Economic Impact of Surgical Intervention in the Treatment of Benign Prostatic Hyperplasia

Photoselective Vaporization of the Prostate

RIUS0004(Laserscope)_10-27.qxd 27/10/06 14:52 Page S9 PHOTOSELECTIVE VAPORIZATION OF THE PROSTATE Economic Impact of Surgical Intervention in the Treatment of Benign Prostatic Hyperplasia John M. Hollingsworth, MD, John T. Wei, MD, MS Michigan Urology Center, University of Michigan, Ann Arbor, MI The economic burden of benign prostatic hyperplasia (BPH) on our health care system is significant and likely to continue to grow given the burgeoning elderly population. Coincident with the rising number of annual physician office visits and expenditures for BPH has been a dramatic shift in the disease’s management, from surgical to medical care. However, long-term cost data call into question the appropriateness of medical therapy as the initial treatment approach for all men with BPH, particularly those with moderate to severe symptoms. Although there has been a paradigm shift away from traditional BPH surgery, there has been renewed interest in the treatment of BPH with novel surgical techniques and minimally invasive surgeries. The economics of surgical interventions for BPH are discussed. [Rev Urol. 2006;8(suppl 3):S9-S15] © 2006 MedReviews, LLC Key words: Benign prostatic hyperplasia • Economics • Surgical procedures, minimally invasive • Transurethral resection of prostate ealth care expenditures in the United States are currently in excess of $1.5 trillion annually, comprising approximately 16% of US gross domestic product.1 Justly or unjustly, many of these expenses have been attributed to health care providers and hospitals. Given this, payor efforts to reduce cost have focused largely on minimizing physician use of expensive tests and treatments, such that phrases like “cost containment” and “resource utilization” have become a part of the physician’s lexicon. And it is the management of highly prevalent medical conditions consuming a significant share of our health care dollars that has come under the greatest scrutiny. With an estimated H VOL. 8 SUPPL. 3 2006 REVIEWS IN UROLOGY S9 RIUS0004(Laserscope)_10-27.qxd 27/10/06 14:52 Page S10 BPH Economics continued 6.5 million white men between 50 and 79 years of age in the United States who meet criteria for its treatment,2 benign prostatic hyperplasia (BPH) represents 1 such highly prevalent disease within the urologic domain. Health Care Burden BPH is the fifth most prevalent non–cancer-related disorder among men aged 50 years and older, and accounts for the seventh highest 1-year disease-specific medical costs. Approximately 1 in 5 men with BPH will have a significant clinical event (ie, an episode of prostate-related acute urinary retention or prostate surgery) within 1 year of initiating treatment for the condition (Figure 1).3 Taken together, the health care burden of BPH is not trivial. Population-based data reveal that outpatient physician office visits made for BPH are on the rise, from an estimated 10,116 visits per 100,000 US population in 1994 to 14,473 visits per 100,000 US population in 2000. It is estimated that the direct costs of medical services provided at hospital inpatient and outpatient settings, emergency departments, and physician offices for BPH management in the US exceed $1.1 billion annually.2 Wei and colleagues examined the incremental medical costs associated with a diagnosis of BPH through the use of medical claims from 280,000 beneficiaries with employer-sponsored insurance, aged 18 to 64 years. After controlling for differences in insurance coverage, patient demographics, and health status, the per-person incremental cost for a primary diagnosis of BPH was determined to be $2,577.2 Equally significant are those indirect costs (eg, lost hours from work for treatment, excluded expenses made by the patient) related to BPH care, which are not easily captured by administrative data sources. Using enrollment files, health care claims, and absence data from a subset of private employers, Saigal and Joyce estimated that the average employee with a diagnosis of BPH misses 7.3 hours of work annually related to his disease, with 10% reporting some work loss related to health care encounters for BPH.4 Paradigm Shift Coincident with the rising number of annual physician office visits and expenditures for BPH has been a dramatic shift in the disease’s manage- ment from surgical to medical care. The reasons underlying this phenomenon are 2-fold. First, effective medications for BPH symptoms were approved by the US Food and Drug Administration (FDA) during the 1990s. In 1993, terazosin became the first
