[Prehabilitation prior to radical prostatectomy : A useful concept?]

Against the background of a continuous improvement of established treatment outcomes and the compatibility of health economic considerations, pre- and perioperative processes are constantly being developed and further optimized. In recent years, the concept of prehabilitation has gained increasing importance as a proactive approach to preparing patients for mostly surgical cancer treatment and improving their physical and mental health. Prehabilitation in oncology is a systematic process aimed at improving the physical, psychosocial, and nutritional condition of patients before and during cancer treatment. The goal of prehabilitation is to enhance patients' ability to cope with the physiological stress of cancer treatment and improve their overall health and well-being. In addition, prehabilitation has the potential to reduce costs for the healthcare system.

Comparison of 1-Year Health Care Costs and Use Associated With Open vs Robotic-Assisted Radical Prostatectomy

IMPORTANCE

With the current patterns of adoption and use of robotic surgery and improvement in the overall survival of patients with prostate cancer, it is important to evaluate the immediate and long-term cost implications of treatments for patients with prostate cancer.

OBJECTIVE

To compare health care costs and use 1 year after open radical prostatectomy (ORP) vs robotic-assisted radical prostatectomy (RARP).

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study used a US commercial claims database from January 1, 2013, to December 31, 2018. A total of 11 457 men aged 18 to 64 years who underwent inpatient radical prostatectomy for prostate cancer and were continuously enrolled with medical and prescription drug coverage from 180 days before to 365 days after inpatient prostatectomy were identified. An inverse probability of treatment weighting analysis was performed to examine the differences in costs and use of health care services by surgical modality. Data analysis was conducted from September 2019 to July 2020.

EXPOSURES

Type of surgical procedure: ORP vs RARP.

MAIN OUTCOMES AND MEASURES

Three outcomes within 1 year after the inpatient prostatectomy were investigated: (1) total health care costs, including reimbursement paid by insurers and out of pocket by patients; (2) health care use, including inpatient readmission, emergency department, hospital outpatient, and office visits; and (3) estimated days missed from work due to health care use.

RESULTS

Of the 11 457 patients who underwent inpatient prostatectomy, 1604 (14.0%) had ORP and 9853 (86.0%) had RARP and most patients (8467 [73.9%]) were aged 55 to 64 years. Compared with patients who underwent ORP, those who received RARP had a higher cost at the index hospitalization (mean difference, $2367; 95% CI, $1821-$2914; P < .001), but similar total cumulative costs were observed within 180 days (mean difference, $397; 95% CI, -$582 to $1375; P = .43) and 1 year after discharge (-$383; 95% CI, -$1802 to $1037; P = .60). One-year postdischarge health care use was significantly lower in the RARP compared with ORP group for mean numbers of emergency department visits (-0.09 visits; 95% CI, -0.11 to -0.07 visits; P < .001) and hospital outpatient visits (-1.5 visits; -1.63 to -1.36 visits; P < .001). The reduction in use of health care services among patients who underwent RARP translated into additional savings of $2929 (95% CI, $1600-$4257; P < .001) and approximately 1.69 fewer days (95% CI, 1.49-1.89 days; P < .001) missed from work for health care visits.

CONCLUSIONS AND RELEVANCE

Total cumulative cost in this study was similar between ORP and RARP 1 year post discharge; this finding suggests that lower postdischarge health care use after RARP may offset the higher costs during the index hospitalization.

[Cost analysis of GreenLight photoselective vaporization of the prostate versus standard transurethral resection of the prostate: Benefit of ambulatory care]

PURPOSE

To compare the costs associated with GreenLight XPS 180W photoselective vaporization of the prostate (PVP) for an outpatient versus standard transurethral resection of the prostate (TURP) with a three nights hospitalization in a French private hospital.

MATERIAL AND METHODS

A retrospective cost minimization analysis was performed between 2017 and 2019 in a French private hospital for the hospital stays associated with TURP and PVP procedures for benign prostatic hyperplasia (BPH). The peri-operative cost-benefit assessment of the two procedures was analyzed from the establishment's point of view according to the micro-costing method.

RESULTS

871 surgical treatment for BPH had been performed during the period of the study, including 743 photoselective laser vaporization (85%). The average length of stay of patients undergoing TURP was 3,7 days versus 0,9 days for PVP including 64,7% ambulatory. The cost-benefit was more of 500€ per patient in favor of ambulatory PVP compared with TURP in conventional three nights hospitalization for level 1 hospital stays.

CONCLUSION

In this private hospital center, ambulatory PVP seemed more cost-effective than TURP with a three nights hospitalization for a severity level 1 patient. The financial profit for the establishment was mostly due to reduction of the main length of stay and ambulatory care.

LEVEL OF EVIDENCE

3.

State of the art: Open prostatectomy for benign prostate hyperplasia: Should we avoid it in all cases?

Surgical procedures for benign prostate hyperplasia (BPH) had considerably evolved during last decades. New techniques can nowadays treat prostate big in size, which are classically treated by open prostatectomy (OP). Therefore, the place of this procedure that has been used for over 150 years is nowadays questioned. Is it outdated? Is there emerging techniques that are more efficient, safer and cost effective? This state of the art based on literature review will assess the place of OP in BPH surgery from efficacy on functional outcomes, security, competitiveness with modern and minimally invasive techniques and socio-economic perspectives. Currently, OP has excellent functional outcomes, with low rate of retreatment after surgery, low morbidity and affordable cost in our country. It remains competitive with new surgery techniques for BPH, even if the latter offer the advantages of a minimally invasive surgery, especially in hospitalization length. Taking in consideration the social and economic context in Tunisia, it remains the most accessible and affordable surgical technique. Besides, OP is a procedure that has to be handled by every urologist given the theoretical risk of conversion during endoscopic surgery of BPH, and its use under certain circumstances (In case of bladder lithiasis ou diverticle or impossibility of lithotomy position).

Modelling the lifetime cost-effectiveness of radical prostatectomy, radiotherapy and active monitoring for men with clinically localised prostate cancer from median 10-year outcomes in the ProtecT randomised trial

BACKGROUND

Optimal management strategies for clinically localised prostate cancer are debated. Using median 10-year data from the largest randomised controlled trial to date (ProtecT), the lifetime cost-effectiveness of three major treatments (radical radiotherapy, radical prostatectomy and active monitoring) was explored according to age and risk subgroups.

METHODS

A decision-analytic (Markov) model was developed and informed by clinical input. The economic evaluation adopted a UK NHS perspective and the outcome was cost per Quality-Adjusted Life Year (QALY) gained (reported in UK£), estimated using EQ-5D-3L.

