Trends and Perioperative Outcomes Across Major Benign Prostatic Hyperplasia Procedures from the ACS-NSQIP 2011

Abstract

Background and Purpose:

There are currently several different surgical options for patients with benign prostatic hyperplasia (BPH). The literature has demonstrated equivalent or superior results for holmium laser enucleation of prostate (HoLEP) but with exceptional long-term durability compared to other minimally invasive options. Despite this, HoLEP is not widely practiced. Herein, we investigate trends and outcomes from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) to support a need for further adoption of HoLEP.

Methods:

Using ACS-NSQIP data from 2011 to 2015, trends, baseline characteristics, and perioperative outcomes were collected for major BPH procedures: transurethral resection of prostate (TURP), TURP for regrowth, photovaporization of prostate (PVP), HoLEP, and simple prostatectomy.

Results:

The most common procedure performed every year was TURP with PVP performed about half as often, while HoLEP (4%–5%) was performed about as infrequently as simple prostatectomy (3%). More African American men underwent simple prostatectomy except in 2011. International normalized ratio (INR) was highest every year for PVP. Hospital stay and transfusion rates were lowest with PVP and HoLEP. Transfusion rates for simple prostatectomy were high (16.0%–25.4%). Lower rates of readmission, reoperation, and urinary tract infection were seen in some years with HoLEP.

Conclusions:

Given the previously reported favorable outcomes and long-term durability of HoLEP, these ACS-NSQIP data further support that HoLEP should be more often practiced for patients undergoing surgery for BPH.

Introduction

Benign prostatic hyperplasia (BPH) is a common disorder among men.¹ As per AUA guidelines, men are offered medical treatment first, but those who fail or have absolute surgical indications (i.e., urinary infections, urinary retention, bladder calculi, and prostatic bleeding) are then offered operative intervention.¹ The list of options for BPH treatment is ever expanding. The old mainstay of BPH treatment, transurethral resection of prostate (TURP), is still taught pervasively to residents and widely practiced despite concerns with retreatment rates and postoperative bleeding.² Fortunately, the ability to perform bipolar TURP has eliminated most of the risk for TUR syndrome.³ Photovaporization of the prostate (PVP) has been the leading rival to TURP since it was introduced in 2002.⁴ Compared to TURP, PVP has less bleeding and can be safely performed in patients on anticoagulation, but postoperative dysuria or irritative voiding symptoms are a concern, as well as BPH regrowth.² Enlarged prostates, over 100 g, classically were treated with open simple prostatectomy, using either a suprapubic intravesical or retropubic extravesical approach.⁵ Today, robotic simple prostatectomy is being performed although no current procedural terminology (CPT) code is available for this; however, its outcomes have not been as favorable as holmium laser enucleation of prostate (HoLEP).⁶ In 2012, the USPSTF grade D for prostate specific antigen (PSA) screening led to a decrease in radical prostatectomy volume in the United States, and this may have in turn increased performance of robotic simple prostatectomy.⁷ The HoLEP procedure, developed in 1997, can be safely performed on any size prostate and has long-term durability.⁸ A challenge for HoLEP has been its prolonged learning curve and that it is not typically taught to residents. Our institution, which performs over 500 HoLEP procedures annually, is a contributor to the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP), and thus, we were given access to the database for this project with the goal of assessing trends and outcomes in BPH treatment among these major procedures. Since HoLEP has been reported to have equivalent if not superior outcomes to other bladder outlet procedures, and as a new gold standard by several authors, we hypothesize that the ACS-NSQIP results will support a need for more widespread practice of HoLEP.⁹

Methods

The ACS-NSQIP is an organization committed to the positive advancement of surgical morbidity and mortality rate through its large database which spurs quality improvement from contributing hospitals both within and outside of the United States.¹⁰ Since its beginning, ACS-NSQIP has led to significant reductions in morbidity and mortality rate from contributing hospitals. The ACS-NSQIP data are from either inpatient or outpatient procedures. The variables are collected by trained surgical clinical reviewers at each participating institution with annual audits requiring at least 95% reliability. Further background information about the database is available on the NSQIP website.¹¹