-adrenergic blocker that was FDA-approved for BPH management. Three years later, finasteride became the first FDA-approved 5
-reductase inhibitor for the care of BPH. Given the known risks associated with surgery, the overwhelming patient demand for these medications was not surprising. The popularity of these medications is further bolstered by clinical trial data from the Proscar Long-Term Efficacy and Safety Study5 and the Medical Therapy Prostatic Symptoms Study,6 which show that medical therapy is not only efficacious in ameliorating patients’ symptoms but that it can also prevent disease progression and future need for invasive surgery. A second factor underlying the shift in BPH care is physician reimbursement reform. Combined, the Omnibus Budget Reconciliation Act of 1989 and the introduction of the Health Care Financing Administration’s resource-based relative value Figure 1. Likelihood of experiencing a significant event within 1 year, classified by diagnosis. CAD, coronary artery disease; GERD, gastroesophageal reflux disease. Reprinted with permission from Fenter TC et al.3 25 23.0 19.2 Percentage 20 15 13.5 9.5 10 8.7 6.5 5 2.2 1.1 0 Bursitis S10 VOL. 8 SUPPL. 3 2006 Enlarged prostate Hypertension REVIEWS IN UROLOGY Type 2 diabetes Osteoarthritis Arrhythmias CAD Depression 0.1 GERD RIUS0004(Laserscope)_10-27.qxd 27/10/06 14:52 Page S11 BPH Economics scale in 1992 had a major impact on professional payments under the Medicare program. Their overall effect has been to increase compensation for outpatient evaluation and management services while decreasing reimbursement for surgical procedures.7,8 As such, the average Medicare professional payment for transurethral resection of the prostate (TURP) has decreased to $669.8 Before these changes in reimbursement, surgery had been the mainstay of BPH care. In fact, TURP was historically the second most commonly performed operation in the United States. However, as the treatment paradigm has shifted, the urologic community has witnessed a dramatic decline in hospitalizations for TURP throughout the 1990s.2 Contemporary Medicare beneficiary data show that outpatient surgery for BPH has decreased across almost all patient age, racial, ethnic, and geographic strata. With the declining use of surgery for BPH, there has been a concomitant rise in the use of prescription medications; US sales for finasteride and tamsulosin topped $400 million and $710 million, respectively, more medical therapy, BPH has been transformed from a pseudo-acute condition (ie, a condition that was treated promptly and “cured” with surgery when it caused symptoms) to a chronic condition that requires ongoing medication and medical care. The long-term economic consequences of this transformation remain unclear. BPH has been transformed from a pseudo-acute condition to a chronic condition that requires ongoing medication and medical care. Several analyses have been performed in an attempt to compare the costs of medical and surgical BPH therapies. One of the earliest was performed in 1994 by the US Agency for Health Care Policy and Research (AHCPR), in which the total costs of 2 years of treatment with watchful waiting (WW), finasteride,
-blockers, TURP, and open prostatectomy were compared. Though the AHCPR model was limited by a short duration of follow-up, surgical therapies were estimated to cost roughly 5 times as much as medical treatment, with
-blockers and finasteride being relatively equivalent.11 A similar cost With the declining use of surgery for BPH, there has been a concomitant rise in the use of prescription medications: US sales for finasteride and tamsulosin topped $400 million and $710 million, respectively, in the year 2004. in the year 2004.9 These statistics are further supported by the findings of a recent American Urological Association (AUA) Gallup Survey, which revealed that 88% of urologists recommended adrenergic
-antagonists for the initial care of men with moderate urinary symptoms and evidence of prostate enlargement.10 Cost-Effectiveness of Medical Therapy With both urologists and primary care physicians prescribing increasingly costs associated with various treatment modalities for BPH, stratified by patient age.13 Medical management (finasteride or terazosin) was found to be less cost effective than TURP when medical therapy was started in patients younger than 70 years, given the potential for prolonged (often indefinite) treatment duration. The Canadian minimization analysis was performed by Lowe and colleagues, in which treatment with terazosin, finasteride, and TURP were compared from the payor’s perspective over a 2-year period. Generally speaking, pharmaceuticals were shown to be more cost effective in the short term relative to surgery.12 Given that