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.

Cost-effectiveness of Retrograde Intrarenal Surgery, Standard and Mini Percutaneous Nephrolithotomy, and Shock Wave Lithotripsy for the Management of 1-2cm Renal Stones.

OBJECTIVE: To perform a cost-effectiveness evaluation comparing the management options for mid-size (1-2cm) renal stones including percutaneous nephrolithotomy (PCNL), retrograde intrarenal surgery (RIRS), and shockwave lithotripsy (SWL). METHODS: A Markov model was created to compare cost-effectiveness of PCNL, mini-PCNL, RIRS, and SWL for 1-2cm lower pole (index patient 1) and PCNL, RIRS, and SWL for 1-2 cm non-lower pole (index patient 2) renal stones. A literature review provided stone free, complication, retreatment, secondary procedure rates, and quality adjusted life years (QALYs). Medicare costs were used. The incremental cost-effectiveness ratio (ICER) was compared with a willingness-to-pay(WTP) threshold of $100,000/QALY. One-way and probabilistic sensitivity analyses were performed. RESULTS: At 3 years, costs for index patient 1 were $10,290(PCNL), $10,109(mini-PCNL), $5,930(RIRS), and $10,916(SWL). Mini-PCNL resulted in the highest QALYs(2.953) followed by PCNL(2.951), RIRS(2.946), and SWL(2.943). This translated to RIRS being most cost-effective followed by mini-PCNL(ICER $624,075/QALY) and PCNL(ICER $946,464/QALY). SWL was dominated with higher costs and lower effectiveness. For index patient 2, RIRS dominated both PCNL and SWL. For index patient 1: mini-PCNL and PCNL became cost effective if cost ≤$5,940 and ≤$5,390, respectively. SWL became cost-effective with SFR ≥75% or cost ≤$1,236. On probabilistic sensitivity analysis, the most cost-effective strategy was RIRS in 97%, mini-PCNL in 2%, PCNL in 1%, and SWL in 0% of simulations. CONCLUSION: For 1-2cm renal stones, RIRS is most cost-effective. However, mini and standard PCNL could become cost-effective at lower costs, particularly for lower pole stones.

Análisis comparativo de costes directos e indirectos de dos técnicas mínimamente invasivas, para el tratamiento de la litiasis renoureteral menor de 2 cm / Comparative analysis of direct and indirect costs of two minimally invasive techniques for the treatment of renal/ureteral calculi smaller than 2 cm

OBJETIVO: Analizar de forma comparativa los costes indirectos y directos de dos técnicas mínimamente invasivas (litotricia extracorpórea (LEOC) vs. ureterorrenoscopia-láser holmium (URS/RIRS)) para el tratamiento de la litiasis reno-ureteral menor de 2 cm. MATERIAL Y MÉTODOS: Estudio prospectivo y comparativo, no aleatorizado de 84 pacientes tratados por litiasis reno-ureteral menor de 2 cm entre enero y diciembre de 2016. De estos, 38 (45,67%) se trataron con LEOC (18 litiasis renales y 20 litiasis ureterales) y 46 (54,32%) con URS/RIRS (22 litiasis renal y 24 litiasis ureteral). Un total de 19 (41,3%) pacientes estaban activos laboralmente en el grupo de URS/RIRS y 15 (39,5%) pacientes en el grupo de LEOC. Las variables analizadas fueron sexo, edad, número y tamaño de las litiasis, días de baja laboral debido al tratamiento, estimación del coste indirecto por la pérdida de productividad laboral y el coste directo del tratamiento aplicado incluyendo el seguimiento (número total de procedimientos, procedimientos auxiliares, visitas y pruebas diagnósticas). Para la estimación del coste indirecto se empleó la Encuesta de Estructura Salarial 2015 (INE). Además, también se utilizó el cuestionario «Work Productivity and Activity Impairment» (WPAI) para determinar el grado de percepción de pérdida de productividad. RESULTADOS: El número medio de sesiones hasta la resolución de la litiasis fue de 2,57 para el grupo de LEOC y de 1,04 para la URS. El promedio de días de baja laboral en el grupo de la URS fue de 7,16 días, mientras que en el caso de la LEOC fue de 3,18 (p = 0,034). Los costes indirectos totales derivados de la pérdida de productividad fueron de 621,55 € y de 276,05 € para la URS y LEOC, respectivamente. Los costes directos en el grupo de la LEOC fueron de 1.382,9 € y 2.317,71 € en el grupo de la URS. El grado de afectación en el trabajo percibido por los pacientes sometidos a URS fue del 18,88% y del 21,33% en el grupo de LEOC. El grado de afectación para realizar actividades cotidianas fue del 24,44% en URS y del 15% en LEOC. CONCLUSIONES: La LEOC es una técnica que precisa de un mayor número medio de sesiones para la resolución de la litiasis reno-ureteral menor de 2 cm, pero con una menor repercusión en los costes totales y en la percepción del grado de afectación

