Introduction
Prostate artery embolization (PAE) is now considered a standard treatment option for the management of lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH) in the UK since the updated National Institute for Health and Care Excellence (NICE) guidance in 2018.1 In Europe, PAE is included in the European Association of Urology guidelines as a standard procedure, but is not supported in the American Urological Association guidelines, which recommends it use in clinical trials only. There have been multiple studies that have demonstrated the clinical effectiveness of PAE versus transurethral resection of the prostate (TURP), with significant improvements in symptoms, as measured by the International Prostatic Symptom Score (IPSS) reduction.2 3 However, there are limited data on the cost utility of TURP compared with PAE.
The prevalence of BPH is known to increase with age.4 This, combined with the UK ageing population, suggests that management of BPH-related LUTS imposes a growing financial burden on the UK healthcare system.5 The limited budget of the National Health Service (NHS) requires efficient resource allocation to ensure maintenance of high-quality patient care. A recent American cost analysis suggested that TURP is more expensive than PAE, but recognized that a more comprehensive cost analysis, such as the cost of physician time and cost of complications, was required to improve accuracy.6 Currently, no UK-based cost-utility analysis has been published.
TURP has good clinical outcomes, low mortality rates (~0.1%)7 and remains the gold standard surgical treatment for BPH-related LUTS.8 However, morbidity such as postoperative retrograde ejaculation and requirement for potential hospitalization and catheterization can reduce its cost-effectiveness.8 Monopolar transurethral vaporization of the prostate (TUVP) and holmium laser enucleation of the prostate (HoLEP) remain cost-effective alternative surgical options. A systematic review comparing cost utility of surgical treatments concluded that TUVP was cheaper but less effective than TURP, whereas HoLEP was more cost-effective than TURP.9 Despite the benefits of HoLEP, the greatest obstacles to its widespread implementation lie with the high start-up cost, technical difficulties and learning curve associated with the procedure.10
PAE offers an alternative non-surgical, minimally invasive option11 and data suggest that the cost of PAE may be lower than TURP, while maintaining a lower morbidity rate.12 The aim of this study was to carry out a retrospective cost-utility analysis comparing TURP and PAE for the treatment of BPH-related LUTS using the UK Register of Prostate Embolisation (UK-ROPE) Study published in 2018.13
The UK-ROPE is a national observational database of patients treated with PAE or surgical procedures from 20 centres, held by the Cardiff-based independent research organization ‘Cedar’, funded by NICE. Procedure costs were covered either through local commissioning streams or through a grant from Cook Medical (Europe), where this was not possible. Male patients were enrolled for either PAE, TURP, open prostatectomy or HoLEP from July 2014 to January 2016. All patients had consultation with a urologist and interventional radiologist prior to PAE. Outcome data including IPSS, quality of life (QoL) and International Index of Erectile Function (IIEF) were collated from questionnaires. Patients were followed up at 1 month, 3 months, 6 months and 12 months post procedure. Various clinician-reported complications were recorded initially post procedure, while patient-reported complications (hematuria, hematospermia, incontinence, urinary infection and retrograde ejaculation) were identified from questionnaire responses at each time point. Briefly, the UK-ROPE demonstrated that PAE showed a statistically significant improvement in IPSS and QoL post procedure, but the improvement in outcomes following TURP was greater. The registry did not have any stipulations on operator/centre experience for either TURP or PAE to simulate ‘real-world’ practice. Due to the experimental nature of PAE at the time of the study, all centres were proctored by an experienced operator for at least six cases. Due to the established practice of TURP in the UK, no proctoring was performed for cases.