the annual maintenance costs of medical therapy can be high, other studies have focused on longterm outcomes. Using claims data, Chirikos and Sanford evaluated the Coordinating Office for Health Technology Assessment has also performed a cost-analysis simulation, comparing WW, finasteride, and TURP over a 15-year interval. For mild symptoms, WW was deemed most appropriate, irrespective of life expectancy; however, for moderate to severe urinary symptoms, the greater the patient’s life expectancy the more likely it was that surgery would be economically superior to medical therapy.14 These long-term cost data call into question the appropriateness of medical therapy as the initial treatment approach for all men with moderate to severe BPH symptoms. When one considers the literature demonstrating the superiority of surgery over medical therapy in terms of symptomatic improvement, as well as the fact that
-blockers do not treat the underlying disorder,15 these cost data suggest a need to better stratify patients according to clinical factors (eg, age and symptom severity) when counseling them about management (WW vs medical therapy vs surgery). Furthermore,
-blockers do not prevent the prostate from continuing to grow, and a large number of patients will still require a surgical intervention despite medical management. Renewed Focus on Surgery Given that patient treatment starting on a pathway with medical therapies VOL. 8 SUPPL. 3 2006 REVIEWS IN UROLOGY S11 RIUS0004(Laserscope)_10-27.qxd 27/10/06 14:52 Page S12 BPH Economics continued and ending in successful TURP has the highest life-time costs,13 the urologic community has begun to reconsider the possibility that some patients might be better off in the long run with initial surgery rather than with medical treatment. Along these lines, there has been renewed interest in novel surgical techniques and minimally invasive surgical therapies (MISTs) for BPH. Although TURP remains the “gold standard”16 and is consistently the most reliable inferior to those of TURP. In addition, the reported retreatment rates of MISTs are much higher than those of TURP.18 In an attempt to maximize patient benefit with respect to effectiveness, morbidity, and cost, several economic analyses of various MISTs have been performed in recent years. Given our escalating health care costs, the onus has been on urologists to prove to third-party payors that “the juice is worth the squeeze.” With reduced use of hospital resources, minimally invasive surgical therapies have the potential for cost savings compared with traditional transurethral resection of the prostate. Minimally Invasive Surgical Therapies MISTs were popularized in the 1990s, including such options as transurethral needle ablation (TUNA) of the prostate and transurethral microwave therapy (TUMT). They are now routinely offered to patients with symptomatic BPH, offering the advantage of requiring little to no anesthesia and limited postoperative care. As such, MISTs are often performed in the clinic or outpatient setting. With reduced use of hospital resources, MISTs have the potential for cost savings compared with traditional TURP. The literature does support achievement of substantial symptomatic improvement with MISTs; however, objective measures of response are S12 VOL. 8 SUPPL. 3 2006 Naslund and colleagues performed a cost-minimization analysis in which the cost of medical management was compared with TUNA. At 5 years, TUNA was more costly than
-blocker monotherapy, but it was equivalent in cost to finasteride therapy and less expensive than combination medical management.19 Recently, DiSantostefano and colleagues reported their own costeffectiveness analysis, in which they Laser Prostatectomy The early 1990s ushered in the era of laser prostatectomy with the introduction of the visual laser ablation of the prostate (VLAP) technique, utilizing Figure 2. Expected costs for each treatment for benign prostatic hyperplasia over time, based on 2004 costs and a 3% discount rate for a cohort of 1000 men aged 65 years. The plot assumes switching among pharmaceuticals and watchful waiting (WW). AB,
-blocker; ARI, 5
-reductase inhibitor; Combo, combination therapy; TUMT, transurethral microwave therapy; TURP, transurethral resection of the prostate. Reprinted with permission from DiSantostefano RL et al.20 15 Cost in US$ (millions) operation for symptom relief, it nonetheless has significant treatmentassociated morbidity (eg, necessity of blood transfusions, urinary clot retention requiring reintervention, transurethral resection syndrome, and urethral strictures).17 It is this therapyrelated morbidity that has provided the impetus for the development of novel surgical techniques. modeled the costs of WW,
