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Noguchi H, Shingaki K, Sato Y, Kubo S, Kaku K, Okabe Y, Nakamura M. Outcomes and Cost Comparison of 3 Different Laparoscopic Approach for Living Donor Nephrectomy: A Retrospective, Single-Center, Inverse Probability of Treatment Weighting Analysis of 551 Cases. Transplant Proc 2024; 56:482-487. [PMID: 38331594 DOI: 10.1016/j.transproceed.2024.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 01/16/2024] [Indexed: 02/10/2024]
Abstract
BACKGROUND At our institution, we switched from hand-assisted retroperitoneal laparoscopic donor nephrectomy (HRN) to hand-assisted transperitoneal laparoscopic donor nephrectomy (HTN); we later switched to standard retroperitoneal laparoscopic donor nephrectomy (SRN). This study was performed to evaluate outcomes and hospital costs among the 3 techniques. METHODS This retrospective, observational, single-center, inverse probability of treatment weighting analysis study compared the outcomes among 551 cases of living donor kidney transplantation between 2014 and 2022. RESULTS After the inverse probability of treatment weighting analysis, there were 114 cases in the HRN group, 204 cases in the HTN group, and 213 cases in the SRN group. Donor complication rates were lowest in the SRN group but did not differ between the HRN and HTN groups (1.1 vs 4.4 and 5.9%, P = .021). Donors in the SRN group had the lowest serum C-reactive protein concentrations on postoperative day 1 (4.3 vs 10.5 and 7.8 mg/dL, P < .001) and the shortest postoperative stay (4.3 vs 7.4 and 8.4 days, P < .001). Donors in the SRN group had the lowest total cost among the 3 groups (8868 vs 9709 and 10,592 USD, P < .0001). Donors in the SRN group also had the lowest costs in terms of "basic medical fees," "medication and injection fees," "Intraoperative drug and material costs," and "testing fees." Furthermore, the presence of complications was significantly correlated with higher total hospital costs (P < .001). CONCLUSION SRN appeared to have the least invasive and complication, and a potential cost savings compared with the HRN and HTN.
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Affiliation(s)
- Hiroshi Noguchi
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kodai Shingaki
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yu Sato
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Shinsuke Kubo
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Keizo Kaku
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yasuhiro Okabe
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Masafumi Nakamura
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
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Barnieh L, Klarenbach S, Arnold J, Cuerden M, Knoll G, Lok C, Sontrop JM, Miller M, Ramesh Prasad GV, Przech S, Garg AX. Nonreimbursed Costs Incurred by Living Kidney Donors: A Case Study From Ontario, Canada. Transplantation 2019; 103:e164-e171. [PMID: 31246933 DOI: 10.1097/tp.0000000000002685] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Living donors may incur out-of-pocket costs during the donation process. While many jurisdictions have programs to reimburse living kidney donors for expenses, few programs have been evaluated. METHODS The Program for Reimbursing Expenses of Living Organ Donors was launched in the province of Ontario, Canada in 2008 and reimburses travel, parking, accommodation, meals, and loss of income; each category has a limit and the maximum total reimbursement is $5500 CAD. We conducted a case study to compare donors' incurred costs (out-of-pocket and lost income) with amounts reimbursed by Program for Reimbursing Expenses of Living Organ Donors. Donors with complete or partial cost data from a large prospective cohort study were linked to Ontario's reimbursement program to determine the gap between incurred and reimbursed costs (n = 159). RESULTS The mean gap between costs incurred and costs reimbursed to the donors was $1313 CAD for out-of-pocket costs and $1802 CAD for lost income, representing a mean reimbursement gap of $3115 CAD. Nondirected donors had the highest mean loss for out-of-pocket costs ($2691 CAD) and kidney paired donors had the highest mean loss for lost income ($4084 CAD). There were no significant differences in the mean gap across exploratory subgroups. CONCLUSIONS Reimbursement programs minimize some of the financial loss for living kidney donors. Opportunities remain to remove the financial burden of living kidney donors.
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Affiliation(s)
- Lianne Barnieh
- Department of Clinical Epidemiology and Biostatistics, London Health Sciences Centre, Western University, London, ON, Canada
| | - Scott Klarenbach
- Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Jennifer Arnold
- Department of Clinical Epidemiology and Biostatistics, London Health Sciences Centre, Western University, London, ON, Canada
| | - Meaghan Cuerden
- Department of Clinical Epidemiology and Biostatistics, London Health Sciences Centre, Western University, London, ON, Canada
| | - Greg Knoll
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Charmaine Lok
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Jessica M Sontrop
- Department of Clinical Epidemiology and Biostatistics, London Health Sciences Centre, Western University, London, ON, Canada
| | - Matthew Miller
- Division of Nephrology and Transplantation, McMaster University, Hamilton, ON, Canada
| | | | - Sebastian Przech
- Department of Clinical Epidemiology and Biostatistics, London Health Sciences Centre, Western University, London, ON, Canada
| | - Amit X Garg
- Department of Clinical Epidemiology and Biostatistics, London Health Sciences Centre, Western University, London, ON, Canada
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Cost-effectiveness in the surgical care of renal cell carcinoma. Clin Adv Hematol Oncol 2018; 16:177-9. [PMID: 29742072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
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Jeong IG, Khandwala YS, Kim JH, Han DH, Li S, Wang Y, Chang SL, Chung BI. Association of Robotic-Assisted vs Laparoscopic Radical Nephrectomy With Perioperative Outcomes and Health Care Costs, 2003 to 2015. JAMA 2017; 318:1561-1568. [PMID: 29067427 PMCID: PMC5818800 DOI: 10.1001/jama.2017.14586] [Citation(s) in RCA: 140] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Accepted: 09/20/2017] [Indexed: 01/06/2023]
Abstract
IMPORTANCE Use of robotic surgery has increased in urological practice over the last decade. However, the use, outcomes, and costs of robotic nephrectomy are unknown. OBJECTIVES To examine the trend in use of robotic-assisted operations for radical nephrectomy in the United States and to compare the perioperative outcomes and costs with laparoscopic radical nephrectomy. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study used the Premier Healthcare database to evaluate outcomes of patients who had undergone robotic-assisted or laparoscopic radical nephrectomy for renal mass at 416 US hospitals between January 2003 and September 2015. Multivariable regression modeling was used to assess outcomes. EXPOSURES Robotic-assisted vs laparoscopic radical nephrectomy. MAIN OUTCOMES AND MEASURES The primary outcome of the study was the trend in use of robotic-assisted radical nephrectomy. The secondary outcomes were perioperative complications, based on the Clavien classification system, and defined as any complication (Clavien grades 1-5) or major complications (Clavien grades 3-5, for which grade 5 results in death); resource use (operating time, blood transfusion, length of hospital stay); and direct hospital cost. RESULTS Among 23 753 patients included in the study (mean age, 61.4 years; men, 13 792 [58.1%]), 18 573 underwent laparoscopic radical nephrectomy and 5180 underwent robotic-assisted radical nephrectomy. Use of robotic-assisted surgery increased from 1.5% (39 of 2676 radical nephrectomy procedures in 2003) to 27.0% (862 of 3194 radical nephrectomy procedures) in 2015 (P for trend <.001). In the weighted-adjusted analysis, there were no significant differences between robotic-assisted and laparoscopic radical nephrectomy in the incidence of any (Clavien grades 1-5) postoperative complications (adjusted rates, 22.2% vs 23.4%, difference, -1.2%; 95% CI, -5.4 to 3.0%) or major (Clavien grades 3-5) complications (adjusted rates, 3.5% vs 3.8%, difference, -0.3%; 95% CI, -1.0% to 0.5%). The rate of prolonged operating time (>4 hours) for patients undergoing the robotic-assisted procedure was higher than for patients receiving the laparoscopic procedure in the adjusted analysis (46.3% vs 25.8%; risk difference, 20.5%; 95% CI, 14.2% to 26.8%). Robotic-assisted radical nephrectomy was associated with higher mean 90-day direct hospital costs ($19 530 vs $16 851; difference, $2678; 95% CI, $838 to $4519), mainly accounted for operating room ($7217 vs $5378; difference, $1839; 95% CI, $1050 to $2628) and supply costs ($4876 vs $3891; difference, $985; 95% CI, $473 to $1498). CONCLUSIONS AND RELEVANCE Among patients undergoing radical nephrectomy for renal mass between 2003 and 2015, the use of robotic-assisted surgery increased substantially. The use of robotic-assistance was not associated with increased risk of any or major complications but was associated with prolonged operating time and higher hospital costs compared with laparoscopic surgery.
