Trends of Benign Prostatic Hyperplasia (BPH) Procedures in Ambulatory Surgery Settings - Beyond the Abstract

Benign prostatic hyperplasia (BPH) has several evidence-based surgical treatments available, with laser enucleation of the prostate remaining one of the guideline recommended prostate-size independent treatment options.1 Holmium laser enucleation of the prostate (HoLEP) can be utilized in a variety of clinical settings ranging from the patient with a very large prostate to the patient who is in urinary retention and unable to safely hold their anticoagulant medications. This wide range of clinical utility offers a great treatment modality in the armamentarium of an endourologist.

In contrast to alternative BPH treatment options, like transurethral resection of the prostate (TURP) which remains a core skill of all urologic residency training programs, a lack of early exposure to HoLEP training along with a historically difficult learning curve may have previously limited widespread uptake of this treatment modality in the United States. In 2008, only 28 hospital referral regions (HRRs) were performing >10 annual HoLEP cases, representing 1% of BPH treatments.2 Since that time, clinical exposure to HoLEP from newly minted fellowship trained endourologists in combination with an increased volume of safety and long-term efficacy publications have increased awareness and utilization of this treatment modality.

To investigate the change in ambulatory HoLEP cases performed in the United States from 2016 to 2019, we conducted a cross-sectional analysis using the Healthcare Cost and Utilization Project (HCUP) Nationwide Ambulatory Surgery Sample (NASS) database.

From 2016 to 2019 the absolute number of ambulatory BPH surgeries decreased from 124,538 to 100,783 with transurethral resection of the prostate (TURP) remaining the most common procedure performed. We found that HoLEP rose to the second most common procedure performed in 2019. Our study highlights that surgical selection remains complex and is not only dictated by evidence for the shortest length of stay (LOS), transfusion rate, readmission rate, and re-treatment rate. For patients with BPH, external factors may include surgeon familiarity or preference, reimbursement incentives, or access to specific technology and surgical equipment.

Although fellowship trained endourologists do not always go on to practice within the geographical region where they taught, there is an association between ambulatory surgical center HoLEP cases performed and the location of fellowship training programs offering prostate enucleation. When we examine 62 Endourological Society accredited fellowship programs in the United States, 43 of these programs have a focus that includes endourology while 19 focus on laparoscopy and robotic surgery. When reviewing the fellowship program descriptions there is a total of 24 programs offering laser enucleation of the prostate training with an uneven geographic distribution that closely mirrors the geographic regional uptake of HoLEP found within our study. Over 70% (17/24) of the fellowship training programs offering laser enucleation of the prostate are found within the Midwestern (10) and Southern (7) regions; the two areas with the most ambulatory HoLEPs performed. When comparing geographical regions like the Northeast to the Midwestern, there is a significantly higher exposure to laser enucleation of the prostate training amongst fellowship programs in the Midwestern region (4/18 (22%) vs. 10/17 (59%), p = 0.041). As future endourologists continue to learn enucleation techniques and distribute subsequent exposure to trainees across the country, it will be interesting to see whether regional differences in utilization of HoLEP remain.

Overall, the most performed BPH procedure in ambulatory surgical settings remains TURP. However, we identified an increase in HoLEP cases performed in ambulatory surgical settings from 2016 to 2019, supplanting photo-selective vaporization of the prostate as the second most common procedure.

Written by: Mark A. Assmus, MD, MPH, University of Calgary, Department of Surgery, Section of Urology. Calgary, Canada


  1. Lerner LB, McVary KT, Barry MJ, Bixler BR, Dahm P, Das AK, et al. Management of Lower Urinary Tract Symptoms Attributed to Benign Prostatic Hyperplasia: AUA GUIDELINE PART II-Surgical Evaluation and Treatment. J Urol. 2021;206(4):818-26.
  2. Robles JP, V.; Miller, N. . Mind the Gaps: Adoption and Underutilization of Holmium Laser Enucleation of the Prostate in the United States from 2008 to 2014. Journal of Endourology. 2020;34:770-6.
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