Cost analysis of laparoscopic versus open orchiopexy in the management of unilateral nonpalpable testicles

Purpose: Laparoscopic exploration for the nonpalpable testicle (NPT) has been criticized for increased costs compared with primary inguinal/scrotal exploration, mostly due to high equipment costs and the need for open inguinal/scrotal exploration in many cases. We assessed costs associated with diagnostic laparoscopy vs inguinal/scrotal exploration followed by selective open or laparoscopic treatment for unilateral NPT to identify the most important factors that influence cost. Materials and Methods: A comprehensive literature review determined the probabilities of intra-abdominal or inguinal nubbins, blind-ending vas/vessels and intra-abdominal or inguinal gonads in patients with unilateral NPT. The costs of anesthesia, equipment and operating room use were obtained from our institution or derived from the literature. A model was created using computer software to compare the costs of initial scrotal/inguinal approach or initial laparoscopic exploration in a theoretical population of boys with unilateral NPT. We established a set of assumptions and generated a series of 1-way sensitivity analyses to detect cost influencing parameters. Results: Based on the probabilities of intraoperative anatomical gonadal findings, use of reusable laparoscopic equipment and encompassing the ultimate surgical procedure needed initial laparoscopic evaluation was less costly than initial scrotal/inguinal exploration by $69 on a population basis. One-way sensitivity analyses showed that initial laparoscopic exploration was less costly if the operative time of laparoscopic exploration did not exceed 19 minutes and the cost of disposable laparoscopic equipment was less than $147. Conclusions: On a population basis initial laparoscopic evaluation of the clinically nonpalpable testicle has a cost saving advantage ($69) over initial inguinal-scrotal exploration when reusable laparoscopic equipment is primarily used, disposable equipment costs are kept low ($147 or less) and operating room time for diagnostic laparoscopy are at national standards (19 minutes or less). These findings hold true for a wide range of probabilities and duration of inguinal exploration time. Given that all of these caveats are easily achievable, cost should not be used as a factor to bias against initial laparoscopic exploration.