Efficiency and cost of treating proximal ureteral stones: Shock wave lithotripsy versus ureteroscopy plus holmium:yttrium-aluminum-garnet laser

doi:10.1016/j.urology.2004.07.040

Urology

Volume 64, Issue 6, December 2004, Pages 1102-1106

https://doi.org/10.1016/j.urology.2004.07.040 Get rights and content

Abstract

Objectives

To compare the success rates, cost effectiveness, and efficiency of ureteroscopy (URS) and extracorporeal shock wave lithotripsy (ESWL) for proximal ureteral stones.

Methods

In a retrospective manner, 220 patients who underwent treatment for proximal ureteral stones were included in the study. The patient records, radiographs, and billing statements of all patients treated for upper ureteral stones between January 1997 and June 2001 at Scott and White Memorial Hospital were reviewed. The patients were placed into two treatment groups according to the method of their stone’s initial treatment. The stones were categorized as less than 1 cm and 1 cm or greater.

Results

A total of 111 patients were in the ESWL group, 73 of whom had stones less than 1 cm, and 109 patients in the URS group, 81 of whom had stones less than 1 cm. In the URS group, 91% were successfully treated with one treatment intervention, and 55% of the ESWL group were successfully treated with their initial intervention (P <0.0001). Of the patients with URS failure, all but one was treated successfully with a second URS. Of the patients with ESWL failure, 52% were treated successfully by subsequent URS. The remaining patients with ESWL failure were treated with repeat ESWL, with a 62% success rate. The efficiency quotient for stones less than 1 cm for URS and ESWL was 0.79 and 0.51, respectively. For stones 1 cm or greater, URS had an efficiency quotient of 0.72 and ESWL of 0.46. The URS group required fewer days to be stone free (8 versus 25.5 days, P <0.0001). No statistically significant difference was found in the overall complication rates (P = 0.43). URS had significantly lower charges for the initial procedure ($7575 versus $9507, P <0.0001). The total charges were also lower for URS ($9378 versus $15,583, P <0.0001). Complications were similar in the two groups. The URS group had two ureteral strictures.

Conclusions

The results of this study indicate that URS is more efficient and cost-effective for stones up to and larger than 1 cm with similar complication rates compared with ESWL.

Section snippets

Material and methods

The institutional review board approved this study before data accrual. All patients treated between January 1997 and June 2001 for proximal ureteral stones with either ESWL or URS and laser lithotripsy were included in this retrospective study. The billing statements, radiographs, and charts were reviewed in all patients treated at a single institution.

The study inclusion criteria included patients with radiopaque, solitary stones located between the ureteropelvic junction and sacroiliac

Results

Group 1 (URS) had 109 patients and group 2 (ESWL) had 111 patients. The patient demographics are shown in Table I. For the 81 patients with stones less than 1 cm in the URS group, the initial stone-free rate was 90% (n = 73). For the 73 patients with stones less than 1 cm in the ESWL group, the initial stone-free rate was 60% (n = 44; P <0.0001). The efficiency quotient was also greater for URS than for ESWL (0.79 versus 0.51, respectively; Table I).

Of the 66 patients with stones 1 cm or

Comment

Traditionally, proximal ureteral stones have been treated by ESWL, as outlined in the 1997 American Urological Association consensus guidelines. ESWL has proved to be safe and relatively effective for treating upper ureteral and renal stones. However, as technology has improved the accessibility and reliability of ureteroscopes, combined with laser innovations, the treatment of upper ureteral stones with URS has become a potential option. As a rural regional referral center, many of our

Conclusions

The results of our study have shown that URS with Ho:YAG laser lithotripsy is more efficient than ESWL for proximal ureteral stones. The size of the stone did not make a difference in the efficiency of removing the stone. Furthermore, the complication rates of URS were acceptably low. We also found that the charges for URS were lower than for ESWL. URS with Ho:YAG laser lithotripsy can be recommended as a safe, cost-effective, first-line therapy for all proximal ureteral stones.