CPT codes were used to identify cases for study. The CPT code for HoLEP, 52649, was first used in 2011, so the NSQIP database was queried from January 1, 2011 to December 31, 2015 to compare trends and perioperative outcomes in TURP (CPT 52601), TURP for regrowth (CPT 52630), PVP (CPT 52648, n.b. through any type of laser), HoLEP (CPT 52649), and simple prostatectomy (CPT 55821—suprapubic, CPT 55831—retropubic). In 2011, it was composed of 315 hospitals who entered a total of 442,149 cases with 3788 major BPH procedures. By 2015, 603 hospitals were in NSQIP that recorded 885,502 cases with 10,655 major BPH procedures. For simple prostatectomy, since no CPT is available to specify the robotic approach, this group must be considered a mix of open or robotic cases although some urologists do code robotic simple prostatectomy with 55866 (CPT for radical prostatectomy) or an unlisted procedure code.

Demographic and baseline characteristics, including age, race, history of diabetes, smoking status, body mass index (BMI), preoperative serum creatinine, hematocrit, and INR, were collected. Race defined as “Other” in this study included unknown or unreported race, as well as Native Hawaiians, Pacific Islanders, American Indians, and Alaskan Natives. For perioperative comparisons, admission status was accounted for, as well as American Society of Anesthesiology (ASA) class, type of anesthesia, and operative time. Postoperative outcomes assessed out to 30 days included readmission, reoperation, transfusion, and symptomatic urinary tract infection (UTI) rates. Statistical tests were performed with STATA 13.1 (College Station, TX). Chi square and ANOVA were used to compare categoric and continuous variables, respectively, between the different major BPH procedures studied. Statistical significance was defined as p < 0.05.

Results

Baseline demographics and characteristics compared for each surgery from years 2011 to 2015 are listed in Table 1. For all years, age was different between surgery groups with TURP for regrowth tending to be higher in nearly every year. In total, men who underwent TURP for regrowth were an average of 2 years older than those undergoing TURP. There were significant differences between surgery groups for race for all years. Nearly twice as many African American men underwent simple prostatectomy compared to those undergoing TURP, PVP, or HoLEP except for 2011 when more underwent HoLEP than any other procedure in this study. A higher percentage of white men underwent HoLEP than any other procedure in all years except 2011. Asian men had no consistent differences between surgeries performed across the years studied, but of note in 2013 many more Asian men underwent BPH procedures than all other years included in this study. Men defined as race “Other” underwent less HoLEP and simple prostatectomy compared to the other procedures.

Table 1.

