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To date, cost issues have not played a major role in driving decisions among treatment options. However,
as health care expenses continue to rise, cost concerns are likely to play an ever-increasing role. Different
studies have assessed cost, but their results differ based on some key postulated differences such as the
period of observation, the definition of success and complication rates, different health-care systems, and
also whether those with benign biopsies should be treated or followed up.

[39]
Chang et al. analyzed the cost-effectiveness of all NSS options for SRMs and concluded that for healthier
younger patients (aged 65 years with a < 2 cm lesion or aged 75 years with a 3-4 cm lesion), immediate
surgery represents the optimal NSS option with the best incremental cost-effectiveness ratio. Surveillance
with possible delayed PCA was a cost-effective option for older patients or those with increased perioperative
mortality risk. Observation represented the best strategy for patients who are poor surgical candidates
and who had a life expectancy < 3 year. It is worth noting that laparoscopic AT was not cost effective in
[39]
[40]
any scenario regardless of age, comorbidities, and tumor size . Bhan et al. , comparing RFA, CA, and
observation for the treatment of SRMs, established that active surveillance with no initial biopsy and with
subsequent PCA in case of disease progression was more cost-effective than immediate CA with or without
biopsy and other observation options. They found that in terms of cost-effectiveness, all CA techniques were
[40]
superior to RFA procedures owing to higher rates of retreatment for RFA . Reporting direct comparative
[41]
costs of LCA and PCA, LCA was significantly more expensive than PCA (3.5 times on average) . However,
these values need to be adjusted for patient and tumor characteristics to better gauge the cost incurred
by each approach. Ideally, we have to consider also the cost of readmission, ongoing surveillance, and
retreatment into the analysis.

[42]
Furthermore, Link et al. analyzed the cost-effectiveness of different treatment options, particularly
comparative analysis between PCA and laparoscopic treatment options. The PCA was 2.2-2.7 times less
costly than the other options and resulted in a cost savings of $3625 to $5155 per case. For Open PN,
Laparoscopic PN, and LCA, the operative time and hospitalization accounted for 69%-91% of the cost. The
Laparoscopic PN and LCA were cost advantageous over PCA only when more than five cryoprobes were
[42]
used during the percutaneous procedure .

CONCLUSION
AT seems to be a valid treatment option that could reduce complications and general impairment of classical
surgical procedures. Finding the perfect candidate for AT is challenging due to the lack of objective criteria
in the literature and of standardized techniques. Notably, the percutaneous approach seems to have lower
complications rate than laparoscopic approach, especially in CA, and it can offer shorter hospital stay and
faster recovery, which can be particularly appealing in an era of cost restriction in healthcare. Afterward,
in the era of a multidisciplinary approach and tailored therapy, LCA could be a useful instrument to
manage lesions for which PCA might have a failure or could be difficult and unfeasible. Hence, LCA should
be collocated in a middle position for the management of SRM between PCA and NSS. Nevertheless, the
application of this approach is dictated by the available technology and specific expertise of each center.

DECLARATIONS
Authors’ contributions
Made contributions to conception and design of the study/review, performed data analysis and
interpretation: Silvestri T, Celia A
Made substantial contributions to conception and design of the study/review, performed an entire revision
of data analysis, re-interpretation and the revision for editors: Silvestri T
Performed data acquisition: de Concilio B, Zeccolini G