Trends and Perioperative Outcomes Across Major BPH Procedures from the ACS-NSQIP 2011-2015- Beyond the Abstract

For men with benign prostatic hyperplasia (BPH), there is a myriad of different surgical approaches available.  Some procedures such as microwave (TUMT) or need ablation (TUNA) of the prostate have come and largely faded from practice due to poor efficacy, while others have recently emerged such as Aquablation, Rezum and UroLift® but lack long-term data.  Many prior studies have compared some approaches to others, such as transurethral resection of the prostate (TURP) vs. photovaporization of the prostate (PVP) in the Goliath Study.  Importantly, this paper accomplished a comparison of several major BPH operations that have withstood the test of time: PVP, TURP, Holmium Laser Enucleation of the prostate (HoLEP) and simple prostatectomy.  Additionally, the ACS-NSQIP database provided data for analysis of these procedures across the 5 year span of data available since a CPT code was first available for HoLEP in 2011. 

This study demonstrated the unfortunate fact that HoLEP is not widely performed, making up only 4-5% of all major BPH operations in the study, despite it being reported as the gold standard for BPH surgical therapy in the literature.  The fact is that not many residency training programs have a urologist who performs HoLEP and is able to teach residents this operation.  Thus, the only urologists doing it are self-taught or have done a fellowship.  The perioperative outcome data from this study also support HoLEP as being the standard of care for BPH surgery because of low transfusion rates and hospital stays comparable to PVP, but also lower rates of readmission, reoperation or urinary tract infection (UTI) within 30 days compared to the other procedures.  Delayed bleeding is very rare after HoLEP which supports these findings.  Also, since a foley is typically left in place only overnight after HoLEP with the vast majority of men passing an initial void trial, infection rates are extremely low.  These findings and the numerous prior studies on HoLEP and its durability should challenge all residency programs to incorporate HoLEP into what they offer patients and teach their residents.

Future studies of surgical treatment for BPH using ACS-NSQIP will continue to provide useful information to both urologists and patients as other new procedures develop their own CPT codes and can be tracked and analyzed for a comparative analysis.  For example, CMS approved CPT codes for transprostatic implant (UroLift) that went into effect January 1, 2015.  Additionally, a limitation of this study was that no CPT code exists for robotic simple prostatectomy.  We were able to infer from the percent of simple prostatectomies coded as an outpatient that rate at which robotic simple prostatectomy is being performed is increasing: 1-3% from 2011-2014 but rose to 7% in 2015.  As CPT codes become available for other BPH procedures, it will be helpful to add these to future analyses using ACS-NSQIP.

Written by: Blake Anderson, MD, Dayton Physicians Network, Urology Division, Centerville, OH

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