Baseline Characteristics by Year and Operation

	TURP	TURP regrowth	PVP	HoLEP	Simple prostatectomy	p
2011
Mean age ± SD	72.5 ± 9.8	73.4 ± 8.5	71.5 ± 9.7	68.9 ± 9.8	72.4 ± 7.9	<0.001
Race (%)
White	61	58	75	76	79	<0.001
African American	4	4	4	14	8
Asian	2	5	2	2	2
Other	33	33	29	8	11
Diabetes (%)	20	19	21	21	17	0.8
Smoking (%)	9	7	9	15	8	0.1
BMI ± SD	27.4 ± 5.3	27.1 ± 5.7	28.0 ± 5.3	27.9 ± 6.5	28.1 ± 5.1	0.04
Mean serum creatinine (mg/dL) ± SD	1.19 ± 0.66	1.23 ± 0.82	1.16 ± 0.64	1.09 ± 0.36	1.13 ± 0.75	0.3
Mean serum hematocrit (%) ± SD	39.6 ± 5.3	39.3 ± 6.0	40.3 ± 5.2	41.7 ± 4.5	40.1 ± 5.5	<0.001
Mean INR ± SD	1.09 ± 0.30	1.08 ± 0.19	1.14 ± 0.38	1.06 ± 0.21	1.07 ± 0.18	0.01
Outpatient (%)	34	34	79	36	3	<0.001
Mean ASA ± SD	2.53 ± 0.64	2.55 ± 0.64	2.53 ± 0.62	2.41 ± 0.61	2.45 ± 0.61	0.1
Anesthesia (%)
General	64	65	82	86	85	<0.001
Spinal/epidural	35	35	17	14	15
MAC/sedation	1	0	1	0	0
2012
Mean age ± SD	72.5 ± 9.7	75.3 ± 9.0	72.5 ± 9.5	69.4 ± 9.3	71.5 ± 8.0	<0.001
Race (%)
White	55	51	74	82	76	<0.001
African American	5	5	5	6	10
Asian	3	2	2	4	4
Other	37	42	20	8	10
Diabetes (%)	21	18	20	18	23	0.2
Smoking (%)	11	8	10	9	8	0.1
Mean BMI ± SD	28.0 ± 5.3	28.1 ± 4.9	28.1 ± 5.4	28.7 ± 5.6	28.3 ± 5.7	0.2
Mean serum creatinine (mg/dL) ± SD	1.16 ± 0.69	1.20 ± 0.76	1.14 ± 0.54	1.13 ± 0.47	1.24 ± 1.20	0.3
Mean serum hematocrit (%) ± SD	39.9 ± 5.2	39.6 ± 5.5	40.3 ± 5.1	40.7 ± 4.7	39.7 ± 5.2	0.01
Mean INR ± SD	1.09 ± 0.32	1.11 ± 0.24	1.14 ± 0.51	1.06 ± 0.23	1.07 ± 0.18	0.03
Outpatient (%)	40	41	77	49	3	<0.001
Mean ASA ± SD	2.50 ± 0.66	2.54 ± 0.64	2.54 ± 0.66	2.43 ± 0.64	2.48 ± 0.58	0.03
Anesthesia (%)
General	66	57	82	93	91	<0.001
Spinal/epidural	33	41	17	7	9
MAC/sedation	1	2	1	0	0
2013
Mean age ± SD	71.7 ± 9.2	73.8 ± 8.5	71.4 ± 9.1	70.3 ± 8.7	70.9 ± 7.7	<0.001
Race (%)
White	60	60	71	90	82	<0.001
African American	5	3	4	4	7
Asian	34	37	23	4	10
Other	1	0	2	2	1
Diabetes (%)	22	23	20	16	18	0.05^a
Smoking (%)	11	8	10	6	9	0.03
Mean BMI ± SD	28.1 ± 5.5	28.4 ± 5.3	28.1 ± 5.2	28.8 ± 5.5	28.1 ± 4.4	0.1
Mean serum creatinine (mg/dL) ± SD	1.18 ± 0.76	1.21 ± 0.81	1.14 ± 0.62	1.11 ± 0.59	1.13 ± 0.69	0.05^a
Mean serum hematocrit (%) ± SD	40.2 ± 5.3	39.9 ± 5.8	40.7 ± 4.9	41.4 ± 4.5	41.2 ± 4.9	<0.001
Mean INR ± SD	1.08 ± 0.24	1.07 ± 0.17	1.12 ± 0.42	1.05 ± 0.20	1.10 ± 0.39	<0.01
Outpatient (%)	48	47	85	66	1	<0.001
Mean ASA ± SD	2.53 ± 0.65	2.57 ± 0.63	2.53 ± 0.61	2.39 ± 0.58	2.45 ± 0.60	<0.001
Anesthesia (%)
General	69	70	84	95	97	<0.001
Spinal/epidural	28	26	14	5	3
MAC/sedation	3	4	2	0	0
2014
Mean age ± SD	71.1 ± 9.2	73.0 ± 8.9	71.1 ± 9.2	68.7 ± 8.2	69.3 ± 8.1	<0.001
Race (%)
White	65	63	73	85	80	<0.001
African American	6	5	6	5	8
Asian	3	3	3	2	2
Other	26	29	18	8	10
Diabetes (%)	21	18	20	17	16	0.1
Smoking (%)	12	7	9	9	10	<0.001
Mean BMI ± SD	27.9 ± 5.9	28.2 ± 6.9	28.2 ± 5.7	28.5 ± 5.2	28.7 ± 4.8	0.01
Mean serum creatinine (mg/dL) ± SD	1.19 ± 0.74	1.16 ± 0.69	1.14 ± 0.55	1.12 ± 0.41	1.15 ± 0.61	0.03
Mean serum hematocrit (%) ± SD	40.2 ± 5.3	40.1 ± 5.3	40.6 ± 5.1	41.7 ± 4.4	41.1 ± 5.3	<0.001
Mean INR ± SD	1.08 ± 0.22	1.12 ± 0.24	1.11 ± 0.30	1.05 ± 0.14	1.06 ± 0.11	<0.01
Outpatient (%)	53	57	86	75	3	<0.001
Mean ASA ± SD	2.53 ± 0.64	2.58 ± 0.63	2.53 ± 0.63	2.39 ± 0.60	2.44 ± 0.59	<0.001
Anesthesia (%)
General	72	72	88	96	97	<0.001
Spinal/epidural	25	25	11	4	3
MAC/sedation	3	3	1	0	0
2015
Mean age ± SD	71.5 ± 9.7	74.0 ± 9.4	71.4 ± 9.5	69.6 ± 9.2	69.5 ± 8.2	<0.001
Race (%)
White	63	61	71	84	77	<0.001
African American	6	6	5	6	13
Asian	3	4	3	2	1
Other	28	29	21	8	9
Diabetes (%)	22	22	22	19	22	0.7
Smoking (%)	12	8	10	10	10	0.04
Mean BMI ± SD	28.4 ± 5.5	28.2 ± 5.2	28.4 ± 5.3	28.8 ± 5.0	29.2 ± 5.0	0.05^a
Mean serum creatinine (mg/dL) ± SD	1.18 ± 0.71	1.21 ± 0.80	1.16 ± 0.62	1.16 ± 0.69	1.13 ± 0.62	0.2
Mean serum hematocrit (%) ± SD	40.6 ± 5.3	40.1 ± 5.9	41.0 ± 5.1	41.4 ± 5.2	41.4 ± 5.0	<0.001
Mean INR ± SD	1.09 ± 0.30	1.08 ± 0.22	1.10 ± 0.33	1.10 ± 0.23	1.06 ± 0.19	0.5
Outpatient (%)	58	56	87	72	7	<0.001
Mean ASA ± SD	2.55 ± 0.65	2.63 ± 0.64	2.53 ± 0.63	2.50 ± 0.60	2.49 ± 0.56	0.002
Anesthesia (%)
General	73	73	86	94	98	<0.001
Spinal/epidural	24	24	12	5	1
MAC/sedation	3	3	2	1	1