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Affiliation(s)
- In Gab Jeong
- Department of Urology, Stanford University Medical Center, Stanford, California
- Department of Urology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yash S. Khandwala
- Department of Urology, Stanford University Medical Center, Stanford, California
- University of California, San Diego School of Medicine
| | - Jae Heon Kim
- Department of Urology, Stanford University Medical Center, Stanford, California
| | - Deok Hyun Han
- Department of Urology, Stanford University Medical Center, Stanford, California
| | - Shufeng Li
- Department of Urology and Dermatology, Stanford University Medical Center, Stanford, California
| | - Ye Wang
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Steven L. Chang
- Division of Urology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Benjamin I. Chung
- Department of Urology, Stanford University Medical Center, Stanford, California
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Abstract
PURPOSE Frailty and functional status have emerged as significant predictors of morbidity and mortality for patients undergoing cancer surgery. To articulate the impact on value (ie quality per cost), we compared perioperative outcomes and expenditures according to patient function for older adults undergoing kidney cancer surgery. MATERIALS AND METHODS Using linked SEER (Surveillance, Epidemiology and End Results)-Medicare data, we identified 19,129 elderly patients with kidney cancer treated with nonablative surgery from 2000 to 2009. We quantified patient function using function related indicators (claims indicative of dysfunction and disability) and measured 30-day morbidity, mortality, resource use and cost. Using multivariable, mixed effects models to adjust for patient and hospital characteristics, we estimated the relationship of patient functionality with both treatment outcomes and expenditures. RESULTS Of 19,129 patients we identified 5,509 (28.8%) and 3,127 (16.4%) with a function related indicator count of 1 and 2 or greater, respectively. While surgical complications did not vary (OR 0.95, 95% CI 0.86-1.05), patients with 2 or more indicators more often experienced a medical event (OR 1.22, 95% CI 1.10-1.36) or a geriatric event (OR 1.55, 95% CI 1.33-1.81), or died within 30 days of surgery (OR 1.43, 95% CI 1.10-1.86) compared with patients with no baseline dysfunction. These patients utilized significantly more medical resources and amassed higher acute care expenditures (p <0.001). CONCLUSIONS During kidney cancer surgery, patients in poor functional health can face a more eventful medical recovery at elevated cost, indicating lower value care. Greater consideration of frailty and functional status during treatment planning and transitions may represent areas for value enhancement in kidney cancer and urology care.
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Affiliation(s)
- Hung-Jui Tan
- Department of Urology, University of North Carolina, Chapel Hill, North Carolina.
| | - Joseph D Shirk
- Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Karim Chamie
- Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Mark S Litwin
- Department of Health Policy and Management, UCLA Fielding School of Public Health and UCLA School of Nursing, Los Angeles, California
| | - Jim C Hu
- Department of Urology, Weill Cornell School of Medicine, New York, New York
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Abstract
Live kidney donation is assuming an increasingly prominent role in kidney transplantation programs. The traditional operative approach has been through an incision in the upper quadrant of the abdomen or in the loin, with the attendant potential postoperative complications associated with a large surgical wound. These problems may act as disincentives to prospective donors. The introduction of laparoscopic donor surgery in 1995 heralded a new era offering reduced postoperative pain and improved cosmetic result. It is hoped that these benefits may counter some disincentives and thereby increase donation rates. Three minimal-access approaches and their advantages and disadvantages are described: classical laparoscopic, hand-assisted laparoscopic, and retroperitoneoscopic surgery. Published reports indicate extensive experience with the first 2 of these approaches and less experience with the latter. All 3 approaches present technical, physiological, and anatomical challenges in the context of retrieving an organ that is fit for transplantation. For minimal-access surgery to be accepted as the procedure of choice for live kidney donors, it must be demonstrated that morbidity is not transferred from donor to recipient when these techniques are used. Some concerns about these procedures are addressed. High-level evidence in the form of randomized controlled trials is generally lacking, but experiences of surgeons and patients suggest that, with appropriate modifications, these techniques are safe for both donors and allografts and also benefit donors' recovery.
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Affiliation(s)
- Nicholas R Brook
- University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
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Shaw RM, Bell LJ. 'Because you can't live on love': living kidney donors' perspectives on compensation and payment for organ donation. Health Expect 2015; 18:3201-12. [PMID: 25418552 PMCID: PMC5810734 DOI: 10.1111/hex.12310] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/30/2014] [Indexed: 11/30/2022] Open
Abstract
CONTEXT AND OBJECTIVE Living kidney donation accounts for approximately half of all kidney transplantation in many countries and is central to health policy focused on increasing organ supply. However, little examination of the economic consequences of living kidney donation has been undertaken from the perspective of donors themselves. This article documents living kidney donors' views regarding recompense and payment for organ donation, based on their experience. PARTICIPANTS Twenty-five living kidney donors from New Zealand participated in this study. METHODS This qualitative study, based on thematic analysis, uses semi-structured in-depth interviews to examine the experiences of living kidney donors. Themes were organized around altruism and the 'gift', perceptions of shared corporeality and identity, and donor support. RESULTS Most participants agreed the donation process was costly in terms of time and money. Many incurred personal costs, and some experienced financial hardship. All the participants viewed financial hardship as a barrier to organ donation and favoured recompense for direct and indirect costs. Most did not support payment for organs, and none supported commercialization. DISCUSSION AND CONCLUSIONS The findings show that framing organ donation as a 'gift' can stymie discussion about reciprocity, remuneration and exchange, making talk about financial recompense difficult. Financial well-being, nonetheless, has implications for the ability to care for self and others post-operatively. We conclude that the economic consequences for living kidney donors in jurisdictions where recompense for direct and indirect costs is insufficient are unfair. Review of financial assistance for live organ donors is therefore recommended.
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Affiliation(s)
- Rhonda M. Shaw
- School of Social & Cultural StudiesVictoria University of WellingtonWellingtonNew Zealand
| | - Lara J.M. Bell
- School of Social & Cultural StudiesVictoria University of WellingtonWellingtonNew Zealand
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Chehab M, Friedlander JA, Handel J, Vartanian S, Krishnan A, Wong CYO, Korman H, Seifman B, Ciacci J. Percutaneous Cryoablation vs Partial Nephrectomy: Cost Comparison of T1a Tumors. J Endourol 2015; 30:170-6. [PMID: 26154481 DOI: 10.1089/end.2015.0183] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
PURPOSE To compare cost of percutaneous cryoablation vs open and robot-assisted partial nephrectomy of T1a renal masses from the hospital perspective. MATERIALS AND METHODS We retrospectively compared cost, clinical and tumor data of 37 percutaneous cryoablations to 26 open and 102 robot-assisted partial nephrectomies. Total cost was the sum of direct and indirect cost of procedural and periprocedural variables. Clinical data included demographics, Charlson Comorbidity Index (CCI), hospitalization time, complication rate, ICU admission rate, and 30-day readmission rates. Tumor data included size, RENAL nephrometry score, and malignancy rate. Student's t-test was used for continuous variables and Fisher's exact or chi-square tests for categorical data. RESULTS Mean total cost was lower for percutaneous cryoablation than open or robot-assisted partial nephrectomy: $6067 vs $11392 or $11830 (p<0.0001) with lower cost of procedure room: $1516 vs $3272 or $3254 (p<0.0001), room and board: $95 vs $1907 or $1106 (p<0.0001), anesthesia: $684 vs $1223 or $1468 (p<0.0001), and laboratory/pathology fees: $205 vs $804 or $720 (p<0.0001). Supply and device cost was higher than open: $2596 vs $1352 (p<0.0001), but lower than robot-assisted partial nephrectomy: $3207 (p=0.002). Mean hospitalization times were lower for percutaneous cryoablation (p<0.0001), while age and CCI were higher (p<0.0001). No differences in tumor size, nephrometry score, malignancy rate complication, ICU, or 30-day readmission rates were observed. CONCLUSION Percutaneous cryoablation can be performed at significantly lower cost than open and robotic partial nephrectomies for similar masses.
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Affiliation(s)
- Monzer Chehab
- 1 Department of Radiology, Oakland University William Beaumont School of Medicine , Royal Oak, Michigan
| | - Joshua A Friedlander
- 1 Department of Radiology, Oakland University William Beaumont School of Medicine , Royal Oak, Michigan
| | - Jeremy Handel
- 1 Department of Radiology, Oakland University William Beaumont School of Medicine , Royal Oak, Michigan
| | - Stephen Vartanian
- 1 Department of Radiology, Oakland University William Beaumont School of Medicine , Royal Oak, Michigan
| | - Anant Krishnan
- 2 Department of Diagnostic and Interventional Radiology, Oakland University William Beaumont School of Medicine , Royal Oak, Michigan
| | - Ching-Yee Oliver Wong
- 2 Department of Diagnostic and Interventional Radiology, Oakland University William Beaumont School of Medicine , Royal Oak, Michigan
| | - Howard Korman
- 3 Department of Urology, Oakland University William Beaumont School of Medicine , Royal Oak, Michigan
| | - Brian Seifman
- 3 Department of Urology, Oakland University William Beaumont School of Medicine , Royal Oak, Michigan
| | - Joseph Ciacci
- 1 Department of Radiology, Oakland University William Beaumont School of Medicine , Royal Oak, Michigan
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Tabib CH, Bahler CD, Hardacker TJ, Ball KM, Sundaram CP. Reducing Operating Room Costs Through Real-Time Cost Information Feedback: A Pilot Study. J Endourol 2015; 29:963-8. [PMID: 25693920 DOI: 10.1089/end.2014.0858] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
PURPOSE To create a protocol for providing real-time operating room (OR) cost feedback to surgeons. We hypothesize that this protocol will reduce costs in a responsible way without sacrificing quality of care. METHODS All OR costs were obtained and recorded for robot-assisted partial nephrectomy and laparoscopic donor nephrectomy. Before the beginning of this project, costs pertaining to the 20 most recent cases were analyzed. Items were identified from previous cases as modifiable for replacement or omission. Timely feedback of total OR costs and cost of each item used was provided to the surgeon after each case, and costs were analyzed. RESULTS A cost analysis of the robot-assisted partial nephrectomy before the washout period indicates expenditures of $5243.04 per case. Ten recommended modifiable items were found to have an average per case cost of $1229.33 representing 23.4% of the total cost. A postwashout period cost analysis found the total OR cost decreased by $899.67 (17.2%) because of changes directly related to the modifiable items. Therefore, 73.2% of the possible identified savings was realized. The same stepwise approach was applied to laparoscopic donor nephrectomies. The average total cost per case before the washout period was $3530.05 with $457.54 attributed to modifiable items. After the washout period, modifiable items costs were reduced by $289.73 (8.0%). No complications occurred in the donor nephrectomy cases while one postoperative complication occurred in the partial nephrectomy group. CONCLUSION Providing surgeons with feedback related to OR costs may lead to a change in surgeon behavior and decreased overall costs. Further studies are needed to show equivalence in patient outcomes.
