Pharmacotherapy vs Minimally Invasive Therapies as Initial Therapy for Moderate-to-Severe Benign Prostatic Hyperplasia: A Cost-Effectiveness Study - Beyond the Abstract

In the past few years, minimally invasive therapies, such as prostatic urethral lift procedure (PUL; UroLift System, Teleflex, Pleasanton, CA) and water vapor thermal therapy (WVTT; Rezum® system, Boston Scientific, Marlborough, MA) have become an alternative to surgery or pharmacotherapy (PhTx) for the management of benign prostate hyperplasia (BPH). Both interventions are performed in an outpatient setting, offer preservation of sexual function an advantage over standard surgical procedures, and provide faster symptom relief than PhTx.


The benefits of office-based surgery may associated with cost savings for the health care system and reduced morbidity for the patient. As such, in this study, we evaluated the BPH progression, and healthcare costs per quality-adjusted life year (QALY) of PUL and WVTT compared to PhTx as initial treatment for men with moderate-to-severe BPH.

We used a microsimulation model, where we considered various clinical scenarios given that most men undergo several therapies up to surgical intervention and potentially thereafter:

  1. First line: PhTx  Second line: PUL  Third line: TURP or PhTx;
  2. First line: PhTx  Second line: WVTT   Third line: TURP or PhTx;
  3. First line: WVTT   Second line: repeat Rezum or PhTx or TURP  Third line: TURP;
  4. First line: PUL   Second line: repeat PUL or PhTx or TURP  Third line: TURP.
The population included in the model reflected characteristics of a typical patient with moderate to severe LUTS managed by a urologist (mean age 65 years, average International Prostate Symptom Score 16.6). Using a lifetime time horizon allowed us to estimate the long-term costs and benefits of alternative interventions.

Our findings showed that MITs are costlier than drug therapies during the first year of treatment. However, they offer cost-savings over longer analytic timeframe. Amongst all scenarios considered WVTT generated the most QALYs (13.05) at a lowest cost ($15,461) over a patient’s lifetime, and appears to be a cost-saving alternative to PhTx.

Our findings showed that initial treatment with WVTT led to the highest QALYs (13.05 QALYs). This was followed by initial PhTx with WVTT (12.92 QALYs) or with PUL (12.87 QALYs) as second line. Initial treatment with PUL lead to the lowest QALYs (12.86) overall. Moreover, initial PhTx with PUL as second line resulted in the highest lifetime costs ($22,424/person) followed by initial treatment with PUL ($20,930/person), and initial pharmacotherapy with WVTT as second line ($20,280/person); whereas initial treatment with WVTT was the least costly option ($15,461/person). In the cost-effectiveness analysis, WVTT as initial treatment dominated all three strategies, i.e. generated more at a lower cost.

Given that shared decision-making between clinicians and patients is at the core of BPH treatment choice, WVTT warrants consideration as a first-line alternative to PhTx in patients with moderate-to-severe BPH, who seek faster improvement and no lifelong commitment to daily medications.

Written by:

  • Yeva Sahakyan, MD, MSc, Toronto Health Economics and Technology Assessment Collaborative (THETA), University Health Network, Toronto, ON, Canada
  • Dean Elterman, MD, MSc, FRCSC, Division of Urology Krembil Research Institute, University Health Network

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