Possible trend toward significance.

Boldface indicates statistically significant p < 0.05.

ASA = American Society of Anesthesiology; BMI = body mass index; HoLEP = holmium laser enucleation of prostate; INR = international normalized ratio; MAC = monitored anesthesia care; PVP = photovaporization of prostate; SD = standard deviation; TURP = transurethral resection of prostate.

For type of anesthesia performed, patients who had TURP and TURP for regrowth had approximately twice the rate of spinal or epidural anesthetics compared to PVP. Spinal or epidural anesthesia was performed in 4% to 14% of men who underwent HoLEP, but only rarely for those who had simple prostatectomy. The most commonly performed outpatient procedure studied was PVP (77%–87%), followed by HoLEP (36%–75%) and TURP or TURP for regrowth (34%–58%). For simple prostatectomy, 1% to 7% (average 3.4%) of men had outpatient admissions, possibly indicating the rate of robotic procedures coded in this manner.

There were no differences between surgery groups in diabetic status, but in 2013 men who underwent HoLEP had a possible trend toward lower rates of diabetes. From 2011 to 2012, there were no differences in smoking status between surgery groups, but from 2013 to 2015 patients who had TURP were more often smokers. Patient BMI was different between groups in 2011 and 2014 with a possible trend toward significance in 2015, and in those years BMI was higher for HoLEP and simple prostatectomy compared to the other procedures. In 2013, there was a possible trend toward differences in serum creatinine between groups with TURP and TURP for regrowth groups having higher levels. In 2014, preoperative serum creatinine was significantly different between surgery groups with the TURP group having the highest mean creatinine. Otherwise, there were no differences in serum creatinine between groups. Preoperative hematocrit was different between groups in all years with the highest hematocrit in the HoLEP group in all years (40.7%–41.7%), but from 2013 to 2015 hematocrit was similarly higher for simple prostatectomy (41.1%–41.4%) compared to the other procedures. In all years except 2015, baseline INR was different between groups with the PVP group having a higher INR than all other procedures except in 2014 where TURP for regrowth was 1.12 and PVP was 1.11. Except for 2011, ASA was different between groups in all years with the highest ASA in the TURP for regrowth group in every year.

