Exploring the economic landscape of ureteric stones: impact of age and gender on direct healthcare costs.

OBJECTIVES: To assess whether age or gender affects ureteric stone management costs, in patients presenting to the Emergency Department (ED) with CT proven ureteric stones. PATIENTS AND METHODS: A retrospective examination was conducted on patients admitted to the ED who were diagnosed with a ureteric stone through CT scans. Data encompassing clinical, laboratory, and imaging parameters were gathered, alongside information on admissions, ED readmissions, surgical procedures, and the overall treatment cost. Comparative analyses were performed on various cost rates in relation to different stone parameters, patient clinical presentations, laboratory results, and personal histories of urolithiasis. RESULTS: From January 2018 to January 2020, 805 patients underwent abdominal CT scans at a single institution's ED and were diagnosed with ureteric stones. Among them, 773 patients met the inclusion criteria, with 78% (609) being males and 22% (169) females. The mean ages for males and females were 49.4 (SD 14.4) and 51.6 (SD 15.7), respectively (p = 0.08). Treatment costs exhibited a direct relationship with age, amounting to 4,025, 5,116, 6,058, and 9,225 US dollars (USD) in the 18-30, 31-50, 51-70, and over 70 age groups, respectively. Female gender was associated with higher treatment costs, averaging 6,831 USD, compared to 5,450 USD in males (p = 0.03). However, there were no significant differences between genders in terms of the type of surgical procedure (p = 0.4) or hospital stay duration (p = 0.1). CONCLUSIONS: Age and gender exerted a significant impact on treatment costs, revealing that advanced age and female gender were both correlated with higher direct treatment costs in the care of ureteric stones.

[Comprehensive comparative assessment of the results of treatment of patients with ureteral stones using two different methods].

AIM: To improve treatment outcomes in patients with ureteral stones by optimizing the use of noninvasive and minimally invasive techniques. MATERIAL AND METHODS: A prospective analysis of 186 patients with ureteral stones who were treated at the "RSSPMCU" in the period from July 2020 to April 2023 was carried out. Among them, 84 were undergone to electromagnetic extracorporeal shock-wave lithotripsy (ESWL) using the Storz Modulith SLX-F2 device (Switzerland). A procedure was performed under ataralgesia. The mean stone size was 8.54+/-2.79 (4-16 mm). The average amount of shock waves per stone was 2436+/-247.78. The session duration was 19.37+/-1.86 minutes. Endoscopic procedures were performed in 102 patients. Among them, 49 stones were removed using the ureteroscopy (URS), while in 49 and 4 cases percutaneous access (PCNL) and a combination of PCNL and URS under spinal anesthesia were done, respectively. The mean stone size was 11.46+/-4.26 (5-26 mm). Holmium laser or pneumatic lithotripsy was performed. The duration of the procedure was 63.38+/-17.48 min. RESULTS: The stone density of patients undergoing ESWL was 855+/-319.84 HU, while those undergoing endoscopic procedures was 943.78+/-319.48 HU (p>0.05). The absorbed dose with ESWL was 18.73+/-4.15 mGy compared to 31.42+/-1.40 mGy for endoscopic procedures (p<0.001). A length of stay was 1.0+/-0.0 and 2.75+0.1, respectively (p<0.001). After 7-10 days, the stone free rate (SFR) was 76.2% (n=64) after ESWL and 99.02% (n=101) after endoscopic interventions (p<0.05). In the ESWL group, 3 patients received second session of ESWL for residual stones and in 9 cases URS was done. The SFR was 100% on day 45. In patients after endoscopic interventions, 1 patient underwent URS and SFR was 100% on the 15th day. CONCLUSION: In general, the endoscopic technique is superior to ESWL in patients with ureteral stones both in terms of SFR and duration of procedure, but is inferior in safety due to invasiveness and the absorbed dose. In our opinion, the key indication for endoscopic treatment should be stone size greater than 6 mm, density more than 1000 HU, and patient preference.

Cost-effectiveness of quality improvement intervention to reduce time between CT-detection and ureteroscopic laser fragmentation in acute symptomatic ureteric stones management.