RESULTS

Costs and QALYs extrapolated over the lifetime were mostly similar between the three randomised strategies and their subgroups, but with some important differences. Across all analyses, active monitoring was associated with higher costs, probably associated with higher rates of metastatic disease and changes to radical treatments. When comparing the value of the strategies (QALY gains and costs) in monetary terms, for both low-risk prostate cancer subgroups, radiotherapy generated the greatest net monetary benefit (£293,446 [95% CI £282,811 to £299,451] by D'Amico and £292,736 [95% CI £284,074 to £297,719] by Grade group 1). However, the sensitivity analysis highlighted uncertainty in the finding when stratified by Grade group, as radiotherapy had 53% probability of cost-effectiveness and prostatectomy had 43%. In intermediate/high risk groups, using D'Amico and Grade group > = 2, prostatectomy generated the greatest net monetary benefit (£275,977 [95% CI £258,630 to £285,474] by D'Amico and £271,933 [95% CI £237,864 to £287,784] by Grade group). This finding was supported by the sensitivity analysis. Prostatectomy had the greatest net benefit (£290,487 [95% CI £280,781 to £296,281]) for men younger than 65 and radical radiotherapy (£201,311 [95% CI £195,161 to £205,049]) for men older than 65, but sensitivity analysis showed considerable uncertainty in both findings.

CONCLUSION

Over the lifetime, extrapolating from the ProtecT trial, radical radiotherapy and prostatectomy appeared to be cost-effective for low risk prostate cancer, and radical prostatectomy for intermediate/high risk prostate cancer, but there was uncertainty in some estimates. Longer ProtecT trial follow-up is required to reduce uncertainty in the model.

TRIAL REGISTRATION

Current Controlled Trials number, ISRCTN20141297: http://isrctn.org (14/10/2002); ClinicalTrials.gov number, NCT02044172: http://www.clinicaltrials.gov (23/01/2014).

Comparative Healthcare Research Outcomes of Novel Surgery in prostate cancer (IP4-CHRONOS): A prospective, multi-centre therapeutic phase II parallel Randomised Control Trial

INTRODUCTION

Focal therapy (FT) targets individual areas of cancer within the prostate, providing oncological control with minimal side-effects. Early evidence demonstrates encouraging short-medium-term outcomes. With no randomized controlled trials (RCT) comparing FT to radical therapies, Comparative Healthcare Research Outcomes of Novel Surgery in prostate cancer (CHRONOS) will compare the cancer control of these two strategies.

PATIENTS AND METHODS

CHRONOS is a parallel phase II RCT for patients with clinically significant non-metastatic prostate cancer, dependent upon clinician/patient decision, patients will enrol into either CHRONOS-A or CHRONOS-B. CHRONOS-A will randomize patients to either radical treatment or FT. CHRONOS-B is a multi-arm, multistage RCT comparing focal therapy alone to FT with neoadjuvant agents that might improve the current focal therapy outcomes. An internal pilot will determine the feasibility of, and compliance to, randomization. The proposed definitive study plans to recruit and randomize 1190 patients into CHRONOS-A and 1260 patients into CHRONOS-B.

RESULTS

Primary outcome in CHRONOS-A is progression-free survival (transition to salvage local or systemic therapy, development of metastases or prostate-cancer-related mortality) and in CHRONOS-B is failure-free survival (includes the above definition and recurrence of clinically significant prostate cancer after initial FT). Secondary outcomes include adverse events, health economics and functional outcomes measured using validated questionnaires. CHRONOS is powered to assess non-inferiority of FT compared to radical therapy in CHRONOS-A, and superiority of neoadjuvant agents with FT in CHRONOS-B.

CONCLUSION

CHRONOS will assess the oncological outcomes after FT compared to radical therapy and whether neoadjuvant treatments improve cancer control following one FT session.

Challenges in the Analysis of Outcomes for Surgical Compared to Radiotherapy Treatment of Prostate Cancer

BACKGROUND/AIM

Prostate cancer can be treated with radical prostatectomy (RP), external-beam radiotherapy (EBRT), or brachytherapy (BT). These modalities have similar cancer-related outcomes. We used an innovative method to analyze the cost of such treatment.

MATERIALS AND METHODS

We queried our Institution's Insurance Division [University of Pittsburgh Medical Center (UPMC) Health Plan] beneficiaries from 2003-2008, who were diagnosed with prostate cancer and also queried the UPMC tumor registry for all patients with prostate cancer treated at our Institution. In a de-identified manner, data from the Health Plan and Tumor Registry were merged.

RESULTS

A total of 354 patients with non-metastatic disease with treatment initiated within 9 months of diagnosis were included (RP=236, EBRT=55, and BT=63). Radiotherapy-treated patients tended to be older, higher-risk, and have more comorbidities. Unadjusted median total health care expenditures during the first year after diagnosis were: RP: $16,743, EBRT: $47,256, and BT: $23,237 (p<0.0005). A propensity score-matched model comparing RP and EBRT demonstrated median total health care expenditures during year one: RP: $8,189, EBRT: $10,081; p=0.48. In a propensity-matched model comparing RP and BT, the median total health care expenditures during year one were: RP: $18,143, BT: $26,531; p=0.015 and per year during years 2 through 5 from diagnosis were: RP: $5,913, BT: $6,110; p=0.68.

CONCLUSION

This pilot study demonstrates the feasibility of combining healthcare costs from the payer's perspective with clinical data from a Tumor Registry within an IDFS and represents a novel approach to investigating the economic impact of cancer treatment.

Cost of New Technologies in Prostate Cancer Treatment: Systematic Review of Costs and Cost Effectiveness of Robotic-assisted Laparoscopic Prostatectomy, Intensity-modulated Radiotherapy, and Proton Beam Therapy

CONTEXT

Some of the high costs of robot-assisted radical prostatectomy (RARP), intensity-modulated radiotherapy (IMRT), and proton beam therapy may be offset by better outcomes or less resource use during the treatment episode.

OBJECTIVE

To systematically review the literature to identify the key economic trade-offs implicit in a particular treatment choice for prostate cancer.

EVIDENCE ACQUISITION

We systematically reviewed the literature according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement and protocol. We searched Medline, Embase, and Web of Science for articles published between January 2001 and July 2016, which compared the treatment costs of RARP, IMRT, or proton beam therapy to the standard treatment. We identified 37, nine, and three studies, respectively.

EVIDENCE SYNTHESIS

RARP is costlier than radical retropubic prostatectomy for hospitals and payers. However, RARP has the potential for a moderate cost advantage for payers and society over a longer time horizon when optimal cancer and quality-of-life outcomes are achieved. IMRT is more expensive from a payer's perspective compared with three-dimensional conformal radiotherapy, but also more cost effective when defined by an incremental cost effectiveness ratio <$50 000 per quality-adjusted life year. Proton beam therapy is costlier than IMRT and its cost effectiveness remains unclear given the limited comparative data on outcomes. Using the Grades of Recommendation, Assessment, Development and Evaluation approach, the quality of evidence was low for RARP and IMRT, and very low for proton beam therapy.

