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.

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.

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.

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.

Comparing extracorporeal shock wave lithotripsy and ureteroscopy laser lithotripsy for treatment of urinary stones smaller than 2 cm: a cost-utility analysis in the Spanish clinical setting.

PURPOSE: To analyze the efficiency and cost-utility profile of ureteroscopy versus shock wave lithotripsy for treatment of reno-ureteral stones smaller than 2 cm. METHODS: Patients treated for urinary stones smaller than 2 cm were included in this study (n = 750) and divided into two groups based on technique of treatment. To assess the cost-utility profile a sample of 48 patients (50% of each group) was evaluated. Quality of life survey (Euroqol 5QD-3L) before-after treatment was applied, Markov model was designed to calculate quality of life in each status of the patients (stone or stone-free with and without double-J stent) and to estimate the incremental cost-utility. Monte carlo simulation was conducted for a probabilistic sensitivity analysis. Chi-square was used for comparing qualitative variables and T student's for continuous variables. RESULTS: Shock wave lithotripsy group had 408 (54.4%) and ureteroscopy group had 342 (45.6%) patients. Of them, 56.3% were treated for renal stones and 43.7% for ureteral stones. Ureteroscopy produced slightly higher overall quality of patients' life, but produced a significant higher overall cost per quality-adjusted life year (QALY) than shock wave lithotripsy, exceeding the cost-utility threshold (20,000€/QALY). Sensitivity analysis confirmed results in 93.65% of cases. Difference was maintained in subgroup analysis (ureteral vs renal stones). CONCLUSIONS: Results suggest that in our clinical setting shock wave lithotripsy has better cost-utility profile than ureteroscopy for treatment of reno-ureteral stones less than 2 cm, but excluding waiting times, in ideal clinical setting, ureteroscopy would have better cost-utility profile than shock wave lithotripsy.

Novel prediction scoring system for simple assessment of stone-free status after flexible ureteroscopy lithotripsy: T.O.HO. score.

OBJECTIVES: To develop a novel simple quantitative scoring model for predicting stone-free status after a flexible ureteroscopy lithotripsy procedure by standardizing the complexity of ureteral stone characteristics. METHODS: We retrospectively reviewed 586 patients with renal or ureteral stones who underwent flexible ureteroscopy lithotripsy at Abiko Toho Hospital, Chiba, Japan, from 2015 to 2018. Multivariate regression was applied to examine the relationship between preoperative descriptors and stone-free status, and a nomogram was developed using significant predictors. Next, the individual components of the nomogram were assigned points to form a simple scoring system. The predictive performance of this new scoring system was compared with the STONE score at optimal cut-off values using receiver operating characteristic curve and area under the curve analyses. RESULTS: Multivariate logistic regression findings showed that factors associated with stone-free status were length, Hounsfield unit and stone location. A nomogram prediction model was developed with an area under the curve value of 0.845, then consequently used to develop a new simple score system termed the T.O.HO. score consisting of three stone characteristics: (T)allness (1-5 points), (O)ccupied lesion (1-3 points) and (HO)unsfield units evaluation (1-3 points). The T.O.HO. score was significantly higher in stone remaining (7.66) than stone-free (5.27; P < 0.001) cases. The area under the curve for the T.O.HO. score was 0.833 at an optimal cut-off value of 7, whereas that for the STONE score was 0.683 at an optimal cut-off value of 9, showing the superiority of this new scoring system. CONCLUSION: The T.O.HO. score is a useful tool for predicting stone-free status in patients who have undergone a flexible ureteroscopy lithotripsy procedure.

Double-Blinded Prospective Randomized Clinical Trial Comparing Regular and Moses Modes of Holmium Laser Lithotripsy.