-blockers, 5
-reductase inhibitors, combination therapy, TUMT, and TURP in treating BPH over a 20-year horizon.20,21 The annual costs for WW were relatively steady, whereas costs for TURP and TUMT were much higher in the first year than in subsequent years. TURP and TUMT were the most expensive treatments at 5 and 7 years, respectively. Thereafter, the costs of combination therapy exceeded those of surgery (Figure 2).20 Using a threshold of $50,000 per quality-adjusted life year,
-blockers and TUMT were found to be cost effective for treating moderate symptoms, and TURP was found to be the most cost effective for treatment of severe symptoms versus WW.21 Although the appropriateness of this threshold can be debated, the analysis of DiSantostefano and colleagues illustrates the utility of patient stratification based on disease severity for predictions of BPH progression and its associated treatment costs. REVIEWS IN UROLOGY Treatment WW Combo 12 AB TUMT ARI TURP 9 6 3 0 2 4 6 8 10 12 Time (y) 14 16 18 20 RIUS0004(Laserscope)_10-27.qxd 27/10/06 14:52 Page S13 BPH Economics Table 1 Preferred Treatment Based on Symptom Severity, Patient Age, and Cost Analyses Cost Analysis Comparative Groups Preferred Treatment Chirikos TN and Sanford E Finasteride, terazosin, TURP TURP in men aged  70 years CCOHTA14 WW, finasteride, and TURP WW for mild symptoms TURP for those with greater life expectancy Naslund MJ et al19 TUNA,
-blocker, finasteride, combination therapy At 5 years, TUNA was equivalent to finasteride and less costly than combination therapy DiSantostefano RL et al20,21 WW,
-blockers, 5
-reductase inhibitors, combination therapy, TUMT, and TURP Alpha-blockers and TUMT for moderate symptoms TURP for severe symptoms Stovsky MD et al28 PVP, TUMT, TUNA, interstitial laser coagulation, and TURP Expected total cost of PVP lower than all other therapies 13 CCOHTA, Canadian Coordinating Office for Health Technology Assessment; TURP, transurethral resection of the prostate; WW, watchful waiting; TUNA, transurethral needle ablation; TUMT, transurethral microwave therapy; PVP, photoselective vaporizaton of the prosate. neodymium yttrium-aluminum-garnet (Nd:YAG) laser coagulation.22 Although initially heralded as a major advancement in BPH treatment, these contact laser therapies fell out of favor because of the high incidence of postoperative dysuria and urinary retention.23 The suboptimal outcomes of VLAP were attributable to the biophysical properties of the Nd:YAG laser wavelength, which led to deep coagulation and delayed tissue necrosis and sloughing.24 The application of the holmium YAG (Ho:YAG) laser for treatment of BPH was described in 1995.25 Unlike the Nd:YAG laser, the Ho:YAG laser produced a relatively thin underlying coagulation zone, but its high absorption in an aqueous irrigant requiring close contact between the laser fiber and the tissue, coupled with its shallow tissue penetration, made the removal of large tissue volumes tedious and lengthy.24 The Ho:YAG laser soon gave way to holmium laser enucleation of the prostate (HoLEP), which takes advantage of the cutting capabilities of this laser wavelength. Though outcomes are similar between HoLEP and TURP, HoLEP has an associated lengthy and steep learning curve.26 The latest innovation in laser prostatectomy is the high-powered potassium-titanyl-phosphate (KTP) laser. This laser offers several advantages, which make it well-suited for BPH surgery. The wavelength used by the KTP laser (532 nm) is highly absorbed by hemoglobin, thus increasing energy transfer. Second, it has a small optical penetration depth in tissue, allowing for the confinement of high- ment for the KTP laser generator and the disposable costs for the single-use laser fiber are significant, there are potential cost savings for payors through shorter hospital stays and procedure safety in high-risk patients. In aggregate, the PVP technique has the potential to reduce health care expenses for the treatment of obstructive BPH. Currently, cost data on these laser techniques are quite limited. Stovsky and colleagues reported on 1 of the few analyses that examined the cost In aggregate, PVP has the potential to reduce health care expenses for the treatment of obstructive BPH. power laser energy to a superficial layer of prostatic tissue that is vaporized rapidly and hemostatically with only a thin rim of coagulation.24 Malek and colleagues reported their series of the photoselective vaporization of the prostate (PVP) procedure. They touted the benefits of real-time tissue removal and excellent intraoperative hemostasis, with complications and objective and subjective outcomes that compared favorably with those of TURP.27 Although the capital invest- characteristics of the various surgical treatment alternatives for BPH. For a hypothetical cohort of 10,000 patients, the expected costs of PVP, TUMT, TUNA, interstitial laser coagulation, and TURP were modeled at 3 and 24 months. The expected total cost of PVP was found to be lower than all other therapies. The expected total cost of PVP would only approximate TURP when the cumulative probability of reoperation in PVPtreated patients was 52%.28 Given the VOL. 8 SUPPL. 