CONCLUSIONS

Treatment with new versus traditional technologies is costlier. However, given the low quality of evidence and the inconsistencies across studies, the precise difference in costs remains unclear. Attempts to estimate whether this increased cost is worth the expense are hampered by the uncertainty surrounding improvements in outcomes, such as cancer control and side effects of treatment. If the new technologies can consistently achieve better outcomes, then they may be cost effective.

PATIENT SUMMARY

We review the cost and cost effectiveness of robot-assisted radical prostatectomy, intensity-modulated radiotherapy, and proton beam therapy in prostate cancer treatment. These technologies are costlier than their traditional counterparts. It remains unclear whether their use is associated with improved cure and reduced morbidity, and whether the increased cost is worth the expense.

Healthcare costs among men with favorable risk prostate cancer managed with observation strategies versus immediate treatment in an integrated healthcare system

OBJECTIVE

This study explored short-term healthcare costs of men managed with observation strategies (OBS) vs immediate treatment (IMT) for favorable risk prostate cancer (PCa) from the Geisinger Health System, a single integrated health system in Pennsylvania, as evidence from the community setting is limited.

METHODS

A retrospective cohort study was conducted using electronic health records from men aged ≥40 years diagnosed with favorable risk PCa (T1 or 2, PSA ≤15 ng/mL, Gleason ≤7 [3 + 4]) between January 2005 and October 2013. Prostate-specific healthcare costs were compared between the OBS and IMT cohorts in men with ≥3 years of follow-up and available linked claims data. Sub-group analyses focused on those men with low-risk PCa (T1-2a, PSA ≤10 ng/mL, Gleason ≤6). Sensitivity analysis stratified the study sample in three cohorts: OBS, switched from OBS to definitive treatment (OBS switch), and IMT.

RESULTS

A total of 352 patients were included (OBS = 70 and IMT = 282). Compared with IMT, OBS resulted in significantly lower cumulative PCa-related healthcare costs for the first 3 years ($15,785 vs $23,177; p-value <.001). The main cost drivers were outpatient procedures. The OBS cohort had the lowest incremental PCa-related healthcare costs in the first 3 years (OBS: $5,011 vs OBS switch: $26,040, net cost savings = $21,029, p < .001; OBS: $5,011 vs IMT: $24,064, net cost savings = $19,053, p < .001).

CONCLUSIONS

In favorable risk PCa, half of the patients who initially chose OBS eventually underwent treatment after their PCa diagnosis. As expected, OBS was associated with reduced disease management costs compared with IMT.

Robot-assisted surgery in a broader healthcare perspective: a difference-in-difference-based cost analysis of a national prostatectomy cohort

OBJECTIVE

To estimate costs attributable to robot-assisted laparoscopic prostatectomy (RALP) as compared with open prostatectomy (OP) and laparoscopic prostatectomies (LP) in a National Health Service perspective.

PATIENTS AND METHODS

Register-based cohort study of 4309 consecutive patients who underwent prostatectomy from 2006 to 2013 (2241 RALP, 1818 OP and 250 LP). Patients were followed from 12 months before to 12 months after prostatectomy with respect to service use in primary care (general practitioners, therapists, specialists etc) and hospitals (inpatient and outpatient activity related to prostatectomy and comorbidity). Tariffs of the activity-based remuneration system for primary care and the Diagnosis-Related Grouping case-mix system for hospital-based care were used to value service use. Costs attributable to RALP were estimated using a difference-in-difference analytical approach and adjusted for patient-level and hospital-level risk selection using multilevel regression.

RESULTS

No significant effect of RALP on resource-use was observed except for a marginally lower use of primary care and fewer bed days as compared with OP (not LP). The overall cost consequence of RALP was estimated at an additional €2459 (95% CI 1377 to 3540, p=0.003) as compared with OP and an additional €3860 (95% CI 559 to 7160, p=0.031) as compared with LP, mainly due to higher cost intensity during the index admissions.

CONCLUSIONS

In this study from the Danish context, the use of RALP generates a factor 1.3 additional cost when compared with OP and a factor 1.6 additional cost when compared with LP, on average, based on 12 months follow-up. The policy interpretation is that the use of robots for prostatectomy should be driven by clinical superiority and that formal effectiveness analysis is required to determine whether the current and eventual new purchasing of robot capacity is best used for prostatectomy.

Robotic Surgical System for Radical Prostatectomy: A Health Technology Assessment

BACKGROUND

Prostate cancer is the second most common type of cancer in Canadian men. Radical prostatectomy is one of the treatment options available, and involves removing the prostate gland and surrounding tissues. In recent years, surgeons have begun to use robot-assisted radical prostatectomy more frequently. We aimed to determine the clinical benefits and harms of the robotic surgical system for radical prostatectomy (robot-assisted radical prostatectomy) compared with the open and laparoscopic surgical methods. We also assessed the cost-effectiveness of robot-assisted versus open radical prostatectomy in patients with clinically localized prostate cancer in Ontario.

METHODS

We performed a literature search and included prospective comparative studies that examined robot-assisted versus open or laparoscopic radical prostatectomy for prostate cancer. The outcomes of interest were perioperative, functional, and oncological. The quality of the body of evidence was examined according to the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) Working Group criteria. We also conducted a cost-utility analysis with a 1-year time horizon. The potential long-term benefits of robot-assisted radical prostatectomy for functional and oncological outcomes were also evaluated in a 10-year Markov model in scenario analyses. In addition, we conducted a budget impact analysis to estimate the additional costs to the provincial budget if the adoption of robot-assisted radical prostatectomy were to increase in the next 5 years. A needs assessment determined that the published literature on patient perspectives was relatively well developed, and that direct patient engagement would add relatively little new information.

RESULTS

Compared with the open approach, we found robot-assisted radical prostatectomy reduced length of stay and blood loss (moderate quality evidence) but had no difference or inconclusive results for functional and oncological outcomes (low to moderate quality evidence). Compared with laparoscopic radical prostatectomy, robot-assisted radical prostatectomy had no difference in perioperative, functional, and oncological outcomes (low to moderate quality evidence). Compared with open radical prostatectomy, our best estimates suggested that robot-assisted prostatectomy was associated with higher costs ($6,234) and a small gain in quality-adjusted life-years (QALYs) (0.0012). The best estimate of the incremental cost-effectiveness ratio (ICER) was $5.2 million per QALY gained. However, if robot-assisted radical prostatectomy were assumed to have substantially better long-term functional and oncological outcomes, the ICER might be as low as $83,921 per QALY gained. We estimated the annual budget impact to be $0.8 million to $3.4 million over the next 5 years.

CONCLUSIONS

There is no high-quality evidence that robot-assisted radical prostatectomy improves functional and oncological outcomes compared with open and laparoscopic approaches. However, compared with open radical prostatectomy, the costs of using the robotic system are relatively large while the health benefits are relatively small.

Communicating Value in Health Care Using Radar Charts: A Case Study of Prostate Cancer

PURPOSE

The transformation from volume to value will require communication of outcomes and costs of therapies; however, outcomes are usually nonstandardized, and cost of therapy differs among stakeholders. We developed a standardized value framework by using radar charts to visualize and communicate a wide range of patient outcomes and cost for three forms of prostate cancer treatment.

