Lack of Diversity in Minimally Invasive Bladder Outlet Surgery Among Urologists in the United States

New bladder outlet procedures have been introduced in the last decade, but there has been limited research into procedural uptake and diversification at provider and regional levels. In this study, we investigated trends in these procedures within Medicare over a six-year period. We hypothesized that provider age and rurality would be associated with procedural diversity.

We conducted a retrospective analysis of bladder outlet procedures in Medicare data from 2014 to 2019, including transurethral resection of prostate (TURP), Greenlight laser vaporization (GL), UroLift (UL), Rezum (RZ), and laser enucleation (LEP). Data were analyzed by provider and U.S. census region. Vector autoregressive modeling was used to test the hypothesis that greater procedural diversity would be found in more urban regions with younger providers.

In 2019, a sample of 2747 Medicare providers performed bladder outlet surgery nationwide. 81% performed one type of procedure, whereas only one performed more than three types. TURP was favored across all regions. TURP and GL volume decreased while UL increased over the study period; RZ and LEP were less common. Two regions, the Northeast and West, demonstrated significantly greater procedural diversity, but differences could not be attributed to provider age or rurality at the national level. In the regional analysis, however, rural areas with less variation in provider age had slower uptake of newer procedures (p = 0.022), and urban areas with more variation in provider age demonstrated more rapid uptake (p = 0.008).   Conclusions: While TURP continues to be the most common bladder outlet procedure, there is steady adoption of new technologies with complex patterns of uptake based on provider age and rurality. Understanding the dissemination of new procedures and the appropriate role of procedural diversification may help to improve both access to and quality of care.