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Affiliation(s)
| | - Clinton D Bahler
- Department of Urology, Indiana University , Indianapolis, Indiana
| | | | - Kevin M Ball
- Department of Urology, Indiana University , Indianapolis, Indiana
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Affiliation(s)
- Roy Mano
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Paul Russo
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
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Affiliation(s)
- Hung-Jui Tan
- VA/UCLA Robert Wood Johnson Clinical Scholars Program, University of California, Los Angeles, CA; Department of Urology, University of California, Los Angeles, CA
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12
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Abstract
PURPOSE While robotic assisted radical nephrectomy is safe with outcomes and complication rates comparable to those of the pure laparoscopic approach, there is little evidence of an economic or clinical benefit. MATERIALS AND METHODS From the 2009 to 2011 Nationwide Inpatient Sample database we identified patients 18 years old or older who underwent radical nephrectomy for primary renal malignancy. Robotic assisted and laparoscopic techniques were noted. Patients treated with the open technique and those with evidence of metastatic disease were excluded from analysis. Descriptive statistics were performed using the chi-square and Mann-Whitney tests, and the Student t-test. Multiple linear regression was done to examine factors associated with increased hospital costs and charges. RESULTS We identified 24,312 radical nephrectomy cases for study inclusion, of which 7,787 (32%) were performed robotically. There was no demographic difference between robotic assisted and pure laparoscopic radical nephrectomy cases. Median total charges were $47,036 vs $38,068 for robotic assisted vs laparoscopic surgery (p <0.001). Median total hospital costs for robotic assisted surgery were $15,149 compared to $11,735 for laparoscopic surgery (p <0.001). There was no difference in perioperative complications or the incidence of death. Compared to the laparoscopic approach robotic assistance conferred an estimated $4,565 and $11,267 increase in hospital costs and charges, respectively, when adjusted for adapted Charlson comorbidity index score, perioperative complications and length of stay (p <0.001). CONCLUSIONS Robotic assisted radical nephrectomy results in increased medical expense without improving patient morbidity. Assuming surgeon proficiency with pure laparoscopy, robotic technology should be reserved primarily for complex surgeries requiring reconstruction. Traditional laparoscopic techniques should continue to be used for routine radical nephrectomy.
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Affiliation(s)
- David Y Yang
- Department of Urology, Indiana University School of Medicine, Indianapolis, Indiana
| | - M Francesca Monn
- Department of Urology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Clinton D Bahler
- Department of Urology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Chandru P Sundaram
- Department of Urology, Indiana University School of Medicine, Indianapolis, Indiana.
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Bayrak O, Seckiner I, Erturhan S, Cil G, Erbagci A, Yagci F. Comparison of the complications and the cost of open and laparoscopic radical nephrectomy in renal tumors larger than 7 centimeters. Urol J 2014; 11:1222-1227. [PMID: 24595928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Received: 05/10/2012] [Revised: 11/28/2012] [Accepted: 01/16/2013] [Indexed: 06/03/2023]
Abstract
PURPOSE To compare the complications and the cost analysis of open radical nephrectomy (ORN) versus laparoscopic radical nephrectomy (LRN) in patients with renal tumors larger than 7 centimeters (cm). MATERIALS AND METHODS A retrospective analysis was performed in 173 patients (ORN group, n = 140; LRN group, n = 33) who underwent surgery for kidney tumors between 2008 and 2011. Patients' age, tumor size, pre-operative surgical risk score (American Society of Anesthesiologists score), duration of hospitalization, complications and the costs of hospitalization were recorded. The complications in ORN group and LRN group were specified with Modified Clavien System in five grades. RESULTS The mean age was found 58.52 ± 13.74 years in ORN group, and 58.15 ± 12.81 years in LRN group (P = .847). Post-operative pain necessitating analgesics was observed in all patients (100%) after early post-operative period in both groups (Grade 1 complications). Blood transfusions were required in 51 patients (36.42%) in the ORN group, and 7 (21.21%) patients in the LRN group (Grade 2 complications) (P = .185). Grade 3 complication was not observed in each groups. Grade 4 complications were occurred in 6 (4.28%) patients [aortic injury, acute tubular necrosis, the need for dialysis, respiratory arrest (2), atrial fibrillation] in the ORN group, and in 1 (3.03%) patient (pulmonary embolism) in the LRN group. Grade 5 complication was occurred in 1 (0.71%) patient (death) in the ORN group. By the cost analysis, the average cost of ORN group was €1328, whereas €1508 in LRN group (P < .05). CONCLUSION Laparoscopy is used in many clinics with an increasing frequency because of the improved patient comfort, better cosmetic results, less post-operative pain, lower transfusion rates, and early return to the daily activities. Besides these advantages, the negligible difference in the costs compared to the open surgery (mean difference = €180 per case) makes it even more attractive.
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Affiliation(s)
- Omer Bayrak
- University of Gaziantep, School of Medicine, Department of Urology, 27310 Gaziantep,Turkey.
| | - Ilker Seckiner
- Department of Urology, Gaziontep University, Gaziantep, Turkey
| | - Sakip Erturhan
- Department of Urology, Gaziontep University, Gaziantep, Turkey
| | - Gokhan Cil
- Department of Urology, Gaziontep University, Gaziantep, Turkey
| | - Ahmet Erbagci
- Department of Urology, Gaziontep University, Gaziantep, Turkey
| | - Faruk Yagci
- Department of Urology, Gaziontep University, Gaziantep, Turkey
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14
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Affiliation(s)
- Lars J Cisek
- Division of Urologic Surgery, University of Minnesota Medical School, Minneapolis, Minnesota.
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15
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Asnis-Alibozek AG, Fine MJ, Russo P, McLaughlin T, Farrelly EM, LaFrance N, Lowrance W. Cost of care for malignant and benign renal masses. Am J Manag Care 2013; 19:617-624. [PMID: 24304211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
BACKGROUND Limitations of current diagnotic techniques may allow some patients with presumed renal cell carcinoma (RCC) to undergo nephrectomy without definitive confirmation of malignancy. OBJECTIVES To confirm previous estimates of postnephrectomy renal mass diagnosis and to assess the economic impact of nephrectomy. METHODS This retrospective cohort analysis identified commercial enrollees who underwent nephrectomy with a diagnosis of RCC between July 1, 2000, and March 30, 2008. Study subjects were stratified based on medical claims for benign or malignant disease after the nephrectomy date. Cohorts were compared on resource utilization before and after nephrectomy, occurrence of postsurgical complications, and associated 1-year costs of care. RESULTS Of 10,404 patients undergoing nephrectomy for presumed RCC, 1613 (15.5%) were subsequently identified as having benign disease, despite median presurgical diagnostic expenditures of $1311 per patient (interquartile range [IQR], $467-$2606). Median expenditures for the 12 months postnephrectomy were $26,920 per patient (IQR, $16,851-$46,982) for those with malignant disease and $23,951 per patient (IQR, $14,873-$38,190) for those with benign disease (P<.0001). For patients with benign disease, 17.5% experienced a postsurgical adverse event, resulting in a 1.5-fold increase in expenditures (median $31,838 per patient for those with event vs $22,770 per patient for those without event; P<.0001). CONCLUSIONS In this study, approximately 1 in 6 patients were found to have a benign renal mass postnephrectomy. Given the risk of surgical complications and related economic consequences, methods for better identifying malignant versus benign disease prior to surgery could provide significant benefits to patients and payers.