MATERIALS AND METHODS

We retrospectively reviewed data from men with low-risk prostate cancer who were treated with low-dose rate brachytherapy (LDR-BT), proton beam therapy, or robotic-assisted prostatectomy. Patient-reported outcomes comprised the Expanded Prostate Cancer Index Composite-50 domains for sexual function, urinary incontinence and/or bother, bowel bother, and vitality 12 months after treatment. Costs were measured by time-driven activity-based costing for the first 12 months of the care cycle. Outcome and cost data were plotted on a single radar chart for each treatment modality.

RESULTS

Outcome and cost data from patients who were treated with robotic-assisted prostatectomy (n = 381), proton beam therapy (n = 165), and LDR-BT (n = 238) were incorporated into the radar chart. LDR-BT seemed to deliver the highest overall value of the three treatment modalities; however, incorporation of patient preferences regarding outcomes may allow other modalities to be considered high-value treatment options.

CONCLUSION

Standardization and visualization of outcome and cost metrics may allow more comprehensive and collaborative discussions about the value of health care services. Communicating the value framework by using radar charts may be an effective method to present total value and the value of all outcomes and costs in a manner that is accessible to all stakeholders. Variations in plotting of costs and outcomes will require future focus group initiatives.

Robot-assisted versus open radical prostatectomy utilization in hospitals offering robotics

INTRODUCTION

Prostate cancer is an extremely prevalent cause of morbidity and mortality among American men. Several different treatments exist, but differences in utilization between these treatments are not well understood.

MATERIALS AND METHODS

We performed an observational study using administrative datasets linked to hospital survey data, which included non-metastatic prostate cancer patients receiving robot-assisted radical prostatectomy (RARP) or open radical prostatectomy (ORP) in California, Florida, or New York from 2009-2011. We developed two hierarchical regression models with fixed effect accounting for hospital clustering and physician clustering to determine factors associated with utilization of RARP versus ORP at hospitals offering robotic surgery.

RESULTS

A total of 36,694 patients were identified, with 77.13% receiving RARP and 22.87% receiving ORP. African American patients had lower RARP rates than White patients (OR = 0.80, p < 0.001). Patients using Medicare (OR = 0.91, p = 0.028), Medicaid (OR = 0.68, p < 0.001), or self-pay (OR = 0.72, p = 0.046) had lower RARP rates than patients using private insurance. Patients in Florida had lower RARP rates than patients in California (OR = 0.48, p = 0.010). Patients treated at teaching hospitals had lower RARP rates than patients treated at non-teaching hospitals (OR = 0.50, p = 0.006). The average cost of RARP was $13,614.83, and the average cost of ORP was $12,167.44 (p < 0.001).

CONCLUSIONS

This population based study suggests that both patient and hospital characteristics are associated with utilization of RARP versus ORP in hospitals where robotic surgery is offered.

A Multidimensional Analysis of Prostate Surgery Costs in the United States: Robotic-Assisted versus Retropubic Radical Prostatectomy

BACKGROUND

The economic value of robotic-assisted laparoscopic prostatectomy (RALP) in the United States is still not well understood because of limited view analyses.

OBJECTIVES

The objective of this study was to examine the costs and benefits of RALP versus retropubic radical prostatectomy from an expanded view, including hospital, payer, and societal perspectives.

METHODS

We performed a model-based cost comparison using clinical outcomes obtained from a systematic review of the published literature. Equipment costs were obtained from the manufacturer of the robotic system; other economic model parameters were obtained from government agencies, online resources, commercially available databases, an advisory expert panel, and the literature. Clinical point estimates and care pathways based on National Comprehensive Cancer Network guidelines were used to model costs out to 3 years. Hospital costs and costs incurred for the patients' postdischarge complications, adjuvant and salvage radiation treatment, incontinence and potency treatment, and lost wages during recovery were considered. Robotic system costs were modeled in two ways: as hospital overhead (hospital overhead calculation: RALP-H) and as a function of robotic case volume (robotic amortization calculation: RALP-R). All costs were adjusted to year 2014 US dollars.

RESULTS

Because of more favorable clinical outcomes over 3 years, RALP provided hospital ($1094 savings with RALP-H, $341 deficit with RALP-R), payer ($1451), and societal ($1202) economic benefits relative to retropubic radical prostatectomy.

CONCLUSIONS

Monte-Carlo probabilistic sensitivity analysis demonstrated a 38% to 99% probability that RALP provides cost savings (depending on the perspective). Higher surgical consumable costs are offset by a decreased hospital stay, lower complication rate, and faster return to work.

Surgeon and Hospital Level Variation in the Costs of Robot-Assisted Radical Prostatectomy

PURPOSE

We assessed surgeon and hospital level variation in robot-assisted radical prostatectomy costs and predictors of high and low cost surgery.

MATERIALS AND METHODS

The study population consisted of a weighted sample of 291,015 men who underwent robot-assisted radical prostatectomy for prostate cancer by 667 surgeons at 197 U.S. hospitals from 2003 to 2013. We evaluated 90-day direct hospital costs (2014 USD) in the Premier Hospital Database. High costs per robot-assisted radical prostatectomy were those above the 90th percentile and low costs were those below the 10th percentile.

RESULTS

Mean hospital cost per robot-assisted radical prostatectomy was $11,878 (95% CI $11,804-$11,952). Mean cost was $2,837 (95% CI $2,805-$2,869) in the low cost group vs $25,906 (95% CI $24,702-$25,490) in the high cost group. Nearly a third of the variation in robot-assisted radical prostatectomy cost was attributable to hospital characteristics and more than a fifth was attributable to surgeon characteristics (R-squared 30.43% and 21.25%, respectively). High volume surgeons and hospitals (90th percentile or greater) had decreased odds of high cost surgery (surgeons: OR 0.24, 95% CI 0.11-0.54; hospitals: OR 0.105, 95% CI 0.02-0.46). The performance of robot-assisted radical prostatectomy at a high volume hospital was associated with increased odds of low cost robot-assisted radical prostatectomy (OR 839, 95% CI 122-greater than 999).

CONCLUSIONS

This study provides insight into the role of surgeons and hospitals in robot-assisted radical prostatectomy costs. Given the substantial variability, identifying and remedying the root cause of outlier costs may yield substantial benefits.

