Budget impact analysis of transurethral water vapor therapy for treatment of lower urinary tract symptoms associated with benign prostatic hyperplasia in the Spanish national healthcare system

Figures & data

Figure 1. Structure of the model designed for the budget impact analysis.

* The states coloured in black include the possibility of short-term complications caused by the surgery. Health states and transitions in discontinued lines are possible in sensitivity analysis including erectile dysfunction.

Table 1. Clinical parameters of the surgical treatments of lower urinary tract symptoms in benign prostatic hyperplasia.

	WVTT	mTURP	bTURP	PVP	HoLEP
Short-term mild/moderate complications occurrence frequency
Non – AUR	2.6% [48,49]	1.2% [34]	2.0% ^A [18,34]	5.9% [34]	0.8% ^B [22,34]
Mild UTI	2.1% [48,49]	5.4% [18]	5.4% [18]	19.1% [34]	5.3% ^C [18,22]
Bleeding	13.8% [49]	12,8% [46]	0.0% ^D [18]	8.8% [34]	7.5% [51]
Short-term severe complications occurrence frequency
AUR	0.5% [48,49]	3.8% [34]	3.8% [34]	6.6% [34]	4.4% [51]
Severe UTI	0.0% [48,49]	0.6% [18]	0.6% ^E [18]	0.0% [34]	0.6% ^F [18,22]
Hemorrhage or transfusion requirement	1.1% [48,49]	7.0% [18]	8.2% ^G [18]	1.0% [35]	5.1% ^H [18,22]
Bladder neck constriction	0.0% [48,49]	8.0% [18]	9.7% ^I [18]	4.4% [34]	3.9% ^J [18,22]
TURS	0.0% [48,49]	3.0% [18]	0.5% ^K [18]	0.0% [34]	0.4% ^L [18,22]
Long-term adverse events occurrence frequency
Urinary incontinence	0.5% [24]	3.0% [18]	1.8% ^M [18]	1.1% [34]	2.9% ^N [18,22]
Procedure characteristics
Operation duration	17.5 minutes [36]	66.0 minutes [37]	66.0 minutes [37]	49.6 minutes [34]	80.2 minutes [38]
Length of hospital stay	0 days [39]	3.67 days [40]	3.63 days [40]	1 day *	2.5 days [41]

AUR: Acute Urinary Retention; bTURP: Transurethral Resection of the Prostate with bipolar diode; HoLEP: Holmium Laser Enucleation of the Prostate; mRTUP: Transurethral Resection of the Prostate with monopolar diode; PVP: Photoselective Vapourization of the Prostate; RR: Relative Risk; TURS: Transurethral Resection Syndrome; UTI: Urinary Tract Infection; WVTT: Water Vapor Thermal Therapy. * Experts opinion.

^AIncidence of mTURP (1.2%) [34] multiplied by a RR (mTURP vs. bTURP) of 1.71 [18].

^BIncidence of mTURP (1.2%) [34] multiplied by a RR (mTURP vs. HoLEP) of 0.71 [22].

^CIncidence of mTURP (5.4%) [18] multiplied by a RR (mTURP vs. HoLEP) of 0.98 [22].

^DAll events of bleeding/hemorrhage were assumed to be severe.

^EIncidence of mTURP (0.6%) [18] multiplied by a RR (mTURP vs. bTURP) of 1.00 [18].

^FIncidence of mTURP (0.6%) [18] multiplied by a RR (mTURP vs. HoLEP) of 0.98 [22].

^GIncidence of mTURP (7.0%) [18] multiplied by a RR (mTURP vs. bTURP) of 1.03 [18].

^HIncidence of mTURP (7.0%) [18] multiplied by a RR (mTURP vs. HoLEP) of 0.27 [22].

^IIncidence of mTURP (8.0%) [18] multiplied by a RR (mTURP vs. bTURP) of 1.38 [18].

^JIncidence of mTURP (8.0%) [18] multiplied by a RR (mTURP vs. HoLEP) of 0.84 [22].

^KIncidence of mTURP (3.0%) [18] multiplied by a RR (mTURP vs. bTURP) of 0.18 [18].

^LIncidence of mTURP (3.0%) [18] multiplied by a RR (mTURP vs. HoLEP) of 0.13 [22].

^MIncidence of mTURP (3.0%) [18] multiplied by a RR (mTURP vs. bTURP) of 0.59 [18].