3 2006 REVIEWS IN UROLOGY S13 RIUS0004(Laserscope)_10-27.qxd 27/10/06 14:52 Page S14 BPH Economics continued preponderance of observational data suggesting a low reoperation rate for PVP, it seems likely that PVP would be preferred from a health economic perspective. Conclusions The economic burden of BPH on our health care system is significant and will likely continue to grow given the burgeoning elderly population. Over the last 2 decades, there has been a tremendous shift in BPH care away from traditional surgery towards medical management for those men with moderate to severe lower urinary tract symptoms (LUTS). As reflected in the most recent AUA Panel Guidelines,29 the current treatment paradigm does not distinguish between patients with moderate and severe symptoms; consequently, all patients with moderate to severe LUTS are “run through the mill” and started initially on a course of medical therapy. The duration of medical therapy is usually indefinite, and many men experience disease progression, leading to eventual surgery. As the cost analyses reviewed herein illustrate (Table 1), a stratified approach to BPH management might be more desirable. As recommended by the AUA BPH Guidelines, men with mild LUTS can be followed expectantly, whereas older men with moderate symptoms may benefit most from single-agent or combination medical therapy or MIST. However, for men with moderate symptoms and a long life expectancy, or men with severe LUTS, early surgery may offer cost savings to the patient, payor, and society. Furthermore, early evidence suggests that PVP may have a role as an alternative to traditional TURP, based on both the clinical benefits the therapy offers. References 1. 2. 3. By the numbers. Health care economics. Modern Healthcare. 2003;suppl:2-38. Wei JT, Calhoun E, Jacobsen SJ. Urologic diseases in America project: benign prostatic hyperplasia. J Urol. 2005;173:1256-1261. Fenter TC, Naslund MJ, Shah MB, et al. The cost of treating the 10 most prevalent diseases in men 4. 5. 6. 7. 8. 9. 10. 11. 50 years of age or older. Am J Manag Care. 2006;12(4 suppl):S90-S98. Saigal CS, Joyce G. Economic costs of benign prostatic hyperplasia in the private sector. J Urol. 2005;173:1309-1313. McConnell JD, Bruskewitz R, Walsh P, et al. The effect of finasteride on the risk of acute urinary retention and the need for surgical treatment among men with benign prostatic hyperplasia. Finasteride Long-Term Efficacy and Safety Study Group. N Engl J Med. 1998;338:557-563. McConnell JD, Roehrborn CG, Bautista OM, et al. The long-term effect of doxazosin, finasteride, and combination therapy on the clinical progression of benign prostatic hyperplasia. N Engl J Med. 2003;349:2387-2398. Goluboff ET, Olsson CA. Urologists on a tightrope: coping with a changing economy. J Urol. 1994;151:1-4. Litwin MS, Sacher SJ, Cohen WS. The resourcebased relative value scale: methods, results and impacts on urology. J Urol. 1993;150:981-987. NDC Health Pharmaceutical Audit Site Prescription Monthly. The Top 200 Prescriptions for 2004 by U.S. Sales ($ billions). RxList: The Internet Drug Index. Available at: http://www.rxlist.com/ top200_sales_2004.htm. Accessed August 19, 2006. Gee WF, Holtgrewe HL, Blute ML, et al. 1997 American Urological Association Gallup survey: changes in diagnosis and management of prostate cancer and benign prostatic hyperplasia, and other practice trends from 1994 to 1997. J Urol. 1998;160:1804-1807. McConnell JD, Barry MJ, Bruskewitz RC, et al. Benign Prostatic Hyperplasia: Diagnosis and Treatment. Rockville, MD: Agency for Health Main Points • Benign prostatic hyperplasia (BPH) is a highly prevalent medical condition; management of the disease consumes a significant share of health care dollars, with an estimated 6.5 million US white men between 50 and 79 years of age meeting criteria for treatment. • Coincident with the rising number of annual physician office visits and expenditures for BPH has been a dramatic shift in the disease’s management from surgical to medical care—a result of approval by the US Food and Drug Administration of effective medications and decreases in reimbursement for surgical procedures. • With doctors increasingly