Economic Evaluation Study (Cheer Compliant) Laser Prostatectomy for Benign Prostatic Hyperplasia: Outcomes and Cost-effectiveness

To determine which surgical treatment for lower urinary tract symptoms, which is suggestive of benign prostatic hyperplasia (BPH), is more cost-effective and yields a better patient's preference. Treatment outcome, cost, and perioperative complications to assess the treatment effectiveness of using laser prostatectomy as a treatment for BPH were investigated in this study.This retrospective study included 100 patients who underwent transurethral resection of prostate (TUR-P) and another 100 patients who received high-powered 120 W (GreenLight HPS) laser prostatectomy between 2005 and 2011.International Prostate Symptom Score and uroflow parameters were collected before the surgery and the uroflow and postvoiding residual volumes were evaluated before treatment and at 3, 6, 12, and 24 months after treatment. The results of 100 treatments after HPS laser prostatectomy were compared with the results of 100 patients who received TUR-P from the same surgeon. Complication rates and admission costs were analyzed.From 2005 to 2011, 200 consecutive patients underwent endoscopic surgery. Study participants were men with BPH with mean age of 71.3 years old. The peak flow rate went from 8.47 to 15.83 mL/s for 3 months after laser prostatectomy. Laser therapy groups showed better improvement in symptom score, shortened length of stay, and quality of life score when compared with those of TUR-P procedures. The estimated cost for laser prostatectomy was high when compared with cost of any other TUR-P procedural option at Chang Gung Hospital (P = 0.001). All admission charges were similar except for the cost of the laser equipment and accessories (mainly the laser fiber) (P = 0.001). Due to this cost of equipment, it increased the total admission charges for the laser group and therefore made the cost for the laser group higher than that of the TUR-P group.Perioperative complications, such as the need for checking for bleeding, urinary retention rate or urosepsis rate within 30 days after the surgery, held no significant differences between both groups.Compared with alternative treatment options, laser prostatectomy of the prostate is clinically effective but yields a high cost of treatment for symptomatic BPH.

Benign prostatic hyperplasia: epidemiology, economics and evaluation

INTRODUCTION

Benign prostatic hyperplasia (BPH) is arguably the most common benign disease of mankind. As men age, the prostate inexorably grows often causing troubling symptoms causing them to seek out care. While traditionally treated by transurethral resection or open surgical removal of the hypertrophied adenoma, today the urologist has numerous medical, surgical and minimally invasive techniques available. In this supplement The Canadian Journal of Urology provides a review of the various techniques and medications available today.

MATERIALS AND METHODS

As an introduction to the supplement, the aim of this article is to review the epidemiology and economy of BPH as well as its natural history and diagnosis. A systematic review of available literature was looking for articles on BPH and its epidemiology, economics, natural history and management using PubMed database.

RESULTS

The prevalence of this condition is increasing with the population aging and so does the economic burden. The exact etiology of this condition is unknown, but some risk factors have been identified. The diagnostic and treatment of this very common disease should rely on a strong collaboration between primary care physician and urologist.

CONCLUSION

There are multiple options in treating BPH including medical, surgical and newer minimally invasive options. The challenge with having a variety of options is to review them with the patient and help the patient select the best treatment option for their condition.

[Economic importance of postoperative urinary incontinence]

In the 22,160 patients treated in Germany for prostate cancer by prostatectomy, the costs for direct and indirect sequelae as the result of postoperative urinary incontinence are estimated to be 71.8 million €. This greatly exceeds the costs of 69.8 million € for the operation itself. This additional economic burden can, however, be decisively influenced by using a surgical technique that preserves the integrity of the urethral sphincter.

Robot assisted radical prostatectomy: the new standard?

Over the past decade, the robotic assisted radical prostatectomy (RARP) has grown increasingly popular and quickly equated itself as the most commonly used modality to treat locally-confined prostate cancer. Despite increased utilization, there is limited comparative research demonstrating superiority for RARP over the conventional radical retropubic prostatectomy (RRP). Furthermore, though perioperative and short-term oncologic outcomes are equivalent if not superior for the robotic approach, the optimal utilization of robotic technology remains to be determined with cost serving as a primary driver. In this review, we performed a literature search to identify comparative effectiveness research as it pertains to RARP versus RRP. We performed a PubMed literature search for a review of articles published between 2000 and 2014 using the following keywords to identify pertinent research: "robot or robotic prostatectomy", "open or retropubic prostatectomy", "cost", "resource utilization". Long-term data comparing RARP and RRP remains limited, though short-term positive surgical margins, biochemical recurrence-free survival, and need for adjuvant therapy appear at least equivocal, if not in favor of RARP versus RRP. Functional outcomes including return of continence and potency favor RARP while cost still favors RRP. Nonetheless, the generalization of results remains difficult with surgeon volume playing a large role in improving efficiency and quality. For the foreseeable future, an increasing number of prostatectomies will continue to be performed robotically. Though RARP appears to offer improved functional outcomes with good short-term oncologic outcomes, there is a need for longer-term studies to assess the true value of RARP. Outcomes aside, rigorous, prospective randomized-controlled trials must also be performed on the cost-effectiveness of RARP to determine its overall utility in an era of health care delivery reform.

Active surveillance strategy for patients with localised prostate cancer: criteria for progression

BACKGROUND

Active surveillance - an initial observational strategy - offers a tailored management of patients with localised prostate cancer. The aim of the strategy is to appoint patients with potentially lethal prostate cancer to curatively intended treatment, while patients with slowly evolving tumours are spared from an unnecessary curative intervention.

MATERIAL AND METHODS

All data included were derived from a single-institution active surveillance cohort of 317 patients which was followed prospectively at Rigshospitalet from 2002 until 2013. The patients were managed with serial PSA measurements, repeated biopsies, and regular digital rectal examinations. The programme recommended change of management from active surveillance to curatively intended treatment based on PSA doubling time, deteriorating histopathology in repeated prostatic biopsies, and increased clinical tumour category.

RESULTS

The programme entailed close monitoring during the first 5 years with 3-4 out-patient contacts annually. Altogether, 2-3 biopsy sessions were performed in most patients. Complications necessitating hospital admissions arose in almost 10% of the repeated biopsy sessions. The 5-year cumulative incidence of curatively intended treatment was estimated to be 39.5%. Active surveillance resulted in a 34.8% cost-reduction following 3.7 years compared to the estimated cost of immediate radical prostatectomy. The calculated PSA doubling times were associated with wide 95% confidence intervals, which resulted in a significant risk of being misclassified according to the definition of progression. The interobserver agreement of biopsy histopathology between expert uropathologist was substantial. Still, the pathologists' disagreement would have resulted in different treatment recommendations in up to 10% of the re-evaluated biopsies. Neither PSA doubling time nor increased clinical tumour category was associated with final histopathological findings following subsequent radical prostatectomy. Although the level of significance was only met in univariate analysis, biopsy progression was associated with defined final histopathological findings at radical prostatectomy that was perceived as unacceptable for a continued observational strategy.

CONCLUSION

The thesis has demonstrated that active surveillance is feasible and reduces the number of patients undergoing curative intended treatment. However, active surveillance necessitates close monitoring during the first 5 years. PSA doubling time is unreliable as a progression criterion, while progression on repeated biopsy in part seems to fulfil the requirements of a dependable progression criterion. The need for more accurate progression criteria in the management of prostate cancer patients on active surveillance is emphasised.

