Published 16 April 2009, doi:10.1136/bmj.b1288
Cite this as: BMJ 2009;338:b1288

Research

Surgical treatments for men with benign prostatic enlargement: cost effectiveness study

¹ Institute of Health and Society, Newcastle University, Newcastle upon Tyne NE2 4AA, ² Health Services Research Unit and Health Economics Research Unit, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen AB25 2ZD, ³ Academic Urology Unit, Institute of Applied Health Sciences, University of Aberdeen, ⁴ Urology Research Group, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne NE2 4HH

Objective To determine which surgical treatment for lower urinary tract symptoms suggestive of benign prostate enlargement is cost effective.

Design Care pathways describing credible treatment strategies were decided by consensus. Cost-utility analysis used Markov modelling and Monte Carlo simulation.

Data sources Clinical effectiveness data came from a systematic review and an individual level dataset. Utility values came from previous economic evaluations. Costs were calculated from National Health Service (NHS) and commercial sources.

Methods The Markov model included parameters with associated measures of uncertainty describing health states between which individuals might move at three monthly intervals over 10 years. Successive annual cohorts of 25 000 men were entered into the model and the probability that treatment strategies were cost effective was assessed with Monte Carlo simulation with 10 000 iterations.

Results A treatment strategy of initial diathermy vaporisation of the prostate followed by endoscopic holmium laser enucleation of the prostate in case of failure to benefit or subsequent relapse had an 85% probability of being cost effective at a willingness to pay value of £20 000 (21 595, $28 686)/quality adjusted life year (QALY) gained. Other strategies with diathermy vaporisation as the initial treatment were generally cheaper and more effective than the current standard of transurethral resection repeated once if necessary. The use of potassium titanyl phosphate laser vaporisation incurred higher costs and was less effective than transurethral resection, and strategies involving initial minimally invasive treatment with microwave thermotherapy were not cost effective. Findings were unchanged by wide ranging sensitivity analyses.

Conclusion The outcome of this economic model should be interpreted cautiously because of the limitations of the data used. The finding that initial vaporisation followed by holmium laser enucleation for failure or relapse might be advantageous both to men with lower urinary tract symptoms and to healthcare providers requires confirmation in a good quality prospective clinical trial before any change in current practice. Potassium titanyl phosphate laser vaporisation was unlikely to be cost effective in our model, which argues against its unrestricted use until further evidence of effectiveness and cost reduction is obtained.

© Armstrong et al 2009
This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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