Cost-Effectiveness of Contemporary Surgical Treatment Options for Benign Prostatic Hyperplasia

Abstract

Objective:

To compare the cost-effectiveness of all guideline-supported surgical management options for BPH, stratified by prostate size.

Methods:

Using a microsimulation model, a cost-effectiveness analysis was performed comparing all guideline-supported surgical management options for BPH, stratified by prostate size. Model probabilities were based on published values and effectiveness was calculated using post-operative outcomes. Costs were from a U.S. Medicare payer perspective, with quality-adjusted life years (QALYs) and incremental cost-effectiveness ratios (ICERs) used to assess cost-effectiveness.

Results:

At a lifetime horizon for patients with 30–80cc prostate size, HoLEP resulted in the highest QALYs (12.25), followed by iTIND (12.02) and WVTT (11.98). BPH costs per patient ranged from $6,557 (WVTT) and $8,431 (HoLEP) to $16,230 (PAE), with a low ICER for HoLEP ($6,931/QALY). For large glands (80–150cc), HoLEP resulted in nearly identical effectiveness relative to SP (12.25 vs. 12.26 QALYs) and more than RWT (12.19 QALYs). HoLEP had a significantly lower cost ($8,361) than SP ($19,012), RWT ($11,969), and PAE ($16,230) and was therefore cost-effective. However, for both index patients, cost-effectiveness was dependent on the value placed on post-operative ejaculatory dysfunction and post-surgery urinary symptom improvement.

Conclusion:

At base-case with population-level assumptions, HoLEP is the most cost-effective BPH surgical option for patients with average or large prostate size. However, this is highly dependent upon patient priorities, highlighting the importance of surgical selection driven by individual patient preferences.

INTRODUCTION

Benign prostatic hyperplasia (BPH) is the most common cause of lower urinary tract symptoms among men and has a prevalence approaching 60% at age 60.^1,2 Furthermore, the incidence and impact of BPH is increasing and is associated with a higher burden of disease than prostate cancer, urolithiasis, and bladder cancer combined. This is likely reflective of an aging population and the chronic nature of the disease process.³ Although most patients are managed conservatively, approximately 2–10% of men with BPH undergo surgical intervention.^4,5

For those patients in whom surgical intervention is indicated, a multitude of options are available. The rate of BPH surgical development is also increasing, with three new surgical interventions approved by the FDA within the last three years. Many of those recently approved, as well as currently in development, are marketed as minimally invasive surgical therapies (MIST). These include temporary implantable devices, stents, catheters, thermal therapies, and balloon dilation that may minimize short-term and long-term side effects, such as impact on ejaculatory function and more limited anesthesia requirements, among others.⁶ However, these benefits must be weighed against durability of the procedure.

In addition to treatment effectiveness, the cost of treatment can have a significant impact on patient outcomes. Estimated yearly individual costs for management of BPH exceed $1,500, and national costs to the private sector approach $4 billion.⁷ Furthermore, costs vary significantly based on the type of procedure chosen. This is true for both the initial procedure cost and follow-up costs.^8,9 Such findings highlight differences in reimbursement, as well as financial implications of complications and retreatment. Additionally, they emphasize the often-incongruent relationship between cost and clinical outcomes.

Although previous studies have evaluated the costs and outcomes associated with some BPH surgical interventions, evaluations of more recent surgical technologies are lacking.^9–14 It is within this background that we performed a cost-effectiveness analysis encompassing all guideline-approved BPH surgical interventions with a comprehensive analysis of clinical impact, durability, and quality of life.

METHODS

Patient Population

In this IRB-exempt analysis, two separate patient cohorts were modeled. Both cohorts represented patients with lower urinary tract symptoms (LUTS) secondary to bladder outlet obstruction caused by BPH planning to undergo surgical intervention. The first cohort (index patient 1) was defined by a prostate volume of 30–80cc and the second cohort (index patient 2) was defined by a prostate volume of 80–150cc. Size was selected as a defining parameter given the importance of volume in the decision-making process and effectiveness of BPH surgical intervention as reflected in the size-based algorithm in the AUA BPH surgical guidelines. All guideline-based surgical options were included based on size criteria. The volumes selected correspond to “average” (index patient 1) and “large” (index patient 2) prostate sizes within the guidelines.¹

Model Structure

R programming software (R version 4.5.0; 4/2025) was used to develop two separate microsimulation health-transition state decision analytic models. For index patient 1, this model included the following treatment options: holmium laser enucleation of the prostate (HoLEP), transurethral resection of the prostate (TURP), water vapor thermal therapy (WVTT), prostatic urethral lift (PUL), temporary implantable nitinol device (iTIND), Optilume, prostatic artery embolizatoin (PAE), photovaporizatoin of the prostate (PVP), and robotic water jet therapy (RWT). For index patient 2, the model included the following treatment options: HoLEP, RWT, PAE, and simple prostatectomy (SP). For all treatment options, the following health states were included (Supplementary Figure 1):

1. Acute Post-operative Health States: Post-operative urethral catheter, urinary retention, transfusion, bladder neck contracture/urethral stricture (BNC), acute urinary incontinence (SUI), urinary tract infection (UTI).