Table 2 summarizes perioperative outcomes and complications of the different procedures for all years 2011 to 2015. Operative time was different between groups for all years studied. Simple prostatectomy was longest in every year except 2011 where it was eclipsed by HoLEP, 136 vs 114 minutes. The operative time for HoLEP improved in the later years to 101–107 minutes, about 50 minutes longer than TURP or PVP, whereas simple prostatectomy was longer from 2013 to 2015 (124–129 minutes) than during years 2011 to 2012 (112–114 minutes). Length of stay was different between surgery groups for all years studied. The shortest stays were for PVP (0.8–1.3 days), but HoLEP was comparable (1.2–1.6 days). The longest hospitalizations were after simple prostatectomy (8.9 days in 2011, 3.9–4.4 days from 2012 to 2015), followed by TURP for regrowth (1.8–3.2 days) and TURP (1.9–2.9 days).

Table 2.

Perioperative Outcomes by Year and Operation

	TURP	TURP regrowth	PVP	HoLEP	Simple prostatectomy	p
2011
Operative time ± SD (minutes)	52 ± 38	47 ± 33	55 ± 37	136 ± 91	114 ± 64	<0.001
Length of stay ± SD (days)	2.9 ± 8.0	2.8 ± 8.7	1.1 ± 4.8	1.3 ± 1.6	8.9 ± 36.2	<0.001
Transfusion (%)	2.8	3.2	0.8	2.2	23.1	<0.001
Reoperation (%)	2.4	2.8	1.3	1.5	1.0	0.2
Readmission (%)	6.9	7.1	5.9	3.7	9.9	0.3
Urinary tract infection (%)	5.7	5.7	6.7	3.0	6.7	<0.001
2012
Operative time ± SD (minutes)	51 ± 38	44 ± 32	54 ± 32	107 ± 68	112 ± 54	<0.001
Length of stay ± SD (days)	2.5 ± 6.5	3.2 ± 17.2	1.3 ± 6.0	1.6 ± 4.8	4.2 ± 2.5	<0.001
Transfusion (%)	2.7	4.3	0.8	3.4	23	<0.001
Reoperation (%)	2.3	2.2	1.4	1.0	1.8	0.2
Readmission (%)	6.7	6.3	6.0	4.1	6.6	0.5
Urinary tract infection (%)	5.8	3.6	4.8	2.8	4.2	0.05^a
2013
Operative time ± SD (minutes)	54 ± 40	52 ± 50	55 ± 39	102 ± 74	124 ± 55	<0.001
Length of stay ± SD (days)	2.3 ± 6.7	2.2 ± 6.2	0.9 ± 3.9	1.2 ± 2.0	4.0 ± 3.3	<0.001
Transfusion (%)	2.1	2.3	0.3	1.6	25.4	<0.001
Reoperation (%)	1.9	2.9	1.7	1.3	6.7	<0.001
Readmission (%)	5.9	6.3	5.4	4.8	7.2	0.7
Urinary tract infection (%)	4.9	3.4	5.9	3.0	5.7	<0.05
2014
Operative time ± SD (minutes)	56 ± 41	47 ± 32	55 ± 39	101 ± 55	126 ± 58	<0.001
Length of stay ± SD (days)	1.9 ± 4.4	1.8 ± 3.1	0.9 ± 4.4	1.3 ± 3.7	3.9 ± 2.9	<0.001
Transfusion (%)	1.9	1.6	0.8	1.0	16.1	<0.001
Reoperation (%)	1.9	3.2	1.4	1.8	1.8	0.09^a
Readmission (%)	5.8	6.4	4.6	2.8	6.7	0.03
Urinary tract infection (%)	4.7	5.4	5.3	4.1	6.2	0.5
2015
Operative time ± SD (minutes)	56 ± 37	51 ± 35	55 ± 33	102 ± 62	129 ± 59	<0.001
Length of stay ± SD (days)	1.9 ± 4.6	2.2 ± 5.2	0.8 ± 3.6	1.3 ± 2.4	4.4 ± 3.9	<0.001
Transfusion (%)	1.8	2.7	0.7	0.8	16.0	<0.001
Reoperation (%)	2.4	2.2	1.7	2.1	3.0	0.2
Readmission (%)	5.6	5.6	6.1	5.6	7.0	0.8
Urinary tract infection (%)	4.3	4.5	5.9	1.7	4.1	<0.001

Possible trend toward significance.

