We were interested to read the study of Lumsden et al. and support their effort to base the introduction of innovative, laparoscopic surgery on evidence. However, we do have some remarks on the study and therefore challenge the authors' conclusion that laparoscopic-assisted vaginal hysterectomy does not represent an efficient use of NHS resources. First, the cost per minute in theatre (excluding disposables) was not explicitly stated in the article. From the data provided, we have calculated the cost per minute in theatre = operating cost − disposables (=total cost − total cost excluding disposables)/mean length of the procedure in minutes. For total abdominal hysterectomy, this amounts to £11.90 per minute operating time and for laparoscopic-assisted vaginal hysterectomy to £11.00. Can the authors explain the difference? Similarly, we calculated the cost per inpatient day for total abdominal hysterectomy to be £204.50 and for laparoscopic-assisted vaginal hysterectomy to be £212.00. We performed in our hospital a cost analysis of uterine surgery in 1995 and 1996. Costs were divided into costs of admission (time dependent), costs of operating theatre (time dependent), gynaecologists' and anaesthesiologists' fees (fixed) and disposable instruments. The costs are shown in Table 1. Dutch guilders are converted to English pounds at a rate of 0.28 pound per guilder.
|Mean operating time (minutes)||69||132|
|Mean inpatient stay (days)||6||4|
|Inpatient stay cost**||1092||728|
We concluded that in our hospital, laparoscopic-assisted vaginal hysterectomy with the use of disposable instruments is more expensive than total abdominal hysterectomy. This difference, however, changes into a beneficial one, if no disposables are used. Since this analysis no disposable instruments are routinely used in laparoscopic-assisted vaginal hysterectomy; nevertheless, the operating time of laparoscopic-assisted vaginal hysterectomy has gradually decreased. In our sensitivity analysis, the lower cost per operating minute in our hospital favours the laparoscopic approach.
The same conclusion was reached by Meikle et al.1 who performed a systematic review of the literature regarding laparoscopic-assisted vaginal hysterectomy and other types of hysterectomy. In 3112 laparoscopic-assisted vaginal hysterectomy, the costs (if disposable instruments were excluded) were lower and recovery of the women faster than in 1618 total abdominal hysterectomy. We also point out that the questionnaire of the ‘recovery milestones’ in the study by Lumsden et al. is not validated.
Moreover, the authors give no insight how the different cost categories are established and one can only speculate on the large difference with our calculated costs in the operating theatre (£11.00 vs£1.82). Lumsden's study on the differences in operating time between a total abdominal hysterectomy and a laparoscopic-assisted vaginal hysterectomy plays a disproportionate part in reaching conclusions about cost effectiveness.
Finally, we think indirect costs (loss of productivity) should be taken into account, which favours a shorter admission.