductionofLOS[19].Thesestudiesareinhomogeneous regarding quality and methodology. Cost effectiveness of PVP comparedtoTURP is stillquestionable. In ourstudy, reduction of LOS was not sufficient to conclude to a significant costreduction withthe surgical alternative when comparedtoTURP.Costeffectivenesswiththesenewsurgi- calalternativescouldprobablyevenbemoreconsiderable with their development in an outpatientsetting. Indeed, severalstudieshavereportedPVPandHoLEParefeasiblein anambulatorysetting[20].Ambulatorysurgeryrequiresthe developmentofdedicatedunitbutisoneofnationalhealth authorities’ priorities [21]. Therefore, Goh and Gonzalez demonstratedthatPVPwiththegreenlight 120W-HPScost lessthanTURP($4266vs.$5097)butmostof thepatients weretreated onan outpatientbasis (definedasdischarge homewithin23hoursofhospitalization)inthisstudy[12].

Inhigh-riskpatients,PVPandHoLEPcouldalsodemonstrate betterresultsandprovidesigniﬁcantcostsavingswedidnot reportinourstudy.

Weobservedalowrateofmajorcomplications.Compli- cation andreadmissionrates werehigherinthe groupsof surgicalalternatives,mostlyduetourinaryretentionsand hemorrhagic events. Urinary retentions were treated by transient recatheterization and patients were discharged one day later. One month after the procedure, only 4patientswerenotcatheterfree.Hemorrhagiceventswere mostlymanagedbytransientirrigationandonlytwopatients requirednewprocedure.The costofreadmissionswasnot evaluableinourstudybutcouldlimitourconclusionscon- cerningcosteffectivenessoftheseprocedures.However,in multivariableanalysis,thetechnique wasnotapredictive factorofcomplicationandtherelationweobservedcouldbe partlyduetoahigherrateofpatientswithanticoagulation orASAscore>2inthesegroups.

Ourstudyhasseveralotherlimitations.First,thestudy is limitedby itsretrospective natureandthe correspond- ing cost minimization analysis methods. Due to the lack of specific data in the National cost study and no spe- cificreimbursementfor PVPandHoLEP/ThuLEPinFrance, costevaluationandprofitabilityismostlyextrapolatedfrom TURPevaluationandcomparisonessentiallybasedondirect costsassociatedwiththeLOSandrelatedFrenchhealthcare specificities. Evaluation of the reduction of some consu- mablessuchasintraoperativeglycineandirrigationfluids, overtimeintheoperatoryroomandpotentialdepreciation expenseassociatedwithgeneratoracquisitionwerenotcon- sidered. Weassumed thatfor PVP onefiberwasused per patient and that for LEP, one fiber was used for twenty

procedures.Ahigheruseofﬁberespeciallyinlargeprostate couldlimit our conclusions in this group. Surgeons’ skills and experienceregarding the procedures were not available.Therefore,theimpactofthelearningcurveandresults fromfewcentersduringtheirinitialimplementationphase of management for some alternative surgical treatments mayhavebiasedtheresults,especiallyregardingtheLOS.

Noassessment ofeconomicvaluerelatedtothereduction ofLOSintermsofbed availability,earlyrehabilitationfor workershasbeen eitherconsidered.Finally,ourstudyisa short-termcostanalysisoftheproceduresthatonlyrelies onthe costsincurred duringﬁrst hospitalization.Integra- tionofthecostsrelatedtoreadmissionsmayconferfurther evidence regarding cost effectiveness of alternative surgical treatments. In a midterm follow-up, some authors suggestnewalternativetreatmentscouldbeassociatedwith a higher reinterventions rate, especially in patients with largerprostatevolume[22].Overcostassociatedwiththese newprocedurescouldlimitourresultsandcosteffective- nessofHoLEPandPVPinlargeprostate.

