Lee MS, Assmus M, Agarwal D et al: A cost comparison of holmium laser enucleation of the prostate with and without MosesTM. Urol Pract 2021; 8: 624.

Introduction

Holmium laser enucleation of the prostate (HoLEP) is a size-independent treatment option for benign prostatic hyperplasia. HoLEP has been shown to have excellent improvements in prostate symptom scores and maximum flow rates that have been durable for 2 decades. However, the steep learning curve associated with HoLEP has prevented its widespread adoption. New advancements in lasers, specifically the Moses™ pulse-modulation technology, have resulted in improvements in hemostasis and led to successful same-day discharges and catheter removals after HoLEP. Given the clinical benefits seen with Moses 2.0-augmented HoLEP (m-HoLEP), we aimed to perform a cost analysis of m-HoLEP vs HoLEP. We hypothesized that m-HoLEP would result in cost savings that were driven primarily by the ability to achieve same-day discharges and low emergency department (ED) visit/readmission rates.

Methods

We performed a retrospective review of all patients who underwent HoLEP from May 2018–November 2020 by 1 fellowship trained surgeon who has been performing HoLEP for 20 years and is well past the learning curve.¹ In June 2019, we began performing m-HoLEP. Prior to this, HoLEP was performed using the Lumenis™ 120H laser without Moses 2.0 using either a 550 μm or 1,000 μm SlimLine™ laser fiber. We obtained baseline patient variables as well as the rates of 30-day postoperative complications, 30-day unplanned clinic visits, and 30-day ED visits and readmissions. Hospital cost data for the initial surgical episode, as well as ED visits and readmissions, were obtained by the Indiana University Office of Clinical Effectiveness (these are not charges billed to the patient or actual payments received from the payer). Due to institutional policy, we could not report absolute hospital cost data, only cost differences.

Results

Figure. Bar graph comparing hospital costs between HoLEP and m-HoLEP. Absolute costs cannot be shown due to institutional policy. m-HoLEP had hospital cost savings of $840 per case for initial surgical episode, which was statistically significant (p=0.0297). Costs for readmissions (orange) and ED visits are shown as well. Mean hospital costs for m-HoLEP on ED visits and readmissions were lower by $3,220, but difference was not statistically significant (p=0.123). Total costs were $747 lower for m-HoLEP (p=0.0574).

A total of 312 men underwent HoLEP during the study period, of whom 192 underwent m-HoLEP and 120 underwent standard HoLEP. Comparing the intraoperative characteristics between the 2 groups, the operative time tended to be shorter in the m-HoLEP group (74.1±35.0 vs 80.8±45.4 minutes), but this difference was not statistically or clinically significant (p=0.686).

When examining 30-day postoperative complications, there was no difference in blood transfusion or complication rates. Similarly, there were no differences in unplanned clinic visits or readmission rates between m-HoLEP and HoLEP (p=0.437 and p=0.558, respectively). However, there were more 30-day ED visits for m-HoLEP than HoLEP (6.3% vs 1.7%, p=0.0571). Of note, 90% of m-HoLEP return visits occurred before January 2020 during our initial pilot period of same-day discharge and same-day catheter removal. No ED visits/readmissions occurred after May 2020.

The mean hospital costs (including equipment use and disposables) were significantly less for m-HoLEP than for HoLEP (p=0.0297), resulting in initial hospital cost savings of $840 (see figure). Savings were driven by ability to perform same-day discharge and shorter operative times. Although m-HoLEP had more ED visits, when comparing costs of ED visits and readmissions between the 2 groups, costs of these visits were lower for the m-HoLEP group by $3,220 (p=0.123). Comparing total costs (including initial surgery and 30-day ED visits/readmissions), m-HoLEP still resulted in hospital cost savings of $747 per case (p=0.0574).

Conclusion

In this retrospective series, m-HoLEP was associated with same-day patient discharge. m-HoLEP was found to be cost-effective with a hospital savings of $840 per case for the initial surgical episode compared to HoLEP. Further study in other institutions and with surgeons of varying experience levels will need to be performed to see if these results can be reproduced.