A cost analysis of stenting in uncomplicated semirigid ureteroscopic stone removal.

OBJECTIVE: To evaluate the outcome and the costs of stenting in uncomplicated semirigid ureteroscopic stone removal. MATERIALS AND METHODS: A decision tree model was created to evaluate the economic impact of routine stenting versus non-stenting strategies in uncomplicated ureteroscopy (URS). Probabilities of complications were extracted from twelve randomized controlled trials. Stone removal costs, costs for complication management, and total costs were calculated using Treeage Pro (TreeAge Pro Healthcare version 2015, Software, Inc, Williamstown Massachusetts, USA). RESULTS: Stone removal costs were higher in stented URS (€1512.25 vs. €1681.21, respectively). Complication management costs were higher in non-stented procedures. Both for complications treated conservatively (€189.43 vs. €109.67) and surgically (€49.26 vs. €24.83). When stone removal costs, costs for stent removal, and costs for complication management were considered, uncomplicated URS with stent placement yielded an overall cost per patient of €1889.15 compared to €1750.94 without stent placement. The incremental costs of stented URS were €138.25 per procedure. CONCLUSION: Semirigid URS with stent placement leads to higher direct procedural costs. Costs for managing URS-related complications are higher in non-stented procedures. Overall, a standard strategy of deferring routine stenting uncomplicated ureteroscopic stone removal is more cost efficient.

Prospective, multi-institutional pain assessment of 150 women undergoing diagnostic cystoscopy.

BACKGROUND: The aim of this study was to prospectively assess women's pain during rigid and flexible diagnostic cystoscopy and afterwards during a one-week follow-up. METHODS: Prospective, multi-institutional trial analyzing numeric rating scales (NRS) of women undergoing diagnostic cystoscopy. Pain categories: no (0 points), mild (1-3), moderate (4-6) and severe pain (7-10). Assessing of pain before, during cystoscopy, and at day 1, 4 and 7 of follow-up. RESULTS: A total of 150 women undergoing rigid (N.=85) or flexible (N.=65) diagnostic cystoscopy were analyzed. Women undergoing flexible cystoscopy were more frequently pain-free (64.6% vs. 40%, P=0.003) and experienced mild pain less frequently (27.7% vs. 52.9% vs. P=0.002). No significant differences were noted among moderate (6.2% vs. 5.9%, P=0.95) and severe pain (1.5% vs. 1.2%, P=0.85). Patients undergoing their first (P=0.14) and repeat cystoscopy (P=0.08) had similar pain perception. In multivariate logistic regression analyses, women undergoing flexible cystoscopy had a 2.6 increased chance of being pain-free (OR=2.6, CI: 1.28-5.11, P=0.08) and their odds of experiencing mild pain were significantly lower (OR=0.34, CI: 0.17-0.71, P=0.004). The likelihood of experiencing moderate (OR=1.1, CI: 0.28- 4.4, P=0.83) or severe pain (OR=2.42, CI: 0.11-51.79, P=0.57) differed insignificantly. CONCLUSIONS: Rigid and flexible cystoscopies were well-tolerated by most women. However, flexible cystoscopy was associated with a higher likelihood of being pain-free and lower chances of experiencing mild pain. Patients' previous experience with cystoscopy did not influence pain perception.

Disparities in the Use of Sacral Neuromodulation among Medicare Beneficiaries.

PURPOSE: Sacral neuromodulation with the InterStim® has been done to treat urinary and bowel control. There are limited data in the literature on use trends of sacral neuromodulation. We explored disparities in use among Medicare beneficiaries. MATERIALS AND METHODS: We queried a 5% national random sample of Medicare claims for 2001, 2004, 2007 and 2010. All patients with an ICD-9 diagnosis code representing a potential urological indication for sacral neuromodulation were included. Patients who underwent device implantation were identified using CPT-4 codes. Statistical analysis was done with the chi-square and Fisher tests, and multivariate logistic regression using software. RESULTS: A total of 2,322,060 patients were identified with a diagnosis that could potentially be treated with sacral neuromodulation. During the 10-year study period the percent of these patients who ultimately underwent implantation increased from 0.03% to 0.91% (p <0.0001) for a total of 13,360 (0.58%). On logistic regression analysis women (OR 3.85, p <0.0001) and patients younger than 65 years (OR 1.00 vs 0.29 to 0.39, p <0.0001) were more likely to be treated. Minority patients (OR 0.38, p <0.0001) and those living in the western United States (OR 0.52, p <0.0001) were less likely to receive treatment. CONCLUSIONS: Sacral neuromodulation use significantly increased among Medicare beneficiaries in a 10-year period. Patients were more likely to be treated with sacral neuromodulation if they were female, white, younger (younger than 65 years) and living outside the western United States.

A cost-effectiveness analysis of retropubic midurethral sling versus transobturator midurethral sling for female stress urinary incontinence.