OBJECTIVE: To prospectively assess clinical and cost effectiveness of emergency ureteroscopic laser fragmentation of urinary stones causing symptoms or obstruction. PATIENTS AND METHODS: 100 consecutive patients with an average (median) age 55.6 (57.5) years and average (median) stone size of 8.2 mm (± 7 mm) between October 2018 and December 2021 who underwent emergency ureteroscopy and laser fragmentation formed the study cohort as part of a clinical service quality improvement. Primary outcome was single procedure stone-free rate and cost-effectiveness. The secondary outcomes were complications, re-admission and re-intervention. A decision analysis model was constructed to compare the cost-effectiveness of emergency ureteroscopy with laser fragmentation (EUL) and emergency temporary stenting followed by delayed ureteroscopy with laser fragmentation (DUL) using our results and success rates for modelling. RESULTS: Single procedure stone-free rates (SFR) for EUL and DUL were 85%. The re-intervention rate, re-admission and complication rates of the study cohort (EUL) were 9%, 18%, and 4%, respectively, compared to 15%, 20%, and 5%, respectively for the control cohort (DUL). The decision analysis modelling demonstrated that the EUL treatment option was more cost-efficient, averting £2868 (€3260) per patient for the UK health sector. Total cost of delayed intervention was £7783 (€8847) for DUL in contrast to £4915 (€5580) for EUL. CONCLUSIONS: Implementation of quality improvement project based on a reduction in CT detection-to-laser fragmentation time interval in acute ureteric obstruction or symptoms caused by stones had similar clinical effectiveness compared to delayed ureteroscopic management, but more cost-effective.

Risk assessment and prevention of urolithiasis in urban areas of Baoding, China.

Urolithiasis, or the formation of calculi in the urinary system, represents a prevalent urological condition frequently encountered among individuals aged 30 to 55 years. An in-depth analysis of the composition of these calculi holds significant promise in shedding light on the underlying etiological and pathogenic factors contributing to this ailment. The primary objective of this study was to delineate the principal components comprising urinary system calculi within a cohort of patients who sought medical intervention at a tertiary grade A hospital located in Baoding City. Furthermore, our investigation entailed a comprehensive examination of the physical and morphological characteristics exhibited by these calculi. In this study, a total of 2307 individuals afflicted with urinary system calculi were recruited as participants, and a corresponding number of 2307 calculous specimens were subjected to thorough examination. The specimens were examined using infrared spectroscopy. We collected and examined patient data including gender, age, location of the calculi, employment status, residential area, and other factors. The middle-aged demographic exhibited a conspicuous predilection for urinary system calculi, wherein a notable gender disparity was observed, with a male-to-female ratio of 1.63 to 1. Among the enrolled patients, kidney calculi were prevalent in 1270 cases, ureteral calculi were documented in 983 cases, and bladder calculi were encountered in 46 instances. Notably, the principal components comprising these calculi were identified as calcium oxalate and apatite, while uric acid and ammonium magnesium phosphate were comparatively less frequently encountered. Furthermore, the analysis of calculus composition across patients residing in distinct geographical regions did not reveal any statistically significant variations. The identification of components within upper urinary tract calculi plays a pivotal role in elucidating the root causes of calculus formation. This valuable information empowers healthcare professionals, particularly nursing staff, to provide personalized dietary and health guidance to patients, thereby enhancing the quality of care and promoting more effective management of this condition.

Evaluation of ultrathin semirigid ureteroscopy in terms of efficiency and cost compared to flexible ureteroscopy in treating proximal ureteric stones: a prospective randomized multicenter study.

PURPOSE: To investigate the outcome and cost-effectiveness of ultrathin 6-7.5-Fr semirigid ureteroscopy in treating proximal ureteric stones compared to flexible ureteroscopy. METHODS: Two hundred and twenty patients with a solitary proximal ureteric stone were eligible for ureteroscopy (stone size = 1-2 cm). Patients were randomly subdivided into two groups: Group I included 105 patients who underwent ultrathin semirigid ureteroscopy and group II included 115 patients who underwent flexible ureteroscopy. Both groups were compared regarding successful stone access, operation time, reoperation rates, the financial cost to stone-free, complications, and stone clearance at 4 and 8 weeks. RESULTS: Groups I and II had no significant differences regarding patient demographics, stone criteria, and hospitalization time. In contrast, the mean operative time was significantly longer in group II (p < 0.001). The overall scope-to-stone access rate was 89.5%. It was 87.6% compared to 91.3% (p = 0.32), while the stone-free rate was 81.9% versus 87.8% (p = 0.22) for groups I and II, respectively. Intraoperative and postoperative complications were statistically insignificant between the study groups. The cost/person in Egyptian pounds was 8619 ± 350 in group I, compared to 17,620 ± 280 in group II (p < 0.001); similarly, the cost to attain the stone-free rate was 8950 ± 720 in group I compared to 17,950 ± 500 in group II. CONCLUSION: Ultrathin semirigid ureteroscopy is safe, durable, and considered a cost-effective method for treating upper ureteric calculi compared to the flexible ureteroscopy and could be considered a first treatment option in developing countries.

