TURP Still Most Common BPH Procedure Despite Growing Use of Other Therapies

Transurethral resection of the prostate (TURP) remains the most commonly performed surgical procedure for benign prostatic hyperplasia (BPH), but certain minimally invasive procedures, such as prostatic urethral lift, are gaining in popularity, according to the findings of multiple studies presented at the 2023 Annual Scientific Meeting of the American Urological Association (AUA).

At the same time, data suggest some minimally invasive procedures are falling out of favor, including transurethral microwave thermotherapy (TUMT) and transurethral needle ablation (TUNA).

Trends Vary by Study

Some studies demonstrate a decrease in the use of TURP with a concomitant increase in the use of some minimally invasive modalities, including an analysis by Jacob H. Feiertag, BS, and Joseph Y. Clark, MD, of Penn State College of Medicine in Hershey, Pennsylvania of 302,531 BPH procedures performed during 2013 to 2019. Using data from TriNetX, a third-party health care database, they found that TURP use declined from 47.2% in 2013 to 44.9% in 2019. Meanwhile, use of prostatic urethral lift (Urolift), which received FDA approval in 2013, increased from 1.6% of BPH procedures in 2015 to 18.3% in 2019. Use of holmium laser enucleation of the prostate (HoLEP) rose from 3.8% of cases in 2013 to 5.1% in 2019.

In addition, from 2013 to 2019, photoselective vaporization of the prostate (PVP) use declined from 31.8% to 21.5% of cases, TUMT use dropped from 9.9% to 1.8% of cases, and TUNA use decreased from 4.4% to 1.3% of cases, Feiertag and Dr Clark reported.

The water vapor thermal therapy Rezūm, which was FDA approved for BPH in 2015, accounted for 5.8% of BPH procedures in 2019.

An analysis of 2014-2021 AUA Quality (AQUA) registry data from 300,215 BPH procedures by Charles Jones, MD, of the University of California, San Francisco, and colleagues revealed a larger decline in TURP use, from 40.1% of cases in 2014 to 25.6% in 2021. During that same timeframe, prostatic urethral lift use increased from 0.7% to 30.1% of cases.

However, a study led by Dhaval Jivanji, MD, of Maimonides Medical Center in Brooklyn, New York, revealed that TURP use remained stable from 2016 to 2020, with approximately two-thirds of BPH cases being treated with that approach. Using the American College of Surgeons’ National Surgical Quality Improvement Program database, Dr Jivanji and colleagues analyzed 60,291 BPH procedures. TURP was used in 62.3%, 62.4%, 64.6%, 62.6%, and 62.8% of cases in 2016, 2017, 2018, 2019, and 2020, respectively. Concurrently, from 2016 to 2020, HoLEP use increased from 4.8% to 7.5% of cases and PVP use declined from 24.4% to 21.0% of cases.

Another study documented a rise in TURP use. In an analysis of ambulatory BPH surgeries performed in 2016 (124,538 cases) and 2019 (100,783 cases), Neil A. Mistry, MD, MPH, of Northwestern University School of Medicine in Chicago, Illinois, and colleagues observed that TURP use increased from 62.6% of cases in 2016 to 90.7% in 2019. During that same timeframe, HoLEP use increased from 4.7% to 8.3% of cases, whereas PVP use declined from 32.6% to 0.7% of cases.

The sharp rise in TURP use may be multifactorial, Dr Mistry said. “Surgeon preference could play a role since it is possible that some of the folks who were doing green light vaporizations switched back to doing regular TURPs,” he said. In addition, he noted that because his team used data from an ambulatory billing database, their study may have captured a broader trend among health systems to move care (including TURP) out of the inpatient setting and into the outpatient setting.

Dr Mistry’s team used data from the Agency for Healthcare Research and Quality’s Nationwide Ambulatory Survey Sample, the largest national all-payer database of ambulatory surgical encounters.

Why TURP Remains Popular

Regarding the continued popularity of TURP despite the availability of numerous minimally invasive options, Dr Jivanji commented, “I believe TURP remains the most commonly used procedure as it has been one of the longest established techniques for BPH management. In addition to being minimally invasive, data has shown TURP to provide excellent long-term outcomes for patients.”

Surgeon comfort with certain approaches, which generally reflects prior training and experience, could explain preferences, he said. In addition, he noted, the availability of certain technologies within a surgeon’s hospital system as well as the learning curve associated with certain techniques such as HoLEP can influence the use of one modality over another.

References

1. Feiertag J, Clark JY. National trends in surgical management for benign prostatic hyperplasia from 20213 to 2019: A Trinetx analysis. Presented at: AUA 2023, Chicago, Illinois, April 28-May 1. Poster MP13-01.
2. Jones C, et al. Trends in surgical management of benign prostatic hyperplasia: Data from the AUA Quality (AQUA) Registry. Presented at: AUA 2023, Chicago, Illinois, April 28-May 1. Poster MP76-20.
3. Jivanji D, Shpeen B, West M, et al. Safety and trends in surgical management of benign prostatic hyperplasia. Presented at: AUA 2023, Chicago, Illinois, April 28-May 1. Poster MP51-05.
4. Mistry NA, Guo J, Lee M, Assmuss M, Krambeck A. National update of HoLEP is increasing in ambulatory surgery settings. Presented at: AUA 2023, Chicago, Illinois, April 28-May 1. Poster MP13-20.