Comparative evaluation of clinical efficacy, safety, and economic expenses of two endoscopic techniques for treating prostatic hyperplasia in elderly patients

Introduction. Rapidly developing highly specialized medical care and the emergence of new medical technologies determine the trend in surgical, minimally invasive treatment of patients with lower urinary tract symptoms due to prostatic hyperplasia. Drug therapy in elderly patients with somatic diseases poses a problem of poor compliance due to pronounced side effects caused by a drug. In this group of patients, surgical treatment of prostate hyperplasia is the most preferred solution. A doctor’s task is to choose the optimal method of surgery which will not only provide a long-term clinical effect, but also will minimize the economic costs of both surgical intervention and the postoperative period. The emergence of various types of energies for enucleating the prostate gland in urological practice has become an attractive alternative to transurethral resection of the prostate (TURP). However, when choosing surgical endoscopic intervention, it is important to consider the economic factor, which is considered to be a crucial problem in the medical care in Russia. Modern treatment options can not only prevent serious complications, and additional surgical interventions, but also improve the quality of patients’ lives. However, the introduction of new technologies is impossible without taking into account data on their cost-effectiveness.

Purpose. To compare the results and evaluate cost-effectiveness of two types of BPH endoscopic surgical treatment (bTURP, HOLEP) in elderly patients (>60 years old).

Materials and methods. The study includes patients who underwent two different methods of endoscopic treatment of HPV (bTURP, HOLEP) from October 2017 to September 2018. The inclusion criteria were the presence of moderate or severe obstructive symptoms of the lower urinary tract, prostate volume >40 cm³, maximum urine flow <15 ml/sec. The exclusion criteria were the presence of cystostomy drainage, oncological process of the urinary system, active inflammatory process of the genitourinary system, previous surgical interventions on the organs of the urinary system, and symptoms of an overactive bladder. In each group of the patients the following indicators were evaluated the international system for the total assessment of prostate diseases (IPSS and QoL), the international index of erectile function, the dynamics of postoperative changes in prostate-specific antigen, the maximum urine flow, the residual volume, safety of the operation, intraoperative and postoperative economic expenses as well as socio-economic consequences. Cost-effectiveness analysis was carried out by calculating the indicators “cost-effectiveness”, “cost-utility”, net monetary benefit. 20-year prediction of the results was carried out by building the Markov chain model.

Results. 150 patients operated within a year were examined. HOLEP has showed its clinical efficacy before bTURP in terms of the duration of surgery, the volume of tissue removed, the time of postoperative catheterization and the length of hospital stay which was significantly lower in the HOLEP group. However, the economic expenses associated with HOLEP were also higher compared to the bTURP group.

Conclusions. Holmium laser enucleation is the preferred method for surgical treatment of prostatic hyperplasia in the prostate of more than 40 cm³, from the point of view of surgical safety, effectiveness, and also the length of the patient’s recovery period in elderly patients. Moreover, laser operations are considered to be economically reasonable in comorbid patients associated with a minimal risk of complications.