Surgical Stone Treatment: Patterns May Predict Performance on Episode-based Cost Measure in the Quality Payment Program.

INTRODUCTION: The Renal or Ureteral Stone Surgical Treatment Episode-based Measure in the Quality Payment Program evaluates clinicians' cost to Medicare for beneficiaries who receive surgical treatment for stones. The measure score is calculated from Medicare claims according to a complex methodology. This paper seeks to describe the stone treatment patterns of urologists and establish benchmarks for 2 surrogate measures-preoperative stenting and postoperative infection-which may predict clinician performance on the episode cost-based measure. METHODS: The study data were drawn from the adjudicated claims of 960 providers who performed at least 30 surgical stone treatments between January 1, 2020, and June 30, 2022. To allow for the correlation of procedures performed by the same providers, generalized estimating equations logistic regression models were used to evaluate the rate of preoperative stenting and postoperative infection. RESULTS: A total of 185,076 surgical episodes (113,799 [61.5%] ureteroscopy, 63,931 [34.5%] extracorporeal shock wave lithotripsy, and 7,346 [4.0%] percutaneous nephrolithotripsy) were identified over the study period. Preoperative stenting was performed in 35,550 episodes (19.2%) and postoperative infection was documented in 13,114 episodes (7.1%). Preoperative stenting and postoperative infection were significantly more common in patients who were female (adjusted OR 1.42, 1.38), in those undergoing ureteroscopy vs extracorporeal shock wave lithotripsy (adjusted OR 3.24, 1.66), and in patients on Medicare vs commercial insurance (adjusted OR 1.19, 1.17). CONCLUSIONS: This large study of surgical stone treatments documents rates of events and associated attributes of patients that may increase episode cost and be relevant to urologists participating in the Quality Payment Program.

Unplanned 120-Day ED Visits and Readmission Rates Following Common Stone Procedures.

OBJECTIVE: To quantify emergency department (ED) visits and hospital admissions (HA) after common urologic stone procedures including ureteroscopy (URS), shockwave lithotripsy (SWL), and percutaneous nephrolithotomy (PCL) which are a concern of payors, providers, and patients. MATERIALS AND METHODS: This is a retrospective cohort study using claims data from the IBM MarketScan Commercial and Medicare Supplement databases. Adults with a urologic stone diagnosis and no history of stone procedure in prior 12 months who underwent stone procedures between 2012 and 2017 were included. All-cause ED visits and HA were evaluated during 30, 60, 90, and 120-day periods following the index urologic stone procedure. RESULTS: A total of 166,287 patients were included in the analytic cohort. For inpatient-indexed procedures, cumulative ED visits rates following stone procedure at 120 days was 18.8% for URS, 19.2% for SWL, and 23.6% for PCL. A similar trend was observed with ED visit rates, following outpatient indexed procedures at 120 days with a cumulative rate of 14.2% of SWL patients, 14.9% of URS patients, and 17.3% of PCL. A similar trend was found when examining HA. ED and HA rates increased steadily through the 120-day time period. CONCLUSION: Rates of ED visits and HA following common stone procedures continue to rise at least up to 120 days following the index procedure whether in the outpatient or inpatient settings. While rates of unplanned care are similar for URS and SWL, patients undergoing PCL return to the hospital at higher rates.

National Utilization, Reimbursement, and Urban Versus Rural Trends of Extracorporeal Shockwave Lithotripsy and Ureteroscopic Laser Lithotripsy.