2. Chronic Post-Operative Health States: chronic urinary incontinence, bladder neck contracture/urethral stricture, ejaculatory dysfunction, persistent or recurrent LUTS (i.e. surgical retreatment)

Patient age at presentation was assumed to be 65 years based on median age reported in the studies used to derive model probability values. A lifetime horizon was utilized, based on Human Mortality Database life tables.¹⁵ Cycle length was 3 months and a half-cycle correction was applied. Costs and utility values were discounted at a 3% annual rate. The full list of assumptions included in the model is delineated in the Supplementary Methodology Appendix. Analyses adhered to the Panel on Cost-Effectiveness Recommendations wherever possible.¹⁶

Probability Values

Post-operative outcomes for HoLEP, TURP, PVP, and SP were based on data published in a meta-analysis comparing outcomes for various BPH surgical interventions.¹⁷ Similar meta-anlyses data was used for PAE.¹⁸ For newer technologies, including WVTT, PUL, Optilume, iTIND, and RWT, data were based on prospective trials that were cited within the AUA guidelines.¹ Randomized controlled trials were prioritized when available. Outcomes for SP were based primarily on a robotic approach. Probabilities were determined by using weighted means based on sample size of each study included. Given limited data and heterogeneity regarding surgical retreatment, it was assumed that all patients undergoing surgical retreatment were managed with a salvage TURP. Furthermore, if symptoms persisted after salvage TURP, it was assumed that no further intervention was performed.

For HoLEP and RWT, which were each included as treatment options for both index patients, size-dependent outcomes were adjusted as indicated. Specifically, short-term SUI, long-term SUI, BNC, transfusion, and overall BPH retreatment rates were assumed to vary significantly based on size for HoLEP, RWT, or both HoLEP and RWT (Table 2).^19–24 PAE outcomes were not varied between index patients as most outcomes data were based on approximately 80cc glands with limited data on smaller prostate sizes.

Table 2.

Model Probabilities

	TURP	HOLEP (Average)	WVTT	PUL	RWT (Average)	iTIND	OPTIL UME	PVP	PAE	HOLEP (Large)	SP	RWT (Large)
Catheter Duration (Days)	2.4	1.0	3.4	1.0	1.0	0.0	2.0	1.5	0.0	1.0	7.0	4.0
UTI	0.043	0.055	0.037	0.001	0.095	0.025	0.14	0.063	0.027	0.033	0.032	0.069
Transfusion	0.021	0	0	0	0.086	0	0	0.003	0.0	0.017	0.023	0.059
AUR	0.031	0.021	0.037	0.004	0.095	0.059	0	0.052	0.045	0.027	0.022	0.129
Short-Term SUI	0.039	0.049	0	0	0.059	0	0.082	0.0	0.04	0.091	0.023	0.059
Chronic SUI	0.008	0.013	0	0	0.01	0	0	0.01	0.0	0.013	0.013	0.013
BNC/Stricture* Retreatment* EjD	0.78	0.76	0.1	0	0.1	0	0.041	0.78	0.0	0.76	0.76	0.15
Sources	17,28–31	17,32–34	35,36	37,38	39–41	42–46	47,47	17,48–52	18,53–55	17,19–21,56,57	19–21,56,57	58,59

Abbreviations: TURP, transurethral resection of prostate; HoLEP, holmium laser enucleation of the prostate; WVTT, water vapor thermal therapy; PUL, prostatic urethral lift; RWT, robotic waterjet therapy; iTIND, temporarily implanted nitinol device; PVP, photovaporization of the prostate; PAE, prostatic artery embolization; SP, simple prostatectomy; UTI, urinary tract infection; AUR, acute urinary retention; SUI, stress urinary incontinence; BNC, bladder neck contracture; BPH, benign prostatic hyperplasia; IPSS, international prostate symptom score.

^*Calculated using logarithmic model, plateau hazard, exponential-decay hazard, spline fallback, or flat hazard depending on the input values.