However,webelieveit isafair evaluationofthe cost- effectivenessofnewalternativesforsurgicaltreatmentsof BPHthatcomparedPVPandHoLEP/thuLEPtoTURPandOP inarealworldsettinginseveralpublicandprivateinstitu- tions.Thisminimizationcostanalysisismainlybasedona simulationofﬁrsthospitalizationcostsbetweentechniques anddifferencesrelatedtoareductionofLOS.Thisendpoint isoftenpartofthediscussionbetweentheurologicalcom- munityandtheirinstitutions.However,long-termlongitudi- nalprospectivestudiesoftotalcostsofthesetechniquesare necessarytoclearlyconcludeontheircosteffectiveness.

Conclusion

In this multi-institutional study, use of PVP and HoLEP/ThuLEP significantly decreases LOS. Regarding first hospitalization cost, these procedures could be cost effective alternatives to OP. However, the mean LOS we observedinourstudyisstillnotsufficienttoconsiderthat theseproceduresarecheaper or morecosteffectivethan TURPforprostatelessthan80mL.

Disclosure of interest

R. Mathieu: support for Congress by AMS; S. Lebdai:

no; J.N. Cornu: consultant for companies, Allergan, Astellas, Boston Scientiﬁc, Bouchara-Recordati,Coloplast,

(7)

Medtronic,Mundipharma,Pﬁzer,SAP,Takedaandinvestiga- torfor Astellas, Cousin Biotech, Coloplast,GT Urological, Ipsen and Medtronic; A. Benchikh: no; A.R. Azzouzi: no;

N.B. Delongchamps: no; O. Dumonceau: no; A. Faix:

no; M. Fourmarier: trainer for company EDAP-TMS and Bostonscientiﬁc;O.Haillot:notstatedconﬂictofinterest;

B.Lukacs:lecturer forMylan; V.Misrai:trainer forBoston Scientiﬁc;A.delaTaille:no;G.Robert:trainerforcompany EDAP-TMSandLumenis;A.Descazeaud:no.

References

[1]WeiJT,CalhounE,JacobsenSJ.UrologicdiseasesinAmerica project:benignprostatichyperplasia.JUrol2008;179:S75—80.

[2]Gratzke C, Bachmann A, Descazeaud A, Drake MJ, Mader- sbacher S, Mamoulakis C, et al. EAU guidelines on the assessment of non-neurogenic male lower urinary tract symptoms including benign prostatic obstruction. Eur Urol 2015;67:1099—109.

[3]Cornu JN,et al. A systematic review and meta-analysis of functionaloutcomesandcomplicationsfollowingtransurethral procedures for lower urinarytract symptoms resultingfrom benign prostatic obstruction: an update. Eur Urol 2014, http://dx.doi.org/10.1016/j.eururo.2014.06.017.

[4]DescazeaudA,RobertG,DelongchampsNB,CornuJN,Saussine C,HaillotO,etal.Initialassessment,follow-upandtreatment oflowerurinary tractsymptomsrelatedto benignprostatic hyperplasia:guidelinesoftheLUTScommitteeoftheFrench UrologicalAssociation.ProgUrol2012;22:977—88.

[5]Dindo D, Demartines N, Clavien PA. Classiﬁcation of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 2004;240:205—13.

[6]Oelke M, Bachmann A, Descazeaud A, Emberton M, Gravas S, Michel MC, et al. EAU guidelines on the treatment and follow-up of non-neurogenic male lower urinary tract symptoms including benign prostatic obstruction. Eur Urol 2013;64:118—40.

[7]Alivizatos G, Skolarikos A, ChalikopoulosD, Papachristou C, SopilidisO,DellisA,etal.Transurethralphotoselectivevapor- ization versus transvesical open enucleation for prostatic adenomas>80mL:12-moresultsofarandomizedprospective study.EurUrol2008;54:427—37.

[8]Raimbault M, Watt S, Bourgoin H, Brichart N, Bruyere F.

Comparative analysis of photoselective vaporization of the prostate withthe Greenlight laser and open prostatectomy for high volume prostate hypertrophy. Prog Urol 2014;24:

470—6.