OBJECTIVE: To perform a comparative analysis of indirect and direct costs of two minimally invasive techniques (extracorporeal shock wave lithotripsy (ESWL) vs. ureteroscopy with holmium laser (URS/RIRS)) for the treatment of renal/ureteral calculi smaller than 2 cm. MATERIAL AND METHODS: Prospective, comparative, non-randomized study of 84 patients treated for kidney stones smaller than 2 cm between January and December 2016. Of these, 38 (45.67%) were treated with ESWL (18 renal lithiasis and 20 ureteral lithiasis) and 46 (54.32%) with URS/RIRS (22 renal lithiasis and 24 ureteral lithiasis). A total of 19 (41.3%) patients in the URS/RIRS group and 15 (39.5%) patients in the ESWL group were actively working before treatment. The variables analyzed were sex, age, number and size of lithiasis, time (days) off from work due to treatment, estimate of indirect cost due to labor productivity loss and direct treatment costs including follow-up (total number of procedures, ancillary care, visits and diagnostic tests). The 2015 Wage Structure Survey (INE) was used to estimate the indirect cost. In addition, the «Work Productivity and Activity Impairment» (WPAI) questionnaire was also used to determine the level of perceived productivity loss. RESULTS: The mean number of sessions until lithiasis resolution was achieved was 2.57 for the ESWL group and 1.04 for the URS. The mean number of days off from work in the URS group was 7.16 days and 3.18 (p = 0.034) in the ESWL group. The total indirect costs resulting from productivity loss were EUR 621.55 and EUR 276.05 for the URS and ESWL, respectively. Direct costs in the ESWL group were EUR 1,382.9 and EUR 2,317.71 in the URS group. The level of work impairment perceived by patients undergoing URS was 18.88% and 21.33% in the ESWL group. The degree of impairment for performing activities of daily living was 24.44% in the URS and 15% in ESWL. CONCLUSIONS: The ESWL technique requires a higher number of sessions for the resolution of kidney stones under 2 cm, but it has a lower impact on total costs and on the perceived degree of affectation

Comparative analysis of direct and indirect costs of two minimally invasive techniques for the treatment of renal/ureteral calculi smaller than 2 cm. / Análisis comparativo de costes directos e indirectos de dos técnicas mínimamente invasivas, para el tratamiento de la litiasis renoureteral menor de 2 cm.