Objective: To compare regular and Moses modes of holmium laser lithotripsy during ureteroscopy in terms of fragmentation/pulverization and procedural times in addition to perioperative complications. Patients and Methods: After obtaining ethics approval, a prospective double-blinded randomized trial was conducted for patients undergoing holmium laser lithotripsy during retrograde ureteroscopy. Patients were randomly assigned to either regular or Moses modes. Patients and surgeons were blinded to the laser mode. Lumenis 120W generator with 200 Moses D/F/L fibers were used. Demographic data, stone parameters, perioperative complications, and success rates were compared. The degree of stone retropulsion was graded on a Likert scale from 0-no retropulsion to 3-maximum retropulsion. Results: A total of 72 patients were included in the study (36 per arm). Both groups were comparable in terms of age and preoperative stone size (1.4 cm vs 1.7 cm, p > 0.05). When compared with the regular mode, Moses mode was associated with significantly lower fragmentation/pulverization time (21.1 minutes vs 14.2 minutes; p = 0.03) and procedural time (50.9 minutes vs 41.1 minutes, p = 0.03). However, there were no significant differences in terms of lasing time (7.4 minutes vs 6.1 minutes, p > 0.05) and total energy applied to the stones (11.1 kJ vs 10.8 kJ, p > 0.05). Moses mode was associated with significantly less retropulsion (mean grade was 1.0 vs 0.5, p = 0.01). There were no significant differences between both modes in terms of intraoperative complications (11.1% vs 8.3%, p > 0.05), with one patient requiring endoureterotomy for stricture in the Moses group. Success rate at the end of 3 months was comparable between both groups (83.3% vs 88.4%, p > 0.05). Conclusion: Moses technology was associated with significantly lower fragmentation/pulverization and procedural times. The reduced fragmentation/pulverization time seen using Moses technology could be explained by the significantly lower retropulsion of stones during laser lithotripsy.

Cost analysis of ureteroscopy (URS) vs extracorporeal shockwave lithotripsy (ESWL) in the management of ureteric stones <10 mm in adults: a UK perspective.

OBJECTIVES: To compare the total cost of a treatment strategy starting with ureteroscopy (URS) vs a strategy starting with extracorporeal shockwave lithotripsy (ESWL). METHODS: For ureteric stones of <10 mm, URS or ESWL are the main treatment options that are considered. Although the interventions differ, the goal of the interventions is to achieve a stone-free status. A systematic review and meta-analysis undertaken as part of the National Institute for Health and Care Excellence (NICE) guideline on 'Renal and ureteric stones: assessment and management' identified URS as more effective, in terms of getting people stone free, but has a higher probability of re-admission and adverse events (AEs) that contributes to downstream resource use. ESWL is initially less costly, but lower effectiveness means a greater need for repeat or ancillary procedures in order to get a patient stone free. Given these trade-offs between benefits and costs, a cost analysis of URS and ESWL was undertaken as part of the NICE guideline, using evidence from the literature of effectiveness, re-admission and AEs. The NICE guideline meta-analysis showed a lot of heterogeneity and differences in how outcomes were reported between studies. The costing analysis, therefore only used studies where: (i) patients were rendered stone free, and (ii) where effectiveness, was based on the first-line (initial) procedures. Exploratory quality adjusted life year (QALY) work was also undertaken to identify the QALY and quality of life (QoL) differences required for the most expensive intervention to be cost effective, based on the assumption that the difference in effectiveness between the initial procedures would be the main source of the QALY gain between the two strategies. RESULTS: The URS strategy was more costly overall than the ESWL strategy (incremental cost of £2387 [pounds sterling]). Sensitivity analysis varying the initial effectiveness of ESWL treatment (between the base case value of 82% and 40%) showed that URS would still be a more costly strategy even if the initial session of ESWL only had a success probability of 40%. A two-way sensitivity analysis as part of the exploratory QALY work showed that ESWL would have to have very low effectiveness and people would have to wait for further treatment for many weeks (following a failed ESWL treatment) for there to be feasible QoL gains to justify the additional cost of the URS strategy. CONCLUSIONS: ESWL is less effective at initial stone clearance and therefore requires more ancillary interventions than URS. However, the magnitude of the difference in costs means URS is unlikely to be cost effective intervention at a population level for first-line treatment, implying ESWL should be the first choice treatment.

