Costs analysis of laparoendoscopic, single-site laparoscopic and open surgery for cT1 renal masses in a European high-volume centre.

OBJECTIVE: To analyse intraoperative costs and healthcare reimbursements of partial/radical nephrectomy in open and minimal invasive surgery (MIS), as laparoscopy and laparoendoscopic single-site surgery (LESS), for the treatment of renal tumour.

MATERIALS AND METHODS: In a non-randomized retrospective study, we selected 90 patients who underwent (01/2010-12/2011) partial and radical nephrectomy for clinical renal masses ≤7 cm (cT1N0M0) and divided them into laparoscopic [laparoscopic partial nephrectomy (LPN), laparoscopic radical nephrectomy (LRN)], LESS [laparoendoscopic single-site partial nephrectomy (LESS-PN), laparoendoscopic single-site radical nephrectomy (LESS-RN)] and open groups [open partial nephrectomy (OPN), open radical nephrectomy (ORN)]. Patients were matched for age, sex, body mass index, ASA score and tumour side. Primary endpoints were evaluation of intraoperative costs (general, laparoscopic, sutures, haemostatic agents, anaesthesia, and surgeon/nurses fee), total insurance and estimated daily reimbursement.

RESULTS: MIS showed longer operative time (p ≤ .02) and shorter hospital stay (p ≤ .04). Total costs were higher (p ≤ .03) in MIS (LRN: 4,091.5 ; LPN: 4,390.4 ; LESS-RN: 3,866 ; and LESS-PN: 3,450 ) if compared with open (OPN: 2,216.8.8 , ORN: 1,606.4 ). Laparoscopic materials incised mainly in total costs of MIS (38-58.1 %). Reusable instruments reduced LESS laparoscopic costs (LESS-PN: 1,312.2 vs. LRN: 2,212.2 , p < .0001). Intraoperative frozen section and DJ ureteric stenting (general costs) (p ≤ .008) and haemostatic agents use (p ≤ .01) were higher in nephron sparing surgery (NSS), due to more frequent use of ancillary procedures necessary for a safe management of such an approach. Estimated anaesthesia costs and doctor/nurses fee were higher in MIS (p ≤ .02). Whereas total final reimbursements were comparable (p ≥ .8), estimated daily reimbursements were lower in MIS (p < .001) due to higher intraoperative costs and longer operative time.

CONCLUSION: Well-known advantages offered by MIS/NSS face higher total intraoperative costs and 'paradoxical' reduced healthcare reimbursement. We believe that local health systems should consider a subclassification with different compensations, which will incentive NSS and MIS approaches.