OBJECTIVE: To perform a comparative analysis of indirect and direct costs of two minimally invasive techniques (extracorporeal shock wave lithotripsy (ESWL) vs. ureteroscopy with holmium laser (URS/RIRS)) for the treatment of renal/ureteral calculi smaller than 2 cm. MATERIAL AND METHODS: Prospective, comparative, non-randomized study of 84 patients treated for kidney stones smaller than 2 cm between January and December 2016. Of these, 38 (45.67%) were treated with ESWL (18 renal lithiasis and 20 ureteral lithiasis) and 46 (54.32%) with URS/RIRS (22 renal lithiasis and 24 ureteral lithiasis). A total of 19 (41.3%) patients in the URS/RIRS group and 15 (39.5%) patients in the ESWL group were actively working before treatment. The variables analyzed were sex, age, number and size of lithiasis, time (days) off from work due to treatment, estimate of indirect cost due to labor productivity loss and direct treatment costs including follow-up (total number of procedures, ancillary care, visits and diagnostic tests). The 2015 Wage Structure Survey (INE) was used to estimate the indirect cost. In addition, the «Work Productivity and Activity Impairment¼ (WPAI) questionnaire was also used to determine the level of perceived productivity loss. RESULTS: The mean number of sessions until lithiasis resolution was achieved was 2.57 for the ESWL group and 1.04 for the URS. The mean number of days off from work in the URS group was 7.16 days and 3.18 (p = 0.034) in the ESWL group. The total indirect costs resulting from productivity loss were EUR 621.55 and EUR 276.05 for the URS and ESWL, respectively. Direct costs in the ESWL group were EUR 1,382.9 and EUR 2,317.71 in the URS group. The level of work impairment perceived by patients undergoing URS was 18.88% and 21.33% in the ESWL group. The degree of impairment for performing activities of daily living was 24.44% in the URS and 15% in ESWL. CONCLUSIONS: The ESWL technique requires a higher number of sessions for the resolution of kidney stones under 2 cm, but it has a lower impact on total costs and on the perceived degree of affectation.

The clinical and cost effectiveness of surgical interventions for stones in the lower pole of the kidney: the percutaneous nephrolithotomy, flexible ureterorenoscopy and extracorporeal shockwave lithotripsy for lower pole kidney stones randomised controlled trial (PUrE RCT) protocol.

INTRODUCTION: Renal stones are common, with a lifetime prevalence of 10% in adults. Global incidence is increasing due to increases in obesity and diabetes, with these patient populations being more likely to suffer renal stone disease. Flank pain from stones (renal colic) is the most common cause of emergency admission to UK urology departments. Stones most commonly develop in the lower pole of the kidney (in ~35% of cases) and here are least likely to pass without intervention. Currently there are three technologies available within the UK National Health Service to remove lower pole kidney stones: extracorporeal shockwave lithotripsy (ESWL), percutaneous nephrolithotomy (PCNL) and flexible ureterorenoscopy (FURS) with laser lithotripsy. Current evidence indicates there is uncertainty regarding the management of lower pole stones, and each treatment has advantages and disadvantages. The aim of this trial is to determine the clinical and cost effectiveness of FURS compared with ESWL or PCNL in the treatment of lower pole kidney stones. METHODS: The PUrE (PCNL, FURS and ESWL for lower pole kidney stones) trial is a multi-centre, randomised controlled trial (RCT) evaluating FURS versus ESWL or PCNL for lower pole kidney stones. Patients aged ≥16 years with a stone(s) in the lower pole of either kidney confirmed by non-contrast computed tomography of the kidney, ureter and bladder (CTKUB) and requiring treatment for a stone ≤10 mm will be randomised to receive FURS or ESWL (RCT1), and those requiring treatment for a stone >10 mm to ≤25 mm will be randomised to receive FURS or PCNL (RCT2). Participants will undergo follow-up by questionnaires every week up to 12 weeks post-intervention and at 12 months post-randomisation. The primary clinical outcome is health status measured by the area under the curve calculated from multiple measurements of the EuroQol five dimensions five-level version (EQ-5D-5L) questionnaire up to 12 weeks post-intervention. The primary economic outcome is the incremental cost per quality-adjusted life year gained at 12 months post-randomisation. DISCUSSION: The PUrE trial aims to provide robust evidence on health status, quality of life, clinical outcomes and resource use to directly inform choice and National Health Service provision of the three treatment options. TRIAL REGISTRATION: ISRCTN: ISRCTN98970319. Registered on 11 November 2015.

