Evaluación de la teleconsulta en el paciente urológico durante la pandemia COVID-19

IntroductionThe global pandemic of COVID-19 has led to rapid implementation of telemedicine, but there is little information on patient satisfaction of this system as an alternative to face-to-face care.ObjectiveTo evaluate urological patient satisfaction with teleconsultation during the COVID-19 pandemic.Material and methodsObservational, prospective, cross-sectional, non-interventional study carried out by telephone survey during the period considered as the peak of the pandemic (March-April 2020). A quality survey composed of 11 questions on urological care provided by physicians during the COVID-19 pandemic was conducted, selecting a representative sample of patients attended by teleconsultation.ResultsTwo hundred patients were contacted by telephone to answer a survey on the quality of teleconsultation. The distribution of patients surveyed among the specialized consultations was homogeneous with the number of consultations cited in the period; 18% of them required assistance from family members. Sixty percent of patients avoided going to a medical center during the pandemic. Of the surveyed patients, 42% had cancelled diagnostic tests, 59% had cancelled medical consultations, 3.5% had cancelled treatments and 1% had cancelled interventions. Ten percent reported a worsening of urological symptoms during confinement. According to physicians, consultations were effectively delivered in 72% of cases, with teleconsultation being carried out by their usual urologist in 81%. Teleconsultation overall satisfaction level was 9 (IQI 8-10), and 61.5% of respondents consider teleconsultation as a «health care option» after the healthcare crisis.ConclusionTeleconsultation has been evaluated with a high level of satisfaction during the COVID-19 pandemic, offering continuous care to urological patients during the healthcare crisis. The perceived quality offers a field of optional telematic assistance in selected patients, which should be re-evaluated in a period without confinement measures.     

Telemedicina y trabajo inteligente: adaptación al español de las recomendaciones de la Asociación Europea de Urología

IntroductionTelemedicine provides remote clinical support through technology tools. It can facilitate medical care delivery while reducing unnecessary office visits. The COVID-19 outbreak has caused an abrupt change in our daily urological practice, where teleconsultations play a crucial role.ObjectiveTo provide practical recommendations for the effective use of technological tools in telemedicine.Materials and methodsA literature search was conducted on Medline until April 2020. We selected the most relevant articles related to «telemedicine» and «smart working» that could provide valuable information.ResultsTelemedicine refers to the use of electronic information and telecommunication tools to provide remote clinical health care support. Smart working is a working approach that uses new or existing technologies to improve performance. Telemedicine is becoming a useful and fundamental tool during the COVID-19 pandemic and will be even more in the future. It is time for us to officially give telemedicine the place it deserves in clinical practice, and it is our responsibility to adapt and familiarize with all the tools and possible strategies for its optimal implementation. We must guarantee that the quality of care received by patients and perceived by them and their families is of the highest standard.ConclusionsTelemedicine facilitates remote specialized urological clinical support and solves problems caused by limited patient mobility or transfer, reduces unnecessary visits to clinics and is useful to reduce the risk of COVID-19 viral transmission.     

Urologists on a Tightrope—Do We Have a Net?

PurposeThe purpose of this review is to analyze the current health care environment and its impact on urological practice.Materials and MethodsThe medical and lay literature as it pertains to the socioeconomics of health care was reviewed.ResultsAnalysis of the political and economic factors that influence the delivery of health care today reveals alarming realities. More than 40 million Americans remain uninsured, and with a retrenched economy that number is likely to increase. Neither government nor the private sector has been either willing or able to address the health care problem in a coherent or comprehensive way. As the population ages, the Medicare and Medicaid programs will become further stressed. Employers are increasingly unwilling to finance the health care expenses of their employees. Academic medical centers are facing unique exigencies that, if left uncorrected, will jeopardize the future training of physicians.ConclusionsIn the current environment of a depressed economy, further proposed tax cuts and increased military spending it appears inevitable that the economic restraints on medical care will increase substantially in the foreseeable future.     