prescribing medical therapy, BPH has become a chronic condition requiring ongoing medication and medical care, with significant economic consequences. Long-term cost data call into question the appropriateness of medical therapy as the initial treatment approach for all men with moderate to severe BPH symptoms. • The urologic community has begun to reconsider the possibility that for many patients initial surgery, rather than medical treatment, might be economically wiser in the long term. As a result, there has been renewed interest in novel surgical techniques and minimally invasive surgical therapies. • The latest innovation in BPH therapy is the use of the high-powered potassium-titanyl-phosphate laser for photoselective vaporization of the prostate (PVP). One hypothetical cost analysis of a cohort of 10,000 patients found the expected total cost of PVP to be lower than other surgical alternatives, including transurethral resection of the prostate and transurethral microwave therapy. • As recommended by the American Urological Association BPH Guidelines, for men with moderate symptoms and a long life expectancy, or men with severe lower urinary tract symptoms, early surgery may offer cost savings to the patient, payor, and society. S14 VOL. 8 SUPPL. 3 2006 REVIEWS IN UROLOGY RIUS0004(Laserscope)_10-27.qxd 27/10/06 14:52 Page S15 BPH Economics 12. 13. 14. 15. 16. Care Policy and Research, Public Health Service, US Dept of Health and Human Services; 1994. Lowe FC, McDaniel RL, Chmiel JJ, Hillman AL. Economic modeling to assess the costs of treatment with finasteride, terazosin, and transurethral resection of the prostate for men with moderate to severe symptoms of benign prostatic hyperplasia. Urology. 1995;46:477-483. Chirikos TN, Sanford E. Cost consequences of surveillance, medical management or surgery for benign prostatic hyperplasia. J Urol. 1996;155: 1311-1316. Canadian Coordinating Office for Health Technology Assessment. Cost-Effectiveness and CostUtility Analyses of Finasteride Therapy for the Treatment of Benign Prostatic Hyperplasia. Ottawa, Ontario, Canada: CCOHTA; 1995. Rossi C, Kortmann BB, Sonke GS, et al. Alphablockade improves symptoms suggestive of bladder outlet obstruction but fails to relieve it. J Urol. 2001;165:38-41. Littlejohn JO Jr, Ghafar MA, Kang YM, Kaplan SA. Transurethral resection of the prostate: the new old standard. Curr Opin Urol. 2002;12: 19-23. 17. 18. 19. 20. 21. 22. 23. Madersbacher S, Marberger M. Is transurethral resection of the prostate still justified? BJU Int. 1999;83:227-237. Larson TR. Rationale and assessment of minimally invasive approaches to benign prostatic hyperplasia therapy. Urology. 2002;59(2 suppl 1):12-16. Naslund MJ, Carlson AM, Williams MJ. A cost comparison of medical management and transurethral needle ablation for treatment of benign prostatic hyperplasia during a 5-year period. J Urol. 2005;173:2090-2093. DiSantostefano RL, Biddle AK, Lavelle JP. An evaluation of the economic costs and patient-related consequences of treatments for benign prostatic hyperplasia. BJU Int. 2006;97:1007-1016. DiSantostefano RL, Biddle AK, Lavelle JP. The long-term cost effectiveness of treatments for benign prostatic hyperplasia. PharmacoEconomics. 2006;24:171-191. Costello AJ, Bowsher WG, Bolton DM, et al. Laser ablation of the prostate in patients with benign prostatic hypertrophy. Br J Urol. 1992; 69:603-608. Kabalin JN, Bite G, Doll S. Neodymium:YAG laser coagulation prostatectomy: 3 years of experience with 227 patients. J Urol. 1996;155:181-185. 24. 25. 26. 27. 28. 29. Te AE. The development of laser prostatectomy. BJU Int. 2004;93:262-265. Gilling PJ, Cass CB, Malcolm AR, Fraundorfer MR. Combination holmium and Nd:YAG laser ablation of the prostate: initial clinical experience. J Endourol. 1995;9:151-153. Gilling PJ, Kennett KM, Fraundorfer MR. Holmium laser resection v transurethral resection of the prostate: results of a randomized trial with 2 years of follow-up. J Endourol. 2000;14:757-760. Malek RS, Kuntzman RS, Barrett DM. High power potassium-titanyl-phosphate laser vaporization prostatectomy. J Urol. 2000;163:1730-1733. Stovsky MD, Laskin CR, Griffiths RI. A clinical outcomes and cost analysis comparing photoselective vaporization of the prostate to alternative minimally invasive therapies and TURP for the treatment of benign prostatic hyperplasia. Presented at the 99th Annual Meeting of the American Urological Association; May 8-13, 2004; San Francisco, CA. AUA Practice Guidelines Committee. AUA guidelines on management of benign prostatic hyperplasia (2003). Chapter 1: diagnosis and treatment recommendations. J Urol. 2003;170(2 pt 1): 530-547. 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