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Gettman MT. Managing the small renal mass: progress and opportunity. BJU Int 2013; 112:E281-2. [PMID: 23879912 DOI: 10.1111/j.1464-410x.2012.11782.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Affiliation(s)
- Michael H Hsieh
- Department of Urology, Stanford University School of Medicine, Stanford, California, USA
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Power NE, Silberstein JL, Touijer K. Is laparoscopic partial nephrectomy already the gold standard for small renal masses? ARCH ESP UROL 2013; 66:90-98. [PMID: 23406804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
OBJECTIVES To examine the role of laparoscopic partial nephrectomy in the management of small renal masses. METHODS We searched MEDLINE (through March 2012) using PubMed, the Cochrane Central Search Library (though March 2012), and Web of Science (through March 2012). We retrieved citations using the text terms "small renal mass," "laparoscopic," "partial nephrectomy,"and "radical nephrectomy." We limited the search to articles in the English language, to T1a renal tumors, and expanded the search using the related articles function. We also performed hand searches of references identified in electronically abstracted articles. RESULTS There is a paucity of well conducted clinical trials to elucidate laparoscopic partial nephrectomy's role. A number of assumptions had to be made to complete the review. Other than possibly less operative blood loss, less operative time, less inpatient stay time, and less cost, there was insufficient evidence to support laparoscopic partial nephrectomy over other modalities. Laparoscopic partial nephrectomy appears to have a higher rate of radical nephrectomy conversion. CONCLUSION There is insufficient evidence to clearly state that laparoscopic partial nephrectomy is the gold standard in the management of small renal masses. If this skill is part of a surgeon's armamentarium, it is certainly not inferior to other modalities, and may offer some benefit to patients.
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Affiliation(s)
- Nicholas E Power
- Urology Service, Department of Surgery, University of Western Ontario, London, Ontario, Canada
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Van Poppel H, Joniau S, Goethuys H. Open partial nephrectomy for complex tumours and >4 cm: Is it still the gold standard technique in the minimally invasive era? ARCH ESP UROL 2013; 66:129-138. [PMID: 23406808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
The objective of this paper is to discuss the role of open partial nephrectomy (OPN) for complex renal tumours and large renal tumours > 4 cm in the minimally invasive era. The current status of OPN, laparoscopic partial nephrectomy (LPN) and robotic PN are reviewed. The literature search is done using the National Library of Medicine database (PubMed). The indication of OPN has been extended to T1b tumours (4-7 cm). PN and radical nephrectomy (RN) provide equivalent oncological outcomes for these tumours. In addition, there is a growing application of OPN for complex tumours (centrally located, hilar, multifocal). Despite the more challenging cohort of patients, there is no increase in the overall morbidity of OPN. In contemporary cohorts there is an increase in overweight patients and a higher incidence of central tumours treated with OPN. LPN has been extended to select patients with larger renal masses (4-7 cm) and centrally located tumours. LPN for tumours > 4 cm was in the early phase associated with increased complication rate and prolonged warm ischemia time (WIT). Complication rates decreased with improvement of surgical technique and expertise. Early experience with robotic PN is promising and perioperative outcomes are at least comparable to LPN. LPN and robotic PN have to compete with the functional and oncological results of OPN. In the era of nephron-sparing surgery (NSS), OPN remains the established standard for the management of T1 renal tumours in centres without advanced laparoscopic expertise. Complex scenarios with centrally located tumours, tumours in a solitary kidney, and multifocal lesions probably are best managed with OPN. LPN is feasible in numerous clinical scenarios in centres with advanced laparoscopic expertise but remains a challenging operation. Long-term studies are needed to further define the role of the robotic approach for PN.
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Affiliation(s)
- Hein Van Poppel
- Department of Urology, University Hospital, K.U.Leuven, Leuven, Belgium.
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20
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McGrath P, Holewa H. 'It's a regional thing': financial impact of renal transplantation on live donors. Rural Remote Health 2012; 12:2144. [PMID: 23127520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023] Open
Abstract
INTRODUCTION There has been no research exploring the financial impact on the live renal donor in terms of testing, hospitalisation and surgery for kidney removal (known as nephrectomy). The only mention of financial issues in relation to live renal transplantation is the recipients' concerns in relation to monetary payment for the gift of a kidney and the recipients' desire to pay for the costs associated with the nephrectomy. The discussion in this article posits a new direction in live renal donor research; that of understanding the financial impact of live renal donation on the donor to inform health policy and supportive care service delivery. The findings have specific relevance for live renal donors living in rural and remote locations of Australia. METHODS The findings are presented from the first interview (time 1: T1) of a set of four times (time 1 to time 4: T1-T4) from a longitudinal study that explored the experience of live renal donors who were undergoing kidney removal (nephrectomy) at the Renal Transplantation Unit at the Princess Alexandra Hospital, Brisbane, Australia. A qualitative methodological approach was used that involved semi-structured interviews with prospective living kidney donors (n=20). The resulting data were analysed using the qualitative research methods of coding and thematic analysis. RESULTS The findings indicate that live renal donors in non-metropolitan areas report significant financial concerns in relation to testing, hospitalisation and surgery for nephrectomy. These include the fact that bulk billing (no cost to the patient for practitioner's service) is not always available, that individuals have to pay up-front and that free testing at local public hospitals is not available in some areas. In addition, non-metropolitan donors have to fund the extra cost of travel and accommodation when relocating for the nephrectomy to the specialist metropolitan hospital. CONCLUSION Live renal transplantation is an important new direction in medical care that has excellent long-term results for individuals diagnosed with end-stage renal disease. An essential element of the transplantation procedure is the voluntary donation of a healthy kidney by the live renal donor. Such an altruistic gift, which has no personal health benefit for the donor, is to be applauded and supported. The present research demonstrates that for some donors, particularly those living outside the metropolitan area, the gift may also include a range of financial costs to the donor. There is no prior research available on the financial impact of live renal donation for individuals living in non-metropolitan areas. Thus, this article is a seminal work in the area. The findings affirm 'rural disadvantage' by demonstrating that it is the live renal donors in non-metropolitan areas who are reporting financial concerns in relation to testing, hospitalisation and surgery for nephrectomy. It is the hope and expectation that the reporting on these costs will encourage further work in this area and the findings will be used for health policy and service delivery considerations.
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Affiliation(s)
- Pam McGrath
- Griffith University, Logan Campus, Meadowbrook, Queensland, Australia.
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Agochukwu NQ, Metwalli AR, Kutikov A, Pinto PA, Linehan WM, Bratslavsky G. Economic burden of repeat renal surgery on solitary kidney--do the ends justify the means? A cost analysis. J Urol 2012; 188:1695-700. [PMID: 22998899 PMCID: PMC3817487 DOI: 10.1016/j.juro.2012.07.029] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2012] [Indexed: 12/29/2022]
Abstract
PURPOSE Despite the high morbidity of repeat renal surgery in patients with multifocal recurrent renal carcinoma, in most patients adequate renal function is preserved to obviate the need for dialysis. To our knowledge the economic burden of repeat renal surgery has not been evaluated. We provide a cost analysis for patients requiring repeat renal surgery on a solitary kidney. MATERIALS AND METHODS We reviewed the charts of patients treated at the National Cancer Institute who required repeat renal surgery from 1989 to 2010. Functional, oncological and surgical outcomes were evaluated and the costs of repeat renal surgery were calculated. We then compared costs in a cohort of 33 patients who underwent repeat renal surgery on a solitary kidney and in a hypothetical patient cohort treated with uncomplicated nephrectomy, fistula placement and dialysis. All costs were calculated based on Medicare reimbursement rates derived from CPT codes. Cost analysis was performed. RESULTS Despite a high 45% complication rate, 87% of patients maintained renal function that was adequate to avoid dialysis and 96% remained metastasis free at an average followup of 3.12 years (range 0.3 to 16.4). Compared to the hypothetical dialysis cohort, the financial benefit of repeat renal surgery was reached at 0.68 years. CONCLUSIONS Repeat renal surgery is a viable alternative for patients with multifocal renal cell carcinoma requiring multiple surgical interventions, especially when left with a solitary kidney. Despite the high complication rate, renal function is preserved in most patients and they have an excellent oncological outcome. The financial benefit of repeat renal surgery is reached at less than 1 year.
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Affiliation(s)
- Nnenaya Q. Agochukwu
- Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Adam R. Metwalli
- Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | | | - Peter A. Pinto
- Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - W. Marston Linehan
- Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Gennady Bratslavsky
- Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD
- Department of Urology, SUNY Upstate Medical University, Syracuse, NY
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Abstract
PURPOSE Despite the explicit endorsement of the American Urological Association guidelines of partial nephrectomy as the treatment of choice for T1a renal cell carcinoma, a considerable underuse of nephron sparing surgery characterizes general practice patterns in the United States. We explored possible financial disincentives associated with partial nephrectomy that may contribute to this important quality of care deficit. MATERIALS AND METHODS A PubMed® query on perioperative outcomes identified 10 series on open or laparoscopic radical nephrectomy and 16 on open, laparoscopic or robot-assisted partial nephrectomy. Mean operative time and hospital length of stay were calculated for each group. Using these data in conjunction with Health Care Financing Administration data on physician work time, which guides the current Resource-Based Relative Value Scale Medicare fee schedule, we calculated global physician time expenditure and hourly Medicare reimbursement rates for each of these 5 surgical services. RESULTS Mean±SD operative time for open and laparoscopic radical nephrectomy, and open, laparoscopic and robot-assisted partial nephrectomy was 180.7±24.7 minutes (95% CI 119.3-242.0) in 3 studies, 178.8±16.5 (95% CI 163.5-194.1) in 7, 226.0±36.9 (95% CI 187.2-264.8) in 6, 227.9±40.2 (95% CI 185.8-270.1) in 6 and 227.9±37.8 (95% CI 167.7-288.1) in 4, respectively (p=0.028). Mean length of stay (days) after open and laparoscopic radical nephrectomy, and open, laparoscopic and robot-assisted partial nephrectomy was 5.8±0.7 days (95% CI 4.0-7.7) in 3 studies, 2.5±1.1 (95% CI 1.4-3.6) in 6, 5.8±0.4 (95% CI 5.3-6.2) in 5, 2.9±0.3 (95% CI 2.6-3.3) in 6 and 2.8±1.0 (95% CI 1.2-4.4) in 4, respectively (p<0.001). The hourly reimbursement rate was calculated at $200.61, $242.03, $185.66, $231.27 and $231.97 for open and laparoscopic radical nephrectomy, and open, laparoscopic and robot-assisted partial nephrectomy, respectively. Hence, open partial nephrectomy emerged as the lowest paying of these procedures. CONCLUSIONS Inferior compensation for open partial nephrectomy relative to that of laparoscopic or open radical nephrectomy may impede the dissemination of nephron sparing surgery for small renal masses. This may occur particularly in a general practice setting, where the expertise required for laparoscopic or robot-assisted partial nephrectomy may be lacking. We propose rectifying this inequity to facilitate wider use of nephron sparing surgery in the clinically appropriate setting.