Costs

The model was conducted from a Medicare payer perspective. Index procedure codes were based on current procedural terminology (CPT) and ambulatory payment classification (APC) codes for procedures eligible for outpatient reimbursement (i.e. HoLEP, TURP, WVTT, PUL, PVP, PAE, RWT, iTIND, and Optilume) and diagnosis related group (DRG) codes for inpatient procedures (i.e. SP). At the time of analysis, CPT category I codes had not yet been implemented for RWT and Optilume; therefore, the appropriate CPT category III codes were used. Similarly, physician reimbursement for Optilume was not yet established given its procedure C code status. Therefore, Optilume physician reimbursement was assumed to be the same as iTIND. Of note, the RWT passthrough code C2596 was not included within the cost as it expired in 2023. Lastly, base-case costs were determined using facility fee reimbursement; however, the cost range included in sensitivity analysis captured reimbursement rates for office-based procedures when applicable (e.g. WVTT, PUL, Optilume).

Utility Values

Utility values using validated patient-reported outcomes (e.g. time trade off, standard gamble methods) were prioritized when available. QALYs were then calculated based on the weighted average of utility value and toll (i.e. time in each health state). Baseline utility values were derived from lower urinary tract symptoms as measured using reported IPSS values. A validated conversion from IPSS to utility values was employed.²⁵ Pre-operative IPSS, as well as IPSS for patients with persistent or recurrent LUTS, was assumed to be 22 regardless of the index procedure, based on a weighted average of pre-operative symptom scores across all index surgery studies included in the model.

Primary Outcomes

The primary outcomes of the model were the per-patient, lifetime costs (US dollars) and effectiveness (QALYs) based on the index procedure. Cost-effectiveness was determined using incremental cost effectiveness ratios (ICER = incremental cost / incremental effectiveness) and net monetary benefit [NMB = (willingness to pay (WTP) * effectiveness) - cost)]. A strategy was cost-effective if the ICER was below a WTP threshold of $100,000/QALY.²⁶

Extrapolation

All acute health states were assumed to occur within the first 3 months (i.e. cycle 1) following the index procedure. For chronic health states, extrapolation was required to infer probabilities for model cycles between and beyond time points reported in the literature. This was used for IPSS values, BNC/urethral stricture, and surgical retreatment rates. Specifically, for BNC/urethral stricture and retreatment, various best-fit models were used for extrapolation. For IPSS values, discrete time frames were identified and for timeframes where primary data were not available, it was assumed that if the value was increasing at the latest follow-up time point, it would continue in a linear progression whereas it was assumed to remain stable if decreased or stable at the latest follow up. Detailed methodology on extrapolation, including graphical representations are included in the Supplementary Methods and Supplementary Figures 6&7.

Sensitivity Analyses

All model input parameters were varied across plausible ranges for a stacked one-way sensitivity analysis to elucidate the impact of individual parameter uncertainty and variation on model outcomes. This was used to identify potential parameter thresholds that altered model outcomes. In addition, given the significant impact of ejaculatory function on the model, two-way sensitivity analyses were performed to better understand how simultaneous variations in the prevalence and significance of ejaculatory function impacted the model.

To test the robustness of the model, multivariable probabilistic sensitivity analyses using 1,000 Monte Carlo simulations were also performed. Beta were used for probability/utility values, and gamma distributions were used for costs. Internal validation of the model was performed to ensure model outcomes accurately reflected the desired input parameters. Lastly, both the time horizon and WTP threshold were varied to further evaluate the implication of the model across various clinical and resource-availability scenarios.

RESULTS

Base Case Analysis

Index Patient 1 (30–80cc gland)

For index patient 1, over a lifetime horizon, per-patient costs ranged from $6,557 (WVTT) to $16,230 (PAE) and effectiveness ranged from 11.87 QALYs (Optilume) to 12.25 QALYs (HoLEP) (Table 1). Due to the high effectiveness and low cost ($8,431), HoLEP was found to be the most cost-effective index procedure with an ICER of $6,931/QALY relative to WVTT.

Table 1.

CEA Results

Strategy	Cost ($)	Effect (QALYs)	Incremental Cost ($)	Incremental Effect (QALYs)	ICER ($/QALY)
Average Gland (30–80cc)
WVTT	$6,557	11.98	NA	NA	NA
HoLEP	$8,431	12.25	$1,874	0.27	$6,931
TURP	$8,641	11.71	NA	NA	NA
RWT	$12,037	11.97	NA	NA	NA
Optilume	$12,669	11.88	NA	NA	NA
ITIND	$13,072	12.02	NA	NA	NA
PAE	$16,230	11.77	NA	NA	NA
PVP	$8,695	11.63	NA	NA	NA
PUL	$13,327	11.96	NA	NA	NA
Large Gland (80–150cc)
HoLEP	$8,361	12.25	NA	NA	NA
SP	$19,012	12.26	$10,651	0.00	$2,679,799
RWT	$11,969	12.19	NA	NA	NA
PAE	$16,230	11.768	NA	NA	NA