A cost-utility analysis of laparoscopic radical prostatectomy and robotic-assisted laparoscopic radical prostatectomy in men with localized prostate cancer in Thailand

OBJECTIVE

Robotic machines are being used with increasing frequency in the treatment of clinically localized prostate cancer in Thailand. While robotics may offer some advantages, it remains unclear whether potential benefits offset higher costs. The objective of this study was to evaluate and compare cost utility between standard and robotic-assisted laparoscopic prostatectomy from a health system perspective.

MATERIAL AND METHOD

The authors created a care pathway and a model to facilitate a comprehensive cost utility analysis. All variables used in our model were derived from our review of the literature, exceptfor cost, utility for erectile dysfunction, and utility for urinary incontinence, which were derived from Chulalongkorn Hospital patient records. All costs described in this report are denominated in Thai baht, with a 2012 currency value. A positive margin was used to simulate the model. Sensitivity analysis was performed to estimate the robustness of the outcome.

RESULTS

Thailand utility values for erectile dysfunction and urinary incontinence were 0.86 and 0.81, respectively. The cost of robotic laparoscopy was, on average, 120,359 baht (95% CI, 89,368-151,350 baht) higher than standard laparoscopy and was more effective with a mean gain of 0.05 quality-adjusted life years (QALYs) (95% CI, 0.03-0.08) for the 100 procedures performed each year. The incremental cost effectiveness (ICER) ratio was 2,407,180 baht per QALYs, with a very low probability that robotic prostatectomy would be cost effective at the Thai-willingness-to pay (WTP) threshold of 160,000 baht/ QALY.

CONCLUSION

Robotic-assisted laparoscopic prostatectomy is not more cost effective than standard laparoscopic prostatectomy for the 100 cases performed each year. An increase in the number of cases may result in better economies of scale and a lower ICER, an outcome that may increase the overall value and cost effectiveness of an investment in this technology.

[Robotic surgery -- the modern surgical treatment of prostate cancer]

Minimally invasive laparoscopic surgery replaces many open surgery procedures in urology due to its advantages concerning post-operative morbidity. However, the technical challenges and need of learning have limited the application of this method to the work of highly qualified surgeons. The introduction of da Vinci surgical system has offered important technical advantages compared to the laparoscopic surgical procedure. Robot-assisted radical prostatectomy became a largely accepted procedure. It has paved the way for urologists to start other, more complex operations, decreasing this way the operative morbidity. The purpose of this article is to overview the history of robotic surgery, its current and future states in the treatment of the cancer. We present our robot-assisted radical prostatectomy and the results.

Modifier 22 on perioperative outcomes of robotic assisted laparoscopic prostatectomy

INTRODUCTION

Robotic assisted laparoscopic prostatectomy (RALP) is a mainstay in the treatment of prostate cancer. Current procedure terminology (CPT) identifies a case that requires substantially greater effort than usual by using the modifier 22 code (M22). Our objective was to identify the most common etiologies leading to M22 at our institution and determine the effect on perioperative outcomes.

MATERIALS AND METHODS

We retrospectively reviewed our prostatectomy database from 2009-2012 to identify patients who underwent RALP with and without M22. Reasons for M22 were determined by review of operative reports. Comparisons were made using Chi-square analysis and independent t-tests for continuous data.

RESULTS

Of 579 patients identified from our database, 208 (36%) had a M22. Eighty-six (41%) patients had ≥ 2 documented reasons for M22. Adhesiolysis was the most common reason for M22 followed by large prostate and previous hernia mesh. Body mass index (BMI) (29.8 versus 28), prostate volume (53 g versus 44 g), operative time (259 minutes versus 234 minutes), and discharge from hospital with pelvic drain in place (6.7% versus 3%) were all significantly higher in the M22 group. Final pathological stage and positive margin rate were not increased in those with a M22. Complications were not different between those with and without M22.

CONCLUSION

The M22 code is associated with longer operative times, larger prostates, and higher BMI. Adverse effects on final pathological stage, margin status and complications were not found in those with M22. Many patients with a M22 have more than one reason documented as for the explanation of the modifier.

Modifiable factors to decrease the cost of robotic-assisted procedures

In 2000, the US Food and Drug Administration approved the da Vinci Surgical System® for use in the United States. Since that time, the number of surgical robotic systems throughout the United States has continued to grow. The costs for using the system include the initial purchase ($1 million to $2.3 million) plus annual maintenance fees ($100,000 to $150,000) and the cost of limited-use or disposable instruments. Increasing the number of procedures that are performed using the robotic system can decrease the per-procedure costs. Two modifiable factors that contribute to increasing the annual caseload are increasing the number of surgeons capable of using the system and having a properly educated perioperative nursing team. An educated surgical team decreases turnover time, facilitates proper flow of each surgical procedure, and is able to actively and passively solve intraoperative problems.

The cost-utility of open prostatectomy compared with active surveillance in early localised prostate cancer

BACKGROUND

There is an on-going debate about whether to perform surgery on early stage localised prostate cancer and risk the common long term side effects such as urinary incontinence and erectile dysfunction. Alternatively these patients could be closely monitored and treated only in case of disease progression (active surveillance). The aim of this paper is to develop a decision-analytic model comparing the cost-utility of active surveillance (AS) and radical prostatectomy (PE) for a cohort of 65 year old men with newly diagnosed low risk prostate cancer.

METHODS

A Markov model comparing PE and AS over a lifetime horizon was programmed in TreeAge from a German societal perspective. Comparative disease specific mortality was obtained from the Scandinavian Prostate Cancer Group trial. Direct costs were identified via national treatment guidelines and expert interviews covering in-patient, out-patient, medication, aids and remedies as well as out of pocket payments. Utility values were used as factor weights for age specific quality of life values of the German population. Uncertainty was assessed deterministically and probabilistically.

RESULTS

With quality adjustment, AS was the dominant strategy compared with initial treatment. In the base case, it was associated with an additional 0.04 quality adjusted life years (7.60 QALYs vs. 7.56 QALYs) and a cost reduction of €6,883 per patient (2011 prices). Considering only life-years gained, PE was more effective with an incremental cost-effectiveness ratio of €96,420/life year gained. Sensitivity analysis showed that the probability of developing metastases under AS and utility weights under AS are a major sources of uncertainty. A Monte Carlo simulation revealed that AS was more likely to be cost-effective even under very high willingness to pay thresholds.

CONCLUSION

AS is likely to be a cost-saving treatment strategy for some patients with early stage localised prostate cancer. However, cost-effectiveness is dependent on patients' valuation of health states. Better predictability of tumour progression and modified reimbursement practice would support widespread use of AS in the context of the German health care system. More research is necessary in order to reliably quantify the health benefits compared with initial treatment and account for patient preferences.

