Water vapor thermal therapy for moderate, severe BPH offers most bang for the buck

In the treatment of moderate-to-severe benign prostatic hyperplasia (BPH) in Singapore, water vapor thermal therapy (WVTT) is more cost effective than medical management (MM) in the first-line setting based on the common willingness-to-pay threshold of SGD 50,000 per quality-adjusted life-years (QALYs), a study has found.

The analysis considered six stepped-up treatment strategies, beginning with MM, WVTT, prostatic urethral lift (PUL), or the invasive transurethral resection of the prostate (TURP). A 20-year Markov model was used to simulate the cost and effectiveness of these strategies for a cohort of treatment-naïve men with moderate or severe BPH at baseline. Men were assumed to be 66 years of age, which is the mean age of BPH patients in Singapore.

“All strategies involving PUL were dominated, as they incurred higher costs for a lower effectiveness than other strategies,” the investigators noted.

In moderate BPH, treatment strategies beginning with MM (ie, MM-TURP-TURP, MM-WVTT-TURP-TURP, and MM-PUL-TURP-TURP) had similar cost and effectiveness, but first-line WVTT was incrementally cost-effective. [J Med Econ 2023;doi:10.1080/13696998.2023.2266958]

For example, WVTT-TURP-TURP cost SGD 4,071 more than MM-TURP-TURP, but WVTT-TURP-TURP resulted in 0.12 more QALYs than MM-TURP-TURP. The corresponding incremental cost-effectiveness ratio (ICER) of WVTT-TURP-TURP versus MM-TURP-TURP was SGD 33,307 per QALY. This was far lower than the ICER of SGD 159,361 per QALY of MM-TURP-TURP versus WVTT-TURP-TURP. This could be interpreted as WVTT being a cost-effective way to delay or avoid TURP.

In severe BPH, on the other hand, TURP was incrementally cost-effective versus WVTT as a first-line treatment, whereas WVTT was incrementally cost-effective versus MM as a first-line treatment.

Relative to WVTT-TURP-TURP, TURP-TURP was SGD 7,958 more expensive but resulted in 0.17 higher QALYs, yielding an ICER of SGD 48,209 per QALY. Meanwhile, WVVT-TURP-TURP was SGD 4,172 more costly but was associated with 0.14 more QALYs as compared with MM-WVTT-TURP-TURP. The ICER of performing WVTT in the first-line vs second-line setting was SGD 30,113 per QALY. These suggest that TURP-TURP and WVTT-TURP-TURP were more likely to be optimal treatment strategies for men with severe BPH.

“TURP is considered the gold standard but, despite its high efficacy, it is the most costly and invasive option, with a higher risk of perioperative and long-term adverse events. For this reason, patients often start treatment with MM,” the investigators pointed out. [Ther Adv Urol 2020;12:17562872209294863; J Urol 2021;206:806-817]

“While generally considered safer than surgical options, MM can cause bothersome side effects, such as dizziness, postural hypotension, ejaculatory dysfunction, decreased libido, erectile dysfunction and may not provide sufficient relief. Long-term MM is also subject to cumulative costs, and outcomes are affected by patient adherence to therapy, which can be poor,” they continued. [Front Pharmacol 2020;11:6585; J Urol 2021;206:806-817; BMC Urol 2015;15:9]

WVTT, along with PUL, is a minimally invasive surgical therapy developed for patients who do not respond to medication therapy but are unwilling or unable to undergo TURP.

“This study demonstrates the cost-effectiveness of WVTT over MM as first-line treatment for patients with moderate or severe BPH, suggesting [that WVTT] represents good value for money and should be considered for subsidy,” according to the investigators, who hope that their data will be used to inform clinical guidelines and subsidy decisions in Singapore.