Introduction

Testicular cancer is the most common solid tumor malignancy among young males ages 20–39 [1]. The American Urological Association (AUA) Guidelines for Early Stage Testicular Cancer strongly recommend radical inguinal orchiectomy for patients with a testicular mass, and this malignancy is highly curable with a 10-year survival rate approaching 95% [2, 3]. Given the high incidence with prolonged survival in young men coupled with the loss of an organ associated with self-esteem, sexuality, and masculinity, it is critical to address the psychologic sequelae and quality of life among long-term survivors of testicular cancer [4–6]. This population has been shown to experience negative changes in body image associated with sexual dysfunction including reduced sexual interest, activity and enjoyment, erectile or ejaculatory dysfunction, and increased sexual discomfort [7].

Testicular prostheses can restore self-image and improve quality of life among patients who have undergone orchiectomy, and satisfaction rates are high, with 71–88% of patients reporting they would undergo implantation again and 79% reporting they would recommend implantation to others [8–10]. Despite the AUA guideline recommendation for discussion of testicular prostheses prior to orchiectomy for testicular cancer, approximately 50% of patients report they were not offered implantation before their surgery [2, 9, 11].

Preoperative counseling regarding testicular prostheses represents an area of clinical improvement, but it remains unknown if the surgical approach of a concurrent implant (CI) versus staged implant (SI) is more desirable. We sought to investigate differences in cost and care utilization between CI and SI insertion after radical orchiectomy. We hypothesized that CI insertion was less costly with non-inferior clinical outcomes, therefore further supporting its value in preoperative counseling.

Materials and methods

Results

We identified a total of 8803 patients underwent orchiectomy. 8564 patients (97.3%) did not receive an implant, 190 patients received CI (2.1%), and 49 patients received SI (0.6%). Testicular prosthesis utilization rate was 2.7% (n = 239/8803).

Demographic characteristics of the total cohort and subgroups stratified by implant status are listed in Table 1. There was no difference in age (p = 0.398), Charlson Comorbidity Index (p = 0.495), insurance coverage (p = 0.135), surgical setting (p = 0.203), rate of metastasis (p = 1.000), or additional cancer treatment (p = 0.921) among patients who received CI versus SI. CI patients were significantly more likely to reside in an urban setting compared to SI (96% vs 86%, p = 0.013). Patients on the West Coast were more likely to receive CI (32%), whereas patients in the South were more likely to receive SI (47%), though this did not reach statistical significance (p = 0.089).

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Table 1. Cohort demographics according to implant status.

https://doi.org/10.1371/journal.pone.0296735.t001

Median preoperative, perioperative, and postoperative costs for the total cohort stratified by implant and cancer status are summarized in Table 2. Median perioperative orchiectomy cost for the no implant, CI, and SI groups were $5682 (3648–8554), $7823 (5403–10973), and $5380 (4130–10521), respectively (p<0.001). Median perioperative cost at the time of SI placement was $8180 (4920–14591) for a total perioperative cost of $13560 (5380 + 8180). Postoperative costs were eight times higher in patients who received additional cancer treatment for the no implant ($24264 vs $3710) and CI ($24686 vs $3210) cohorts.

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Table 2. Median costs in each time period stratified by implant status and additional cancer treatment.

https://doi.org/10.1371/journal.pone.0296735.t002

90-day postoperative care utilization and costs are summarized in Table 3. CI patients were more likely to have a 90-day postoperative urology follow-up (59% vs 37%, p = 0.006) with an overall higher number of visits (268 vs 28, p = 0.030) compared to SI group during the implant period, but had similar follow-up rates (59% vs 73%, p = 0.065) compared to the SI patients during the initial orchiectomy period. Cost of readmission was also significantly higher in the CI group compared to the SI group during initially orchiectomy period ($25887 vs $8093, p = 0.019), but this was difference was negated if cost of median admission during the subsequent implant period ($13006) was considered.

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Table 3. 90-day postoperative care utilization and costs.

https://doi.org/10.1371/journal.pone.0296735.t003

Over the entire follow-up period, prosthesis explant rates were 4.7% for the CI and 14.3% for the SI cohort (p = 0.04) with a median time to explant of 166 (135–210) and 40 (9.5–141.5) days, respectively (p = 0.06; Table 4). Median cost of explant surgery was $2060 (IQR: 967–2880).