OBJECTIVE: To describe temporal utilization and reimbursement trends of extracorporeal shockwave lithotripsy (ESWL) and ureteroscopy (URS) with laser lithotripsy. METHODS: The Medicare Provider Utilization and Payment Database was queried for all ESWL and URS performed between 2013 and 2020 using Current Procedural Terminology codes: ESWL - 50590; URS - 52352, 52353, 52356. Cases that lacked rural or urban identification codes were excluded. A total of 347,174 ESWL and 401,899 URS cases were identified. Linear regression was performed with statistical significance set to 95% confidence intervals. RESULTS: There was a significant upward trend for URS utilization over the study period (R2 = 0.91, P <.001), but there was not a significant trend for ESWL utilization. In 2013, ESWL was used more frequently than URS, but by 2016, URS was used more frequently than ESWL. From 2013 to 2019, URS utilization increased by 241% and 168% by urban and rural urologists, respectively. URS was also associated with a slight increase in physician reimbursement over time (R2 = 0.87, P <.001), whereas there was no association between ESWL and physician reimbursement. For URS, rural and urban urologists were reimbursed an average of $312.07 (standard deviation [SD] $14.03) and $404.86 (SD $21.96), respectively. For ESWL, rural and urban urologists were reimbursed an average of $456.22 (SD $5.74) and $562.66 (SD $16.68), respectively. CONCLUSION: According to the Medicare database, URS has surpassed ESWL in utilization, especially by urban urologists. Physician reimbursement for ESWL remained higher than URS reimbursement, though URS reimbursement increased slightly in recent years.

Delays in Ureteroscopy and Shockwave Lithotripsy After Ureteral Stent Placement: Impact on Infectious Complications, Resource Use, and Medical Costs.

Purpose: To evaluate the effects of ureteral stent duration before ureteroscopy (URS) or extracorporeal shockwave lithotripsy (SWL) on infectious complications, health care resource utilization (HCRU), and costs. Materials and Methods: Patients who underwent URS/SWL within 6months of ureteral stent placement were identified from commercial claims, categorized by time from stent placement to URS (0-15, 16-30, 31-60, and >60 days) or SWL (0-15, 16-30, and >30 days), and followed 1-month postprocedure. The relationship between ureteral stent duration and emergency department (ED) visits, inpatient admissions, infectious complications (pyelonephritis/sepsis), imaging, and costs was evaluated. Results: Mean time to URS (n = 9276 patients) was 21.3 ± 24.4 days and SWL (n = 4689 patients) was 19.0 ± 24.8 days. Compared with patients who underwent URS within 15 days of ureteral stent placement, URS 31 to 60 days after ureteral stent placement was significantly associated with inpatient admissions (odds ratio [OR] 2.56, 95% confidence interval [CI] 2.03-3.22); infectious complications (OR 2.82, 95% CI 2.09-3.81); imaging (OR 2.12, 95% CI 1.82-2.46); and medical costs (OR 1.49, 95% CI 1.40-1.58). Compared with patients who underwent SWL within 15 days of ureteral stent placement, SWL more than 30 days after ureteral stent placement was significantly associated with ED visits (OR 1.79, 95% CI 1.37-2.34); inpatient admissions (OR 3.34, 95% CI 2.38-4.69); infectious complications (OR 3.54, 95% CI 2.20-5.70); imaging (OR 2.65, 95% CI 2.23-3.15); and medical costs (OR 1.45, 95% CI 1.36-1.54). Conclusions: URS or SWL >30 days after ureteral stent placement increased the likelihood of infectious complications, HCRU, and medical costs.

Economic burden of complicated ureteral stent removal in patients with kidney stone disease in the USA.

Aim: To examine the medical costs of simple versus complicated ureteral stent removal. Materials & methods: We included adults with kidney stones undergoing simple or complicated cystoscopy-based stent removal (CBSR) post ureteroscopy from the 2014 to 2018 Merative™ MarketScan® Commercial Database. The medical costs of patients with complicated and simple CBSR were compared. Results: Among 16,682 patients, 2.8% had complicated CBSR. Medical costs for patients with complicated CBSR were higher than for simple CBSR ($2182 [USD] vs $1162; p < 0.0001). Increased stenting time, increased age, southern US geography and encrusted stent diagnoses were significantly associated with complicated CBSR. Conclusion: Complicated ureteral stent removal doubled the medical costs associated with CBSR. Ureteral stents with anti-encrustation qualities may reduce the need for complicated CBSR and associated costs.

