55: Cost-effectiveness analysis of surgical repair for apical prolapse

Abstract

To evaluate the cost effectiveness of three routes of surgical repair for apical prolapse. We constructed a decision tree model to assess the cost effectiveness of apical suspension procedures, including vaginal sacrospinous and uterosacral ligament suspension, laparoscopic sacrocolpopexy, and robotic sacrocolpopexy, compared to expectant management. We modeled time horizons of 1 and 10 years, accounting for differing morbidities and recurrence rates. Outcomes included up to two separate surgical repairs for apical prolapse, effectiveness of prolapse repair, risk of re-operation, and complications. We calculated costs from the healthcare system’s perspective for the vaginal ($17,265), laparoscopic ($18,485) and robotic ($22,053) procedures, as well as an office visit ($379), lab tests ($184), imaging ($947) and antibiotics ($9). We estimated health utilities for no prolapse/cure at 1.0, symptomatic prolapse at 0.71, vaginal surgery at 0.96, laparoscopic and robotic surgeries at 0.90, and re-operation at 0.60. We discounted future costs and utilities at a rate of 3% annually. The base case analysis showed that, over a 1-year period, initial vaginal surgery followed by repeat vaginal surgery for recurrence, is the most cost-effective option. The incremental cost-effectiveness ratio (ICER) for this option is $150,756/QALY, whereas the ICER for initial laparoscopic surgery followed by repeat laparoscopic surgery if needed is $170,350/QALY, and the ICER for initial robotic surgery followed by repeat robotic surgery if needed is $201,282/QALY. However, over a 10-year period, initial laparoscopic surgery followed by repeat laparoscopic surgery for recurrence is the most cost-effective option (ICER $9,990/QALY). Whereas the ICER for initial vaginal surgery followed by repeat vaginal surgery for recurrence is $11,207/QALY, and the ICER for initial robotic surgery followed by repeat robotic surgery if needed for recurrence is $11,804/QALY. Sensitivity analyses showed that for patients with increased morbidity associated with laparoscopic surgery, initial vaginal surgery was the more cost-effective option when the QALY for laparoscopic surgery decreased below 0.68. Initial robotic surgery was more cost-effective than initial vaginal surgery when the cost of robotic surgery decreased by at least $1,175 per surgery. These results suggest that vaginal apical suspension is more cost-effective if the relevant time horizon is short-term or if there is increased morbidity with a laparoscopic approach. However, laparoscopic sacrocolpopexy is most cost-effective if the relevant time horizon is long-term. Further sensitivity analyses and Monte Carlo simulation is planned in our future analyses.