Although efficacy and safety are paramount, monetary cost is relevant in treatment comparisons. To be accepted, LRPLND should either be more cost-effective than conventional RPLND, or require a nominal additional cost such that the health benefits to the patient justify the added expenditure. Any new surgical approach will initially take longer and be associated with more complications. Projecting long-term cost-effectiveness based on data during this learning curve is not appropriate. Janetschek and colleagues [47] quantified the learning curve early in their experience. Compared with the first 14 cases, the subsequent 15 cases had a mean operative time that was 36% shorter and a postoperative hospital stay that was 27% shorter.

There have been two reports addressing the cost-effectiveness of LRPLND. The first, published in 2002, estimated the cost per case of LRPLND at $7804 compared with $7162 for open RPLND [62]. This differential was almost entirely explained by the increased expense of equipment and the cost of longer operating times with LRPLND. In a sensitivity analysis, LRPLND became less costly when operative times were less than 216 minutes and hospital stays were shorter than 2.2 days; however, this study has several limitations. First, the investigators only used three LRPLND series totaling 136 patients, and two open series, totaling 115 patients, to model their findings. All the LRPLND series and one of two open series are from Europe and thus do not adequately represent clinical practice in North America. Second, they modeled the recurrence rate for LRPLND after data with considerably shorter follow-up time than the open series data. Thus, LRPLND would appear to have fewer relapses. Finally, they did not budget for the fact that all patients undergoing LRPLND who are identified as having positive nodes currently also incur the costs of chemotherapy and the costs of complications from the chemotherapy.

A second, more detailed, cost-effectiveness study modeled all options for treating stage I NSGCT including surveillance, primary chemotherapy, and surgery (LRPLND and open RPLND). They found that LRPLND cost $9968 per case, whereas open RPLND cost $13,212 per case [63]. Here the largest contributor to the differential costs was hospital stay, which was estimated to be twice as long for open RPLND. This study similarly did not account for the costs of chemotherapy in the LRPLND group and triple counted data from the Innsbruck group, which reported one of the shortest operative times for LRPLND.

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