Ureteral Strictures Following Ureteroscopy for Kidney Stone Disease: A Population-based Assessment.

PURPOSE: As the prevalence of urolithiasis increases and ureteroscopy is used more frequently, the risks of uncommon complications such as ureteral stricture may become more notable. Our objective is to assess the rate and associated risk factors of ureteral stricture formation in patients undergoing ureteroscopy. MATERIALS AND METHODS: Utilizing the IBM MarketScan research database, we evaluated data from 2008 to 2019 and compared ureteral stricture rates and their management following ureteroscopy to subjects who had shock wave lithotripsy. Shock wave lithotripsy was used as a comparison group to represent the rate of stricture from stone disease alone. A third group of those having both shock wave lithotripsy and ureteroscopy was included. Patients and secondary procedures were identified using Current Procedural Terminology, and International Classification of Diseases-9 and -10 codes. RESULTS: A total of 329,776 patients received ureteroscopy, shock wave lithotripsy, or shock wave lithotripsy+ureteroscopy between 2008 and 2019. Stricture developed in 2.9% of patients after ureteroscopy, 1.5% after shock wave lithotripsy, and 2.6% after shock wave lithotripsy+ureteroscopy. In the multivariable model, rates of stricture were 1.7-fold higher after ureteroscopy vs shock wave lithotripsy (OR:1.71, 95% CI 1.62-1.81). Preoperative hydronephrosis, age, prior stones/intervention, and concurrent kidney and ureteral stones were associated with increased risk of stricture. Of those with strictures incurred after ureteroscopy, 35% required drainage, 21% had endoscopic intervention, 4.8% required reconstructive surgery, and 1.7% underwent nephrectomy. CONCLUSIONS: Ureteral stricture rate after ureteroscopy of nearly 3% was higher than expected and approximately twice the rate attributable to stone disease alone. Factors associated with the stone as well as instrumentation were found to be risk factors. The morbidity of stricture disease following ureteroscopy was significant.

Acute extracorporeal shockwave lithotripsy for ureteric stones - 7-years' experience from a busy district general hospital.

OBJECTIVES: To demonstrate the efficacy and cost-effectiveness of acute extracorporeal shockwave lithotripsy (ESWL) for ureteric stones we present our experience of ESWL in 530 ureteric stone cases, in the largest UK series we are aware of to date. ESWL is underutilised in ureteric stone management. The Getting It Right First Time (GIRFT) report showed just four units nationally treated >10% of acute ureteric stones with ESWL. Despite guideline recommendations as a first-line treatment option, few large volume studies have been published. PATIENTS AND METHODS: Retrospective review of prospectively collected data between December 2012 and February 2020 was performed. Data relating to patient demographics, stone characteristics, skin-to-stone distance, and treatment failure were collected. Cost analysis was conducted by the Trust's surgical financial manager. Multivariable analyses were performed to assess for predictors of ESWL success. RESULTS: A success rate of 68% (95% confidence interval 64%-72%) at 6 weeks was observed (n = 530). The median (interquartile range) number of treatment sessions was 2 (1, 2). Stone diameter was observed to be a predictor of ESWL success. The small number of stones treated of >13 mm or >1250 HU had an ~50% chance of successful treatment. Acute ureteric ESWL was less costly than acute ureterorenoscopy, consistent with findings from previous NHS studies. CONCLUSION: Acute ESWL is a safe, reliable, and financially viable treatment option for a wider spectrum of patients than reflected in international guidelines based on our large, heterogenous series. In the coronavirus disease 2019 (COVID-19) era, with theatre access reduced and concerns over aerosol generating procedures, acute ESWL remains an attractive first-line treatment option.

Ureteroscopy with thulium fiber laser lithotripsy results in shorter operating times and large cost savings.