Managed care implications in castration-resistant prostate cancer

The management of prostate cancer (PrCa) and especially castration-resistant disease can be complex, challenging, and costly. Significant developments in the field of oncology have led to the further development of safe and effective therapies that are better targeted to particular tumor types and to individual patients. This is evident in castration-resistant prostate cancer (CRPC), where 5 new therapies proved to increase overall survival have debuted in just the past few years. With new therapies, however, come new treatment paradigms and new potential costs. It is vital that managed care clinicians and providers analyze the burden and the costs of cancer in the United States, especially those relating to PrCa and especially CRPC. This will allow a better understanding of how costs and issues relating to healthcare utilization affect the treatment of patients with CRPC, and impact individualized therapy and management decisions.

Robot assisted laparoscopic prostatectomy in 2013

Robot assisted laparoscopic prostatectomy has surpassed open radical prostatectomy as the most common surgical approach for radical prostatectomy in the United States. In this article we briefly describe the evolution of this minimally invasive technique. The current diagnostic approaches of multiparametric magnetic resonance imaging and fusion biopsy used in preoperative workup of the patients are discussed, followed by a description of risk stratified a thermal nerve sparing approach with total anatomical reconstruction. Finally we present a critical appraisal of the published oncological, continence and potency outcomes.

[Robotic surgery in the Netherlands: lack of high-quality proof of efficacy]

More than 10 years after its first introduction, robot-assisted surgery is now performed in 17 Dutch hospitals. Robotic-assisted radical prostatectomy (RARP) is the most frequently performed, though its clinical superiority compared to open (RRP) and laparoscopic prostatectomy (LRP) has not been demonstrated. One randomized controlled trial showed better outcome in erectile function after RARP compared to LRP. The quality of the other studies into RARP is too limited to draw reliable conclusions on clinically relevant outcome measures such as survival, disease-free survival and quality of life. Given the high costs and small scientific evidence, the introduction of robotic surgery has been irresponsibly quick. Better scientific research of robotic surgery is needed before this technology can be broadly applied in clinical practice.

Perineal radical prostatectomy in the minimally invasive era

Radical prostatectomy is currently the standard of care for localized prostate cancer. In the last decade, the minimally invasive surgery, especially the robotic surgery has been growing and open techniques are less frequent performed. A non-systematic review of the literature is performed, highlighting the current situation of the perineal radical prostatectomy in the minimally invasive era, its indications, and functional and oncological outcomes. Radical perineal prostatectomy, when compared with other surgical approaches, still experience favorable outcomes. Urologist might be abandoning an underused surgical approach.

Comparative effectiveness, cost, and utilization of radical prostatectomy among young men within managed care insurance plans

BACKGROUND

Costs and benefits of emerging prostate cancer treatments for young men (age < 65 years) in the United States are not well understood. We compared utilization, clinical outcomes, and costs between two types of radical prostatectomy (RP)--minimally invasive prostatectomy (MIRP) and retropubic prostatectomy (RRP)--among young patients.

METHODS

We extracted from LifeLink Health Plan Claims Database, a commercial claims database, information on 10,669 patients receiving either MIRP or RRP between 2003 and 2007. In unadjusted analyses, we used chi-square tests to compare clinical outcomes and nonparametric bootstrapping method to compare costs between the MIRP and RRP groups. We applied logistic, Cox proportional hazard, and extended estimation equation methods to examine the association between surgical modality and perioperative complications, anastomotic stricture, and costs while controlling for age, comorbidity, and health plan characteristics.

RESULTS

The percentage of prostatectomies performed as MIRP increased from 5.7% in 2003 to 50.3% in 2007. Patients with more comorbidity were more likely to undergo RRP than MIRP. Compared with the RRP group, the MIRP group had a significantly lower rate of perioperative complications (23.0% vs. 30.4%; P < 0.001) and a lesser tendency for anastomotic strictures (hazard ratio 0.42; 95% CI 0.35-0.50) within the first postoperative year but had higher hospitalization costs ($19,998 vs. $18,424; P < 0.001) despite shorter hospitalizations (1.7 days vs. 3.1 days; P < 0.001). Similar findings were reported in the subgroup analysis of patients with comorbidity score 0.

CONCLUSION

MIRP among nonelderly patients increased substantially over time. MIRP was found to have fewer complications. Lower costs of complications appeared to have offset higher hospitalization costs of MIRP.

Cost study of the clinical management of prostate cancer in France: results on the basis of population-based data

Prostate cancer is an important disease in terms of economic implications because of its increasing incidence and health care costs. We assessed the direct costs of the clinical management of prostate cancer in France. A retrospective study based on population-based data was carried out. Eight hundred and seventy-nine cases of prostate cancer diagnosed in five departments were included in a 5-year follow-up study. The economic analysis adopted the health-care payer's perspective and took into account only the direct costs. The mean cost of managing patients was estimated at euro12,731. It is composed of 49 to 82% of initial treatments according to the therapeutic strategy. The follow-up constituted between 3 and 11%, the costs of treatments for side effects between 1 and 3% and the travel cost between 3 and 7%. Cumulative total costs over 5 years for each treatment group showed variation in costs. Costs were highest for patients who were treated with external-beam radiotherapy and lowest for those with watchful waiting. The cost burden of prostate cancer is high and varies according to the treatment type. This study yielded a cost analysis of the different management practices of patients with prostate cancer.

[Methods of increasing the effectiveness of radical prostatectomy]

In search of ways to improve the results of radical surgical treatment of patients with prostatic cancer (PC), we analysed the results of examination and treatment of 130 patients with local PC performed in 2000-2010 years. All the patients have undergone retropubic radical prostatectomy (RPE). Of them, 25.4% received neoadjuvant hormonal therapy. Follow-up median was 53 months (16-122 months). We also estimated direct and indirect costs of RPE. Erectile dysfunction after RPE was registered in 93.1% patients, urinary incontinence--in 20% patients, anastomosis stricture--in 22.6%. Five and 10 year recurrence-free survival was 80 and 72%, respectively. Total (direct and indirect) costs of one PC patient's surgical treatment (RPE) reached 140891,29 roubles. Our calculations show that certain measures taken in practical activity of the urologists can reduce direct costs by about 25%. Thus, our study demonstrates that it is possible to avoid unjustified expenses and achieve good outcomes in surgical treatment of PC.

Active surveillance vs. treatment for low-risk prostate cancer: a cost comparison

OBJECTIVE

Radical prostatectomy (RP) and radiation therapy are standard curative approaches for low-risk prostate cancer (PC). Active surveillance (AS) is becoming an increasingly accepted management alternative for low-risk PC. Our aim is to compare the cumulative medical costs of treatment vs. AS.