Canadian cost data associated with treating overactive bladder is lacking

IntroductionCost-effectiveness analysis forms an integral part of the approval process for new medical treatments in Canada, including drug and non-drug technologies. This study’s primary objective was to identify peer-reviewed studies that report Canadian-specific cost data for treating overactive bladder (OAB) based on the Canadian Urological Association (CUA) guideline. A secondary objective was to identify studies that report cost data from other healthcare jurisdictions that could be generalizable to the Canadian context.MethodsWe conducted a systematic review of the published peer-reviewed literature. We included studies from Organization for Economic Cooperation and Development countries, excluding the U.S., published in English since January 2009.ResultsFrom 165 abstracts identified in our initial search, 18 studies were ultimately included for analysis. This included one Canadian-based study reporting costs in Canadian dollars, all related to second-line treatments. The other studies were primarily from Europe, reporting costs in Euros or British pounds. There were no studies reporting costs for first-line treatments. Gaps in costs for select second-line and third-line treatments recommended by the CUA were also identified.ConclusionsCanadian-specific cost data for OAB treatments published in the peer-reviewed literature is limited to a single study reporting costs for only a few second-line treatments sourced from a single province over 10 years ago. Cost data from other healthcare jurisdictions are available, but the generalizability of costs associated with third-line treatments is questionable.     

The future of urology

The Future of Urology has been written in times of economic downturn, with the inevitable effects on health sector spending. Nevertheless, this document aims to define a path whereby the EAU can play a pivotal role in ensuring the highest standard of care throughout Europe, and by setting standards, throughout the rest of the world. The future of urology will be dependent on improved education and training leading to high quality urological care, and to developing a service that is patient focused. The patient focus is becoming increasingly important in urology. This means providing full information about disease processes and urological procedures to patients and allowing them to judge the quality of the urological service that they may choose. Education must start in medical school and as 5% of community medical practice is urology then every medical student must receive urological training. This also applies to nurses and the other professions allied to medicine (PAMS). The EAU should provide a urological curriculum for training of medical students, nurses and PAMS, as well as the more conventional curriculum for postgraduate training and continued medical education for urological specialists. An integrated EAU Knowledge and Learning Centre would provide an invaluable resource to patients and to those who deliver urologic care alike. With high quality training must come a vigorous assessment of knowledge and competence. In the future, the competence of all those delivering urological care will need to be assessed. For urologists in training and specialist urologists this will include not only an assessment of knowledge but an assessment of surgical competence. Improving quality will be supported by the continued subspecialisation of urology, ensuring that all urologists have a surgical portfolio which ensures their competency in the procedures they deliver. This will inevitably result in a concentration of urological services and indeed to the development of larger urological centres. The concept of Centres of Excellence could be developed to include all aspects and subspecialties of urological care. The SPO envisages that all urology will be carried out in Centres of Excellence which will vary in terms of their size and the range of urology offered, but nevertheless all urological care will be of the highest quality.Finally, the future of urology will depend on the medico-political interface and the EAU has a great deal to offer in this respect. The patterns of urological care differ throughout Europe but this should be seen as a challenge for the EAU to define quality, irrespective of the different methods of healthcare provision. The EAU has made extraordinary advances in the last two decades and the SPO hope this document will support the EAU's efforts to maintain its aim of improving urological care for the benefit of patients.     

Crohn’s Disease is Associated with Longer In-Hospital Lengths of Stay and Higher Rates of Complications and Costs after Primary Total Hip Arthroplasty

BackgroundAs the incidence and prevalence of Crohn’s disease continues to change worldwide, rates within North America have been increasing. The objective of this study was to evaluate whether patients who have Crohn’s disease undergoing primary total hip arthroplasties have worse outcomes compared with matched cohorts. Specifically, we evaluated 1) medical complications, 2) in-hospital lengths of stay (LOS), and 3) costs of care.MethodsTwo cohorts of patients who underwent primary total hip arthroplasties from January 1, 2005 to March 31, 2014 were identified from the Medicare claims of the PearlDiver platform. Cohorts were matched by age, sex, and following comorbidities—anemia, diabetes, hyperlipidemia, hypertension, malnutrition, pulmonary disease, and renal failure, yielding 55,361 patients within the study (n = 9229) and matching cohorts (n = 46,132). Outcomes assessed included 90-day medical complications, in-hospital LOS, and costs of care. A P-value less than .005 was considered statistically significant.ResultsPatients with Crohn’s disease were found to have significantly higher incidences and odds ratios of 90-day medical complications (30.2 vs 13.8; odds ratios: 2.2, P < .0001). They were also found to have significantly longer LOS (3.8- vs 3.6-days, P < .0001) and higher day of surgery ($12,662.00 vs 12,271.15, P < .0001) and 90-day episode costs ($16,933.18 vs $15,670.32, P < .0001).ConclusionCrohn’s disease is associated with higher rates of medical complications, longer in-hospital LOS, and increased costs of care. This study may aid physicians to perform appropriate risk adjustment for adverse outcomes and to educate these patients about potential postoperative complications in these patients.     