Cost-Effectiveness Analysis of the Management of Distal Ureteral Stones in Children.

OBJECTIVE: To determine the most cost-effective approach to the management of distal ureteral stones in children given the potential for recurrent renal colic during a trial of passage versus potential stent discomfort and complications of ureteroscopy. METHODS: We developed a decision tree to project costs and clinical outcomes associated with observation, medical explusive therapy (MET), and ureteroscopy for the management of an index patient with a 4-mm-distal ureteral stone. We determined which strategy would be least costly and offer the most pain-free days within 30days of diagnosis. We performed a one-way sensitivity analysis on the probability of successful stone passage with MET. We obtained probabilities from the literature and costs from the 2016 Pediatric Health Information System Database. RESULTS: Ureteroscopy was the costliest strategy but maximized the number of pain-free days within 30days of diagnosis ($5282/29 pain-free days). MET was less costly than ureteroscopy but also less effective ($615/21.8 pain-free days). Observation cost more than MET and was also less effective ($2139/15.5 pain-free days). The one-way sensitivity analysis on the probability of successful stone passage with MET demonstrated that ureteroscopy always has the highest net monetary benefits value and is therefore the recommended strategy given a fixed willingness-to-pay. DISCUSSION: Using a rigorous decision-science approach, we found that ureteroscopy is the recommended strategy in children with small distal ureteral stones. Although it costs more than MET, it resulted in more pain-free days in the first 30days following diagnosis given the faster resolution of the stone episode.

Factors Associated with Regional Adoption of Ureteroscopy in California from 2005 to 2016.

PURPOSE: To explore regional adoption of ureteroscopy (URS) over extracorporeal shockwave lithotripsy (SWL) in the state of California (CA) and to identify factors associated with this adoption over time. MATERIALS AND METHODS: We used the California Office of Statewide Health Planning and Development (OSHPD) public data to identify URS and SWL procedures performed for renal and ureteral stones from 2005 to 2016. The level of analysis was the region wherein each procedure was performed, defined by the 19 CA labor market regions. OSHPD data were supplemented with the Area Health Resource File to provide information on regional characteristics. Generalized linear regression was used to determine procedural rates adjusted for age, gender and race. Choropleth time series maps were used to illustrate adoption of URS by region over time. RESULTS: A total of 328,795 URS and SWL procedures were identified from 2005 to 2016. The number of URS procedures surpassed the number of SWL procedures in 2011. Fourteen regions became URS predominant by 2016 and were characterized as having a higher per capita income, higher percentages with a college education and lower percentage of female heads-of-household (all p-values <0.05). A higher percentage of patients in these regions were male and had private or Medicare insurance (p = 0.03 for both). CONCLUSIONS: From 2005 to 2016, most CA regions adopted URS as the primary renal and ureteral stone management strategy. These regions demonstrated characteristics of higher socioeconomic status compared to regions that remained SWL predominant. A better understanding of such differences in practice patterns will allow urologists to better negotiate for the capital expenditures required to conform to evolving standards of care and allow patients the ability to make more informed decisions on where they receive care.

Contemporary practice patterns in the treatment of pediatric stone disease.

