Surgery-First Strategy Cost-Effective in Benign Prostatic Hyperplasia

By Will Boggs MD

August 30, 2018

NEW YORK (Reuters Health) - Using surgery as an initial treatment for moderate-to-severe benign prostatic hyperplasia (BPH) is more economically attractive than upfront pharmacotherapy followed by surgery for those who fail, researchers from Canada report.

"This is possibly a little counterintuitive to how most physicians would think, which is that using a more conservative approach first is always best," Aysegul Erman from the University of Toronto, Canada, told Reuters Health by email. "There is also an assumption that surgery is very costly and that all efforts should be made to avoid surgery. It turns out, though, that upfront surgery is cost-effective compared to the long durations of medical treatment."

Options for managing BPH include pharmacotherapy, transurethral resection of the prostate (TURP), greenlight laser photoselective vaporization of the prostate (GL-PVP) and other novel treatments. Which approach is most economically sound remains unclear.

Erman's team compared the cost-effectiveness of eight strategies for treating men with moderate-to-severe BPH-related lower-urinary-tract symptoms (LUTS), employing a microsimulation decision analytic model performed from a public payer perspective.

On average, upfront surgery strategies cost $1,221-$3155 more per person, compared with upfront pharmacotherapy with delayed surgery, the researchers report in BJU International, online August 16.

In contrast, upfront BPH surgeries resulted in quality-unadjusted life-year (QALY) gains of 0.12 to 0.27 per person, compared with the upfront pharmacotherapy strategies.

In cost-effectiveness analyses, all strategies involving upfront pharmacotherapy followed by delayed TURP appeared less favorable.

Upfront TURP cost an average $1,015 more and provided 0.03 QALY more than upfront GL-PVP, for an incremental cost per QALY gained of $29,066, well below most willingness-to-pay thresholds.

In fact, upfront surgeries were more likely to be cost-effective than other strategies at thresholds over $15,000/QALY, with increasing thresholds generally favoring upfront TURP over upfront GL-PVP as the optimal strategy.

"While our study indicates that upfront surgery is economically attractive and that early surgical treatment may be a rational choice especially for patients who value prompt relief of symptoms, patients' preferences for treatment and risk attitudes towards invasive therapies are likely to vary," said Erman, who is a Ph.D. candidate. "Therefore, BPH treatment should be individualized to the personal preferences and priorities of men."

"As new, minimally invasive options emerge in the treatment of BPH, patient preference and cost-effectiveness are two key factors which can help decision-making regarding treatment options, and the idea of always using the less-invasive medical therapy first followed by BPH surgery when men fail could be reconsidered," she added.

Dr. Bradley C. Gill from Cleveland Clinic Lerner College of Medicine in Ohio has studied the costs of managing BPH in the office and operating room. He told Reuters Health by email, "The findings of this study, and others recently published, make a strong argument for consideration of upfront surgical or procedural BPH treatments."

"This study does not directly address it, but newer office-based BPH procedures have shown promising short-term and intermediate-term results and may serve as a cost-effective approach," said Dr. Gill, who was not involved in the research. "Taken together, surgical and procedural BPH treatments provide excellent first-line options for men who cannot take medications (for any number of reasons) or for men who prefer to avoid the need for a daily pill (or two) for the remainder of their lives."

"Each man has a specific situation that may best be treated by medical therapy, surgery, or an office-based procedure," Dr. Gill said. "Each approach has benefits and risks, and discussing these in an informed fashion with patients is a great reason to consult a urologist."

Boston Scientific funded this research and had ties to one of Erman's coauthors.

SOURCE: https://bit.ly/2BU0jIL

BJU Int 2018.

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