Cancer in the Elderly: What is Different?

ObjectivesThe aging population will have a dramatic impact on urologic practice. Therefore it is becoming increasingly necessary to understand the impact of aging on both the diagnosis and treatment of urological cancers in elderly and fragile people.MethodsThe data of the recent series in the international literature have been analyzed.ResultsEvaluation of functional status plays a unique role in the assessment of older cancer patients. Currently available data indicate that well-selected elderly patients, even those 75 years old or older do not have a significantly higher risk of morbidity or mortality from major surgery for urologic malignancies than do younger patients. There is an emerging need to develop a means for urologists and oncologists to characterize the “functional age” of older cancer patients in order to tailor treatment decisions and stratify outcomes based on factors other than chronological age and to develop interventions to optimize urological cancer treatment.ConclusionsElderly patients have traditionally been viewed as poor candidates for urologic surgery. However, a review of renal, prostate and bladder cancer literature supports what most urologists know intuitively: properly selected elderly patients are safe to operate on and can potentially gain survival benefits from surgery.     

Availability of platelet-rich plasma for treatment of erectile dysfunction and associated costs and efficacy: A review of current publications and Canadian data

IntroductionPlatelet-rich plasma (PRP) is an increasingly used unconventional treatment option for erectile dysfunction (ED). The validity of PRP as a potential treatment for ED has been proposed in limited human trials. Furthermore, the costs associated with PRP for ED treatment are not readily promoted to patients. The goal of this review was to determine the efficacy and costs of PRP based on currently available literature and Canadian data.MethodsA comprehensive literature review of available PRP studies and current published data pertaining to cost, availability, and provider clinics globally was conducted using the PubMed database. Physicians offering genital PRP in Canada were identified using internet searches and PRP provider directories. Physician qualifications, clinic locations, and cost information were obtained from provider websites and telephone calls to identified clinics.ResultsAvailability of PRP injections offered for treating ED is increasing globally. There are currently no peer-reviewed publications to substantiate anecdotal evidence pertaining to the efficacy of PRP as a viable treatment option for ED patients. Our results indicate 19 providers for PRP injections in Canada, costing on average $1777 CAD per injection. No providers were affiliated with academic institutions and providers varied in their area of clinical speciality and training.ConclusionsTo our knowledge, there is currently no research underway investigating the clinical efficacy of PRP for ED treatment despite its broad availability and significant cost. Patients should be informed of the lack of substantiated efficacy and safety data, as the reliability of PRP treatments requires further evaluation.     

Healthcare utilization and costs for spinal conditions in Ontario,Canada - opportunities for funding high-value care: a retrospective cohort study

BACKGROUND CONTEXTAn important step in improving spinal care is understanding how current health-care resources and associated cost are being utilized and distributed across a health-care system.PURPOSEOur objective was to examine the magnitude and distribution of direct health care costs for spinal conditions across physician type and hospital setting.DESIGN/SETTINGCross-sectional analysis of administrative health data for the fiscal year 2013–2014 from the province of Ontario, Canada.PATIENT SAMPLEAdult population aged 18+ years (N=10,841,302).OUTCOME MEASURESPerson visit rates and total number of people and visits by specific care settings were calculated for all spinal conditions as well as stratified by nontrauma and trauma-related conditions. Variation in rates by age and sex was examined. The proportion of patients seeing physicians of different specialties was calculated for each condition grouping. Direct medical costs were estimated and their percentage distribution by care setting calculated for nontrauma and trauma-related conditions. Additionally, costs for spinal imaging overall and stratified by type of scan were determined.METHODSAdministrative health databases were analyzed, including data on physician services, emergency department visits, and hospitalizations. ICD-9 and -10 diagnostic codes were used to identify nontraumatic (degenerative or inflammatory) and traumatic spinal disorders. A validated algorithm was used to estimate direct medical costs.RESULTSOverall, 822,000 adult Ontarians (7.6%) made 1.6 million outpatient physician visits for spinal conditions; the majority (1.1 million) of these visits were for nontrauma conditions. Approximately, 86% of outpatient visits were in primary care. Emergency Department (ED) visits for nontrauma spinal conditions (130,000 out of 156,000 ED visits) accounted for 2.8% of all ED visits in the province. Total costs for spine-related care were $264 million (CDN) with 64% of costs due to nontrauma conditions. For these nontrauma conditions, ED visits cost $28 million for 130,000 visits ($215 per visit). For $32 million spent in primary care, 890,000 visits were made ($36 per visit). Spine imaging costs were $66.5 million, yielding a combined total of $330 million in health care spending for spinal conditions.CONCLUSIONSSpinal conditions place a large and costly burden on the health-care system. The disproportionate annual cost associated with ED visits represents a potential opportunity to redirect costs to fund more clinically and cost-effective models of care for nontraumatic spinal conditions.     