INTRODUCTION: To compare endourology versus pediatric urology exposure to pediatric stone cases during fellowship, comfortability in treating pediatric stone cases, and access to pediatric surgical equipment. MATERIALS AND METHODS: A survey was distributed to all pediatric urology fellowship programs and the Endourological Society. Age was stratified into < 12 months old, 12 months-4 years, 5-12 years, and 13-18 years. Exposure and comfortability performing extracorporeal shock wave lithotripsy (SWL), ureteroscopy (URS) and percutaneous nephrolithotomy (PCNL) were assessed across age groups. Exposure was assessed as 'yes/no' and comfortability was scaled from 1-5 ('would not do' to 'very comfortable'). RESULTS: Seventy-two surveys met inclusion criteria, with 23 (31.9%) from pediatric urologists and 49 (68.1%) by endourologists. During fellowship, pediatric urologists had more exposure to SWL in toddlers (p = 0.03) and school age children (p = 0.045), URS in toddlers (p = 0.012) and school age children (p = 0.002), and PCNL in infants (p = 0.031) and school age children (p = 0.025) compared to endourologists. Pediatric urologists were significantly more comfortable performing SWL in toddlers (p = 0.04), URS in toddlers (p = 0.04) and school age children (p = 0.04), and PCNL in school age children (p = 0.02) compared to endourologists. Endourologists were significantly more uncomfortable than pediatric urologists in performing URS in toddlers (p = 0.03) and PCNL in infants (p = 0.04) and school age children (p = 0.03). There were no differences in availability of pediatric equipment. CONCLUSIONS: Pediatric urologists, have significantly more exposure than endourologists during fellowship and are more comfortable performing surgical treatment for urolithiasis in most pediatric ages. Endourology fellowships may benefit from greater exposure to pediatric patients with stones.

Ureteroscopy is more cost effective than shock wave lithotripsy for stone treatment: systematic review and meta-analysis.

INTRODUCTION: A rising incidence of kidney stone disease has led to an increase in ureteroscopy (URS) and shock wave lithotripsy (SWL). Our aim was to compare the cost of URS and SWL for treatment of stones. METHODS: A systematic review and meta-analysis based on Cochrane and PRISMA standards was conducted for all studies reporting on comparative cost of treatment between URS and SWL. The cost calculation was based on factual data presented in the individual studies as reported by the authors. English language articles from January 2001 to December 2017 using Medline, PubMed, EMBASE, CINAHL, Cochrane library and Google Scholar were selected. Our study was registered with PROSPERO (International prospective register of systematic reviews)-registration number CRD 42017080350. RESULTS: A total of 12 studies involving 2012 patients (SWL-1243, URS-769) were included after initial identification and screening of 725 studies with further assessment of 27 papers. The mean stone size was 10 and 11 mm for SWL and URS, respectively, with stone location in the proximal ureter (n = 8 studies), distal ureter (n = 1), all locations in the ureter (n = 1) and in the kidney (n = 2). Stone free rates (84 vs. 60%) were favourable for URS compared to SWL (p < 0.001). Complication rates (23 vs. 30%) were non-significantly in favor of SWL (p = 0.11) whereas re-treatment rates (11 vs. 27%) were non-significantly in favor of URS (p = 0.29). Mean overall cost was significantly lower for URS ($2801) compared to SWL ($3627) (p = 0.03). The included studies had high risk of bias overall. On sub-analysis, URS was significantly cost-effective for both stones < 10 and ≥ 10 mm and for proximal ureteric stones. CONCLUSION: There is limited evidence to suggest that URS is less expensive than SWL. However, due to lack of standardization, studies seem to be contradictory and further randomized studies are needed to address this issue.

TISU: Extracorporeal shockwave lithotripsy, as first treatment option, compared with direct progression to ureteroscopic treatment, for ureteric stones: study protocol for a randomised controlled trial.