^NIncidence of mTURP (3.0%) [18] multiplied by a RR (mTURP vs. HoLEP) of 0.97 [22].

Table 2. Costs included in the economic evaluation.

Device/Components	Unit Cost (€, 2023)
Intervention Resources
WVTT	€ 1,564.49*
mTURP	€ 61,32*
bTURP	€ 276,31*
PVP	€ 1,740.51*
HoLEP	€ 700.58*
Hospital Resources
WVTT	€ 1,512.57*
mTURP	€ 5,202.17*
bTURP	€ 5,171.98*
PVP	€ 2,875.96*
HoLEP	€ 4,588.12*
Short-term mild/moderate adverse events management
Non – AUR	€ 71.61*
Non – acute UTI	€ 92.01*
Non – acute bleeding	€ 64.3764.37 *
Short-term severe adverse events management
AUR	€ 301.50 [42]
Acute UTI	€ 3,011.18 [43]
Bleeding/Blood transfusion	€ 1,125.64*
TURS	€ 7,845.54*
Bladder neck constriction	€ 4,388.36*
Long-term adverse events management
Urinary Incontinence	€ 2,292.77 ** [43–45]

AUR: Acute Urinary Retention; bTURP: Transurethral Resection of the Prostate with bipolar diode; DRG-APR: Diagnosis Related Group – All Patients Reported; HoLEP: Holmium Laser Enucleation of the Prostate; mTURP: Transurethral Resection of the Prostate with monopolar diode; MSCBS: Ministerio de Sanidad Consumo y Bienestar Social; PSA: Prostatic Specific Antigen; PVP: Photoselective Vapourization of the Prostate; TURS: Transurethral Resections Syndrome; UTI: Urinary Tract Infection; WVTT: Water Vapor Thermal Therapy. * Disaggregated resources consumption is included in Appendix. ** It was considered 5% of severe incontinence (€11,633.58) [43], 40% of moderate incontinence (€2,519.44) [44] and 55% of mild incontinence (€1,278.75) [45].

Figure 2. Cost breakdown per first intervention with the techniques in the base case.

HoLEP: Holmium Laser Enucleation of the Prostate; PVP: Photoselective Vapourization of the Prostate; TURP: Transurethral Resection of the Prostate; WVTT: Water Vapour Thermal Therapy.

Table 3. Base case and alternative scenario results.

	Use (%)	Analysis	Year 1	Year 2	Year 3	Year 4	Cumulative
Scenario W/O WVTT
WVTT	0.00%		€0	€0	€0	€0	€0
TURP	60.00%	Base Case	€401,628,106	€11,224,679	€11,143,053	€11,063,042	€435,058,880
		Alternative scenario	€401,881,609	€11,229,489	€11,147,766	€11,067,662	€435,326,525
PVP	30.00%	Base Case	€161,987,025	€3,366,653	€3,348,874	€3,331,351	€172,033,903
		Alternative scenario	€157,919,504	€3,338,965	€3,321,582	€3,304,451	€435,326,525
HoLEP	10.00%	Base Case	€62,002,072	€1,106,185	€1,108,282	€1,110,365	€65,326,905
		Alternative scenario	€63,513,003	€1,115,308	€1,117,347	€1,119,374	€66,865,032
Total per year	100%	Base Case	€625,617,203	€15,697,517	€15,600,209	€15,504,758	€672,419,688
		Alternative scenario	€623,314,116	€15,683,760	€15,586,696	€15,491,486	€670,076,057
Scenario W WVTT
WVTT	10.00%	Base Case	€34,351,113	€602,616	€601,993	€601,376	€36.157,099
		Alternative scenario	€32,943,572	€597,827	€597,247	€596,673	€34,735,319
TURP	55.00%	Base Case	€368,159,097	€10,289,289	€10,214,465	€10,141,122	€398,803,973
		Alternative scenario	€368,391,475	€10,293,698	€10,218,786	€10,145,357	€34,735,319
PVP	25.00%	Base Case	€134,989,187	€2,805,544	€2,790,729	€2,776,126	€143,361,586
		Alternative scenario	€131,599,586	€2,782,470	€2,767,985	€2,753,709	€139,903,750
HoLEP	10.00%	Base Case	€62,002,072	€1,106,185	€1,108,282	€1,110,365	€65,326,905
		Alternative scenario	€63,513,003	€1,115,308	€1,117,347	€1,119,374	€66,865,032
Total per year	100.00%	Base Case	€599,501,470	€14,803,635	€14,715,469	€14,628,989	€643,649,562
		Alternative scenario	€596,447,636	€14,447,636	€14,701,366	€14,615,112	€640,553,416
Budget Impact (Scenario W vs W/O WVTT)
Incremental cost		Base Case	- €26,115,733	- €893,883	- €884,740	- €875,769	- €28,770,125
		Alternative scenario	- €26,866,479	- €894,458	- €885,330	- €876,374	- €29,522,641