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Table 4. Testicular prosthesis explantation rates.

https://doi.org/10.1371/journal.pone.0296735.t004

Discussion

Testicular cancer is associated with high incidence and prolonged survival in young men. Subsequently, there are several efforts aimed towards evaluating and improving quality of life among this patient population. Testicular loss has been demonstrated to result in feelings of uneasiness, with one-third of men reporting that they miss their testicle and one-fourth of men reporting feelings of bodily shame [12]. One surgical option that may alleviate this identity crisis and restore self-image following the loss of a testicle is implantation of a testicular prosthesis [13]. It remains undetermined whether outcomes differ for patients who undergo concurrent versus staged prosthesis implantation. Herein we demonstrate that CI placement has less total perioperative cost, lower explant rate, and similar postoperative care utilization to SI.

Despite recommendation by the AUA guidelines and several studies demonstrating high patient satisfaction rates with testicular prostheses, many patients are not offered implantation [10, 11]. Specifically, the AUA guidelines state that patients should be counseled that they have the choice to elect for testicular prosthesis at the time of orchiectomy [2]. The rationale for this guideline is the high satisfaction rates coupled with low morbidity risk [10, 11]. Nevertheless, patients should be counseled on possible sequelae of infection, malposition, deflation, or need for explantation [14]. If patients decline concurrent prosthesis, they should be counseled that they can elect to undergo delayed insertion of testicular prosthesis later in their clinical course per the guidelines. Our results are in concordance with these findings, with a testicular prosthesis utilization rate under 3%. Men who have never been offered a prosthesis were significantly more likely to report feelings of loss (RR 2.0, 95% CI 1.3–3.0), and uneasiness or shame (RR 2.0, 95% CI: 1.3–3.2) compared to men who were offered a prosthesis but declined [12]. Thus, lack of discussion surrounding testicular prostheses with patients undergoing radical orchiectomy represents a significant missed opportunity.

One question that may arise during preoperative counseling is when to perform implantation. It has been previously demonstrated that concurrent insertion of testicular prosthesis during radical orchiectomy is safe, and this extra procedure does not increase the complication rate as determined by length of stay (p = 0.387), hospital readmission rates (p = 0.539), or reoperation (p = 0.999) compared to radical orchiectomy alone [15]. Another study demonstrated that concurrent implantation is safe even in the setting of adjuvant therapy, with no difference in complication rates between patients who did not undergo adjuvant treatment versus those who underwent chemotherapy (p = 0.75) or radiation (p = 0.83) [16]. Ours is the first study to directly compare the cost and clinical outcomes between a concurrent versus staged approach. We found that CI offers the benefits of lower perioperative cost by almost two-fold and lower explantation rates by almost three-fold. Reasons for testicular prosthesis explantation include infection, extrusion, rupture of prosthesis, or patient dissatisfaction [14]. Given the utilization of a claims dataset, reasons for explantation among our patients were not specified thus postulation regarding the difference between the two groups is limited.

The mean age of our cohort was 39 years, which is concordant with the known high incidence of testicular cancer in young men. Given that comorbidities increase with age, it was assumed that this young population would be less likely to have other medical conditions, and therefore we chose to specifically stratify our patients by presence of metastatic disease to account for confounding increased costs of additional cancer treatments. Specifically, 90-day postoperative costs were eightfold in patients who required additional cancer treatment in our cohort.

There were several limitations to this study. Firstly, prospective investigation is needed to confirm our findings as our study was retrospective in nature. Second, our data was obtained from an insurance claims dataset. Though a valuable resource, claims data are inherently limited due to their dependence on International Classifications of Diseases (ICD) coding, which may result in some variability and inaccuracy. More granular data is not available, and results generated from the dataset also only apply to the insured population.

Conclusions

Preoperative counseling regarding testicular prostheses is an important component that urologists should discuss with patients undergoing radical orchiectomy for testicular cancer. CI placement has less total perioperative cost, lower explantation rates, and similar postoperative costs and utilization compared to SI.

Supporting information