Five-year Retreatment and Medication Restart Rates Following Benign Prostate Hyperplasia Treatments: A Nationwide Real-world Analysis Using Epic Cosmos

Background and objective: Surgical treatments for benign prostatic hyperplasia (BPH) have expanded with the diffusion of minimally invasive surgical treatments (MISTs), but concerns persist regarding their long-term durability. This study aimed to provide a comprehensive, real-world description of current treatment trends, retreatment rates, and medication reinitiation up to 5 yr following MISTs and traditional procedures. Methods: This observational retrospective fixed-cohort study was conducted using Epic Cosmos, including data of 6 450 295 patients and 420 611 procedures between 2014 and 2024. The primary outcome was procedural trend; the secondary outcomes were surgical retreatment and medication reinitiation. Analyses were descriptive and unadjusted for potential confounders due to the aggregated nature of the dataset. Key findings and limitations: At 5 yr, retreatment rates were higher after prostatic urethral lift (PUL; 16%), transurethral needle ablation of the prostate (15%), transurethral microwave thermotherapy (17%), and Rezūm (14%), and lower after holmium laser enucleation of the prostate (HoLEP)/thulium laser enucleation of the prostate (ThuLEP; 4.4%) and simple prostatectomy (1.2%) when compared with transurethral resection of the prostate (TURP; 7.1%). Medication reinitiation at 5 yr was more common after MISTs (PUL: 21% α-blockers, 25% 5α-reductase inhibitors [5-ARIs], and 27% overactive bladder [OAB] drugs; all p < 0.001; Rezūm: 18% α-blockers, p = 0.001; 22% 5-ARIs, p = 0.05; and 23% OAB drugs, p > 0.99) and lower following traditional procedures, including HoLEP/ThuLEP—11% α-blockers (p < 0.001), 12% 5-ARIs (p < 0.001), and 21% OAB drugs (p = 0.3), and simple prostatectomy—5.4% α-blockers (p < 0.001), 6.5% 5-ARIs (p < 0.001), and 9.4% OAB drugs (p < 0.001), when compared with TURP (15% α-blockers, 17% 5-ARIs, and 23% OAB drugs). Limitations include the use of aggregated electronic health record data subject to coding errors and the inability to adjust for clinical variables such as prostate size and symptom severity. Conclusions and clinical implications: In this large, real-world cohort, anatomical procedures such as HoLEP, ThuLEP, and simple prostatectomy were associated with the lowest long-term rates of retreatment and medication restart, whereas higher rates were observed with MISTs, particularly PUL and Rezūm. TURP remained the most performed procedure. As the use of MISTs declines after its initial uptake, future studies should clarify which patient characteristics may underlie these observed differences.