BIA: Budget Impact Analysis; HoLEP: Holmium Laser Enucleation of the Prostate; PVP: Photoselective Vapourization of the Prostate; TURP: transurethral Resection of the Prostate; W: With; WVTT: Water Vapor Thermal Therapy; W/O: Without.

Table 4. One-way sensitivity analyses results.

	Base Case Value	Sensitivity Analysis Value	Incremental cost (Scenario W WVTT vs W/O WVTT)
			Year 1	Year 2	Year 3	Year 4	Cumulative
Base case results			- €26,115,733	- €893,883	- €884,740	- €875,769	- €28,770,125
One-way sensitivity analyses
Proportion of use of mTURP and bTURP	mTURP: 50% bTURP: 50%	mTURP: 100% bTURP: 0%	- €25,978,278	- €969,292	- € 961,328	- €953,507	- €28,862,405
		mTURP: 20% bTURP: 80%	- €26,198,206	- €848,637	- €838,787	- €829,126	- €28,714,757
		mTURP: 10% bTURP: 90%	- €26,225,697	- €833,556	- €823,470	- €813,579	- €28,696,301
		mTURP: 0% bTURP: 100%	- €26,253,188	- €818,474	- €808,152	- €798,031	- €28,677,845
mTURP mild UTI frequency	5.4% [22]	18.2% [46]	- €26,148,259	- €894,383	- €885,228	- €876,245	- €28,804,115
PVP intervention duration	49.6 minutes [34]	75 minutes *	- €28,764,293	- €912,487	- €903,077	- €893,843	- €31,473,700
		100 minutes *	- €31,371,143	- €930,798	- €921,125	- €911,632	- €34,134,699
Surgery theater cost	€18.96 [47]	€12.04 [54]	- €23,035,080	- €846,562	- €838,529	- €830,646	- €25,550,816
Retreatment with TURP	TURP: 100% WVTT: 60% PVP: 50% HoLEP: 0%	TURP: 100%** WVTT: 0% PVP: 0% HoLEP: 0%	- €26,179,328	- €1,021,442	- €1,012,792	- €1,004,312	- €29,217,874
		TURP: 100%** WVTT: 100% PVP: 100% HoLEP: 100%	- €26,080,775	- €823,845	- €814,541	- €805,407	- €28,524,568
Proportion of use in the alternative scenario	TURP: 55% WVTT: 10% PVP: 25% HoLEP: 10%	TURP: 50% WVTT: 20% PVP: 20% HoLEP: 10%	- €52,231,467	- €1,787,765	- €1,769,480	- €1,754,538	- €57,540,250
		TURP: 45% WVTT: 30% PVP: 15% HoLEP: 10%	- €78,347,200	- €2,681,648	- €2,654,220	- €2,627,307	- €86,310,376
Erectile dysfunction as a complication	Erectile dysfunction excluded	Erectile dysfunction included	- €26,679,955	- €1,652,720	- €1,653,116	- €1,653,450	- €31,639,242

bTURP: Transurethral Resection of the Prostate with bipolar diode; HoLEP: Holmium Laser Enucleation of the Prostate; mTURP: Transurethral Resection of the Prostate with monopolar diode; PVP: Photoselective Vapourization of the Prostate; UTI: Urinary Tract Infection; WVTT: Water Vapor Thermal Therapy. * Experts opinion. ** The designment of the model did not allow the modification of this parameter.

Figure 3. Probabilistic Sensitivity Analysis Results: Probability of Incremental Cost (WVTT vs. Other surgical therapies).

HoLEP: Holmium Laser Enucleation of the Prostate; PVP: Photoselective Vapourization of the Prostate; TURP: Transurethral Resection of the Prostate; WVTT: Water Vapour Thermal Therapy.

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