Holmium laser enucleation of the prostate (HoLEP) is recognized as a size-independent treatment for benign prostatic hyperplasia (BPH), and when compared to transurethral resection of the prostate (TURP), is demonstrated to have superior outcomes in less blood loss, shorter catheterization time, decreased hospital stay, and durability.¹ For these reasons, many agree HoLEP has become the new gold standard for surgical treatment of BPH, particularly for larger prostates. When considering patient-reported outcomes with HoLEP, nearly all studies demonstrate a statistically significant and durable improvement in quality of life (QoL). In a retrospective study of 96 patients, Alkan and colleagues reported a mean International Prostate Symptom Score (IPSS) of 2.6 and QoL of 1.1 at 7 years following HoLEP compared to IPSS 22.1 and QoL 4.6 preoperatively.² Sun and colleagues compared QoL in 1,193 patients who underwent HoLEP (n = 754) vs photovaporization of the prostate (n = 439) and found the degree of improvement in QoL at 60 months was greater for HoLEP.³ The improved QoL for HoLEP was attributed to the durability of surgical outcomes supported by improvement in voiding symptoms, peak flow rate, and reduction in serum PSA at long-term follow-up.

When considering the cost of HoLEP, several studies have demonstrated the cost-effectiveness of the procedure. Crivellaro and colleagues used a Markov chain model to create cost-effectiveness trade-off curves across different BPH severities and assessing patient outcomes via IPSS.⁴ The model found HoLEP to have superior cost-effectiveness at any BPH severity compared to TURP. These findings were corroborated by Aladesuru et al, who reviewed the economics of surgical treatment options for BPH and similarly found that HoLEP demonstrated superior cost-effectiveness for mild, moderate, and severe BPH.⁵ In a cost analysis comparing HoLEP, bipolar TURP, and open prostatectomy (OP), Schiavina et al reported the median global costs for HoLEP to be similar to TURP, but significantly lower when compared to OP (€2,174.15 vs €4,064.97, P < .001).⁶ The reduced cost of HoLEP was due to a 4-day decrease in length of hospital stay compared to OP. The cost of HoLEP has also been compared to convective water vapor thermal therapy (Rezum) and found to have lower total cost (€2,005 vs €2,228). Convective water vapor thermal therapy had reduced cost of hospitalization compared to HoLEP, but the disposable device significantly increased the cost of surgery.⁷

The landscape of HoLEP has dramatically changed with new developments in holmium laser technology. The introduction of holmium laser pulse modulation, or Moses technology, has been shown in randomized controlled trials to decrease total operative time and hemostasis time.⁸ The question that is commonly raised is whether the introduction of this new technology increases cost. In a post-hoc cost analysis performed using data obtained from patients with ≥80 g prostates randomized to undergo HoLEP using Moses laser settings (M-HoLEP) or standard laser settings (HoLEP), Nimmagadda et al found the mean costs to the hospital per case between M-HoLEP and HoLEP were $4,272 vs $5,068 (Figure 1).⁹ When considering the cost of each machine amortized over 1,000 procedures, the mean cost of each M-HoLEP increases to $4,492 compared to $5,213.13 per HoLEP, favoring M-HoLEP (Figure 2). This study found approximately 277 cases are required to recuperate the cost of the laser, suggesting a benefit particularly for high-volume centers. Similar significant cost savings for M-HoLEP were found by Lee and colleagues, who reported an $840 decrease per case compared to standard HoLEP.¹⁰ The cost savings were predominantly driven by reduced operative time per case. Perhaps the most significant benefit of this technology has been the ability to offer many patients same-day surgery, avoiding the considerable costs associated with an inpatient hospital stay.

Despite the benefits in QoL, cost, and the durability of patient outcomes, there is evidence that HoLEP is not adequately reimbursed in the U.S. compared to other BPH procedures. HoLEP has been more readily adopted globally, where reimbursement systems differ. The current reimbursement system in the U.S. does not adequately recognize surgeon skill and procedural outcomes. Using National Surgical Quality Improvement Program data from over 27,000 cases, Jiang and colleagues evaluated whether current work relative value unit (wRVU) assignments for 5 BPH procedures (HoLEP, TURP, photovaporization of the prostate, and retropubic and suprapubic simple prostatectomy) accounted for operative time and complexity of the procedure.¹¹ When using Relative Value Update Committee-estimated operating room times, TURP had the highest wRVU/h at 12.2, and HoLEP the lowest at 7.3 wRVU/h. The results were similar for measured operating room time, where TURP had the highest wRVU/h compared to HoLEP and simple prostatectomy (19.1 vs 9.4 vs 7.3). These findings have caused many to question whether the current reimbursement model risks disincentivizing complex BPH care with less effective treatments compensating more for the time required to complete them.¹²