PURPOSE: Prolonged ureteroscopy (URS) is associated with complications including ureteral perforation, stricture, and urosepsis. As laser lithotripsy is one of the most common urologic procedures, small cost savings per case can have a large financial impact. This retrospective study was designed to determine if Thulium fiber laser (TFL) lithotripsy decreases operative time and costs compared to standard Holmium:YAG (Ho:YAG) lithotripsy without pulse modulation. METHODS: A retrospective review of URS with laser lithotripsy was conducted for 152 cases performed from August 2020 to January 2021. Variables including cumulative stone size, location, chemical composition, prior ureteral stenting, and ureteral access sheath use were recorded for each case. A cost benefit analysis was performed to show projected cost savings due to potentially decreased operative times. RESULTS: Compared to Ho:YAG, use of TFL resulted in an average decrease of 12.9 min per case (p = .021, 95% CI [2.03-23.85]). In subgroup analysis of cases with cumulative stone diameter less than 15 mm, the difference was 14.0 min (p = .007, CI [3.95-23.95]). For cases less than 10 mm, the mean difference was 17.3 min in favor of TFL (p = .002, 95% CI [6.89-27.62]). This ~ 13 min reduction in operative time resulted in saving $440/case in direct operating room costs giving our institution a range of $294,000 to $381,900 savings per year. CONCLUSIONS: TFL has a significantly shorter operative time and decreased cost when compared to the standard Ho:YAG for equivalent kidney stone and patient characteristics. Longer term follow up is needed to see if recurrence rates are affected.

Cost-effectiveness of anti-retropulsive devices varies according to the locations of proximal ureteral stones: a retrospective cohort study.

BACKGROUND: Anti-retropulsive devices are often used to prevent stone migration in the treatment of proximal ureteral calculi. They are helpful. However, in the meantime, they also add extra expenses. This study was carried out to investigate the best criteria for treating proximal ureteral stones with anti-retropulsive devices. METHODS: Data from all patients who underwent ureteroscopic holmium: YAG laser lithotripsy for solitary upper ureteral stones in 2018 were collected. Patients who encountered stone retropulsion during the process of inserting the ureteroscope were excluded. Patients were divided into either group URS or group URS + ARD depending on whether the anti-retropulsive device was used. Then, the stone-free rate, expenses and other criteria were compared between groups according to stone location. Stone-free was defined as no stones present. RESULTS: For stones located ≤ 30 mm from the ureteropelvic junction (UPJ), the stone-free rates for the URS group were 80% and 80% at one day and one month after the operation, respectively. Those for the URS + ARD group were 71.4% and 78.6% at one day and one month, respectively. For stones located 31-90 mm from the UPJ, the stone-free rates were 84.7% and 84.7% for the URS group and 89.6% and 95.5% for the URS + ARD group at one day and one month, respectively. A statistically significant difference occurred at one month. For stones located > 90 mm from the UPJ, the two groups were both stone free. In the URS + ARD group, expenses were higher. In addition, the mean diameter of residual stones derived from stones located at 31-90 mm from the UPJ was statistically smaller, and 4 of 7 residual stones passed spontaneously within one month, which was obviously more than that in other locations and the URS group. Other outcomes, including operation time and postoperative stay, showed no significant difference between the groups. CONCLUSION: Anti-retropulsive devices are indeed helpful, but they might be cost-effective for stones located solely in the middle part of the upper ureter, not for those too close to or far from the ureteropelvic junction.

Cost-effectiveness of using stone cone, balloon dilator, stone basket, and entrapment device in ureteroscopic laser lithotripsy for ureteric stones.

OBJECTIVE: To evaluate the costs and stone-free rates of ureteroscopic laser lithotripsy (ULL) performed with and without auxiliary equipment and to compare first-time ULL with total treatment. METHODS: One hundred patients who underwent first-time ULL without the use of auxiliary equipment because its unavailability comprised the no-device ULL (ndULL) group. Additionally, 100 patients who underwent first-time ULL with the use of auxiliary equipment when necessary comprised the device ULL (dULL) group. RESULTS: In the ndULL and dULL groups, the stone-free rates after first-time ULL were 72% and 94% and the mean cost was US $1037 ± 15.10 and US $1452 ± 19.80 per case, respectively, with a statistically significant difference. The stone-free rates at the end of treatment were 98% and 99%, respectively, without a statistically significant difference. When secondary treatment costs were added to the first ULL costs after failed treatment, the mean total cost was US $1625 ± 12.60 in the ndULL group and US $1566 ± 11.01 in the dULL group without a statistically significant difference. CONCLUSIONS: The stone-free rates and costs after first-time ULL were significantly different between the groups. However, after total treatment, there was no statistically significant difference between the two groups.