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Extracorporeal shock wave lithotripsy versus ureteroscopy for management of pediatric nephrolithiasis in upper urinary tract stones: multi-institutional outcomes of efficacy and morbidity
2019, Journal of Pediatric Urology
Citation Excerpt :
Neither study provides detail on specific chief complaints or complications. Finally, several studies on adults have reported higher postoperative pain scores after URS [31–35]. Yet data are lacking regarding pain experiences after SWL and URS in children.
As the incidence of pediatric nephrolithiasis rises, understanding the efficacy and morbidity of surgical treatment options is critical. Currently, there are limited comparative data assessing shock wave lithotripsy (SWL) and ureteroscopy (URS) outcomes in children.
The objective of this study was to compare stone clearance, 30-day emergency department visits, and the number of general anesthetics required per stone treatment for both modalities.
A multi-institutional retrospective review of children presenting for either URS or SWL between 2000 and 2017 was performed. Stone clearance, need for retreatment, the number of anesthetics, as well as the number and reason for emergency room visit were captured and compared between groups. Multivariate statistical analysis accounting for age, stone location, stone diameter, pre-intervention stent, and provider volume was performed for adjusted analysis.
A total of 84 SWL and 175 URS procedures were included. Complete stone clearance and rates of residual stone fragments <4 mm after final procedure for SWL were 77.0% and 90.8% and for URS were 78.5% and 91.7%, respectively. Retreatment rates for both procedures were not significantly different (17.9% SWL vs. 18.9% URS, P = 0.85). Children who underwent SWL had lower rates of emergency room visits for infections (0% vs. 5.1%, P = 0.03) and flank pain (3.6% vs. 10.9%, P = 0.05) and required fewer general anesthetics per treatment (1.2 vs. 2.0, P < 0.01) than those who underwent URS (Figure).
Stone clearance after both the initial and final treatments and need for repeat interventions were similar between surgical modalities. However, SWL carries less morbidity than URS. Specifically, patients who underwent SWL experienced lower rates of ED visits for urinary tract infection and for flank pain, parallel to conclusions in current comparative literature. In addition, SWL requires less general anesthetics (2.0 vs. 1.2), secondary to lower rates of ureteral stent placement and removal. Data on the potential risk of general anesthetics to neurodevelopment support thoughtful utilization of these medications. Limitations of this study include its retrospective nature and the prolonged 20-year time period over which data were collected.
When adjusting for confounders, SWL and URS achieve similar stone clearance. In the setting of equivalent efficacy, considerations regarding necessity of repeat interventions, morbidity of anesthesia, and complications should be integrated into clinical practice.
Time-Driven Activity-Based Costing Analysis of Urological Stone Disease
2018, Urology Practice
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While our costing method provides an accurate depiction of service line costs, we did not incorporate treatment effectiveness, complication rates or patient preferences in our analysis. Several analyses have previously been performed incorporating surgical success rates to compare SWL and URS.13–18 In a cost-effectiveness analysis of ureteral stone treatments comparing ureteroscopy, SWL and observation, Lotan et al created a model incorporating treatment failure rates.13
The documented increasing incidence of nephrolithiasis in the United States will likely be associated with significant economic impact. Time-driven activity-based costing is an analytical method that has been successfully adapted from industrial analysis for use in health care. Using this costing approach we characterized the cost of 4 stone treatment modalities at our academic medical center, including trial of passage, semirigid ureteroscopy, flexible ureteroscopy and extracorporeal shock wave lithotripsy.
We developed process mapping for urological evaluation, treatment and followup of renal or ureteral stones less than 10 mm in size for each treatment method. We calculated cost of resources, equipment, disposables, personnel and space used for each step in the process. Cost was based on the capacity of each resource and the amount of time required for the treatment process.
The cost for trial of stone passage, $389, was expectedly lower than for surgical interventions and was mainly driven by clinic visit costs. Extracorporeal shock wave lithotripsy and semirigid and flexible ureteroscopy costs were $4,367, $4,830 and $5,356, respectively. Intraoperative disposables and personnel were the top contributors to overall treatment costs.
Conservative management is less costly than surgical interventions. Flexible ureteroscopy is the most expensive of surgical interventions. We describe the first time-driven activity-based cost analysis of stone management to our knowledge. Identifying the main drivers of cost can help to improve the value of urological care and improve future cost-effectiveness analyses.
What are the Benefits and Harms of Ureteroscopy Compared with Shock-wave Lithotripsy in the Treatment of Upper Ureteral Stones? A Systematic Review
2017, European Urology
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In general, the reported pain levels were relatively low. Two studies reported significantly higher rates of pain after URS [11,23], while the three remaining studies showed no significant difference in pain after SWL or URS treatment [9,26,31]. Retreatment was defined as a subsequent intervention for the stone disease using the same therapeutic technique as the initial treatment.
Extracorporeal shock wave lithotripsy (SWL) and ureteroscopy (URS), with or without intracorporeal lithotripsy, are the most common treatments for upper ureteric stones. With advances in technology, it is unclear which treatment is most effective and/or safest.
To systematically review literature reporting benefits and harms of SWL and URS in the management of upper ureteric stones.
