The cost‐effectiveness of intraoperative margin assessment strategies during radical prostatectomy

OBJECTIVE: To determine whether current intraoperative margin assessment (IOMA) techniques (such as Neurovascular Structure Adjacent Frozen-section Examination [NeuroSAFE] or confocal laser microscopy [CLM]) used during radical prostatectomy (RP) to enhance nerve-sparing surgery (NSS) while reducing positive surgical margins (PSMs) justify their extra costs, this study assessed their cost-effectiveness. METHODS: A decision analytical model assessed health outcomes and costs associated with NeuroSAFE and CLM (using the Histolog® Scanner) compared to bilateral, unilateral, and non-NSS. Outcomes were calculated in quality-adjusted life years (QALYs), with a cost-effectiveness threshold of €50 000 per QALY. NSS reduced erectile dysfunction and incontinence probabilities. However, when extraprostatic extension was present but not identified pre- or intraoperatively, NSS resulted in a PSM, increasing the risk of biochemical recurrence (BCR) and development of metastases. RESULTS: The NeuroSAFE and CLM were cost-effective strategies compared to non-IOMA strategies. NeuroSAFE was most cost-effective if NeuroSAFE and CLM were used in an equal number of patients. However, if NeuroSAFE was used in >8% fewer patients compared to CLM, CLM was most cost-effective. Sensitivity analyses highlighted the impact of PSMs on cost-effectiveness. In hospitals with higher RP volumes (>160 per year), CLM had lower costs per procedure than NeuroSAFE. CONCLUSIONS: Intraoperative margin assessment during RP is a cost-effective intervention. The choice to implement NeuroSAFE or CLM should be guided by both surgical volume and available capacity, as the more labour-intensive nature of NeuroSAFE may limit its use and reduces its cost-effectiveness compared with CLM.