title: Costs analysis of laparoendoscopic, single-site laparoscopic and open surgery for cT1 renal masses in a European high-volume centre.
abstract: OBJECTIVE
  To analyse intraoperative costs and healthcare reimbursements of partial/radical nephrectomy in open and minimal invasive surgery (MIS), as laparoscopy and laparoendoscopic single-site surgery (LESS), for the treatment of renal tumour.
  
  
  METHODS
  In a non-randomized retrospective study, we selected 90 patients who underwent (01/2010-12/2011) partial and radical nephrectomy for clinical renal masses ≤7 cm (cT1N0M0) and divided them into laparoscopic [laparoscopic partial nephrectomy (LPN), laparoscopic radical nephrectomy (LRN)], LESS [laparoendoscopic single-site partial nephrectomy (LESS-PN), laparoendoscopic single-site radical nephrectomy (LESS-RN)] and open groups [open partial nephrectomy (OPN), open radical nephrectomy (ORN)]. Patients were matched for age, sex, body mass index, ASA score and tumour side. Primary endpoints were evaluation of intraoperative costs (general, laparoscopic, sutures, haemostatic agents, anaesthesia, and surgeon/nurses fee), total insurance and estimated daily reimbursement.
  
  
  RESULTS
  MIS showed longer operative time (p ≤ .02) and shorter hospital stay (p ≤ .04). Total costs were higher (p ≤ .03) in MIS (LRN: 4,091.5 <euro>; LPN: 4,390.4 <euro>; LESS-RN: 3,866 <euro>; and LESS-PN: 3,450 <euro>) if compared with open (OPN: 2,216.8.8 <euro>, ORN: 1,606.4 <euro>). Laparoscopic materials incised mainly in total costs of MIS (38-58.1 %). Reusable instruments reduced LESS laparoscopic costs (LESS-PN: 1,312.2 <euro> vs. LRN: 2,212.2 <euro>, p < .0001). Intraoperative frozen section and DJ ureteric stenting (general costs) (p ≤ .008) and haemostatic agents use (p ≤ .01) were higher in nephron sparing surgery (NSS), due to more frequent use of ancillary procedures necessary for a safe management of such an approach. Estimated anaesthesia costs and doctor/nurses fee were higher in MIS (p ≤ .02). Whereas total final reimbursements were comparable (p ≥ .8), estimated daily reimbursements were lower in MIS (p < .001) due to higher intraoperative costs and longer operative time.
  
  
  CONCLUSIONS
  Well-known advantages offered by MIS/NSS face higher total intraoperative costs and 'paradoxical' reduced healthcare reimbursement. We believe that local health systems should consider a subclassification with different compensations, which will incentive NSS and MIS approaches.
authors.affiliation: Department of Urology and Kidney Transplantation Centre, Martin-Luther-University Halle, Ernst-Grube-Strasse 40, 06120, Halle/Saale, Germany, gpini3@gmail.com.
authors.forename: Giovannalberto
authors.initials: G
authors.lastname: Pini
authors.forename: Luigi
authors.initials: L
authors.lastname: Ascalone
authors.forename: Francesco
authors.initials: F
authors.lastname: Greco
authors.forename: Nasreldin
authors.initials: N
authors.lastname: Mohammed
authors.forename: Paolo
authors.initials: P
authors.lastname: Fornara
mesh_terms: D000368:Aged; D002292:Carcinoma, Renal Cell / Q000191:economics / Q000473:pathology / Q000601:surgery*; D005060:Europe; D005260:Female; D017048:Health Care Costs; D006801:Humans; D007680:Kidney Neoplasms / Q000191:economics / Q000473:pathology / Q000601:surgery*; D010535:Laparoscopy / Q000191:economics*; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging; D009392:Nephrectomy / Q000191:economics* / Q000379:methods; D061646:Operative Time; D012189:Retrospective Studies