Ultrasound-Guided Pudendal Nerve Block in Patients Undergoing Open Hemorrhoidectomy: A Post-Hoc Cost-Effectiveness Analysis from a Double-Blind Randomized Controlled Trial

Background

Pudendal nerve block (PNB) has been demonstrated to reduce postoperative pain and re-admission rates after open hemorrhoidectomy and may reduce costs but, to date, no study has reported data on this aspect. The aim of our study was to perform a cost analysis on PNB use in in- and outpatients undergoing open hemorrhoidectomy.

Methods

From January 2018 to December 2019, patients undergoing open hemorrhoidectomy were included and randomized to undergo spinal anesthesia either with or without the PNB. Clinical data, direct and indirect costs for in- and outpatients, operating time and operating theatre occupancy were recorded. A cost-effectiveness analysis based on the diagnosis-related groups (DRG) and TARMED reimbursement systems was performed.

Results

Patients who underwent PNB in addition to spinal anesthesia had significantly less pain and a shorter length of hospital stay after open hemorrhoidectomy. The cost analysis included all 49 patients, 23 of whom, in addition to spinal anesthesia, received a PNB. There were no significant differences in operating theatre occupancy (p=0.662), mean operative time (p=0.610) or time required for anesthesia (p=0.124). Direct costs were comparable (482±386 vs 613±543 EUR, p=0.108), while indirect costs were significantly lower in the PNB group (2606±816 vs 2769±1506 EUR, p=0.005). We estimated an incremental cost-effectiveness ratio (ICER) of −243 ± 881 EUR/pain unit on the VAS.

Conclusion

Despite limitations, the ultrasound-guided PNB seems to reduce costs in patient undergoing open hemorrhoidectomy under spinal anesthesia. It was shown to be clinically beneficial and cost-effective, and therefore recommendable in patients undergoing open hemorrhoidectomy.

Open and Laparoscopic Inguinal Hernia Surgery: A Cost Analysis

Background: In the treatment of inguinal hernias, there is little hard evidence concerning the economic reimbursement in the diagnosis-related group (DRG) era. Factors that affect whether a hospital may earn or lose financially depending on open or laparoscopic approach is still underexplored. The aim of this study was to provide a reliable analysis of in-hospital costs and reimbursements in inguinal hernia surgery. Methods: This retrospective study analyzed the 1-year experience in inguinal hernia repair in patients undergoing open Lichtenstein (OL), laparoscopic totally extraperitoneal unilateral (UTEP), or bilateral (BTEP) hernia repair. Demographics, results, costs, and DRG-based reimbursements were recorded and analyzed. Results: During the study period, 39 patients underwent OL, 82 patients UTEP, and 16 patients BTEP. The average total cost amounted to 4126 EUR in OL, 5134 EUR in UTEP, and 7082 EUR in BTEP groups (P < .001). The hospital reimbursement amounted to 5486 EUR, 5252 EUR, and 6555 EUR in the OL, UTEP, and BTEP groups, respectively (P < .001). Finally, the mean hospital earnings were 1360 EUR, 118 EUR, and -527 EUR for each patient in OL, UTEP, and BTEP, respectively (P < .001). Conclusions: In-hospital costs were higher in UTEP and BTEP as compared with OL. The DRG-based reimbursement provided adequate compensation for patients with unilateral inguinal hernia, whereas hospital earnings were profitable in OL group only, and led an overall financial loss in the BTEP group. Surgeons should be conscious that clinical advantages of the laparoscopic approach are not adequately compensated for, from an economic point of view.

Cost-efficacy comparison of extracorporeal shock wave lithotripsy and endoscopic laser lithotripsy in distal ureteral stones

Distal ureteral stones are usually treated today by extracorporeal shock wave lithotripsy or extraction by retrograde ureteroscopy with or without previous fragmentation. We performed a cost-efficacy study of three methods to treat them: extracorporeal lithotripsy using either a spark gap lithotripter, the unmodified Dornier HM3 (SWL), or the piezoelectric Wolf Piezolith 2300 (EPL) and endoscopic lasertripsy (LISL) using an alexandrite pulsed laser, the HMT Alexantriptor. The records of 520 patients with distal ureteral stones treated by extracorporeal lithotripsy were reviewed to establish the mean cost of the procedure. Concerning LISL, the first 30 stone patients treated in our institution were evaluated. Four measures were examined: (1) number of sessions; (2) success rate; (3) auxiliary maneuvers; and (4) complications. The economics evaluation considered the direct costs related to personnel, consumables, depreciation, and maintenance. The EPL procedure was the cheapest: $873 US, and SWL the most expensive: $3,572 US. The best cost-efficacy rate was seen with LISL because of its 93% success rate and its cost of $1,390 US.