Boldface indicates statistically significant p < 0.05.

Transfusion rates were different between surgery groups for all years studied, and not surprisingly simple prostatectomy had the highest transfusion rates (16.0%–25.4%). The lowest transfusion rates were seen after PVP (0.3%–0.8%), closely followed by HoLEP (0.8%–3.4%), then by TURP and TURP for regrowth (1.6%–4.3%). There were no differences in reoperation rates except for year 2013 (HoLEP 1.3%, PVP 1.7%, TURP 1.9%, TURP for regrowth 2.9%, simple prostatectomy 6.7%, p < 0.001). There were no differences in readmission rates except for year 2014 (HoLEP 2.8%, PVP 4.6%, TURP 5.8%, TURP for regrowth 6.4%, simple prostatectomy 6.7%, p = 0.03). For postoperative UTI, there were differences between groups in 2011, 2013, and 2015 with a possible trend in 2012, and HoLEP had the lowest rate at each year studied.

Table 3 demonstrates little to no change in proportions of each operation for BPH from years 2011 to 2015.

Table 3.

Proportion of Different Benign Prostatic Hyperplasia Surgeries by Year

Year	2011	2012	2013	2014	2015
Total No. of cases	3788	5851	6872	7898	10,655
TURP (%)	58	57	55	56	58
TURP-regrowth (%)	7	8	7	6	6
PVP (%)	28	27	30	30	29
HoLEP (%)	4	5	5	5	5
Simple prostatectomy (%)	3	3	3	3	3

Discussion

In this study using the ACS-NSQIP database, we have reported the largest comparative dataset to date for HoLEP, TURP, PVP, and simple prostatectomy. The expansion of HoLEP has been stagnant despite its documented advantages, including less blood loss, shorter catheter time, and decreased hospital stay.^12,13 Many cite its learning curve, but in reality, this is not excessive being reported as 27 or 50 cases with fewer cases needed if under expert supervision.^14
–16 During the learning curve, a HoLEP can be safely abandoned and switched to a TURP. The adoption of robotic prostatectomy faced a similar learning curve, but this was incorporated in practice and residency training without the level of evidence that HoLEP already has had for over a decade.^12,17,18 Only recently has a randomized controlled trial been conducted to compare robotic radical prostatectomy to the open retropubic approach.¹⁹ The data from our study further support that HoLEP is comparable to PVP with regard to transfusion rate and length of hospital stay. In addition, HoLEP appears superior with regard to reoperation and readmission rates, although significant differences were only seen in 2013 and 2014, respectively. These outcomes are tracked to 30 days in ACS-NSQIP, and thus, for reoperation one can infer that this was mainly done for clot evacuation. There were also lower rates of UTI seen after HoLEP than all other procedures which was significant in 3 out of 5 years studied. This is most likely a result of shorter catheter time for HoLEP which was significantly shorter in a large meta-analysis comparing HoLEP and TURP and reported at an average of a large single center experience.^8,13

Why is HoLEP, often called the “gold standard” for BPH surgical treatment, performed at such low rates? As demonstrated in Table 3, HoLEP comprised only 4% to 5% of all major BPH surgeries performed from 2011 to 2015, barely more than simple prostatectomy (3%). The ratio of TURP to PVP in this study is 1.97:1 which compared to that from 2007 to 2012 was 1.86:1 (65% TURP vs 35% PVP).²⁰ This increase in TURP may reflect the adoption of bipolar TURP. The HoLEP procedure is not cost-prohibitive given that most urologists already frequently use a holmium:yttrium-aluminum-garnet laser for laser lithotripsy, and the laser fibers are reusable. A previous study demonstrated HoLEP as being 10% less costly than open simple prostatectomy.²¹ Compared to TURP, HoLEP costs 24.5% less in the first year in a randomized prospective study.²² Some urologists may be hesitant to learn HoLEP over concerns with use of the morcellator and also postoperative short-term urinary incontinence. From a 10-year experience of over 1000 HoLEP procedures, Krambeck et al. reported only one morcellator complication in the large cohort and a short-term postoperative stress urinary incontinence rate of 12.5% that decreased to 1.8% on long-term follow-up.⁸ Importantly, from a large meta-analysis of six randomized controlled trials, there was no difference in postoperative stress urinary incontinence between men who underwent HoLEP compared to TURP.¹³ Future studies of the reasons why urologists do not practice HoLEP would be beneficial to help the field better utilize this procedure for patients suffering from BPH. Open simple prostatectomy should be performed as a last resort if HoLEP is not available given its high morbidity as evident from this study (16%–25.4% transfusion rate, 3.9–8.9 day hospital stay, and 6.6%–9.9% 30-day readmission rate). Robotic simple prostatectomy is more invasive than HoLEP and from a multi-institutional study had higher transfusion rates, blood loss, catheter duration, and hospital stay compared to HoLEP.⁶ From the ACS-NSQIP data presented herein, there also appears to be a disparity for higher rates of African American men having this invasive type of BPH operation. Further studies should investigate factors affecting BPH treatment options for African American men.