Percutaneous nephrolithotomy versus flexible ureteroscopy in terms of cost-effectiveness in patients with 10-30 mm renal stones.

PURPOSE: Kidney stones are one of the most common urological problems. When deciding on the method of treatment for this common disease, the cost of the procedure should also be taken into consideration. MATERIALS AND METHODS: We performed a retrospective analysis of 55 patients who underwent percutaneous nephrolithotomy and 75 patients who underwent retrograde intrarenal surgery between January 2016 and November 2018. Until operative success was achieved, all additional surgical procedures, extracorporeal shock wave lithotripsy procedures, and interventional procedures required to resolve complications were recorded. Total cost was compared between the percutaneous nephrolithotomy and retrograde intrarenal surgery groups. RESULTS: No significant difference was found between the percutaneous nephrolithotomy and retrograde intrarenal surgery groups in terms of gender, mean age, stone side, stone localization and stone surface area. The total cost of 55 patients that underwent percutaneous nephrolithotomy was calculated as US$14.766 after the first operation, and the total cost of 75 patients that underwent retrograde intrarenal surgery was determined to be US$46.627. The mean cost per patient was calculated US$320 ± US$186 for percutaneous nephrolithotomy and US$749 ± US$242 for retrograde intrarenal surgery (p < 0.001). CONCLUSIONS: Percutaneous nephrolithotomy is a lower-cost and successful method in the surgical treatment of 1-3 cm stones, but the serious complications involved in this operation should be kept in mind.

Flexible ureteroscopy: reuse? Or is single use the new direction?

PURPOSE OF REVIEW: Single-use flexible ureteroscopes (su-fURS) aim at overcoming the main limitations of conventional reusable ureteroscopes in terms of acquisition and maintenance costs, breakages, and reprocessing. However, little data exist to date regarding the superiority of su-fURS at this regard. We aimed to perform a systematic literature review on available su-fURS performance with a focus on clinical data for all articles in the last 10 years. RECENT FINDINGS: To date, more than 10 different su-fURS are available on the market, with different characteristics and performance. Some of these devices have top-level features, almost catching up with those observed in reusable flexible ureteroscopes. Clinical evidence is mainly available only for two models, LithoVue and Uscope PU3022, and to date it is not strong enough to support routine adoption and use of su-fURS, with a consequent lack of consensus of specific clinical indications. Cost-effectiveness analyses seem to indicate an economic disadvantage in the routine adoption of su-fURS. Environmental issues related to the use of su-fURS also remain to be inquired and addressed. SUMMARY: Since their introduction, su-fURS have gained widespread popularity. Despite their ability at addressing reusable ureteroscope limitations, high-cost and a substantial lack of evidence are still limiting their routine adoption.

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.

Single use versus reusable digital flexible ureteroscopes: A prospective comparative study.

OBJECTIVES: To compare the performance and surgical outcomes of two different single-use digital flexible ureteroscopes with a reusable video flexible ureteroscope. METHODS: Patients undergoing retrograde flexible ureteroscopy at Nepean Hospital, Sydney, Australia, were included in this study. Three different flexible ureteroscopes were used in this study: (i) single-use digital LithoVue (Boston Scientific, Marlborough, MA, USA); (ii) single-use digital PU3022A (Pusen, Zhuhai, China); and (iii) reusable digital URF-V2 (Olympus, Tokyo, Japan). Visibility and maneuverability was rated on a 5-point Likert scale by the operating surgeon. Operative outcomes and complications were collected and analyzed. RESULTS: A total of 150 patients were included in the present study. Of these, 141 patients had ureteroscopy for stone treatment, four for endoscopic combined intrarenal surgery and five for diagnostic/tumor treatment. There were 55 patients in the LithoVue group, 31 in the PU3022A group and 64 patients in the Olympus URF-V2 group. The URF-V2 group had higher visibility scores than both the single-use scopes and higher maneuverability scores when compared with the PU3022A. The LithoVue had higher visibility and maneuverability scores when compared with the PU3022A. There were no differences in operative time, rates of relook flexible ureteroscopes, scope failure or complication rates observed. CONCLUSIONS: Single-use digital flexible ureteroscopes have visibility and maneuverability profiles approaching that of a reusable digital flexible ureteroscope. Single-use flexible ureteroscopes achieve similar clinical outcomes to the more expensive reusable versions.