Abbreviations: TURP, transurethral resection of prostate; HoLEP, holmium laser enucleation of the prostate; WVTT, water vapor thermal therapy; PUL, prostatic urethral lift; RWT, robotic waterjet therapy; iTIND, temporarily implanted nitinol device; PVP, photovaporization of the prostate; PAE, prostatic artery embolization; SP, simple prostatectomy; UTI, urinary tract infection; AUR, acute urinary retention; SUI, stress urinary incontinence; BNC, bladder neck contracture; BPH, benign prostatic hyperplasia; IPSS, international prostate symptom score.

Index Patient 2 (80–150cc gland)

For index patient 2, per-patient costs were lower for HoLEP ($8,361) relative to RWT ($11,969), PAE ($16,230), and SP ($19,011.70). Effectiveness was nearly identical between SP (12.257) and HoLEP (12.253), with RWT being slightly lower (12.190) follwed by PAE (11.77). Overall, HoLEP was found to be the most cost-effective index procedure, driven by the low cost and minimal difference in efficacy (Table 1).

One-Way Sensitivity Analysis

Index Patient 1 (30–80cc gland)

The relative cost-effectiveness was highly sensitive to the probability and utility associated with post-operative ejaculatory dysfunction as well as the utility value associated with post-operative LUTS. Specifically, if the utility value associated with ejaculatory dysfunction decreased below 0.93 (baseline 0.94), or if the probability of ejaculatory dysfunction following HoLEP increased above 0.98 (baseline 0.76), HoLEP was no longer favored by the model. Similarly, if 5-, 10-, or 20-year HoLEP post-operative LUTS utility values decreased below 0.95–0.96 (baseline 1.0), HoLEP was no longer the most cost-effective option (Figure 1).

Figure 1.

One Way Sensitivity Analysis- Average Gland

Index Patient 2 (80–150cc gland)

Similar to the model for index patient 1, the model for large glands was sensitive to the probability and utility associated with post-operative ejaculatory dysfunction as well as the utility value associated with post-operative LUTS (Supplementary Figure 2). Only slight decreases in the utility value of ejaculatory dysfunction (EjD) to <0.94 (baseline 0.94) or 5-, 10-, or 20-year HoLEP post-operative LUTS utility values to below 0.99 (baseline 1.0) were needed to shift the model in favor of RWT. Additionally, a significant decrease in SP cost would result in HoLEP no longer being favored by the model.

Probabilistic Sensitivity Analysis with Monte-Carlo Simulations

Index Patient 1 (30–80cc gland)

At a WTP threshold of $100,000/QALY, HoLEP was cost-effective in 44% of simulations followed by WVTT (19%), TURP (16%), iTIND (7%), RWT (5%), Optilume (5%), and PUL (5%). The preferred index procedure varied as a function of WTP threshold and follow-up time (Supplementary Figures 4; Figure 2). Specifically, at very low WTP thresholds (below $10,000/QALY) or at shorter follow-up (<12 years), WVTT became favored.

Figure 2.

Cost-Effectiveness Acceptability Curve Over Time- Average Gland

Index Patient 2 (80–150cc gland)

At a WTP threshold of $100,000/QALY, HoLEP was cost-effective in 42% of simulations, followed by RWT (36%) and SP (22%). The difference in the probability of each index procedure being favored was most pronounced at shorter follow-up times and lower WTP thresholds. These findings are consistent with the minimal difference in effectiveness between HoLEP, SP, and RWT, but widely varying costs (Supplementary Figures 3, 5).

DISCUSSION

Using a comprehensive decision-analytic model, we found that, regardless of prostate size, HoLEP was the most cost-effective surgical management option for BPH. These findings support prior studies assessing cost utility of established surgical treatments.⁹ Among patients with prostates between 30–80cc, the cost-effectiveness of HoLEP was primarily driven by an intermediate procedure cost (reimbursement), significant symptom improvement, and long-term durability. Among patients with large prostates, the cost-effectiveness of HoLEP was secondary to a low cost compared to other surgical modalities.

Equally as important as the overall findings of the model was the identification of variables and thresholds that impacted surgical cost-effectiveness. On univariable sensitivity analysis, the cost-effectiveness of HoLEP was dependent upon longer follow-up time (>12 years) and high post-operative utility value- a measure that was directly linked to IPSS scores post-operatively. HoLEP had a maximal utility value throughout post-operative follow-up which was not true for any other surgical modality evaluated for 30–80cc prostates. Indeed, when this difference decreased and the post-HoLEP utility value decreased moderately (<0.95 from 1.0), HoLEP was no longer the most cost-effective.

