Cost Minimisation and Threshold Analysis of Anatomical Endoscopic Enucleation of the Prostate
This cost minimisation analysis reveals that while bipolar transurethral enucleation of the prostate (B-TUEP) is the most cost-effective option for low-volume practices, high-volume centers utilizing reusable thulium laser fibers can achieve significant cost savings over B-TUEP, highlighting the critical influence of case volume and consumable strategy on the economic viability of anatomical endoscopic enucleation of the prostate.
Original paper licensed under CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). This is an AI-generated explanation of the paper below. It is not written or endorsed by the authors. For technical accuracy, refer to the original paper. Read full disclaimer
For millions of men around the world, a condition called benign prostatic hyperplasia causes the prostate gland to grow larger, squeezing the urethra and making it difficult to pass urine. While medication can sometimes help, surgery is often the most effective solution. For decades, the standard operation involved shaving away the excess tissue piece by piece. However, in recent years, a more modern approach has emerged where surgeons use specialized tools to peel the entire inner lining of the prostate away from its outer shell in one go. This technique, known as anatomical endoscopic enucleation, is now considered the gold standard for many cases because it works well regardless of how large the prostate is. The challenge for hospitals is that several different types of technology can perform this peeling procedure. Some use electrical currents, while others rely on powerful lasers. Since the medical results are nearly identical across these different methods, the decision of which machine to buy and use often comes down to a different kind of calculation: cost.
A team of researchers from several major hospitals in Singapore set out to solve this puzzle by comparing the true price tag of four different surgical approaches. They looked at the bipolar electrical method, which uses a standard generator, and three laser-based methods: one using a holmium laser, one using a pulsed thulium laser, and a newer one using a thulium fiber laser. The researchers built a detailed financial model to calculate the cost of a single surgery from the hospital's point of view. They included the price of the expensive machines, the cost of maintaining them, and the price of the disposable parts used during each operation, such as the cutting loops or the laser fibers. Crucially, they did not just look at one fixed number; they simulated how costs would change if a hospital performed very few surgeries a year versus a very high number. They also tested a specific variable: whether the delicate laser fibers used in the thulium procedures could be cleaned and reused multiple times, or if they had to be thrown away after a single use.
The study found that the answer depends entirely on how busy the hospital is and how they manage their equipment. When the researchers calculated the cost for a typical year with about 180 surgeries, the bipolar electrical method was the cheapest option, costing just over 1,000 Singapore dollars per procedure. All three laser methods were more expensive, ranging from roughly 1,580 to 1,655 dollars. The main reason for this gap was the massive upfront price of the laser machines, which cost between 188,000 and 320,000 dollars to buy, compared to the much cheaper electrical generator. When the team simulated a hospital with a low volume of only 50 surgeries a year, the electrical method remained the clear winner, with the laser options costing more than double. Even when they simulated a very busy hospital performing 500 surgeries a year, the electrical method stayed cheaper, provided that the laser fibers were treated as single-use items that were discarded after every operation.
The researchers discovered a specific scenario where the laser technology could become the cheaper choice, but it required a very specific combination of factors. If a hospital used the pulsed thulium laser and adopted a strategy of cleaning and reusing the laser fibers up to ten times, the cost dynamics shifted. In this case, the cost per surgery dropped significantly because the expensive fiber was no longer a single-use expense. However, this savings only kicked in once the hospital reached a certain threshold of activity. The analysis showed that the hospital needed to perform at least 198 surgeries a year with this reusable fiber strategy for the laser method to finally match the price of the electrical method. If the hospital performed even more surgeries, such as 500 a year, the reusable laser method actually became the most affordable option, saving the hospital money on every single procedure compared to the electrical alternative.
The study also examined what factors could change these results. The researchers found that the most powerful drivers of cost were simply the number of surgeries performed and the price of the disposable parts. If the price of the electrical cutting loops went up, or if the hospital could perform more surgeries, the balance could tip. However, the study ruled out the idea that laser surgery could ever be cheaper than the electrical method if the fibers were thrown away after one use. No matter how many surgeries were performed, the high cost of the laser machines combined with the price of single-use fibers meant the laser option would always cost more. The researchers concluded that for most hospitals, especially those with lower patient volumes, the electrical method remains the most economical choice. For high-volume centers, however, investing in laser technology becomes financially viable, but only if they are disciplined enough to reuse the fibers safely. This work provides a clear roadmap for hospital administrators, showing that the cheapest way to treat patients is not a fixed rule but a calculation that changes with the size of the hospital and the strategy for using its tools.
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