Predicting negative ureteroscopy for stone disease - Minimizing risk and cost.

INTRODUCTION: Urolithiasis is common worldwide, with ureteric stones being a particular burden. Ureteroscopy (URS) is one of the most useful procedures in treating ureteric stones not passed spontaneously; this procedure has a complication risk of 4%. Negative URS, with described rates up to 15%, represents an avoidable patient risk and use of medical resources. OBJECTIVES: To describe rates and identify predictive factors for negative URS and to define strategies which would minimize patient and financial burden from these unnecessary procedures. MATERIALS AND METHODS: A retrospective cohort study analyzed patients who underwent URS in our Center to treat ureteric stones over a period of 2 years. Patient age, gender, and comorbidities, as well as laboratory and imaging findings, were analyzed. RESULTS: 262 patients underwent URS for ureteric stones. The female population was 50.8% with a mean age of 56.89 years. A total of 78 (29.8%) URS procedures were negative. Univariate analysis showed a higher prevalence of negative URS in female patients, as well as in primary, smaller, and radiolucent stones. At multivariate analysis, a logistic regression model correctly classified 76% of patients, with smaller stone size and radiolucency being significant predictors of negative URS. DISCUSSION AND CONCLUSIONS: Our Center showed a high rate of negative URS, higher than commonly described in the literature. Female patients tend to have an even higher rate, possibly due to unnoticed passage of stones. Patients with small, radiolucent stones showed the highest rates of negative URS.

Determining Variable Costs in the Acute Urolithiasis Cycle of Care Through Time-Driven Activity-Based Costing.

OBJECTIVE: To characterize full cycle of care costs for managing an acute ureteral stone using time-driven activity-based costing. METHODS: We defined all phases of care for patients presenting with an acute ureteral stone and built an overarching process map. Maps for sub-processes were constructed through interviews with providers and direct observation of clinical spaces. This facilitated calculation of cost per minute for all aspects of care delivery, which were multiplied by associated process times. These were added to consumable costs to determine cost for each specific step and later aggregated to determine total cost for each sub-process. We compared costs of eight common clinical pathways for acute stone management, defining total cycle of care cost as the sum of all sub-processes that comprised each pathway. RESULTS: Cost per sub-process included $920 for emergency department (ED) care, $1665 for operative stent placement, $2368 for percutaneous nephrostomy tube placement, $106 for urology clinic consultation, $238 for preoperative center visit, $4057 for ureteroscopy with laser lithotripsy (URS), $2923 for extracorporeal shock wave lithotripsy, $169 for clinic stent removal, $197 for abdominal x-ray, and $166 for ultrasound. The lowest cost pathway ($1388) was for medical expulsive therapy, whereas the most expensive pathway ($8002) entailed a repeat ED visit prompting temporizing stent placement and interval URS. CONCLUSION: We found a high degree of cost variation between care pathways common to management of acute ureteral stone episodes. Reliable cost accounting data and an understanding of variability in clinical pathway costs can inform value-based care redesign as payors move away from pure fee-for-service reimbursement.

Laparoscopic ureterolithotomy; an equally effective and a sensible alternative to flexible ureterorenoscopy in the management of large ureteral stones in terms of effectivity and cost.

OBJECTIVES: We aimed to understand whether laparoscopic ureterolithotomy (LU) is a good alternative to flexible ureterorenoscopic lithotripsy (FURS) by comparing these techniques concerning cost-effectiveness. METHODS: We analysed 79 patients with upper ureteral stones larger than 1.5 cm underwent FURS or LU concerning cost-effectiveness analysis. The data including age, body mass index (BMI), stone size, operation time, hospitalisation time, complications and stone-free rates of 15th day and 3rd months. We audited the costs of FURS and LU and compared them concerning cost-effectiveness. RESULTS: There was not any statistically significant difference between the two groups with regard to age, BMI, stone size, stone-free rates at the 3rd month, and complication rates, (p>0.05). The operation times were statistically lower in the FURS than in the LU (61.5±24.3 min and 140.9±49.1 min, respectively, p<0.05). The stone-free rate at the 15th day was lower in the FURS group than in the LU group (31 (81.6%) and 41 (100%), respectively, p<0.05) (Table   I). However, this statistical difference disappears at 3 months (p>0.05). The mean costs of FURS and LU were $194.2±12.4 and $179.2±58.5, respectively (p<0.001). CONCLUSION: FURS is equally effective to LU in terms of stone-free rates. The cost of FURS is higher statistically than LU. FURS is shown as the first choice for the upper ureteral stones larger than 10 mm in size, if the laparoscopic experience is in high-level situations in that clinic, LU may be a suitable alternative to FURS, especially for challenging cases.