Prevalence and out-patient medical costs of comorbid conditions in patients with rheumatoid arthritis

ObjectivesTo evaluate the prevalence, types, and out-patient direct medical costs of comorbid conditions in patients with RA in Thailand.MethodsInformation of the patients with RA treated by rheumatologists with at least one disease modifying antirheumatic drugs (DMARDs), including demographic data, RA-related medication types and treatment costs, comorbidity-related medication types and treatment costs, and total direct medical costs, was captured from King Chulalongkorn Memorial Hospital databases.ResultsThe data from 684 patients with RA were included for analysis. The majority of the patients were prescribed combined DMARDs, while only 2.5% received biologics. Comorbid conditions were reported in 434 patients (63.5%). The most common comorbid condition was hypertension (51.2%). Advanced age and presence of healthcare coverage was associated with comorbid conditions. The average annual cost of non-RA-related treatments in patients with comorbid diseases was 15 times the cost in those without comorbidities (1546 vs. 104 USD; P < 0.001) while the total direct medical cost in patients with comorbid conditions was twice that in patients without comorbid diseases (4118 vs. 2045 USD; P < 0.001). Parameters that influenced total direct medical costs were RA medications costs, comorbidity, healthcare coverage, patient's age, and types of DMARDs.ConclusionsComorbid conditions were common in this study. However, the major cost component incurred in RA patients was the costs of RA medications and services, while the out-patient costs of comorbid conditions accounted for approximately 38% of the total costs.     

Value-Based Healthcare in Urology: A Collaborative Review

ContextIn response to growing concerns over rising costs and major variation in quality, improving value for patients has been proposed as a fundamentally new strategy for how healthcare should be delivered, measured, and remunerated.ObjectiveTo systematically review the literature regarding the implementation and impact of value-based healthcare in urology.Evidence acquisitionA systematic review was performed to identify studies that described the implementation of one or more elements of value-based healthcare in urologic settings and in which the associated change in healthcare value had been measured. Twenty-two publications were selected for inclusion.Evidence synthesisReorganization of urologic care around medical conditions was associated with increased use of guidelines-compliant care for men with prostate cancer, and improved outcomes for patients with lower urinary tract symptoms. Measuring outcomes for every patient was associated with improved prostate cancer outcomes, while the measurement of costs using time-driven activity-based costing was associated with reduced resource utilization in a pediatric multidisciplinary clinic. Centralization of urologic cancer care in the UK, Denmark, and Canada was associated with overall improved outcomes, although systems integration in the USA yielded mixed results among urologic cancer patients. No studies have yet examined bundled payments for episodes of care, expanding the geographic reach for centers of excellence, or building enabling information technology platforms.ConclusionsFew studies have critically assessed the actual or simulated implementation of value-based healthcare in urology, but the available literature suggests promising early results. In order to effectively redesign care, there is a need for further research to both evaluate the potential results of proposed value-based healthcare interventions and measure their effects where already implemented.Patient summaryWhile few studies have evaluated the implementation of value-based healthcare in urology, the available literature suggests promising early results.     

Challenges and Opportunities for Real-World Evidence in Metastatic Luminal Breast Cancer

BackgroundThe therapeutic armamentarium for patients with metastatic breast cancer is becoming more and more specific. Recommendations from clinical trials are not available for all treatment situations and patient subgroups, and it is therefore important to collect real-world data.SummaryTo develop recommendations for up-to-date treatments and participation in clinical trials for patients with metastatic breast cancer, the Prospective Academic Translational Research PRAEGNANT Network was established to optimize the quality of oncological care in the advanced therapeutic setting. The main aim of PRAEGNANT is to systematically record medical care for patients with metastatic breast cancer in the real-life setting, including the outcome and side effects of different treatment strategies, to monitor quality-of-life changes during therapy, to identify patients eligible for participation in clinical studies, and to allow targeted therapies based on the molecular structures of breast carcinomas.Key MessagesThis article describes the PRAEGNANT network and sheds light on the question of whether the various end points from clinical trials can be transferred to the real-world treatment situation.     