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Affiliation(s)
- Youssef S Tanagho
- Division of Urology, Washington University School of Medicine, St. Louis, Missouri 63110, USA
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Castle SM, Gorbatiy V, Avallone MA, Eldefrawy A, Caulton DE, Leveillee RJ. Cost comparison of nephron-sparing treatments for cT1a renal masses. Urol Oncol 2012; 31:1327-32. [PMID: 22361086 DOI: 10.1016/j.urolonc.2012.01.006] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2011] [Revised: 01/10/2012] [Accepted: 01/12/2012] [Indexed: 11/18/2022]
Abstract
OBJECTIVES Treatment options for small renal tumors have evolved from radical nephrectomy (RN) to partial nephrectomy (PN), thermal ablation, or active surveillance. With the advancement of techniques, costs differences are unclear. The objective of this study is to compare the 6-month costs associated with nephron-sparing procedures for cT1a renal tumors. MATERIALS AND METHODS We performed a review of patients diagnosed with a solitary cT1a renal mass who underwent surgical treatment from June 2008 to May 2011. Open partial nephrectomy (OPN), robot-assisted partial nephrectomy (RLPN), laparoscopic radio-frequency ablation (LRFA), or computed tomography guided radio frequency ablation (CTRFA) was performed on 173 patients. Cost data were collected for surgical costs, associated hospital stay, and the 6-month postoperative period. RESULTS Patients underwent surgery, including 52 OPN, 48 RLPN, 44 LRFA, and 29 CTRFA. Median total costs associated were $17,018, $20,314, $13,965, and $6,475, for OPN, RLPN, LRFA, and CTRFA, respectively. When stratified by approach differences were noted for total cost (P < 0.001), operating room (OR) time (P < 0.001), surgical supply (P < 0.001), and room and board (P < 0.001) in univariable analysis. Multivariable linear regression (R(2) = 0.966) showed surgical approach (P = 0.007), length of stay (P < 0.001), and OR time (P < 0.001) to be significant predictors of total cost. However, tumor size (P = 0.175), and Charlson comorbidity index (P = 0.078) were not statistically significant. CONCLUSIONS Six-month cost of nephron-sparing surgery is lowest with radio frequency ablation (RFA) by either laparoscopic or computed tomography (CT)-guided approach compared to RLPN and OPN. As oncologic and safety outcomes improve and become comparable in all nephron-sparing surgery (NSS) approaches, cost of each procedure will start to play a stronger role in the clinical and healthcare policy setting.
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Affiliation(s)
- Scott M Castle
- Department of Urology, University of Miami, Miller School of Medicine, Miami, FL 33136, USA
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Tugcu V, Ilbey YO, Mutlu B, Tasci AI. Laparoendoscopic single-site surgery versus standard laparoscopic simple nephrectomy: a prospective randomized study. J Endourol 2010; 24:1315-20. [PMID: 20626273 DOI: 10.1089/end.2010.0048] [Citation(s) in RCA: 102] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND AND PURPOSE Laparoendoscopic single-site surgery (LESS), an attempt to further enhance the cosmetic benefits of minimally invasive surgery while minimizing the potential morbidity associated with multiple incisions, has been developed recently. Our aim was to compare LESS simple nephrectomy (LESS-SN) and conventional transperitoneal laparoscopic simple nephrectomy (CTL-SN). PATIENTS AND METHODS In this randomized study that was conducted between December 2008 and September 2009, 27 patients who needed simple nephrectomy were randomized to either LESS-SN or CTL-SN. All procedures in both groups were performed by the first author, who is experienced in laparoscopic surgery. Patient characteristics, perioperative details, and time to return to work were recorded. Postoperative evaluation of pain and use of analgesic medication were recorded. RESULTS There was no difference in median operative time (117.5 vs 114 min, P = 0.52), blood loss (50.71 vs 47.15 mL, P = 0.60), transfusion rates (0% for both), and hospitalization time (2.07 vs 2.11 days, P = 0.74) between the LESS-SN and CTL-SN groups. Time to return to normal activities was shorter in the LESS-SN group compared with the CTL-SN group (10.7 vs 13.5 days, P = 0.001). Both the visual analogue scale and the postoperative use of analgesics were significantly lower during postoperative days 1, 2, and 3 in patients who underwent LESS-SN, compared with patients who underwent CTL-SN. There were no intraoperative or postoperative complications in both groups. Compared with CTL-SN, LESS-SN was more expensive, but all patients undergoing LESS-SN were very pleased with the cosmetic outcome (no visible scars). CONCLUSION The early experience described in this study suggests that LESS-SN is a safe and effective alternative to CTL-SN that provides surgeons with a minimally invasive surgical option and the ability to hide the surgical incision within the umbilicus; however, a larger series is necessary to confirm these findings and to determine if there are any benefits in pain, recovery, or cosmesis.
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Affiliation(s)
- Volkan Tugcu
- Bakirkoy Dr Sadi Konuk Training and Research Hospital, Istanbul, Turkey
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Kirollos M. Re: Outcome after cytoreductive nephrectomy for metastatic renal cell carcinoma is predicted by fractional percentage of tumour volume removed. BJU Int 2008; 101:906; author reply 906-7. [PMID: 18321323 DOI: 10.1111/j.1464-410x.2008.07548_1.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
PURPOSE OF REVIEW Several technical modifications of laparoscopic partial nephrectomy have resulted in a reduction of complications and warm ischemia time. The most recent results are reviewed with a focus on oncologic outcome and postoperative renal function. RECENT FINDINGS The indications for laparoscopic partial nephrectomy are the same as for open surgery. All tumors up to 4 cm should be included and selected tumors up to 7 cm may be considered as well. In experienced hands, the complication rate is considerably low. Oncologic outcome is comparable with open partial nephrectomy and 5-year survival data have been published recently. Long warm ischemia time may be of some concern. The published functional results are excellent. Cost should not be the main argument in favor of a method. Laparoscopic partial nephrectomy, however, combines advantages for the patient with lower cost as shown by two studies. SUMMARY Laparoscopic partial nephrectomy duplicates the principles of open surgery and has been standardized to a great extent. It is technically difficult and is being performed by a small number of centers only; however, the interest of the urologists and patient demand is growing quickly. At the present time, laparoscopic partial nephrectomy cannot be considered a standard of care, but excellent results have been reported when performed by experienced laparoscopists.
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Cervellione RM, Gordon M, Hennayake S. Financial Analysis of Laparoscopic Versus Open Nephrectomy in the Pediatric Age Group. J Laparoendosc Adv Surg Tech A 2007; 17:690-2. [PMID: 17907990 DOI: 10.1089/lap.2007.0015] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The authors compared the cost of laparoscopic nephrectomy to open nephrectomy in the pediatric age group. One hundred seventeen consecutive laparoscopic nephrectomies performed by a surgeon with extensive experience with this approach between April 2003 and August 2006 were included. A control group of 24 consecutive open nephrectomies performed by urologists who do not use the laparoscopic approach were also included. Inclusion criteria for surgery were a poor or nonfunctioning kidney related to severe obstructive or refluxing nephropathy and a multicystic dysplastic kidney. The length of operation, length of stay, and disposable equipment used were recorded and the different approaches were compared statistically with an unpaired t test. The mean (standard deviation [SD]) duration of the procedure was 79 minutes (32) in the laparoscopic group and 85 minutes (35) in the control group (P = 0.41). The mean (SD) cost of the disposable instruments used during the operation was pounds sterling274 (160) in the laparoscopic group and pounds sterling20 (5) in the control group (P = 0.0001). The mean (SD) hospital stay was 1 night (0.43) with a mean (SD) cost of pounds sterling677 (291) in the laparoscopic group, and 3 nights (2) with a mean (SD) cost of pounds sterling2031 (1354) in the control group (P = 0.0001). The mean (SD) total cost of the procedure was pounds sterling951 (451) for the laparoscopic group and pounds sterling2051 (1359) for the open one (P = 0.0001). In our experience, the laparoscopic approach in the pediatric age group is 54% less expensive than the open approach.
