Contemporary Trends of Holmium Laser Enucleation of the Prostate Utilization in the United States: A Comprehensive Analysis Using the National Surgical Quality Improvement Program Database (2011

Abstract

Introduction:

The most recent American Urological Association (AUA) Guidelines advocated laser enucleation of the prostate (LEP) as a size-independent surgical option for benign prostatic hyperplasia (BPH). Despite its endorsement by AUA and the growing body of evidence supporting its safety and efficacy, the utilization of LEP remains limited in the United States. This study aimed to evaluate the utilization trends and perioperative outcomes of LEP compared with other surgical procedures used for BPH management.

Methods:

A retrospective cohort analysis was performed using American College of Surgeons National Surgical Quality Improvement Program data from 2011 to 2020. Patients undergoing prostatectomy for BPH were identified using specific current procedural terminology (CPT) codes. Baseline demographic data, preoperative risk factors, and postoperative outcomes were collected. Multivariable logistic regression was employed to assess predictors of holmium laser enucleation of the prostate (HoLEP) utilization and postoperative complications.

Results:

Out of 8,415,549 patients, 95,144 underwent prostatectomy for BPH. Procedures included HoLEP 5305 cases, transurethral resection of the prostate (TURP) 57,803 cases, repeated TURP (re-TURP) 5549 cases, photoselective vaporization of the prostate (PVP) 23,739 cases, and simple prostatectomy 2748 cases. HoLEP utilization showed a gradual increase, from 4.8% in 2015 to 7.6% in 2020. Multivariable regression revealed that HoLEP selection significantly increased from 2016 to 2020 (odds ratio [OR]: 1.251, p < 0.001), and there was less likelihood of HoLEP selection for African American patients (OR: 0.752, p < 0.001). HoLEP had significantly lower complication rates, including urinary tract infections, blood transfusions, 30-day readmission, and reoperation.

Conclusion:

Despite underutilization, the adoption of HoLEP has slightly increased since 2015, rising from 4.8% in 2015 to 7.6% in 2020. The underutilization could be attributed to a lack of availability and the steep learning curve.

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References

Verhamme

, Dieleman

, Bleumink

, et al. Incidence and prevalence of lower urinary tract symptoms suggestive of benign prostatic hyperplasia in primary care—The Triumph project. Eur Urol, 2002; 42(4):323–328; doi: 10.1016/S0302-2838(02)00354-8

Michielsen

, Coomans

, Braeckman

, et al. Bipolar transurethral resection in saline: The solution to avoid hyponatraemia and transurethral resection syndrome. Scand J Urol Nephrol, 2010; 44(4):228–235; doi: 10.3109/00365591003720275

Oelke

, Bachmann

, Descazeaud

, et al. EAU guidelines on the treatment and follow-up of non-neurogenic male lower urinary tract symptoms including benign prostatic obstruction. Eur Urol, 2013; 64(1):118–140; doi: 10.1016/j.eururo.2013.03.004

Gilling

, Kennett

, Das

, et al. Holmium laser enucleation of the prostate (HoLEP) combined with transurethral tissue morcellation: An update on the early clinical experience. J Endourol, 1998; 12(5):457–459; doi: 10.1089/end.1998.12.457

Zhong

, Feng

, Peng

, et al. A systematic review and meta-analysis of efficacy and safety following holmium laser enucleation of prostate and transurethral resection of prostate for benign prostatic hyperplasia. Urology, 2019; 131:14–20; doi: 10.1016/j.urology.2019.03.034

Jones

, Alzweri

, Rai

, et al. Holmium laser enucleation versus simple prostatectomy for treating large prostates: Results of a systematic review and meta-analysis. Arab J Urol, 2016; 14(1):50–58; doi: 10.1016/j.aju.2015.10.001

Bachmann

, Tubaro

, Barber

, et al. A European multicenter randomized noninferiority trial comparing 180 W GreenLight XPS laser vaporization and transurethral resection of the prostate for the treatment of benign prostatic obstruction: 12-Month results of the GOLIATH study. J Urol, 2015; 193(2):570–578; doi: 10.1016/j.juro.2014.09.001

Thomas

, Tubaro

, Barber

, et al. A multicenter randomized noninferiority trial comparing GreenLight-XPS laser vaporization of the prostate and transurethral resection of the prostate for the treatment of benign prostatic obstruction: Two-yr outcomes of the GOLIATH study. Eur Urol, 2016; 69(1):94–102; doi: 10.1016/j.eururo.2015.07.054

Pfitzenmaier

, Gilfrich

, Pritsch

, et al. Vaporization of prostates of ≥80 mL using a potassium-titanyl-phosphate laser: Midterm-results and comparison with prostates of <80 mL. BJU Int, 2008; 102(3):322–327; doi: 10.1111/j.1464-410X.2008.07563.x

10.

Stone

, Chughtai

, Forde

, et al. Safety and efficacy of GreenLight XPS laser vapoenucleation in prostates measuring over 150 mL. J Endourol, 2016; 30(8):906–912; doi: 10.1089/end.2016.0288

11.

Hueber

, Bienz

, Valdivieso

, et al. Photoselective vaporization of the prostate for benign prostatic hyperplasia using the 180 watt system: Multicenter study of the impact of prostate size on safety and outcomes. J Urol, 2015; 194(2):462–469; doi: 10.1016/j.juro.2015.03.113

12.