Medical Comorbidities Impact the Episode-of-Care Reimbursements of Total Hip Arthroplasty

BackgroundTotal hip arthroplasty (THA) costs are a source of great interest in the currently evolving health care market. The initiation of a bundled payment system has led to further research into costs drivers of this commonly performed procedure. One aspect that has not been well studied is the effect of comorbidities on the reimbursements of THA. The purpose of this study was to determine if common medical comorbidities affect these reimbursements.MethodsA retrospective, level of evidence III study was performed using the PearlDiver supercomputer to identify patients who underwent primary THA between 2007 and 2015. Patients were stratified by medical comorbidities and compared using the analysis of variance for reimbursements of the day of surgery, and over the 90-day postoperative period.ResultsA cohort of 250,343 patients was identified. Greatest reimbursements on the day of surgery were found among patients with a history of cirrhosis, morbid obesity, obesity, chronic kidney disease (CKD) and hepatitis C. Patients with cirrhosis, hepatitis C, chronic obstructive pulmonary disease, atrial fibrillation, and CKD incurred in the greatest reimbursements over the 90-day period after surgery.ConclusionMedical comorbidities significantly impact reimbursements, and inferentially costs, after THA. The most costly comorbidities at 90 days include cirrhosis, hepatitis C, chronic obstructive pulmonary disease, atrial fibrillation, and CKD.     

Etiology,characteristics and management of ureteric injury: experience from a nationwide study

BackgroundTo investigate the common etiologies, characteristics, and management of ureteric injury.MethodsA nationwide study was performed in 38 medical centers from Mar 2017 to Mar 2019. The data of patients with ureteric injury were retrospectively collected.ResultsOverall, 294 patients were included in this study. Ten cases (3.4%) were due to abdominal injuries, and 284 cases (96.6%) were due to iatrogenic injuries, including 48.6% from urological procedures, 41.9% from gynecological procedures, 6.3% from general surgery, and 3.2% from other treatments. Most urological injuries (79.7%) were caused by endourological procedures. Injury occurred in the distal ureter in 178 cases (60.5%), the mid-ureter in 31 cases (10.5%), and the proximal ureter in 85 cases (28.9%). Only 51 patients (17.3%) were diagnosed immediately during primary surgery. Immediate ureter reconstruction was performed in 30 patients (58.8%), while delayed urinary diversion was performed in 148 patients (60.9%) in the delayed diagnosis group. The side and the location of the injury were different between the urological and nonurological injury groups (P<0.001). Ureteric injuries were diagnosed timelier in the urological group than in the nonurological group (P=0.037).ConclusionsIatrogenic injury was the most common cause of ureteric injury. The majority of iatrogenic injuries were caused by urological procedures and were primarily due to aggressive endourological techniques. Depending on the condition of the patient, the time of diagnosis, and the location and length of the ureteric injury, different management strategies should be applied.     

Medicoeconomic evaluation of hyaluronic acid for knee osteoarthritis in everyday practice: the MESSAGE study

IntroductionMedicoeconomic data on treatments for osteoarthritis are scant. We investigated the impact of hyaluronic acid therapy on the cost of management of knee osteoarthritis. Our primary objective was to compare medical costs (admissions, outpatient visits, investigations, and treatments) and non-medical costs (sick leaves and transportation) from the perspective of the national health insurance system during the 3 months before and the 6 months after three intraarticular injections of hyaluronic acid. Our secondary objective was to evaluate treatment benefits in terms of pain, function, and quality of life.MethodsObservational, multicenter, longitudinal, before-after study of the medical and economic effects of hyaluronic acid therapy for symptomatic knee osteoarthritis.ResultsOf the 296 assessable patients (mean age, 69 years; 30% with obesity; 65% women), only 5% of patients were withdrawn prematurely from the study. Significant improvements in the Lequesne index were found 3 and 6 months after treatment; the improvement was greater than 50% in over half the patients. Pain and quality-of-life scores improved significantly. Total cost of the disease decreased from €334 for the 3 pretreatment months to €295 and €233 for posttreatment months 1–3 and 4–6, respectively.ConclusionThe costs of knee osteoarthritis decreased during the 6 months after Suplasyn^® therapy, indicating that the cost of the medication was more than offset by the decreased need for other treatments. Concomitantly, clinical benefits were obtained. Under the conditions of everyday practice, hyaluronic acid may provide medical benefits at an acceptable cost.     