Databases including Medline, Embase, and the Cochrane library were searched from January 2000 to November 2014. All randomised controlled trials (RCTs), quasi-randomised controlled trials, and nonrandomised studies comparing any subtype or variation of URS and SWL were included. The primary benefit outcome was stone-free rate (SFR). The primary harm outcome was complications. Secondary outcomes included retreatment rate, need for secondary, and/or adjunctive procedures. The Cochrane risk of bias tool was used to assess RCTs, and an extended version was used to assess nonrandomised studies. Grading of Recommendations Assessment, Development, and Evaluation was used to assess the quality of evidence.
Five thousand-three hundred and eighty abstracts and 387 full-text articles were screened. Forty-seven studies met inclusion criteria; 19 (39.6%) were RCTs. No studies on children met inclusion criteria. URS and SWL were compared in 22 studies (4 RCTs, 1 quasi-randomised controlled trial, and 17 nonrandomised studies). Meta-analyses were inappropriate due to data heterogeneity. SFR favoured URS in 9/22 studies. Retreatment rates were higher for SWL compared with URS in all studies but one. Longer hospital stay and adjunctive procedures (most commonly the insertion of a JJ stent) were more common when primary treatment was URS. Complications were reported in 11 out of 22 studies. In eight studies, it was possible to report this as a Clavien-Dindo Grade. Higher complication rates across all grades were reported for URS compared with SWL. For intragroup (intra-SWL and intra-URS) comparative studies, 25 met the inclusion criteria. These studies varied greatly in outcomes measured with data being heterogeneous.
Compared with SWL, URS was associated with a significantly greater SFR up to 4 wk but the difference was not significant at 3 mo in the included studies. URS was associated with fewer retreatments and need for secondary procedures, but with a higher need for adjunctive procedures, greater complication rates, and longer hospital stay.
In this paper, the relative benefits and harms of the two most commonly offered treatment options for urinary stones located in the upper ureter were reviewed. We found that both treatments are safe and effective options that should be offered based on individual patient circumstances and preferences.
Urolithiasis in pregnancy: A cost-effectiveness analysis of ureteroscopic management vs ureteral stenting
2015, American Journal of Obstetrics and Gynecology
The purpose of this study was to determine the cost-effectiveness of serial stenting vs ureteroscopy for treatment of urolithiasis during pregnancy as a function of gestational age (GA) at diagnosis.
We built decision analytic models for a hypothetical cohort of pregnant women who had received a diagnosis of symptomatic ureteral calculi and compared serial stenting to ureteroscopy. We assumed ureteral stent replacement every 4 weeks during pregnancy, intravenous sedation for stent placement, and spinal anesthetic for ureteroscopy. Outcomes were derived from the literature and included stent infection, migration, spontaneous kidney stone passage, ureteral injury, failed ureteroscopy, postoperative urinary tract infection, sepsis, and anesthetic complications. Four separate analyses were run based on the GA at diagnosis of urolithiasis. Using direct costs and quality-adjusted life years, we reported the incremental costs and effectiveness of each strategy based on GA at kidney stone diagnosis and calculated the net monetary benefit. We performed 1-way and Monte-Carlo sensitivity analyses to assess the strength of the model.
Ureteroscopy was less costly and more effective for urolithiasis, irrespective of GA at diagnosis. The incremental cost of ureteroscopy increased from –$74,469 to –$7631, and the incremental effectiveness decreased from 0.49 to 0.05 quality-adjusted life years for a kidney stone diagnosed at 12 and 36 weeks of gestation, respectively. The net monetary benefit of ureteroscopy progressively decreased for kidney stones that were diagnosed later in pregnancy. The model was robust to all variables.
Ureteroscopy is less costly and more effective relative to serial stenting for urolithiasis, regardless of the GA at diagnosis. Ureteroscopy is most beneficial for women who received the diagnosis early during pregnancy.
Contemporary surgical trends in the management of upper tract calculi
2015, Journal of Urology
Upper tract nephrolithiasis is a common surgical condition that is treated with multiple surgical techniques, including shock wave lithotripsy, ureteroscopy and percutaneous nephrolithotomy. We analyzed case logs submitted to the ABU by candidates for initial certification and recertification to help elucidate the trends in management of upper tract urinary calculi.
Annualized case logs from 2003 to 2012 were analyzed. We used logistic regression models to assess how surgeon specific attributes affected the way that upper tract stones were treated. Cases were identified by the CPT code of the corresponding procedure.
A total of 6,620 urologists in 3 certification groups recorded case logs, including 2,275 for initial certification, 2,381 for first recertification and 1,964 for second recertification. A total of 441,162 procedures were logged, of which 54.2% were ureteroscopy, 41.3% were shock wave lithotripsy and 4.5% were percutaneous nephrolithotomy. From 2003 to 2013 there was an increase in ureteroscopy from 40.9% to 59.6% and a corresponding decrease in shock wave lithotripsy from 54% to 36.3%. For new urologists ureteroscopy increased from 47.6% to 70.9% of all stones cases logged and for senior clinicians ureteroscopy increased from 40% to 55%. Endourologists performed a significantly higher proportion of percutaneous nephrolithotomies than nonendourologists (10.6% vs 3.69%, p <0.0001) and a significantly smaller proportion of shock wave lithotripsies (34.2% vs 42.2%, p = 0.001).
Junior and senior clinicians showed a dramatic adoption of endoscopic techniques. Treatment of upper tract calculi is an evolving field and provider specific attributes affect how these stones are treated.
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Adult urologyEfficiency and cost of treating proximal ureteral stones: Shock wave lithotripsy versus ureteroscopy plus holmium:yttrium-aluminum-garnet laser

Abstract

Objectives

Methods

Results

Conclusions

Section snippets

Material and methods

Results

Comment

Conclusions

J Urol

J Urol

J Urol

J Urol

Adult urology
Efficiency and cost of treating proximal ureteral stones: Shock wave lithotripsy versus ureteroscopy plus holmium:yttrium-aluminum-garnet laser