AIMS: To compare the cost-effectiveness (CE) of retropubic midurethral sling (RMS) versus transobturator midurethral sling (TMS) for the treatment of female stress urinary incontinence (SUI). METHODS: A Markov chain decision model was created to simulate treatment of SUI with RMS versus TMS. Costing data were obtained from the Medicare RBRVS. Data regarding the efficacy and complications associated with RMS versus TMS was compiled from a literature review of 21 randomized RCTs with a minimum of 12 months follow-up, as were corresponding utilities for different continence states. Deterministic and probabilistic estimates of cost-effectiveness (CE) for each procedure were calculated and compared, and sensitivity analyses were performed. RESULTS: In the base-case deterministic analysis, the efficacy of RMS was 6.275 versus 6.272 QALYs for TMS. QALYs represent a measure of disease burden accounting for both quantity and quality of life lived and are used to assess the monetary value of a medical intervention. The average cost for treatment with RMS however was higher at $9,579 versus $9,017 with TMS. TMS was therefore overall more cost-effective than RMS (CE = $1,438/QALY vs. $1,527/QALY). Sensitivity analysis demonstrated that physician and sling characteristics such as device cost, surgeon fee, efficacy of treatment, operative time, and duration of hospitalization could all affect the relative CE of the therapies. CONCLUSIONS: Our study demonstrated that TMS was more cost-effective than RMS as a treatment for female SUI. The efficacy of the two treatments could be affected by physician and sling characteristic factors.

Trends and inequalities in the surgical management of ureteric calculi in the USA.

OBJECTIVE: To assess trends in the surgical management of ureteric calculi over a 10-year period. MATERIALS AND METHODS: An analysis of the 5% Medicare Public Use Files, from 2001, 2004, 2007 and 2010, was performed to assess the use of ureteroscopy (URS), extracorporal shockwave lithotripsy (ESWL) and ureterolithotomy (UL) in treating ureteric calculi. Patients were identified using International Classification of Diseases 9th edition (Clinical Modification) and Current Procedure Terminology codes. Statistical analyses using the Fisher and chi-squared tests, and multivariate logistic regression analysis (dependent variables: URS, ESWL, UL, treatment, no treatment; independent variables: age, gender, ethnicity, geography and year of treatment) were performed. RESULTS: A total of 299 920 patients with ureteric calculi were identified. Of these, 115 200 underwent surgery. Men (odds ratio [OR] = 1.15, P < 0.001) were more likely, while patients from ethnic minorities (OR = 0.84, P = 0.004) were less likely to be treated. Patients in the West of the USA were also less likely to be treated (OR = 0.76, P < 0.001) as were patients aged <65 or >84 years old (P = 0.29). The predominant surgical approach was URS (65.2%), followed by ESWL (33.6%) and UL (1.2%). The use of URS increased over time, while the use of ESWL and UL declined. Women (OR = 1.25, P < 0.001) were more likely to undergo URS. Patients in the South of the USA (OR = 1.51, P < 0.001) and patients from ethnic minorities were more likely to undergo ESWL (OR = 1.23, P = 0.03). CONCLUSIONS: The surgical treatment of ureteric calculi changed significantly between 2001 and 2010. The use of URS expanded at the expense of ESWL and UL. Multiple inequalities existed in overall surgical treatment rates and in the choice of treatment; age, gender, ethnicity and geography influenced both whether patients underwent surgical intervention and the type of surgical approach used.

Cost-effectiveness analysis of tension-free vaginal tape vs burch colposuspension for female stress urinary incontinence in the USA.

OBJECTIVE: To compare the cost-effectiveness (CE) of tension-free vaginal tape (TVT) with that of burch colposuspension (BC) for the treatment of female stress urinary incontinence (SUI). MATERIALS AND METHODS: A Markov-chain decision model was created to simulate treatment of SUI with TVT or BC using Treeage Pro 2011 software (Treeage Software Inc., Williamstown, MA, USA). Costing data were obtained from the Medicare Resource-Based Relative Value Scale. Data regarding the success of TVT vs BC were obtained from the peer-reviewed literature, as were corresponding utilities for different continence states. The CE of each procedure was calculated and compared, and sensitivity analyses were performed. RESULTS: At 10-year follow-up, TVT was more cost-effective (CE = $1495/quality-adjusted life year [QALY]) than BC (CE = $1824/QALY). Sensitivity analysis showed that TVT was more cost-effective than BC if the cost of the TVT device was <$3220. If the probability of success after TVT was <42%, then BC became the more cost-effective strategy (CE = $1827/QALY). CONCLUSION: Our study showed that TVT was more cost-effective than BC as a treatment for female SUI. Both cost of TVT device and efficacy of the procedure affect the CE analysis.

Psychological stress assessment of patients suffering from prostate cancer.

OBJECTIVE: The aim of this study was to assess the psychological distress of men with prostate cancer (PC) throughout the whole process from initial diagnosis to therapy and to evaluate patients' tolerance regarding treatment delay. MATERIAL AND METHODS: This prospective study, performed between July 2007 and March 2010, evaluated the psychological distress of 28 men who underwent prostate biopsy (PB), who were confronted with a cancer diagnosis and were about to undergo radical prostatectomy (RP). Three evaluation points were defined: E1, immediately before PB; E2, after definitive diagnosis and when RP was scheduled; and E3, on the day of admission for RP. RESULTS: Emotional distress was highest before PB, declining significantly until RP (p = 0.02). Symptoms of depression and anxiety were low at all evaluation points, with anxiety rising significantly after cancer diagnosis (p = 0.008). Concerns about postoperative erectile dysfunction and incontinence were registered at all evaluation points. Concerns about the effect on their partnership due to PC were low. The patient's tolerable waiting time for RP differed significantly from daily practice. CONCLUSIONS: Anxiety and depression as well as concerns about a negative effect on their partnership were shown to play a minor role in patients during the interval between PB and RP, while distress and concerns about erectile dysfunction and urinary incontinence were more prevalent. Support from the patient's medical and social environment and a sound partnership may have a protective effect on emotional status. Waiting time for surgery exceeded the patients' tolerated time-frames and may further contribute to the psychological distress of PC.