Cost-Effectiveness of Pelvic Floor Reconstruction Using Biological Mesh After Extralevator Abdominoperineal resection for Rectal Cancer

BACKGROUND: Perineal complications are a major source of morbidity following extralevator abdominoperineal resection for low rectal cancer, especially after neoadjuvant (chemo)radiotherapy. Biological mesh reconstruction can reduce perineal hernia formation, but its cost-effectiveness remains unclear. OBJECTIVE: To evaluate the cost-effectiveness of biological mesh reconstruction compared with primary perineal closure following extralevator abdominoperineal resection in patients with low rectal cancer. DESIGN: Long-term economic evaluation conducted alongside a multicenter, parallel-group, randomized controlled trial. SETTINGS: Eleven hospitals in the Netherlands and one hospital in the United Kingdom, including non-teaching, teaching, and university centers. PATIENTS: Adult patients with primary low rectal cancer. INTERVENTIONS: Primary layered perineal closure versus pelvic floor reconstruction using a biological, non-cross-linked porcine dermal mesh. MAIN OUTCOME MEASURES: Total healthcare costs from a healthcare payer perspective, incorporating surgery, hospitalization, outpatient care, wound management, readmissions, and reinterventions; and patient health outcomes measured as quality-adjusted life years calculated from standardized health utility scores. RESULTS: Of 104 randomized patients, 101 were included in the final analysis (53 primary closure, 48 biological mesh). Mean total healthcare costs were higher in the mesh group (€57,991 vs €56,232; mean difference €1,571; 95% CI: -€9,840 to €12,981; p = 0.785). Perineal complications significantly reduced quality of life, but wound complication rates and quality of life gains were modest for mesh, with no significant differences between groups over time. LIMITATIONS: The study sample size limited precision in cost and subgroup estimates. CONCLUSIONS: Biological mesh reconstruction increases procedural and hospitalization costs without improving long-term patient outcomes. Routine use cannot be recommended from a cost-effectiveness perspective. (See Video Abstract).