Niche No More? Mapping US Trends and Regional Disparities in Holmium Laser Enucleation of the Prostate from 2018 to 2022.

Introduction: The clinical benefits of holmium laser enucleation of the prostate (HoLEP) for managing benign prostatic hyperplasia (BPH) are well-documented. However, HoLEP was performed in less than 5% of all BPH surgeries in the United States (US) prior to 2016, with large regional gaps in care. This study assessed temporal trends and geographic distribution of HoLEP utilization and providers in the US from 2018 to 2022. Methods: Claims data from Definitive Healthcare (2018-2022) were used to identify urologists who performed HoLEP and assess utilization across the US. HoLEP rates were calculated by dividing patients who underwent HoLEP by total patients with BPH who underwent any procedure for BPH. Active HoLEP surgeons were defined as those who performed ≥10 annual HoLEP procedures. Regional patient concentration was calculated by dividing patients with BPH by active HoLEP surgeons. Utilization trends over time were analyzed through Cochran-Armitage tests. Results: HoLEP utilization in the US increased by 52% between 2018 and 2022. The number of urologists performing HoLEP rose by 16%, from 386 in 2018 to 451 in 2022, while active HoLEP surgeons increased by 43% (106 to 151). High-volume surgeons performed 40.8% of all HoLEP cases in 2018 and 57.6% in 2022. States with ≥1 active HoLEP surgeon increased from 32 to 34, leaving 33% of states without a single active surgeon. The West (1050) and Northeast (786.3) had the highest BPH patient-to-surgeon ratios in 2018 and 2022, respectively, while the South had the best ratio and the most surgeons. Conclusions: HoLEP utilization has increased significantly, highlighting the growing demand in the US. Almost a third of states still lack access to an active HoLEP surgeon, and the high ratio of patients per provider in regions like the Northeast indicates a need for facilitating the dissemination of expertise to ensure equitable access to HoLEP.