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Affiliation(s)
- Raimondo M Cervellione
- Department of Paediatric Urology, Royal Manchester Children's Hospital, Manchester, United Kingdom
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Kok NFM, Adang EMM, Hansson BME, Dooper IM, Weimar W, van der Wilt GJ, Ijzermans JNM. Cost effectiveness of laparoscopic versus mini-incision open donor nephrectomy: a randomized study. Transplantation 2007; 83:1582-7. [PMID: 17589341 DOI: 10.1097/01.tp.0000267149.64831.08] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Cost-effectiveness remains an issue surrounding the introduction of laparoscopic donor nephrectomy (LDN). METHODS In a randomized controlled trial the cost-effectiveness of LDN versus mini-incision open donor nephrectomy (ODN) was determined. Fifty donors were included in each group. All in-hospital costs were documented. Postoperatively, case record forms were sent to the donors during 1-year follow-up to record return-to-work and societal costs. To offset costs against quality of life, the Euroqol-5D questionnaire was administered preoperatively and 3, 7, 14, 28, 90, 180, and 365 days postoperatively. RESULTS Mean total costs were euro6,090 (US$7,308) after LDN and euro4,818 ($5,782) after ODN (P<0.001). Disposables influenced the cost difference most. Mean productivity loss was 68 and 75 days after LDN and ODN respectively, corresponding to euro783 ($940) gained per donor after LDN. The main gain in quality of life in the LDN group was realized within 4 weeks postoperatively. LDN resulted in a mean gain of 0.03 quality-adjusted life years at mean costs of euro1,271 ($1,525) and euro488 ($586) from a healthcare perspective and a societal perspective, respectively. This implies that one additional Quality-Adjusted Life Year after LDN costs about euro16,000 ($19,200) from a societal point of view and about euro41,000 ($49,200) from a health-care perspective. Activities other than work were resumed significantly earlier after LDN (66 vs. 91 days, P=0.01). CONCLUSION In addition to a clinically relevant donor-experienced benefit from LDN, this technique appeared, given a societal perspective, a cost-efficient procedure mainly due to less productivity losses.
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Affiliation(s)
- Niels F M Kok
- Department of Surgery, Erasmus MC, and Department of Medical Technology Assessment, Radboud University Medical Center, Nijmegen, The Netherlands
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Wonderling D, Fenu E. Laparoscopic donor nephrectomy: is it cost effective? Perspective from health economists. Transplantation 2007; 83:1540-1. [PMID: 17589334 DOI: 10.1097/01.tp.0000267156.06687.da] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- David Wonderling
- National Collaborating Centre for Acute Care, Royal College of Surgeons of England, London, United Kingdom.
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Affiliation(s)
- Jonas Wadström
- Department of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden.
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Abstract
AIMS The aims of this study was to determine whether an active policy of cost curtailment would impact on the theater cost of laparoscopic surgery in a pediatric setting; to document the extent of cost changes over time and to identify factors that adversely influence expenditure; and to investigate whether the surgeon is a significant factor in the price of the procedure. MATERIALS AND METHODS A prospective audit of laparoscopic procedures was performed in a single unit over a 36-month period. Detailed costs of theater inventory for all procedures were compiled on a case-by-case basis and recorded on a database. The cost of six index procedures were collated and changes over the period of the study analyzed. The factors responsible for increased expenditure were flagged and appraised to enable the implementation of cost-saving measures. The prices of the laparoscopic equipment were based on invoiced figures provided by hospital managers, and no long-term outcome measures were taken into account. RESULTS A total of 179 cases were performed by six surgeons over a 3-year period between January 1, 2003 and December 31, 2005, with no adverse intraoperative events. The procedures studied in further detail were appendicectomy (n = 50), fundoplication (n = 25), cholecystectomy (n = 12), nephrectomy (n = 10), Fowler Stevens for undescended testes (n = 10), and modified Palomo operations for varicocoele (n = 7). The mean cost of these procedures fell year by year over the period of study but was significant only in appendicectomy (P = 0.017). For this procedure, there was a significant difference in costs between the various surgeons (P = 0.007), but this trend was not noted with the other procedures. There were no major intraoperative events, although 2 patients required conversion owing to technical difficulties posed by the cases. Among the factors that influenced costs were the use of disposables, particularly for hemostasis and suctioning, and an inability to procure reuseable instruments. CONCLUSIONS The costs of commonly performed laparoscopic procedures are falling year by year. The surgeon is a factor in the costs of some procedures. A cost-saving strategy has not been compromised of patient safety; however, some cost-saving measures, though attractive, are labor intensive and are not practical. An overall commitment to the sensible use of health care resources translates into savings for hospitals, thereby strengthening the case for laparoscopic surgery.
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Affiliation(s)
- Anies A Mahomed
- Department of Paediatric Surgery, Royal Alexandra Children's Hospital, Brighton, United Kingdom.
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Herranz Amo F, Subirá Ríos D, Hernández Fernández C, Martínez Salamanca JI, Monzó JI, Cabello Benavente R. [Opened vs. laparoscopic radical nephrectomy in renal adenocarcinoma cost comparison]. Actas Urol Esp 2007; 30:921-5. [PMID: 17175932 DOI: 10.1016/s0210-4806(06)73559-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE To undertake a cost comparison (cost minimization) between transperitoneal laparoscopic and opened nephrectomy in renal adenocarcinoma treatment. METHOD Retrospective study on the first 26 patients submitted to LN without intra or postoperative complications in the period 2002-2003, using as control 22 patients treated with ON with the same characteristics and in the same period. Demographic variables were evaluated (age, sex, tumor size, etc.), intraoperative (operative time and fungible material used) and postoperative (length of stay in Postanaesthesic Care Unit, Acute Pain Unit needs and hospital stay). Our Hospital costs plus those imputed during year 2003 to the Urology Service, as well as the cost of fungible material for the same year were applied, carrying out a comparison of costs between both groups. RESULTS There were no differences between the demographic variables between both groups except in the tumor, bigger size in the opened nephrectomy (p=0,001). Transperitoneal laparoscopic was 29,4% globally more expensive than opened nephrectomy. The transperitoneal laparoscopic intraoperative cost (operating room, anesthesia and fungibles) the exceeded in 151,6% to that of the opened nephrectomy, whereas in the opened nephrectomy the postoperative cost was a 63 % higher than in the transperitoneal laparoscopic cases. CONCLUSIONS Transperitoneal laparoscopic in our Center is more expensive than opened nephrectomy due to a major occupation of operating room and that the specific fungible material used at the surgical act has a very high cost. It would be necessary to drastically reduce surgical time and decrease fungible material expenses, thus transperitoneal laparoscopic procedure could be competitive in our Hospital.
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Affiliation(s)
- F Herranz Amo
- Servicio de Urología, Hospital General Universitario Gregorio Marañón, Madrid.
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Mouraviev V, Nosnik I, Robertson C, Albala D, Walther P, Polascik TJ. Comparative Financial Analysis of Minimally Invasive Surgery to Open Surgery for Small Renal Tumours ≤3.5cm: A Single Institutional Experience. Eur Urol 2007; 51:715-20; discussion 720-1. [PMID: 16904255 DOI: 10.1016/j.eururo.2006.06.050] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2006] [Accepted: 06/30/2006] [Indexed: 11/23/2022]
Abstract
OBJECTIVE We analysed total hospital costs by comparing minimally invasive surgery (MIS) procedures, such as laparoscopic cryoablation (LCA), laparoscopic partial nephrectomy (LPN), and hand-assisted laparoscopic nephrectomy (HALN), with conventional surgery. METHODS Between March 2000 and July 2005, 184 consecutive patients underwent surgery for a small, organ-confined renal tumour < or =3.5 cm in diameter. The distribution of patients among the surgical procedures was: HALN (n=53); LPN (n=20); open radical nephrectomy (ORN; n=20); open partial nephrectomy (OPN; n=71); and LCA (n=20). Total hospital costs were analysed for each procedure. RESULTS Patients undergoing OPN at a mean age of 58+/-13 yr were significantly younger those undergoing HALN, ORN, and LCA. The mean hospital length of stay in the LCA group (2.0+/-1.2 d) was shorter than all other groups (p<0.05). Higher surgical costs occurred with LCA, LPN, and HALN compared (p<0.05) with ORN and OPN. However, total financial costs were lower for LCA and HALN with more obvious differences between LCA and the other four groups. CONCLUSIONS The costs of MIS remain competitive with traditional surgery. Although the surgical costs were higher, LCA had the lowest total hospital costs for the renal tumour < or =3.5 cm at our institution. Long-term oncologic efficacy studies will be needed to fully appreciate the cost-efficacy ratio of MIS.