BACKGROUND: Urinary stone disease is very common with an estimated prevalence among the general population of 2-3%. Ureteric stones are associated with severe pain as they pass through the urinary tract and have significant impact on patients' quality of life due to the detrimental effect on their ability to work and need for hospitalisation. Most ureteric stones can be expected to pass spontaneously with supportive care. However, between one-fifth and one-third of cases require an intervention. The two standard active intervention options are extracorporeal shockwave lithotripsy (ESWL) and ureteroscopic stone retrieval. ESWL and ureteroscopy are effective in terms of stone clearance; however, they differ in terms of invasiveness, anaesthetic requirement, treatment setting, complications, patient-reported outcomes (e.g. pain after intervention, time off work) and cost. There is uncertainty around which is the most clinically effective in terms of stone clearance and the true cost to the NHS and to society (in terms of impact on patient-reported health and economic burden). The aim of this trial is to determine whether, in adults with ureteric stones, judged to require active intervention, ESWL is not inferior and is more cost-effective compared to ureteroscopic treatment as the initial management option. METHODS: The TISU study is a pragmatic multicentre non-inferiority randomised controlled trial of ESWL as the first treatment option compared with direct progression to ureteroscopic treatment for ureteric stones. Patients aged over 16 years with a ureteric stone confirmed by non-contrast computed tomography of the kidney, ureter and bladder (CTKUB) will be randomised to either ESWL or ureteroscopy. The primary clinical outcome is resolution of the stone episode (no further intervention required to facilitate stone clearance) up to six months from randomisation. The primary economic outcome is the incremental cost per quality-adjusted life years (QALYs) gained at six months from randomisation. DISCUSSION: Determining whether ESWL is not inferior clinically and is cost-effective compared to ureteroscopic treatment as the initial management in adults with ureteric stones who are judged to require active treatment is relevant not only to patients and clinicians but also to healthcare providers, both in the UK and globally. TRIAL REGISTRATION: ISRCTN registry, ISRCTN92289221 . Registered on 21 February 2013.

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.

The economics of stone disease.

The rising prevalence of kidney stone disease is associated with significant costs to healthcare systems worldwide. This is in part due to direct procedural and medical management costs, as well as indirect costs to health systems, patients, and families. A number of manuscripts evaulating the economics of stone disease have been published since the 2008s International Consultation on Stone Disease. These highlight costs associated with stone disease, including acute management, surgical management, and medical management. This work hopes to highlight optimization in care by reducing inefficient treatments and maximizing cost-efficient preventative strategies.

Cost-effectiveness comparison of ureteral calculi treated with ureteroscopic laser lithotripsy versus shockwave lithotripsy.

PURPOSE: To evaluate the cost-effectiveness of shockwave lithotripsy (SWL) versus ureteroscopic lithotripsy (URS) for patients with ureteral stones less than 1.5 cm in diameter. METHODS: Patient age, stone diameter, stone location, and stone-free status were recorded for patients treated with SWL or URS for ureteral stones under 1.5 cm over a 1 year period. Institutional charges were obtained from in-house billing. A decision analysis model was constructed to compare the cost-effectiveness of SWL and URS using our results and success rates for modeling. Three separate models were created to reflect differing practice patterns. RESULTS: A total of 113 patients were included-51 underwent SWL and 62 underwent URS as primary treatment. Single procedure stone-free rates for SWL and URS were 47.1 and 88.7 %, respectively (p < 0.002). Decision analysis modeling demonstrated cost-effectiveness of SWL when SWL single procedure stone-free rates (SFR) were greater than or equal to 60-64 % or when URS single procedure SFRs were less than or equal to 57-76 %, depending on practice patterns. CONCLUSIONS: This retrospective study revealed superior SFR for ureteral stones less than 1.5 cm treated with URS compared to SWL. Our decision analysis model demonstrated that when SFR for SWL is less than 60-64 % or is greater than 57-76 % for URS, SWL is not a cost-effective treatment option. Based on these findings, careful stratification and selection of stone patients may enable surgeons to increase the cost-effectiveness of SWL.

Cost-Free Laser Caging in the Operating Room.

We have assembled a three-step process for securing and presetting the functional length of the laser fiber to be used for ureteroscopic lithotripsy. For this process, three components are required: a sterile piece of adhesive, an empty guidewire casing with a pre-attached Luer-Lok™ fitting, and a SureSeal® adapter. The only additional piece of equipment for this arrangement not routinely used during ureteroscopy is the sterile adhesive strip.