Lerner

, McVary

, Barry

, 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):818–826; doi: 10.1097/JU.0000000000002184

13.

Anderson

, Heiman

, Large

, et al. Trends and perioperative outcomes across major benign prostatic hyperplasia procedures from the ACS-NSQIP 2011–2015. J Endourol, 2019; 33(1):62–68; doi: 10.1089/end.2018.0266

14.

Elzayat

, Habib

, Elhilali

. Holmium laser enucleation of the prostate in patients on anticoagulant therapy or with bleeding disorders. J Urol, 2006; 175(4):1428–1432; doi: 10.1016/S0022-5347(05)00645-2

15.

Rivera

, Krambeck

, Lingeman

. Holmium laser enucleation of the prostate in patients requiring anticoagulation. Curr Urol Rep, 2017; 18:1–5; doi: 10.1007/s11934-017-0727-2

16.

Zhang

, El Tayeb

, Borofsky

, et al. Comparison of perioperative outcomes between holmium laser enucleation of the prostate and robot-assisted simple prostatectomy. J Endourol, 2017; 31(9):847–850; doi: 10.1089/end.2017.0095

17.

Elzayat

, Habib

, Elhilali

. Holmium laser enucleation of prostate for patients in urinary retention. Urology, 2005; 66(4):789–793; doi: 10.1016/j.urology.2005.04.049

18.

Mitchell

, Mynderse

, Lightner

, et al. Efficacy of holmium laser enucleation of the prostate in patients with non-neurogenic impaired bladder contractility: Results of a prospective trial. Urology, 2014; 83(2):428–432; doi: 10.1016/j.urology.2013.09.035

19.

Robert

, Cornu

, Fourmarier

, et al. Multicentre prospective evaluation of the learning curve of holmium laser enucleation of the prostate (Ho LEP). BJU Int, 2016; 117(3):495–499; doi: 10.1111/bju.13124

20.

Gilling

, Mackey

, Cresswell

, et al. Holmium laser versus transurethral resection of the prostate: A randomized prospective trial with 1-year followup. J Urol, 1999; 162(5):1640–1644; doi: 10.1016/S0022-5347(05)68186-4

21.

Robles

, Pais

, Miller

. Mind the gaps: Adoption and underutilization of holmium laser enucleation of the prostate in the United States from 2008 to 2014. J Endourol, 2020; 34(7):770–776; doi: 10.1089/end.2019.0603

22.

Wright

, Fedrigon

, De

. Learning from those who learned: A survey of fellowship trained HoLEP surgeons and their current practice patterns. Urology, 2021; 149:193–198; doi: 10.1016/j.urology.2020.12.023

23.

Kim

, Byun

. Robotic-assisted simple prostatectomy versus holmium laser enucleation of the prostate for large benign prostatic hyperplasia: A single-center preliminary study in Korea. Prostate Int, 2022; 10(3):123–128; doi: 10.1016/j.prnil.2022.05.004

24.

Elshal

, Nabeeh

, Eldemerdash

, et al. Prospective assessment of learning curve of holmium laser enucleation of the prostate for treatment of benign prostatic hyperplasia using a multidimensional approach. J Urol, 2017; 197(4):1099–1107; doi: 10.1016/j.juro.2016.11.001

25.

Shelton

, Drake

, Vasquez

, et al. Comparison of contemporary surgical outcomes between holmium laser enucleation of the prostate and robotic-assisted simple prostatectomy. Curr Urol Rep, 2023; 24(5):221–229; doi: 10.1007/s11934-023-01146-9

26.

Umari

, Fossati

, Gandaglia

, et al. Robotic assisted simple prostatectomy versus holmium laser enucleation of the prostate for lower urinary tract symptoms in patients with large volume prostate: A comparative analysis from a high volume center. J Urol, 2017; 197(4):1108–1114; doi: 10.1016/j.juro.2016.08.114

27.

Elmansy

, Baazeem

, Kotb

, et al. Holmium laser enucleation versus photoselective vaporization for prostatic adenoma greater than 60 ml: Preliminary results of a prospective, randomized clinical trial. J Urol, 2012; 188(1):216–221; doi: 10.1016/j.juro.2012.02.2576

28.

Cho

, Song

, Park

, et al. Long-term outcomes of laser prostatectomy for storage symptoms: Comparison of serial 5-year followup data between high performance system photoselective vaporization and holmium laser enucleation of the prostate. J Urol, 2018; 199(6):1591–1599; doi: 10.1016/j.juro.2018.01.022

29.

Jain

, Nassour

, Khannani

, et al. Australian surgical revision rate for benign prostatic obstruction. BJU Int, 2023; 131:43–47; doi: 10.1111/bju.16031

30.

Kaplan

, Kaufman

Jr ., Mueller

, et al. Retreatment rates and postprocedural complications are higher than expected after BPH surgeries: A US healthcare claims and utilization study. Prostate Cancer Prostatic Dis, 2023; 1–7; doi: 10.1038/s41391-023-00741-8

Contemporary Trends of Holmium Laser Enucleation of the Prostate Utilization in the United States: A Comprehensive Analysis Using the National Surgical Quality Improvement Program Database (2011–2020)