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Affiliation(s)
- Vladimir Mouraviev
- Division of Urologic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC 27710, United States
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Link RE, Permpongkosol S, Gupta A, Jarrett TW, Solomon SB, Kavoussi LR. Cost analysis of open, laparoscopic, and percutaneous treatment options for nephron-sparing surgery. J Endourol 2007; 20:782-9. [PMID: 17094755 DOI: 10.1089/end.2006.20.782] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND AND PURPOSES A variety of nephron-sparing options exist for the management of small renal masses. The perioperative cost of open (OPN) and laparoscopic (LPN) partial nephrectomy, laparoscopic (LCA), and CT-guided percutaneous (PCA) cryoablation was compared using a detailed computer model. PATIENTS AND METHODS The model incorporates operative time, consumables, anesthesia, CT usage, percutaneous biopsy, hospitalization, and transfusion expenses. Starting values were derived from a retrospective review of 317 patients treated at the Johns Hopkins Medical Institutions within the past 7 years. Hypothesis testing was performed with sensitivity analysis. RESULTS The PCA was 2.2 to 2.7 times less costly than the other options and resulted in a cost savings of $3625 to $5155 per case. For OPN, LPN, and LCA, the operative time and hospitalization accounted for 69% to 91% of the cost. In contrast, cryoprobe consumables were responsible for >70% of total cost of PCA. An OPN was 1.2x as costly as LPN and could achieve cost equivalence only with operative times of <2.8 hours or hospitalization of <3 days. An LCA was more costly than all forms of extirpative surgery if more than two cryoprobes were used. Reusing cryoprobes during LCA was always a less-costly option than adding a second cryoprobe to the procedure. The LCA was no longer cost advantageous over OPN if more than four CT scans were obtained during the first postoperative year or if local recurrence rates exceeded 23%. CONCLUSIONS This model defines and simplifies a series of complex cost relations between the options for nephron-sparing surgery.
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Affiliation(s)
- Richard E Link
- James Buchanan Brady Urological Institute, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA.
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Izaki H, Fukumori T, Takahashi M, Nakatsuji H, Oka N, Taue R, Nishitani MA, Kanayama HO. Clinical research of renal vein control using Hem-o-lok clips in laparoscopic nephrectomy. Int J Urol 2006; 13:1147-9. [PMID: 16903952 DOI: 10.1111/j.1442-2042.2006.01493.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Control of the renal vein represents a crucial step in laparoscopic nephrectomy. Although endovascular gastrointestinal anastomosis (GIA) staplers have generally been used for renal vein control because of the large diameter of the vessel, Hem-o-lok clips have recently been used for renal artery control. GIA staplers are expensive and can malfunction on rare occasions, resulting in severe complications. We evaluated renal vein control using Hem-o-lok clips (adaptive vascular width 7-16 mm) in laparoscopic nephrectomy. Since April 2004, we have ligated renal arteries using Hem-o-lok clips. From June 2004, this method was applied for renal vein control in 40 laparoscopic nephrectomies. After renal pedicle dissection, renal pedicle ligation was accomplished using extra large (XL) Hem-o-lok clips on both the renal arteries and veins by placing two clips on the patient side and one clip on the specimen side. Ligation times for obtaining renal vein control were compared between XL Hem-o-lok clips and GIA staplers in 40 cases before June 2004. Vascular control using XL Hem-o-lok clips was successful in all 40 cases, without any slipping of clips or uncontrolled bleeding. After renal pedicle dissection, ligation time for achieving renal vein control was 167.0 +/- 48 s (range: 122-295 s) using XL Hem-o-lok clips (mean, three clips) and 68 +/- 24.0 s (range: 54-150 s) using a GIA stapler. XL Hem-o-lok clips allow safe and reliable control of renal veins in laparoscopic nephrectomy. Ligation time is only 100 s longer than using a GIA stapler. In addition, costs are reduced by more than 90% compared to GIA stapling.
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Affiliation(s)
- Hirofumi Izaki
- Department of Urology, The University of Tokushima Graduate School Institute of Health Bioscience, Tokushima, Japan
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Borley NC, O'Donnell A, Anderson CJ. Inadequacies in funding for the cost of nephrectomies in a tertiary referral centre in the UK. BJU Int 2006; 98:722-4. [PMID: 16978265 DOI: 10.1111/j.1464-410x.2006.06338.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Hollingsworth JM, Miller DC, Dunn RL, Montgomery JS, Wolf JS. Cost Trends for Oncological Renal Surgery: Support for a Laparoscopic Standard of Care. J Urol 2006; 176:1097-101; discussion 1101. [PMID: 16890699 DOI: 10.1016/j.juro.2006.04.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2005] [Indexed: 11/26/2022]
Abstract
PURPOSE There may be inherent costs associated with the cultivation of laparoscopic expertise. We compared the cost trends for laparoscopy during the development of our program with that of open surgery for renal neoplasms. MATERIALS AND METHODS We retrospectively reviewed the records of 381 patients treated surgically for renal cortical neoplasms from 1998 to 2003. Demographic information and cancer specific data were recorded on each subject. Direct variable costs, which are directly traceable to the patient care service provided and vary with patient volume, were used to analyze cost. Temporal trends were assessed using multivariate models developed to determine smoothed mean costs by year. RESULTS Although it was initially more expensive, by 2003 mean costs were lower for laparoscopic than for open radical nephrectomy ($5,157 vs $5,808). This reflected a significantly lower annual increase in direct variable costs for laparoscopy vs open surgery even after adjustment for patient age, sex, race and clinical stage (p = 0.013). Although a similar trend was observed when comparing nephron sparing procedures vs open surgery, this did not attain statistical significance. In addition to surgical technique, only higher clinical stage was independently associated with increased direct variable costs after adjustment for operative year (p <0.0001). CONCLUSIONS Relative to their open counterparts the costs of laparoscopic treatment of renal cortical neoplasms have increased at a lower rate in the last 6 years. When considered in the context of the well established benefits of laparoscopy, our findings lend additional support in favor of laparoscopy as the standard of care.
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Affiliation(s)
- John M Hollingsworth
- Department of Urology, University of Michigan Health System, 1500 E. Medical Center Drive, Ann Arbor, MI 48109-0330, USA
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Guazzoni G, Cestari A, Naspro R, Riva M, Rigatti P. Cost Containment in Laparoscopic Radical Nephrectomy: Feasibility and Advantages over Open Radical Nephrectomy. J Endourol 2006; 20:509-13. [PMID: 16859466 DOI: 10.1089/end.2006.20.509] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE To highlight the impact of the laparoscopic experience of the surgical team on achievement of satisfactory results with cost containment in performing laparoscopic radical nephrectomy (LRN). PATIENTS AND METHODS We compared the cost components of 15 consecutive uncomplicated LRNs performed in 2001 (LRN01) with 15 consecutive uncomplicated laparoscopic radical nephrectomies performed in 2003 (LRN03) and with 15 consecutive uncomplicated procedures performed at our institution by the same surgical team in the year 1999 matched for patient age, tumor size, and disease stage. The groups were comparable in demographics. RESULTS The operative times were 250, 225, and 195 minutes in the LRN01, LRN03, and open-surgery groups, respectively, while the lengths of postoperative stay were 3.8, 3.1, and 6.5 days. Operating room costs, excluding the disposable instruments, were 11.00 /min for the open surgery and 10.00 /min for laparoscopic nephrectomy, and the cost of the postoperative stay was 300 to 310 per day. The cost of disposable instruments was 952.18 for LRN01 and 146.37 for LRN03. The overall costs were 4155.00 for the open-surgery group, 4672.00 for LRN01, and 3336.37 for LRN03. CONCLUSIONS Cost containment in laparoscopic nephrectomy is possible. A proper team learning curve and the employment of reliable reusable instruments is the key to reducing costs, making this procedure as economically advantageous as the equivalent open procedure.
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Affiliation(s)
- Giorgio Guazzoni
- Department of Urology, University Vita-Salute Scientific Institute H. San Raffaele Turro, Milan, Italy.
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Siqueira TM, Mitre AI, Simoes FA, Maciel AF, Ferraz AM, Arap S. A cost-effective technique for pure laparoscopic live donor nephrectomy. Int Braz J Urol 2006; 32:23-8; discussion 28-30. [PMID: 16519824 DOI: 10.1590/s1677-55382006000100004] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/26/2005] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE Compare two different techniques for laparoscopic live donor nephrectomy (LDN), related to the operative costs and learning curve. MATERIALS AND METHODS Between April/2000 and October/2003, 61 patients were submitted to LDN in 2 different reference centers in kidney transplantation. At center A (CA), 11 patients were operated by a pure transperitoneal approach, using Hem-O-Lok clips for the renal pedicle control and the specimens were retrieved manually, without using endobags. At center B (CB), 50 patients were also operated by a pure transperitoneal approach, but the renal pedicles were controlled with endo-GIA appliers and the specimens were retrieved using endobags. RESULTS Operative time (231 +/- 39 min vs. 179 +/- 30 min; p < 0.000), warm ischemia time (5.85 +/- 2.85 min vs. 3.84 +/- 3.84 min; p = 0.002) and blood loss (214 +/- 98 mL vs. 141 +/- 82 mL; p = 0.02) were statistically better in CB, when compared to CA. Discharge time was similar in both centers. One major complication was observed in both centers, leading to an open conversion in CA (9.1%). One donor death occurred in CB (2%). Regarding the recipients, no statistical difference was observed in all parameters analyzed. There was an economy of US$1.440 in each procedure performed in CA, when compared to CB. CONCLUSIONS Despite the learning curve, the technique adopted by CA, showed no deleterious results to the donors and recipients when compared with the CB. On the other hand, this technique was cheaper than the technique performed in the CB, representing an attractive alternative for LDN, mainly in developing centers.
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Affiliation(s)
- Tiberio M Siqueira
- Kidney Transplantation Center General Hospital, Federal University of Pernambuco, Recife, Pernambuco, Brazil.