A comprehensive literature-based equation to compare cost-effectiveness of a flexible ureteroscopy program with single-use versus reusable devices.

PURPOSE: To critically review all literature concerning the cost-effectiveness of flexible ureteroscopy comparing single-use with reusable scopes. MATERIALS AND METHODS: A systematic online literature review was performed in PubMed, Embase and Google Scholar databases. All factors potentially affecting surgical costs or clinical outcomes were considered. Prospective assessments, case control and case series studies were included. RESULTS: 741 studies were found. Of those, 18 were duplicated and 77 were not related to urology procedures. Of the remaining 646 studies, 59 were considered of relevance and selected for further analysis. Stone free and complication rates were similar between single-use and reusable scopes. Operative time was in average 20% shorter with digital scopes, single-use or not. Reusable digital scopes seem to last longer than optic ones, though scope longevity is very variable worldwide. New scopes usually last four times more than refurbished ones and single-use ureterorenoscopes have good resilience throughout long cases. Longer scope longevity is achieved with Cidex and if a dedicated nurse takes care of the sterilization process. The main surgical factors that negatively impact device longevity are lower pole pathologies, large stone burden and non-use of a ureteral access sheath. We have built a comprehensive fi nancial costeffective decision model to fl exible ureteroscope acquisition. CONCLUSIONS: The cost-effectiveness of a fl exible ureteroscopy program is dependent of several aspects. We have developed a equation to allow a literature-based and adaptable decision model to every interested stakeholder. Disposable devices are already a reality and will progressively become the standard as manufacturing price falls.

A comprehensive literature-based equation to compare cost-effectiveness of a flexible ureteroscopy program with single-use versus reusable devices

ABSTRACT Purpose to critically review all literature concerning the cost-effectiveness of flexible ureteroscopy comparing single-use with reusable scopes. Materials and Methods A systematic online literature review was performed in PubMed, Embase and Google Scholar databases. All factors potentially affecting surgical costs or clinical outcomes were considered. Prospective assessments, case control and case series studies were included. Results 741 studies were found. Of those, 18 were duplicated and 77 were not related to urology procedures. Of the remaining 646 studies, 59 were considered of relevance and selected for further analysis. Stone free and complication rates were similar between single-use and reusable scopes. Operative time was in average 20% shorter with digital scopes, single-use or not. Reusable digital scopes seem to last longer than optic ones, though scope longevity is very variable worldwide. New scopes usually last four times more than refurbished ones and single-use ureterorenoscopes have good resilience throughout long cases. Longer scope longevity is achieved with Cidex and if a dedicated nurse takes care of the sterilization process. The main surgical factors that negatively impact device longevity are lower pole pathologies, large stone burden and non-use of a ureteral access sheath. We have built a comprehensive financial cost-effective decision model to flexible ureteroscope acquisition. Conclusions The cost-effectiveness of a flexible ureteroscopy program is dependent of several aspects. We have developed a equation to allow a literature-based and adaptable decision model to every interested stakeholder. Disposable devices are already a reality and will progressively become the standard as manufacturing price falls.

Assessing Cost-Effectiveness of New Technologies in Stone Management.

Diagnosis, treatment, and follow-up are all influential in determining the overall cost to the health care system for kidney stones. New innovations in the field of nephrolithiasis have been abundant, including disposable ureteroscopes, ultrasound-guided approaches to percutaneous nephrolithotomy, and advanced laser lithotripters. Identifying cost-effective treatment strategies encourages practitioners to be thoughtful about providing value-based high-quality care and remains on important principle in the treatment of urinary stone disease.