Furthermore, EjD had a profound impact on the model output, regardless of gland size. For our base case analysis, we set the utility value of EjD at 0.94 based on previously published, validated patient questionairres.¹² The base case value is meant to signify a population-level average for systems-level modeling. However, urology providers are acutely aware that patient preferences and priorities can vary widely, and this is certainly true for ejaculatory function. Indeed, a recently published quantification of patient preferences surrounding BPH surgery found significant heterogeneity in prioritization of EjD.²⁷ Within our model, if the utility value assigned to EjD decreased slightly to 0.91 (i.e. lower quality of life due to EjD), the model favored approaches with higher ejaculatory preservation for each index patient (i.e. iTIND for index patient 1, and RWT for index patient 2). Therefore, if patients prioritize ejaculatory function, ejaculatory-preserving options quickly become favored over HoLEP for both average and large prostates. Similarly, the influence of post-operative symptom scores and sexual function priorities highlight a key takeaway from the model: the cost-effectiveness of the surgical management of BPH is highly dependent on individual patient priorities. Furthermore, even relatively small changes in some of these parameters can alter the favored outcome of the model.

For patients with large prostates (80–150cc), SP became cost-effective with a significant cost reduction of greater than 60% (approximately $10,000). Unlike the implications associated with the impact of patient symptom response and sexual function, the impact of cost changes is more relevant to broader, policy-level decisions. Viewing the model as an aggregate representation of patient priorities and resource utilization, cost-effectiveness thresholds can be used as a bellwether for possible reimbursement setpoints for other technologies. For example, this model suggests that RWT and SP are valuable surgical options, but that HoLEP is comparatively undervalued in terms of reimbursement for large glands. Similarly, PAE was not favored even for a patient prioritizing ejaculatory preservation due to it’s relatively high cost and a less costly alternative (RWT). It is important to note that costs in this context refer to Medicare reimbursement for a given CPT code.

Although prior cost-effectiveness analyses evaluating BPH surgical management have been performed, we believe that the current study offers multiple key and significant additions. To the best of our knowledge, it is the only CEA to include the most recent BPH surgical modalities as of 2026. Additionally, the model parameters in the present study are the most comprehensive to date--with detailed inclusion of both short-term and long-term complications such as retreatment, symptom improvement, and sexual function. The model also includes novel logarithmic modeling to most accurately account for longer-term outcomes. Lastly, the in-depth sensitivity analyses were critical in establishing the impact of patient-level and system-level changes that alter outcomes.

Despite these strengths, the current study has multiple limitations. As with any decision model, the study is limited by the data available for inclusion. Within the BPH surgical disease space, there are no head-to-head comparisons of most of these modalities, particularly with long-term follow up. Therefore, patient inclusion criteria and definition of outcomes, as well as follow-up time can vary widely, making direct comparisons potentially misleading. Specifically, outcomes such as incontinence and retreatment are reported with high variability within the literature. Incontinence rates in particular are often based on non-standardized measures. Given the signicant potential impact of this outcome, we included wide ranges for temporary and chronic SUI within the model sensitivity anlayses (e.g. up to 5% chronic incontinence). Furthermore, some of the data included were based on prospective, industry-sponsored studies, while others were based on large, retrospective cohort studies. Even within technologies and approaches, techniques can rapidly change, and reported outcomes may not necessarily represent the most up-to-date clinical data. Lastly, we did not include medical management as a treatment (or retreatment) option within the model. This was partly based on the intent of the model to replicate the decision regarding surgical intervention specifically and partly due to inconsistent reporting of medication usage in the literature.

However, with robust sensitivity analyses and inclusion this model can be viewed as a significant step in framing how we assess and discuss value-based care in the surgical management of BPH. This is true both on an individual-patient level- with key insights into the impact of specific patient priorities, as well as on a systems level- as we consider cost and reimbursement implications. Both perspectives will be critical in maintaining an evidence-based approach to best treating a widely ubiquitous disease.

CONCLUSION

Using a comprehensive microsimulation decision-analytic model with robust sensitivity analyses, we found that HoLEP represents the most cost-effective surgical modality for both average and large prostates in the contemporary era of BPH surgery. However, the outcomes of the model were heavily influenced by patient priorities- particularly regarding sexual function, relative clinical improvement, and cost. Such findings highlight the complexities of BPH surgical decision making on an individual and systems-level and offer a framework for evaluating value-based care in this disease space.