[9]SaloniaA,SuardiN,NasproR,MazzoccoliB,ZanniG,Gallina A,etal.Holmiumlaserenucleationversusopenprostatectomy for benign prostatichyperplasia:aninpatient costanalysis.

Urology2006;68:302—6.

[10]FraundorferMR,GillingPJ,KennettKM,DuntonNG.Holmium laser resectionof the prostate is morecost effective than transurethralresectionoftheprostate:resultsofarandomized prospectivestudy.Urology2001;57:454—8.

[11]Lourenco T, Armstrong N, N’Dow J, Nabi G, Deverill M, PickardR,et al.Systematicreviewandeconomicmodelling of effectiveness and cost utility of surgical treatments for menwithbenignprostaticenlargement.HealthTechnolAssess 2008;12:iii[ix-x,1-146,169-515].

[12]Goh AC, Gonzalez RR. Photoselective laser vaporization prostatectomyversustransurethralprostateresection:acost analysis.JUrol2010;183:1469—73.

[13]Bouchier-HayesDM,VanAppledornS,BugejaP,CroweH,Chal- lacombeB,CostelloAJ.Arandomizedtrialofphotoselective vaporizationoftheprostateusingthe80-Wpotassium-titanyl- phosphatelaservs.transurethralprostatectomy,witha1-year follow-up.BJUInt2010;105:964—9.

[14]StovskyMD,GrifﬁthsRI,DuffSB.Aclinicaloutcomesandcost analysiscomparingphotoselectivevaporizationoftheprostate toalternativeminimallyinvasivetherapiesandtransurethral prostateresectionforthetreatmentofbenignprostatichyper- plasia.JUrol2006;176:1500—6.

[15]StaﬁnskiT,MenonD,HarrisK,MdGG,JhangriG.Photoselec- tivevaporizationoftheprostateforthetreatmentofbenign prostatichyperplasia.CanUrolAssocJ2008;2:124—34.

[16]Whitty JA, Crosland P, Hewson K, Narula R, Nathan TR, Campbell PA, et al. A cost-minimisation analysiscomparing photoselectivevaporisation(PVP)andtransurethralresection oftheprostate(TURP) forthemanagementofsymptomatic benignprostatichyperplasia (BPH)inQueensland,Australia.

BJUInt2014;113(Suppl2):21—8.

[17]LiatsikosE,KyriazisI,Kallidonis P,Sakellaropoulos G, Mani- adakisN.PhotoselectiveGreenLightlaservaporizationversus transurethralresectionoftheprostateinGreece:acompara- tivecostanalysis.JEndourol2012;26:168—73.

[18]ArmstrongN,ValeL,DeverillM,NabiG,McClintonS,N’Dow J,et al. Surgical treatments for men withbenignprostatic enlargement:costeffectivenessstudy.BMJ2009;338:b1288.

[19]Benejam-Gual JM, Sanz-Granda A, Budia A, Extramiana J, Capitan C. Multicenter study on costs associated with two surgical procedures: GreenLight XPS 180W versus the gold standardtransurethral resectionof theprostate.ActasUrol Esp2014;38:373—7.

[20]BerquetG,CorbelL,DellaNegraE,HuetR,TrifardF,CodetY, etal.Prospectiveevaluationofambulatorylaservaporization oftheprostateforbenignprostatichyperplasia.LasersSurg Med2015;47:396—402.

[21]SinclairAM,GunendranT,PearceI.Day-caseurologicalsurgery:

areweimproving?BJUInt2007;99:491—3.

[22]Al-AnsariA,YounesN,SampigeVP,Al-RumaihiK,GhafouriA, GulT,etal.GreenLightHPS120-Wlaservaporizationversus transurethralresectionoftheprostatefortreatmentofbenign prostatichyperplasia:arandomizedclinicaltrialwithmidterm follow-up.EurUrol2010;58:349—55.