Cost Of Ureteroscopy Research Articles

Urolithiasis in pregnancy: a cost-effectiveness analysis of ureteroscopic management vs ureteral stenting

The purpose of this study was to determine the cost-effectiveness of serial stenting vs ureteroscopy for treatment of urolithiasis during pregnancy as a function of gestational age (GA) at diagnosis. We built decision analytic models for a hypothetical cohort of pregnant women who had received a diagnosis of symptomatic ureteral calculi and compared serial stenting to ureteroscopy. We assumed ureteral stent replacement every 4 weeks during pregnancy, intravenous sedation for stent placement, and spinal anesthetic for ureteroscopy. Outcomes were derived from the literature and included stent infection, migration, spontaneous kidney stone passage, ureteral injury, failed ureteroscopy, postoperative urinary tract infection, sepsis, and anesthetic complications. Four separate analyses were run based on the GA at diagnosis of urolithiasis. Using direct costs and quality-adjusted life years, we reported the incremental costs and effectiveness of each strategy based on GA at kidney stone diagnosis and calculated the net monetary benefit. We performed 1-way and Monte-Carlo sensitivity analyses to assess the strength of the model. Ureteroscopy was less costly and more effective for urolithiasis, irrespective of GA at diagnosis. The incremental cost of ureteroscopy increased from -$74,469 to -$7631, and the incremental effectiveness decreased from 0.49 to 0.05 quality-adjusted life years for a kidney stone diagnosed at 12 and 36 weeks of gestation, respectively. The net monetary benefit of ureteroscopy progressively decreased for kidney stones that were diagnosed later in pregnancy. The model was robust to all variables. Ureteroscopy is less costly and more effective relative to serial stenting for urolithiasis, regardless of the GA at diagnosis. Ureteroscopy is most beneficial for women who received the diagnosis early during pregnancy.

Preoperative Stent Placement Decreases Cost of Ureteroscopy

To examine the effect of preoperative stent placement on total cost of ureteroscopic stone intervention. Passive ureteral dilation with a preoperative ureteral stent has been proposed as a method to facilitate both upper tract access and stone removal. We retrospectively reviewed the records of patients who underwent ureteroscopic stone intervention at our institution from 2005 to 2009. A sample of patients who had undergone stenting before ureteroscopy was selected and nonstented matched controls were used as a comparison group. A cost model was used to compare the total healthcare costs for the prestented and nonstented patients with a large (>1 cm) and small (≤1 cm) stone burden using the actual cost accrued for each patient. Sensitivity analyses were used to examine the robustness of the cost model. A total of 104 patients were included in the present study (45 prestented, 59 not prestented). The median stone size was 1 cm (range 0.3-4). The overall stone clearance rate was 95.8%. The median number of procedures was 1. Pre-stenting significantly decreased the total healthcare cost in patients with stones >1 cm. The median cost for the prestented and nonstented cohorts was $17,706 and $27,806, respectively (P < .01). However, prestenting increased the total cost for smaller stones of ≤1 cm, although not significantly. The median cost for the prestented and nonstented cohorts was $10,872 and $12,344, respectively (P = .70). Sensitivity analysis confirmed that the model conclusions are robust. Preoperative stent placement is cost-effective for successful ureteroscopic treatment of stones >1 cm.

Percutaneous Nephrostolithotomy Versus Flexible Ureteroscopy/Holmium Laser Lithotripsy: Cost and Outcome Analysis

While percutaneous nephrostolithotomy is the standard of care for renal stones greater than 2 cm, recent studies have shown that staged ureteroscopy/holmium laser lithotripsy may be a reasonable option. Stones 2 to 3 cm may be amenable to ureteroscopy as well as to 1-stage treatment based on their intermediate size. We compared clinical outcomes and the estimated cost of percutaneous nephrostolithotomy vs ureteroscopy for 2 to 3 cm renal stones. We retrospectively identified patients who underwent percutaneous nephrostolithotomy and ureteroscopy at our institution from 2004 to 2008 with a maximal renal stone diameter of 2 to 3 cm. Demographic information, disease characteristics, intraoperative and postoperative data, and complications were recorded. Stone clearance was reported as a residual stone burden of 0 to 2 mm and less than 4 mm. Cost was estimated using local Medicare reimbursements for surgeon, anesthesia, hospital and outpatient services. A total of 20 patients underwent percutaneous nephrostolithotomy and 19 underwent ureteroscopy for 2 to 3 cm renal stones. The estimated cost of percutaneous nephrostolithotomy was significantly greater than that of ureteroscopy ($19,845 vs $6,675, p <0.0001). There were significantly more second stage procedures among percutaneous nephrostolithotomy cases (11 vs 1, p = 0.003). Stone clearance (0 to 2 mm) was superior for percutaneous nephrostolithotomy vs ureteroscopy (89% vs 47%, p = 0.01). Using a less than 4 mm threshold stone clearance improved to 100% vs 95% (p not significant). Two patients (10.5%) with ureteroscopy required subsequent ipsilateral stone surgery. They were noncompliant with medical/dietary therapy or radiographic surveillance. While percutaneous nephrostolithotomy achieves superior stone clearance, ureteroscopy achieves acceptable treatment outcomes with a low risk of subsequent stone related events or interventions. The lower relative cost of ureteroscopy in this population may have implications for the development of treatment guidelines.

