Cost Minimisation and Threshold Analysis of Anatomical Endoscopic Enucleation of the Prostate

Introduction Anatomical endoscopic enucleation of the prostate (AEEP) techniques, including bipolar enucleation (B-TUEP), holmium laser enucleation (HoLEP), thulium laser enucleation (ThuLEP), and thulium fibre laser enucleation (ThuFLEP), demonstrate comparable clinical outcomes for benign prostatic hyperplasia. As clinical equivalence is increasingly established, cost becomes a key determinant of modality selection. We performed a cost minimisation analysis comparing index procedural costs across AEEP modalities from an institutional perspective. Methods A cost minimisation model was developed from the institutional perspective, incorporating amortised capital costs, maintenance, and consumables. In addition to the base-case scenario of 180 cases per year, we modelled two additional case volume scenarios: low (50 cases/year) and high (500 cases/year) volume. Thu:YAG laser fibres were modelled on two scenarios: disposable single-use, and reusable fibres (up to 10 cases per fibre). Breakeven analysis determined the threshold volume at which each laser modality achieves cost parity with B-TUEP, and one-way sensitivity analysis was performed on key cost parameters. Analysis was limited to index procedural costs calculated in Singapore dollars. Results At the base case of 180 cases per year, B-TUEP had the lowest index procedure cost (SGD 1,018), followed by ThuFLEP (SGD 1,584), ThuLEP (1,599), and HoLEP (SGD 1,655). Breakeven analysis demonstrated that HoLEP, ThuLEP, and ThuFLEP can never achieve cost parity with B-TUEP when laser fibres are single-use, as laser modalities carry higher costs on both capital and per-case dimensions. ThuLEP with reusable fibres (10 uses per fibre) was the only modality to cross below B-TUEP, at a breakeven volume of 198 cases per year. At 500 cases per year with reusable fibres, ThuLEP achieved the lowest cost (SGD 847), representing a 15.4% saving over B-TUEP. Sensitivity analysis identified annual case volume and B-TUEP loop cost as the most influential parameters. Conclusion Index procedural costs in AEEP are strongly influenced by case volume and consumable strategy. While B-TUEP remains cost-efficient at low volume, high-volume practice combined with reusable Thu:YAG fibre technology enables cost parity and potential cost advantage for laser enucleation. These findings highlight the importance of economies of scale and device utilisation in technology adoption.