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Yamataka A, Satake S, Kaneko K, Ohtomo Y, Okada Y, Lane GJ, Yamashiro Y, Miyano T. Outcome and cost analysis of laparoscopic or open surgery versus conservative management for multicystic dysplastic kidney. J Laparoendosc Adv Surg Tech A 2005; 15:190-3. [PMID: 15898916 DOI: 10.1089/lap.2005.15.190] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE To determine whether laparoscopic nephrectomy (LN), open nephrectomy (ON), or observation (OB) is most efficient for managing multicystic dysplastic kidney (MCDK). METHODS We performed a retrospective review of the management of our 12-year clinical experience of 32 MCDK patients to analyze the estimated total cost (ETC) of various treatment options and compare them with respect to survival, development of hypertension, and postoperative cosmetic appearance, to determine the most efficient treatment option. RESULTS There were 12 cases in the LN group, 6 in the ON group, and 14 in the OB group. ETC was lower for ON than for LN. But the length of preoperative observation and length of follow-up after spontaneous regression greatly affected ETC. If MCDK cases were observed > 5 years with standard investigations performed regularly, ETC was higher for the OB group than for the LN group. In 6/14 (42.9%) of OB cases, MCDK resolved within 5 years, and this subgroup had the lowest ETC up to the time of this review. Six cases initially in the OB group were managed surgically (4 by LN and 2 by ON) in accordance with parental requests, and ETC in these cases was highest. All cases are well after a mean follow-up of 5.7 years, without any impairment of renal function, or hypertension. CONCLUSION The decision to operate after lengthy observation increases costs. Overall, the most efficient surgical technique for managing MCDK was LN because of greater patient satisfaction with postoperative cosmesis. We recommend MCDK be treated by LN after a short period of observation.
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Affiliation(s)
- Atsuyuki Yamataka
- Department of Pediatric Surgery , Juntendo University School of Medicine, Tokyo, Japan.
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Abstract
Kidney transplantation is quite a routine complex procedure, not without risks and consequences to the donor, the recipient, and the health care professionals. Kidney-related medical malpractice suits are growing rapidly, and for clinicians and surgeons, the risk of being sued can be only reduced by practicing high-quality medicine and by appropriately communicating with donors and recipients. Actually relevant guidelines are available including safety and quality assurance standards for procurements, preservation, processing, and distribution for organs to maximize their quality and thereby the rate of success of transplants and to minimize the risk of such a procedure. We also find it essential that practice of living donor kidney transplant is in line with the general rules of the Convention for the Protection of Human Rights and its Additional Protocol. In this article, financial incentives and insurance aspects related with living donors kidney transplants are also illustrated.
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Affiliation(s)
- C P Campobasso
- Section of Legal Medicine (Di.M.I.M.P.), University of Bari, Bari, Italy
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Abstract
OBJECTIVE To compare costs associated with open partial nephrectomy (OPN), laparoscopic PN (LPN) and percutaneous radiofrequency ablation (PRF) in consecutive patients undergoing nephron-sparing surgery. PATIENTS AND METHODS The charts and costs were reviewed for all 46 patients undergoing nephron-sparing PN at our institution from March 2003 to March 2004. Clinical characteristics, operative techniques, radiographic and pathological information were recorded. Detailed cost information for room and board, laboratory, pharmacy, radiology, operating room, surgical supplies, anaesthesia, recovery room, electrocardiography and respiratory services were obtained from our institution. RESULTS The hospital stay was significantly shorter for PRF (0.5 days) than either LPN (1.86) and OPN (4.94). PRF was statistically less costly than LPN and OPN, with mean (sd) costs of (US dollars) 4454 (938), 7013 (934) and 7767 (1605). There was no significant difference in cost between LPN and OPN. Surgical supply costs were significantly higher for LPN and PRF than OPN. LPN had less than a third of the room and board costs of OPN (P < 0.001). Decreases in room and board were also associated with lower pharmacy and laboratory costs. CONCLUSIONS PRF is significantly less costly than LPN and OPN; LPN is cost-equivalent to OPN as the shorter stay compensates for significantly higher surgical supply costs. In those patients with tumours of appropriate size and location, minimally invasive approaches can decrease the morbidity, with cost benefits.
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Affiliation(s)
- Yair Lotan
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX 75390-9110, USA.
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Simforoosh N, Basiri A, Tabibi A, Shakhssalim N. Laparoscopic donor nephrectomy--an Iranian model for developing countries: a cost-effective no-rush approach. EXP CLIN TRANSPLANT 2004; 2:249-53. [PMID: 15859937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
OBJECTIVES This study aimed to evaluate donor and graft outcome in kidney transplantations from laparoscopic donor nephrectomies. MATERIALS AND METHODS From June 2000 to June 2004, 341 laparoscopic donor nephrectomies were performed. Demographics and hospital records were reviewed. Mean ages of donors and recipients were 27.59+/-4.80 years (range, 20-56 years) and 35.36+/-14.85 years (range, 3-75 years). RESULTS Nephrectomy was left sided in 96.2%. Mean follow-up was 13.32+/-35.98 months. Mean warm ischemia time was 8.17 minutes (range, 2.5-19 minutes). Mean operative time was 260.34 minutes. Median serum creatinine levels (mg/dL) of the recipients were 1.30, 1.45, and 1.20 at day 7, and at 1 and 12 months. One-year graft survival was 92.7%, 94.6%, and 92.6% in the laparoscopic donor nephrectomy groups with warm ischemia times of less than 6, 6-10, and more than 10 minutes (P=NS). Conversion to open surgery occurred in 2.1% of donors, and reoperation was performed in 3.8% of laparoscopic donor nephrectomies. Blood transfusion was required in 7.1% of donors. Ureteral complications were observed in 2.1% of recipients. Vascular control was performed using medium-large clips instead of endo GIA, and the kidney was extracted via a suprapubic approach using the hand instead of an ENDOCATCH bag; hence, $600 was saved in each nephrectomy. No vascular accident occurred from pedicular vessels. CONCLUSIONS Laparoscopic donor nephrectomy can be performed with a less-expensive setup (to be expanded in developing countries) without jeopardizing results. Because warm ischemic time in our study did not affect graft outcome significantly, there appears to be no need to rush harvesting the kidney to achieve a better quality kidney. Vascular control using nonautomatic clips instead of more costly endo GIA and hand extraction of the kidney is safe, practical, and economical.
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Affiliation(s)
- Nasser Simforoosh
- Department of Urology & Renal Transplantation, Urology Nephrology Research Center, Shahid Labbafinejad Hospital and Shahid Beheshti University of Medical Science, Tehran, Iran.
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Abstract
Currently, potential kidney transplant candidates are dying on the waiting list. One potential solution would be a regulated system of living kidney sales (with safeguards to protect the vendor). Potential objections and practical concerns are discussed.
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Affiliation(s)
- Arthur J Matas
- Department of Surgery, University of Minnesota, Minnesota, USA.
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Affiliation(s)
- Ben Challacombe
- Department of Transplantation, Guy's Hospital, London SE1 9RT, UK
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Beasley KA, Al Omar M, Shaikh A, Bochinski D, Khakhar A, Izawa JI, Welch RO, Chin JL, Kapoor A, Luke PPW. Laparoscopic versus open partial nephrectomy. Urology 2004; 64:458-61. [PMID: 15351570 DOI: 10.1016/j.urology.2004.04.028] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2004] [Accepted: 04/20/2004] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To compare, retrospectively, the results of laparoscopic partial nephrectomy (LPN) to open partial nephrectomy (OPN) using a tumor size-matched cohort of patients. Limited data are available comparing LPN to OPN in the treatment of small renal tumors. METHODS Between September 2000 and September 2003, 27 LPNs and 22 OPNs were performed to treat renal masses less than 4 cm. Patient demographics and tumor location and size (2.4 +/- 1.0 cm versus 2.9 +/- 0.9 cm, respectively; P = not statistically significant) were similar between the LPN and OPN groups. RESULTS Although the mean operative time was longer in the LPN than in the OPN group (210 +/- 76 minutes versus 144 +/- 24 minutes; P <0.001), the blood loss was comparable between the two groups (250 +/- 250 mL versus 334 +/- 343 mL; P = not statistically significant). No blood transfusions were performed in either group. The hospital stay was significantly reduced after LPN compared with after OPN (2.9 +/- 1.5 days versus 6.4 +/- 1.8 days; P <0.0002), and the postoperative parenteral narcotic requirements were lower in the LPN group (mean morphine equivalent 43 +/- 62 mg versus 187 +/- 71 mg; P <0.02). Three complications occurred in each group. With LPN, no patient had positive margins or tumor recurrence. Also, direct financial analysis demonstrated lower total hospital costs after LPN (4839 dollars+/- 1551 dollars versus 6297 dollars+/- 2972 dollars; P <0.05). CONCLUSIONS LPN confers several benefits over OPN concerning patient convalescence and costs, despite prolonged resection times at our current phase of the learning curve. Long-term results on cancer control in patients treated with LPN continue to be assessed.
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Affiliation(s)
- Kenneth A Beasley
- Division of Urology, University of Western Ontario, London, Ontario, Canada
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