Cost-Effectiveness of Medical Expulsive Therapy Using Alpha-Blockers for the Treatment of Distal Ureteral Stones

ObjectiveMedical expulsive therapy (MET) has recently emerged as an efficacious and safe option for the initial management of ureteral stones. The objective of this study was to assess the cost-effectiveness of MET compared with conservative therapy for the treatment of ureteral stones using international cost data from the United States and four European countries. Material and methodsA decision analysis model was built with the use of TreeAge Pro 2004 software with linear success rate assumptions. The likelihood of spontaneous passage of ureteral stones according to their size and location was estimated with the use of data derived from a published meta-analysis. The estimated cost of ureteroscopy (URS) in the United States ($4973) was based on the mean cost of 121 consecutive cases performed at a large metropolitan hospital. URS costs for other countries were obtained from a published international survey. The cost of tamsulosin ($2.08 per day), currently the most commonly used medical expulsive agent, was estimated as a mean of the costs obtained from two national pharmacy chains. MET and conservative therapies were compared with the use of one-way and two-way sensitivity analyses. ResultsIn the United States, MET using tamsulosin resulted in a $1132 cost advantage over observation. MET maintained its cost advantage even in countries where the cost of URS is much lower than in the United States. Two-way sensitivity analysis showed that MET remained cost-effective even with very low rates of spontaneous passage, minimal benefit of MET, or low cost of URS. ConclusionMET is a cost-effective strategy for the management of distal ureteral stones—even those with a low rate of spontaneous passage—providing another incentive for initial “facilitated observation” before embarking on surgical intervention.

Management Of Ureteral Calculi: A Cost Comparison And Decision Making Analysis

We compared the cost of treatment strategies for ureteral calculi using a decision tree model. A comprehensive literature review was performed to determine the average success rate of each of 3 treatment modalities, namely observation, ureteroscopy and shock wave lithotripsy. Using these success rates decision analysis models were constructed using Data 3.5 software (TreeAge Software, Inc., Williamstown, Massachusetts) to estimate the cost of treatment and followup for each of the 3 treatments. One-way sensitivity analysis was performed to evaluate the effect of varying individual probabilities of success and costs, and 2-way sensitivity analysis was done to evaluate the model for a wide range of potential costs and success rates of ureteroscopy and shock wave lithotripsy. In addition, a table was constructed to enable individual surgeons and institutions to determine the cost impact of ureteroscopy and shock wave lithotripsy in their unique clinical scenarios. Observation was the least costly pathway if no financial cost, such as emergency room visits, was incurred by failed observation. Ureteroscopy was less costly than shock wave lithotripsy for stones at all ureteral locations. A cost difference between the 2 modalities of approximately $1,440, $1,670 and $1,750 was noted for proximal, mid and distal ureteral calculi, respectively. One-way sensitivity analysis showed that the cost of ureteroscopy would have to increase by more than $1,400, $1,700 and $1,850, and the success rate would have to decrease by 28%, 36% and 39% for proximal, mid and distal stones, respectively, before reaching cost equivalence with shock wave lithotripsy. Likewise, the cost of shock wave lithotripsy would have to decrease by more than $1,489 to achieve cost equivalence with ureteroscopy. Overall ureteroscopy was more cost-effective at all stone sites regardless of the success rate of shock wave lithotripsy. Ureteroscopy is the most cost-effective treatment strategy for ureteral stones at all locations after observation fails. The high cost of purchasing and maintaining a lithotriptor is responsible for the high treatment cost associated with shock wave lithotripsy. However, cost is only one of a number of important factors that are considered when determining an appropriate treatment strategy.