Editorial Comment on: “Ambulatory-Based Bladder Outlet Procedures Offer Significant Cost Savings and Comparable 30-Day Outcomes Relative to Inpatient Surgery” by Nguyen et al.

The Heterogeneous Health Care Landscape—Regional Differences

One must be cautious when extrapolating findings in large states such as Florida and New York to other areas of the country. Multiple studies have reported significant regional variability in treating a variety of urologic conditions. ^2,3 Wennberg and colleagues ⁴ observed the utilization of transurethral resection of the prostate (TURP) for BPH treatment ranged from 6/1000 male Medicare patients up to 23/1000 male Medicare patients depending on geographical location.

The current authors observe that “small metro area, micropolitan, and rural patients were more likely to receive care in the ambulatory setting likely due to reduced access to patient care.” Consistent with their findings is compelling data to suggest that there is growing urbanization of the United States. It is projected that from 2010 to 2030, the number of Americans living in urban areas with populations >300,000 will increase from 180 million to 220 million. ⁵ In addition, there is a trend for urologists to practice in more populated areas, which will compound the urologist shortage with a urologist maldistribution. ⁶ This may exacerbate the regional differences and utilization of procedures even further.

The Buffet of Health Insurance Options

The authors also found utilization differences based on the patient's health insurance type. Today, patients have a myriad of health insurance options—Obamacare, Medicare, Medicaid, Veterans Administration Insurance, and private insurance is a partial list. It is no secret that single-payer universal health care has been seriously discussed during the current campaign season. What the nature of health insurance will be in the future is perhaps more uncertain now than ever before. ^7,8 The ultimate resolution of this issue will have an enormous influence on the treatment options and settings of BPH intervention in the future.

Build It and They Will Come—Impact of New Technology

Thirty years ago, Logan Holtgrewe was the prophet of the changing panorama of BPH treatment. He observed the emerging role of medical therapy for BPH and decreased reimbursement for surgical interventions. ^{9 –11} Today the majority of BPH patients are managed with medications or watchful waiting. ¹² However, there continues to be active research on a variety of minimally invasive approaches for BPH treatment, which promise to make outpatient surgery more prevalent and attractive. ¹³

The Elephant in the Room—Postoperative UTIs

The authors report ¹ an alarming rate of 15% of urinary tract infection associated with bladder outlet surgery, which was the most common diagnosis associated with a revisit. In the United States, UTIs result in an estimated 7 million office visits, 1 million emergency department visits, and >100,000 hospitalizations with an associated annual cost of $1.6 billion. ¹⁴ Osman and colleagues ¹⁵ in a prospective series of 100 patients treated with TURP, identified the following risk factors for UTI: old age, history of diabetes mellitus, large prostate size, positive preoperative U/A and C+S, preoperative catheterization, previous urologic interventions, large size of resectoscope sheath, duration of operation, postoperative catheterization, and postoperative bladder irrigation. ¹⁵

Regardless of the modality used to treat prostatic obstruction or whether the setting is inpatient or outpatient, the most compelling message from Nguyen and colleagues ¹ would appear to be the need to mitigate the UTI risk factors. This challenge goes far beyond prostate surgery as the cost of antibiotics and incidence of resistant organisms both continue to escalate. ¹⁶ As the male population continues to age, it will be even more critical to develop treatment strategies that are both successful and cost-effective.