Although from the ACS-NSQIP data PVP had a higher INR in all years except 2014, patients undergoing BPH surgery on anticoagulation can safely have either PVP or HoLEP. Contrary to PVP, HoLEP has the advantage of removing tissue for pathologic analysis. Furthermore, durability of HoLEP is superior to TURP or PVP, with BPH long-term reoperation rates for HoLEP being 0.1% to 0.7% after 5 to 10 years.^8,23 For comparison, reported long-term reoperation rates are 7.4% at 8 years for TURP and 5.6% for PVP at 1 year.^24,25 From the ACS-NSQIP data presented herein, the patients who underwent TURP for regrowth were an average of 2 years older than those undergoing TURP, and from Table 3 the rate of TURP for regrowth was an average of 6.8% from 2011 to 2015. In addition, from the studies mentioned above the risk of bladder neck contracture or stricture after HoLEP is low, 2.4% to 2.6% after 5 to 10 years which are comparable to that for PVP and TURP.^8,23,25

The higher operative time for HoLEP, although partially attributable to morcellation, can be explained from the learning curve but also likely from the size of prostates typically treated with HoLEP compared to TURP or PVP. For example, the average preoperative transrectal ultrasound (TRUS) volume in a previously reported 1000 HoLEP series was 99.3 g compared to the Goliath Study showing 48.6 g for PVP and 46.2 g for TURP.^2,8 From the ACS-NSQIP data, there are no prostate size measurements available, but a possible indicator of this is the higher BMI seen in the HoLEP and simple prostatectomy groups as a prior study.²⁶ These data should challenge urologists to embrace and utilize HoLEP as the new gold standard for patients with BPH requiring surgical intervention.

A limitation of this study is its retrospective nature, relying on information obtained from the NSQIP database. However, given the extremely large number of hospitals and cases represented in this database, we feel that it does represent practice patterns and outcomes well for BPH surgical treatment in the United States. Future studies of other populations using similar large databases will be helpful to confirm our findings. As previously mentioned, the absence of a CPT code for robotic simple prostatectomy only allows us to infer that a portion of the simple prostatectomy cases in the years studied herein is attributed to robotic cases rather than open. From 2011 to 2014, 1% to 3% of open simple prostatectomy cases were outpatient procedures which could represent the robotic cases. The outpatient rate rose to 7% in 2015, possibly indicating a rise in robotic simple prostatectomy. Supporting this assumption is the 16.2% decrease in number of radical prostatectomies since the USPSTF recommendation against population-based PSA screening in 2012.⁷

Conclusions

From the ACS-NSQIP database, using data from 2011 to 2015 on 35,064 major BPH procedures, HoLEP was found to have lower rates of UTI, reoperation, and readmission. Transfusion rates and length of hospital stay closely followed PVP. The safety profile of open simple prostatectomy indicate that it should only be performed as a last resort, but a robotic approach may be an option although initial studies indicate inferior perioperative outcomes compared to HoLEP. Given the previously reported long-term follow-up of HoLEP, these data support the notion that this procedure should be offered much more commonly for patients requiring surgical intervention for BPH.

Footnotes

Author Disclosure Statement

No competing financial interests exist.

Abbreviations Used

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Trends and Perioperative Outcomes Across Major Benign Prostatic Hyperplasia Procedures from the ACS-NSQIP 2011–2015

Abstract

Background and Purpose:

Methods:

Results:

Conclusions:

Introduction

Methods

Results

Discussion

Conclusions

Footnotes

Author Disclosure Statement

Abbreviations Used

References