A survey of physician perception and practices regarding pharmacological thromboprophylaxis during chemotherapy for bladder cancer

IntroductionPatients with advanced bladder cancer receiving chemotherapy have a high risk of venous thromboembolism (VTE); however, we hypothesized these patients were not routinely offered thromboprophylaxis. The objective of this study was to characterize practice patterns and perceptions of Canadian urologic and medical oncologists, and to identify research needs regarding thromboprophylaxis for patients with bladder cancer.MethodsAn online survey was distributed to Canadian urologic and medical oncologists who manage advanced bladder cancer. The survey explored physician opinions regarding VTE rates, risk stratification scores, thromboprophylaxis use in different treatment settings, and interest in clinical trials.ResultsSeventy physicians were invited and 36 (51%) completed the survey, including 20 (56%) urologic oncologists and 16 (44%) medical oncologists. Most respondents (35; 97%) believed that exposure to platinum chemotherapy increases VTE risk. For patients receiving neoadjuvant chemotherapy, 34 (94%) respondents estimated the risk of VTE to be 10% or higher, yet 25 (69%) indicated they do not routinely recommend thromboprophylaxis. Physicians frequently (10; 40%) defer the decision to another physician, while eight (32%) believe there is not enough evidence to guide best management. Similar responses were obtained for metastatic patients. Almost all (94%) respondents were interested in participating in a thromboprophylaxis trial for patients with bladder cancer.ConclusionsPatients with bladder cancer receiving chemotherapy in Canada are not routinely offered thromboprophylaxis. We found strong interest among Canadian oncologists to participate in clinical trials examining this topic.

Key Messages

• Physicians in Canada believe that patients with advanced bladder cancer have a high risk of venous thromboembolism.
• There is evidence to support thromboprophylaxis in patients receiving chemotherapy, but data may not be generalizable to patients with bladder cancer, as few of them were included in prior trials.
• Physicians in Canada do not routinely offer thromboprophylaxis to patients with bladder cancer receiving chemotherapy.
• Medical and urological oncologists in Canada have a strong interest to participate in clinical trials examining thromboprophylaxis in bladder cancer patients.

     

Active surveillance vs. treatment for low-risk prostate cancer: A cost comparison

ObjectiveRadical prostatectomy (RP) and radiation therapy are standard curative approaches for low-risk prostate cancer (PC). Active surveillance (AS) is becoming an increasingly accepted management alternative for low-risk PC. Our aim is to compare the cumulative medical costs of treatment vs. AS.Methods and materialsWe collected data on the cumulative medical costs of open radical retropubic prostatectomy (RRP), robotic-assisted radical prostatectomy (RARP), external beam radiotherapy (EBRT), brachytherapy (BT), and AS at our institution. For physicians' reimbursements, Medicare values of our region were used to maintain uniformity. For inpatient costs other than reimbursements, we used the mean cost at our institution. The costs of RRP and RARP involve preoperative investigations, medical clearance, physicians' fees, inpatient costs, and pathologic examination of prostatectomy specimen and follow-up. The inpatient costs include the operating room, disposable equipment, anesthesia, post-anesthesia care, transfusion, and hospital stay. The cost of EBRT involves the cost of consultation, planning, simulation and treatment sessions, and follow-up. BT costs involved radiotherapy planning as well as inpatients costs. AS protocol involves regular visits, transrectal ultrasound guided biopsies, prostate specific antigen (PSA) testing. To evaluate the cost of treating complications, treatment after AS, and treatment for recurrence, we created a Markov model based on recent studies and our experience.ResultsThe cumulative costs of RRP are $9,732 (1 year), $10,360 (2 years), $12,209 (5 years), and $15,084 (10 years). While for RARP, the costs are $17,824 (1 year), $18,308 (2 years), $20,117 (5 years), and $22,762 (10 years). The costs of EBRT are $20,730 (1 year), $20,969 (2 years), $22,043 (5 years), and $23,953 (10 years). BT costs are $14,061 (1 year), $14,300 (2 years), $15,374 (5 years), and $17,284 (10 years). The costs of AS are $1,154 (1 year), $2,308 (2 years), $8,761 (5 years), and $13,116 (10 years).ConclusionsThe cumulative medical costs of RARP and EBRT are much higher than BT, RRP, and AS. AS is associated with a different cost distribution in which the initial cost is low and relatively higher cost of follow-up. Despite the higher follow-up cost, AS remains the most cost effective alternative for low-risk PC.