Use of minimally invasive BPH treatment up significantly

July 1, 2008

Use of minimally invasive surgical treatments (MISTs) for BPH has increased tremendously in the past decade, but urologists should be careful about overusing these newer technologies, given the lack of long-term evidence of their efficacy, according to researchers from the University of Minnesota, Minneapolis.

Key Points

Orlando, FL-Use of minimally invasive surgical treatments (MISTs) for BPH has increased tremendously in the past decade, but urologists should be careful about overusing these newer technologies, given the lack of long-term evidence of their efficacy, according to a urologist and his health service research colleagues from the University of Minnesota, Minneapolis. Their data were presented at the AUA annual meeting here.

Investigators reported a remarkable 529% increase in the number of MIST procedures performed from 1999 to 2005. This accompanied a 44% increase in the overall number of BPH procedures and a 5% annual decrease in the rate of transurethral resections of the prostate.

"The data on efficacy and complications with minimally invasive surgical treatments have very short follow-up," said first author Sean P. Elliott, assistant professor of urologic surgery at the University of Minnesota.

Dr. Elliott and colleagues identified BPH procedures from 100% Medicare fee-for-service carrier files (ie, physician claims for services reimbursed under Medicare Part B) from 1999 through 2005.

By 2005, they reported, MIST procedures comprised 57% of all BPH surgeries, while TURP comprised only 39% of the total. Office clinics were the setting for virtually all transurethral microwave therapy (TUMT) procedures, 86% of transurethral needle ablations (TUNA), and 54% of laser coagulations. Most laser vaporizations (78%) were carried out in hospital outpatient clinics.

Racial gap closing

Interestingly, the study found that African-Americans were 17% less likely than Caucasians were to receive MIST procedures. In 2006, the same University of Minnesota group published a paper showing that age-adjusted usage rates of TUMT and TUNA were twice as high in Caucasians as in African-Americans (J Urol 2006; 175:1830-5).

"In the present study, we actually see a narrowing of the racial gap in some MIST procedure rates compared with [those described in] the previous paper, which is consistent with the diffusion of new technology over time," Dr. Elliott said. "Still, these differences persist after controlling for geography and socioeconomic status."

Given the increase not only in MIST, but also in BPH procedures as a whole, it would appear the market for BPH therapies is expanding significantly. The question, Dr. Elliott said, is from where these patients are coming.

"Are they patients who previously would have been treated medically?" he asked. "Medicare Part D prescription claims are not yet available, so this question remains for future study."

One surprise in the data was the size of the increase in MIST use, Dr. Elliott said.

"While we hypothesized an expansion of MIST into an increasingly larger share of BPH procedures, the degree of market penetration was unexpected," he said. "Furthermore, it was surprising that the increased utilization of these new technologies has significantly lagged behind their introduction and FDA approval.

"The cause for this is unclear, though we speculate that im-provements in technology and disproportionately higher reimbursement rates for MIST compared with TURP may play important parts."

Dr. Elliott noted the irony of shifting practice patterns for BPH. In the 1980s, he said, BPH was "primarily a surgical disease." With the introduction of alpha-antagonists, it became more of a medically treated affliction. Now, with the advent of MIST procedures, the pendulum is swinging back toward surgical therapies.