METHODS AND MATERIALS

We collected data on the cumulative medical costs of open radical retropubic prostatectomy (RRP), robotic-assisted radical prostatectomy (RARP), external beam radiotherapy (EBRT), brachytherapy (BT), and AS at our institution. For physicians' reimbursements, Medicare values of our region were used to maintain uniformity. For inpatient costs other than reimbursements, we used the mean cost at our institution. The costs of RRP and RARP involve preoperative investigations, medical clearance, physicians' fees, inpatient costs, and pathologic examination of prostatectomy specimen and follow-up. The inpatient costs include the operating room, disposable equipment, anesthesia, post-anesthesia care, transfusion, and hospital stay. The cost of EBRT involves the cost of consultation, planning, simulation and treatment sessions, and follow-up. BT costs involved radiotherapy planning as well as inpatients costs. AS protocol involves regular visits, transrectal ultrasound guided biopsies, prostate specific antigen (PSA) testing. To evaluate the cost of treating complications, treatment after AS, and treatment for recurrence, we created a Markov model based on recent studies and our experience.

RESULTS

The cumulative costs of RRP are $9,732 (1 year), $10,360 (2 years), $12,209 (5 years), and $15,084 (10 years). While for RARP, the costs are $17,824 (1 year), $18,308 (2 years), $20,117 (5 years), and $22,762 (10 years). The costs of EBRT are $20,730 (1 year), $20,969 (2 years), $22,043 (5 years), and $23,953 (10 years). BT costs are $14,061 (1 year), $14,300 (2 years), $15,374 (5 years), and $17,284 (10 years). The costs of AS are $1,154 (1 year), $2,308 (2 years), $8,761 (5 years), and $13,116 (10 years).

CONCLUSIONS

The cumulative medical costs of RARP and EBRT are much higher than BT, RRP, and AS. AS is associated with a different cost distribution in which the initial cost is low and relatively higher cost of follow-up. Despite the higher follow-up cost, AS remains the most cost effective alternative for low-risk PC.

[Has time already passed the open radical prostatectomy?]

Besides radiotherapy, open radical prostatectomy is an established therapy for localized prostatic cancer. Continuous improvements have been made to the surgical technique, with constantly improving results. Erection is preserved in approximately half of the operated patients, and the risk of urinary incontinence is about 3%. In recent years, open surgery has become rivalled by less invasive forms of surgery, laparoscopic prostatectomy and, above all, robotic laparoscopic prostatectomy, by producing slight reductions in the length of the hospital stay and in surgical bleeding. Even so, the costs of surgical operations may increase even twofold, especially with robotic laparoscopic prostatectomy.

A short-term cost-effectiveness study comparing robot-assisted laparoscopic and open retropubic radical prostatectomy

OBJECTIVE

To evaluate cost effectiveness and cost utility comparing robot-assisted laparoscopic prostatectomy (RALP) versus retropubic radical prostatectomy (RRP).

METHODS

In a retrospective cohort study a total of 231 men between the age of 50 and 69 years and with clinically localised prostate cancer underwent radical prostatectomy (RP) at the Department of Urology, Aarhus University Hospital, Skejby from 1 January 2004 to 31 December 2007, were included. The RALP and RRP patients were matched 1:2 on the basis of age and the D'Amico Risk Classification of Prostate Cancer; 77 RALP and 154 RRP. An economic evaluation was made to estimate direct costs of the first postoperative year and an incremental cost-effectiveness ratio (ICER) per successful surgical treatment and per quality-adjusted life-year (QALY). A successful RP was defined as: no residual cancer (PSA <0.2 ng/ml, preserved urinary continence and erectile function. A one-way sensitivity analysis was made to investigate the impact of changing one variable at a time.

RESULTS

The ICER per extra successful treatment was €64,343 using RALP. For indirect costs, the ICER per extra successful treatment was €13,514 using RALP. The difference in effectiveness between RALP and RRP procedures was 7% in favour of RALP. In the present study no QALY was gained 1 year after RALP, however this result is uncertain due to a high degree of missing data. The sensitivity analysis did not change the results noticeably.

LIMITATIONS

The study was limited by the design resulting in a low percentage of information on the effect of medication for erectile dysfunction and only short-term quality of life was measured at 1 year postoperatively.

CONCLUSION

RALP was more effective and more costly. A way to improve the cost effectiveness may be to perform RALP at fewer high volume urology centres and utilise the full potential of each robot.

[Use of 2-octylcyanoacrylate tissue glue for skin closure in radical retropubic prostatectomy]

2-Octylcyanoacrylate tissue adhesive (2-OCA ; Dermabond® , Ethicon, Inc., Sommerville, New Jersey) is a synthetic tissue adhesive recently used for skin closure in the treatment of minor lacerations and minor surgical incisions. We have been using this adhesive for wound closure in radical retropubic prostatectomy (RRP) since August 2006. Before that we used a skin stapler. We assessed the effectiveness of the adhesive as a sole dressing after open radical prostatectomy and compared the economic outcomes of 2-OCA and stapled repair. We retrospectively evaluated patients undergoing RRP for whom 2-OCA (101 patients) and a skin stapler (133 patients) were used at our institution. Superficial surgical site infection (SSI) was seen in 3 patients in the glue group and 3 patients in the staple group (p=0.99). Wound dehiscence without SSI was seen in 1 patient in the glue group. The cost of surgery with 2-OCA was much lower than that with the skin stapler. Wound closure using 2-OCA following RRP is acceptable and has benefits in terms of surgical costs.

The burden of out-of-pocket and indirect costs of prostate cancer

BACKGROUND

Out-of-pocket and indirect (OPI) costs play an important role in prostate cancer (PCa) outcomes research. We sought to analyze OPI costs of newly diagnosed PCa patients receiving either radical prostatectomy (RP) or external beam radiation therapy (EBRT).

METHODS

Prospective cohort design was used to recruit 512 newly diagnosed PCa patients from urology clinics of an urban academic hospital and a Veterans Administration medical center. Participants provided demographic information and completed self-reported generic and prostate-specific Health Related Quality of Life (HRQoL) and indirect-cost surveys at baseline and at 3, 6, 12, and 24 months follow-up. Linear mixed models were applied to study the association between OPI costs, treatment and HRQoL outcomes. Propensity scores adjusted for potential confounders and Bonferroni correction was used to account for multiple testing.

RESULTS

Total mean OPI costs varied between RP group and EBRT group at 3-month ($5576 vs. $2010), 6-month ($1776 vs. $2133), 12-month ($757 vs. $774), and at 24-month follow-up ($458 vs. $871). Linear mixed models indicated that RP was associated with lower medication costs (OR = 0.61, CI = 0.48-0.89) and total OPI costs (OR = 0.71, CI = 0.64-0.92). Total OPI costs were inversely related to most of the generic HRQoL items. Similarly, prostate-specific HRQoL items of urinary function (OR = 0.72; adjusted-CI = 0.58-0.84), bowel function (OR = 0.96; adjusted-CI = 0.78-0.98), sexual function (OR = 0.85; adjusted-CI = 0.72-0.92), urinary bother (OR = 0.79; adjusted-CI = 0.67-0.83), and sexual bother (OR = 0.88; adjusted-CI = 0.76-0.93) were inversely related to OPI costs.

CONCLUSIONS

OPI costs of PCa care are substantial and vary across time and treatment.