Surgery for Some Cases

“Today, about 80% of men can be managed medically and never need surgery for BPH. That’s a huge change from 10 to 15 years ago,” said Canales. For those whose symptoms continue to worsen despite medication, the surgical options have substantially improved over the last few years.

For decades, transurethral resection of the prostate (TURP) was the gold standard for surgery, but less-invasive laser surgeries have become increasingly common. In 2000, for instance, photoselective vaporization (PVP) accounted for about 7% of outpatient BPH surgeries in the VA system, according to a 2008 letter in the Journal of Urology by Todd Wagner, MD, of the VA Palo Alto Health Care System and Stanford University. In 2007, about 25% of outpatient BPH surgeries used the method. ⁴

Overall, “of the BPH surgeries performed in VA in FY 2000, 11.5% were minimally invasive. By FY 2005, 32.5% of the outpatient BPH procedures were minimally invasive,” and the percentage did not increase during the next two years. “VA providers are increasingly turning to minimally invasive surgical techniques for benign prostatic hyperplasia but have done so at a slower rate than Medicare providers,” Wagner wrote.

In the last few years, though, the adoption of laser procedures in the VA has accelerated.

“Laser procedures  — whether PVP, laser ablation, or others — are increasingly replacing TURP in the VA,” said Canales. Laser procedures are associated with far fewer adverse events, as well as quicker recoveries, he noted.

“With TURP, patients often have a one- or two-day hospital stay, and 5% to 10% require transfusions,” he said. “Many need a catheter for a week to 10 days. Laser procedures are typically done on an outpatient basis. The chance of needing a transfusion is very small, and there are relatively few complications.”

Laser surgery is not without drawbacks. “The laser burns instead of cuts, so patients often have dysuria, because urinating is so painful. We may leave a catheter in for a day or two, just to provide relief,” Canales noted.

A study by Canales’ colleagues at the Gainesville VAMC and presented at the American Urological Association conference last year found PVP and TURP to be equally effective but noted that expenses related to PVP at the VHA were substantially lower than for TURP. In addition to the $100,000 to $150,000 cost of the generator, PVP also requires disposable materials that cost about $2,000 per patient, Canales said. The study showed that savings related to decreased hospital stays more than made up for the equipment expenses associated with lasers.⁵

The lead author, Daniel Willis, MD, wrote that the reduced morbidity, decreased hospitalization and other benefits have led to the “introduction of PVP to the Veterans Administration Health System as a management strategy in order to decrease the length of hospitalization and treat patients with multiple medical comorbidities, particularly those who are chronically anticoagulated.”

The researchers reviewed records of 6,718 TURP patients and 772 patients undergoing PVP. Researchers compared the cost of initial therapy, hospital stay, subsequent clinic followup and costs related to adverse events for 12 months after surgery.

[1] Helfand M, Muzyk T, Garzotto M. Benign Prostatic Hyperplasia (BPH) Management in Primary Care-Screening and Therapy. Washington (DC):Department of Veterans Affairs; February 2007.

2 Lepor H, Williford WO, Barry MJ, et al. The efficacy of terazosin, finasteride, or both in benign prostatic hyperplasia. N Engl J Med. 1996;335:533–539.

3 McConnell JD, Roehrborn CG, Bautista OM, Andriole GL, Dixon CM, et al. The long-term effect of doxazosin, finasteride, and combination therapy on the clinical progression of benign prostatic hyperplasia. N Engl J Med. 2003;349(25):2387-98.

4 Wagner TH. Re: Practice Patterns in Benign Prostatic Hyperplasia Surgical Therapy: The Dramatic Increase in Minimally Invasive Technologies.  J Urol. 2009;181(6):2829-30; author reply 2830. Epub 2009 Apr 18.

5 Willis D, Mejia M, Knapp C, Wagner T, Wang X, Nseyo U. Long Term Cost Analysis of Photoselective Vaporization of the Prostate and Transurethral Resection of the Prostate for Symptomatic Benign Prostatic Hypertrophy in the Veterans Administration Health System. Presentation 2273: AUA 2011. http://www.aua2011.org/abstracts/printpdf.cfm?ID=2273

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