Ureteral stenting practices following routine ureteroscopy: an international survey.

PURPOSE: Stent omission after routine ureteroscopy (rtURS) is accepted by current guidelines and may result in decreased patient morbidity and treatment costs. In a value-based healthcare model, the added morbidity and cost of routine stent placement may be scrutinized. Furthermore, data are limited on urologist cost knowledge and it is effect on ureteral stent placement. As such, we seek to describe ureteral stenting practices and urologist cost knowledge amongst US and non-US-based urologists. METHODS: The ureteroscopic practice patterns and cost awareness of members of the Endourological Society were surveyed using an international email listserv. Respondents were grouped by practice location (US vs non-US). Logistic regression was used to evaluate the associations of surgeon practice location with stenting practices. RESULTS: 233 completed responses were received with a response rate of 13.5%. Results revealed that 55% and 71% of respondents reported ureteral stent insertion after rtURS more than 75% of the time for ureteral and renal stones, respectively. Reporting stent insertion following more than 75% of rtURS was more common among US participants for both ureteral and renal stones. Overall, reported cost knowledge was high, but lower among US participants. On multivariable analysis, US respondents were more likely to place ureteral stents after rtURS for ureteral stones more than 75% of the time when compared to those abroad (OR 3.43 p < 0.01). CONCLUSION: Ureteral stenting after rtURS is over utilized in the US compared to other countries. While this phenomenon is multifactorial in nature, cost knowledge may be under recognized as a determinant of ureteral stent placement following rtURS.

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.

Single-Use Flexible Ureteroscopes: How Do They Compare with Reusable Ureteroscopes?

Flexible ureteroscopy has become an important tool in the urologist's armamentarium. Until recently, reusable ureteroscopes were the only tools available to perform ureteroscopy. However, in recent years, single-use flexible and semirigid ureteroscopes have been developed as an alternative to reusable ureteroscopes. These disposable ureteroscopes were designed to mitigate problems associated with the use of reusable ureteroscopes, including the high costs related to ureteroscope acquisition, maintenance, processing, sterilization, and repairs. In this review, we provide an overview of currently available single-use flexible ureteroscopes, which include LithoVue, Uscope, NeoFlex, and Shaogang, as well as the Neoscope semirigid ureteroscope. The functional capabilities (deflection, irrigation, and optical properties) of each ureteroscope are also discussed.

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.

Fiberoptic versus Digital: A Comparison of Durability and Cost Effectiveness of the Two Flexible Ureteroscopes.

AIMS: We aimed to evaluate the durability and cost effectiveness of the latest digital flexible ureterescope by comparing it with the conventional fiberoptic one. MATERIALS AND METHODS: Data of patients who underwent retrograde intrarenal surgery between January 2013 and December 2014 were collected. Fiberoptic Flex-X2 or digital Cobra vision flexible ureteroscopes were used for the procedures. The comparison of both ureteroscopes was performed in terms of patient and stone characteristics, operative outcomes, durability, and cost effectiveness. RESULTS: A total of 105 patients were evaluated for the study. The patient and stone characteristics and operative outcomes were similar between the groups. Overall, 54 and 51 procedures were performed using Flex-X2 and Cobra vision, respectively, before they were sent for renovation. The purchase prices were USD 29,500 for Flex-X2 and USD 58,000 for Cobra vision. Costs of per case were determined as USD 549.29 for Flex-X2 and as USD 1,137.25 for Cobra vision. Per minute working time costs were USD 772.04 and 1,471.33 for Flex-X2 and Cobra vision respectively. CONCLUSIONS: The digital Cobra vision has high costs without any difference in durability as compared to Flex-X2. Moreover, it has no benefit over Flex-X2 in terms of surgical outcomes.