OBJETIVOS: El objetivo es determinar si la ureterolitectomia laparoscópica (UL) es una buena alternativa a la ureterorenoscopia flexible con litotricia (URSF) a través de la comparación de ambas técnicas en lo que a coste y efectividad radica.MÉTODOS: Analizamos 79 pacientes con litiasis ureterales proximales de más de 1,5 cm que recibieron URSF o UL en relación a coste-efectividad. Los datos recogidos incluyeron edad, IMC, tamaño de la litiasis, tiempo de la cirugía, tiempo de hospitalización, complicaciones y tasa libres de litiasis a los 15 días y 3 meses de la cirugía. Auditamos los costes de las URSF y UL y se compararon en relación a coste-efectividad. RESULTADOS: No hubo diferencias estadísticamente significativas entre los grupos en relación a la edad, IMC, tamaño de la litiasis, tasa libre de litiasis a los 3 meses y complicaciones (p>0,05). Los tiempos quirúrgicos fueron estadísticamente menores en URSF en comparación a UL (61,5±24,3 min y 140,9±49,1 min, respectivamente, (pz0,05). La tasa libre de litiasis a los 15 días fue mas baja en el grupo de URSF que UL (31 (81,6%) y 41 (100%), respectivamente, p <0,05](Tabla I).Aunque la diferencia estadística desaparece a los 3 meses (p>0,05). El coste medio de URSF y UL fue de $194,2 ± 12,4 y $ 179,2 ± 58,5, respectivamente (pCONCLUSIÓN: URSF es igualmente efectiva que UL en términos de tasa libre de litiasis. Los costes de URSF es más alto que UL. URSF es la primera opción en el tratamiento de litiasis de más de 1 cm en uréter proximal. En caso de experiencia laparoscópica de alto nivel, UL puede sustituir a URSF, especialmente en casos difíciles.

A randomized prospective study: assessment of transient ureteral stenting by mono-J insertion after primary URS and stone extraction (FaST 3).

To compare the outcome of a short-term insertion of a mono-J catheter for 6 h following ureteroscopic stone removal to a conventional double-J catheter. This single-center academic study (Fast Track Stent study 3) evaluated stenting in 108 patients with urinary calculi after ureterorenoscopy. Patients were prospectively randomized into two study arms before primary ureterorenoscopy: (1) mono-J insertion for 6 h after ureterorenoscopy and (2) double-J insertion for 3-5 days after ureterorenoscopy. Study endpoints were stent-related symptoms assessed by an ureteral stent symptom questionnaire (USSQ) and reintervention rates. Stone sizes and location, age, operation duration, BMI, and gender were recorded. Of 67 patients undergoing ureterorenoscopy, 36 patients were analyzed in the double-J arm and 31 patients in the mono-J arm. Mean operation time was 27.5 ± 1.3 min versus 24.0 ± 1.3 min, and stone size was 5.2 mm versus 4.5 mm for mono-J versus double-J, respectively (p = 0.06 and p = 0.15). FaST 3 was terminated early due to a high reintervention rate of 35.5% for the mono-J group and 16.7% for the double-J group (p = 0.27). One day after ureterorenoscopy, USSQ scores were similar between the study arms (Urinary Index: p = 0.09; Pain Index: p = 0.67). However, after 3-5 weeks, the Pain Index was significantly lower in those patients who had a double-J inserted after ureterorenoscopy (p = 0.04). Short-term insertion of mono-J post-ureterorenoscopy results in similar micturition symptoms and pain one day after ureterorenoscopy compared to double-J insertion. The reintervention rate was non-significant between the treatment groups most likely due to the early termination of the study (p = 0.27). Ethics approval/Trail Registration: No. 18-6435, 2018.