Holmium laser enucleation of the prostate (HoLEP) has been shown in multiple studies to be the definitive surgery for benign prostatic hyperplasia (BPH). It is size independent, allows for maximum removal of prostate tissue, and has a retreatment rate of about 1% at two decades.1,2 We’ve seen great success, even for patients with chronic catheters or underactive bladders. When those patients can urinate on their own for the first time in months or years, they are some of the happiest patients we treat. In my opinion, HoLEP is the best BPH surgery available.

Our urology group uses the Lumenis Pulse 120H laser with MOSES 2.0 for HoLEP. We previously published a study that demonstrates how the technology has allowed us to safely remove the catheter and discharge patients on the same day of surgery.3 Recently, we published a study on the cost implications of HoLEP with MOSES 2.0 (“m-HOLEP”).4 It’s the first study to evaluate 30-day costs of standard HoLEP without the MOSES upgrade vs. costs of m-HoLEP— a question that’s critical to justify the MOSES 2.0 upgrade. We found that m-HoLEP saves us $747 per patient over standard HoLEP. Here are the details:

  • Focusing on a single experienced HoLEP surgeon for consistency (Dr. Amy Krambeck), we did a retrospective review of all HoLEP cases performed with the 120H laser before the MOSES 2.0 upgrade (May 2018 to November 2020) and with the MOSES 2.0 (after June 2019). In total, 312 men had HoLEP during the study period: 120 standard HoLEP and 192 m-HoLEP.
  • Patient data collected for comparison included baseline patient variables, as well as 30-day post-op complication rates, 30-day unplanned clinic visits, and 30-day ED visits and readmissions. Cost data included the initial surgery, ED visits and readmissions. Institutional policy prevented us from reporting absolute hospital costs, so we focused on cost differences.
  • Patients with standard HoLEP were kept overnight, whereas m-HoLEP patients were discharged the same day in almost all cases.
  • At 30 days, transfusion and complication rates were the same. Although all patients had the same rates of unplanned clinic visits and readmissions, patients with m-HoLEP were more likely to visit the ED within 30 days (6.3% vs. 1.7%, p=0.0571). We noted that most of those ED visits occurred during implementation of our same-day discharge pathway, and there were none after May 2020. The most common reason was blood in the urine. Costs of 30-day ED visits were lower for the m-HoLEP group by $3,220 (p=0.123) due to less serious complaints and shorter length of stay (0.361.34 vs 1.403.13 days, p=0.506).
  • Costs for the initial surgical episode, including equipment use and disposables, were $840 less for m-HoLEP compared to standard HoLEP, primarily because patients underwent same-day discharge and surgery was shorter (74.1±35.0 vs. 80.8±45.4 min). Factoring in the costs of 30-day ED visits/readmissions, m-HoLEP still saved the hospital $747 per case (p=0.0574).
  • Based on the savings demonstrated in our study, it would take 74 HoLEP procedures to recoup the investment in a MOSES 2.0 upgrade.

It’s important to note that the study is based on the work of a surgeon experienced in HoLEP. To achieve similar cost savings, a surgeon must first become proficient at HoLEP. Although there is a learning curve, I have found that the procedure’s outcomes and the difference it makes in patients’ lives are worth the effort.

  1. Gilling PJ, Wilson LC, King CJ, Westenberg AM, Frampton CM, Fraundorfer MR. Long-term results of a randomized trial comparing holmium laser enucleation of the prostate and transurethral resection of the prostate: results at 7 years. BJU Int. 2012 Feb; 109(3):408-11.
  2. Gilling PJ, Aho TF, Frampton CM, King CJ, Fraundorfer MR. Holmium laser enucleation of the prostate: results at 6 years. Eur Urol. 2008 Apr; 53(4):744-9.
  3. Agarwal DK, Rivera ME, Nottingham CU, Large T, Krambeck AE. Catheter Removal on the Same Day of Holmium Laser Enucleation of the Prostate: Outcomes of a Pilot Study. Urology. 2020 Dec; 146: 225–229.
  4. Lee MS, Assmus M, Agarwal G, Large T, Krambeck A. A Cost Comparison of Holmium Laser Enucleation of the Prostate with and without Moses. Urology Practice. November 1, 2021.

*Risk information and laser safety label are available at Lumenis website, operator’s manual and brochure.

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