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The Economic Evaluation of Chronic Kidney Disease in the Outcomes for Radical versus Partial Nephrectomy in the Management of Small Renal Masses
Steven L. Chang, MD1, Lauren E. Cipriano, MS2, Lauren C. Harshman, MD2, Alan M. Garber, MD PhD2, Benjamin I. Chung, MD2.
1Brigham and Women's Hospital, Boston, MA, USA, 2Stanford University, Stanford, CA, USA.

BACKGROUND: Radical nephrectomy has been the gold standard for localized renal masses for over 40 years. Recently, for the management of stage T1a renal masses, partial nephrectomy has been becoming the treatment of choice because of comparable oncologic outcomes and decreased risk of chronic kidney disease (CKD) compared to radical nephrectomy. However, there have been no comprehensive analyses incorporating overall cost and quality of life with long-term clinical outcomes in the comparison of these two procedures. Therefore, we assessed the relative cost-effectiveness of radical and partial nephrectomy in the management of stage T1a renal masses.
METHODS: A decision-analytic Markov model was constructed to evaluate open radical nephrectomy (ORN), laparoscopic radical nephrectomy (LRN), open partial nephrectomy (OPN), and laparoscopic partial nephrectomy (LPN) for the treatment of stage T1a renal masses. The base case was a 65-year old healthy individual with an asymptomatic unilateral stage 1a renal mass and normal renal function. We used a 3-month cycle length with a lifetime horizon, societal perspective, and 3% discount rate. The direct and indirect costs, quality of life adjustments, and transition probabilities were estimated from the literature, Medicare, and expert opinion. Benefits were measured in quality-adjusted life-years (QALY) gained and costs were in 2008 US dollars. We assumed the 3-year risk of stage 3 CKD among healthy 65-year old patients was 40% following radical nephrectomy and 15% following partial nephrectomy. The model was tested with one-way and multi-way sensitivity analyses.
RESULTS: LPN was the optimal management option yielding an average of 9.76 QALYs-gained with an average lifetime discounted cost of $115,216. All other options were more expensive and less effective than LPN. Preference for OPN over LPN required a $2500 reduction in the cost of convalescence. In the base case, the average discounted cost of complications was $1,400 for LPN, $800 for OPN, $430 for LRN, and $467 for ORN. The cost of post-operative CKD was $27,000 for partial nephrectomy and $34,500 for radical nephrectomy.
CONCLUSIONS: LPN is the preferred management option for healthy 65-year old patients with a stage T1a renal mass. Partial nephrectomy provides cost-savings over radical nephrectomy primarily associated with the decreased risk of developing post-operative CKD.


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