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Purpose: To help rein in surgical spending there is growing interest in the application of payment bundles to common outpatient procedures like ureteroscopy and shock wave lithotripsy. However, before urologists can move to such a payment system they need to know where episode costs are concentrated., Materials and Methods: Using claims data from Michigan Value Collaborative we identified patients who underwent ureteroscopy or shock wave lithotripsy at hospitals in Michigan from 2012 to 2015. We then totaled expenditures for all relevant services during the 30-day surgical episodes of these patients and categorized component payments (ie those for the index procedure, subsequent hospitalizations, professional services and postacute care). Finally we quantified the variation in total episode expenditures for ureteroscopy and shock wave lithotripsy across hospitals, examining drivers of this variation., Results: A total of 9,449 ureteroscopy and 6,446 shock wave lithotripsy procedures were performed at 62 hospitals. Among these hospitals there was threefold variation in ureteroscopy and shock wave lithotripsy spending. The index procedure accounted for the largest payment difference between high vs low cost hospitals (ureteroscopy $7,936 vs $4,995 and shock wave lithotripsy $4,832 vs $3,207, each p <0.01), followed by payments for postacute care (ureteroscopy $2,207 vs $1,711 and shock wave lithotripsy $2,138 vs $1,104, each p <0.01). Across hospitals the index procedure explained 68% and 44% of the variation in episode spending for ureteroscopy and shock wave lithotripsy, and postacute care payments explained 15% and 28%, respectively., Conclusions: There exists substantial variation in ambulatory surgical spending across Michigan hospitals for urinary stone episodes. Most of this variation can be explained by payment differences for the index procedure and for postacute care services., (Copyright © 2018 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: Questions remain regarding the durability and longevity of flexible ureteroscopes. The objective of this study was to estimate the potential economic benefits of single use, flexible digital ureteroscopes compared to our recent experience with reusable flexible digital ureteroscopes using cost-benefit analysis., Materials and Methods: Ureteroscopic procedures were prospectively recorded over the 12-month period of February 2014 to February 2015. All flexible ureteroscopies were performed using Flex X C digital ureteroscopes (Karl Storz Endoscopy-America, El Segundo, California). Cost assessment was based on the original purchasing cost and repair-exchange fees divided by the number of cases. An algorithm was created to include per case reprocessing costs and calculate the benefit-to-cost ratio. This cost was compared to potential costs of the LithoVue™, a single use digital ureteroscope., Results: In 160 cases a flexible reusable ureteroscope was used. There was damage to 11 ureteroscopes during this time with an average of 12.5 cases to failure. Excluding original purchasing costs, the cost analysis revealed an amortized cost of $848.10 per use. After 99 ureteroscope cases the cost-benefit analysis favored reusable ureteroscopes compared to disposable ureteroscopes., Conclusions: Digital ureteroscopes are the latest trend in the evolution of endourology. It appears that a disposable ureteroscope may be cost beneficial at centers with a lower case volume per year. However, institutions with a high volume of cases may find reusable ureteroscopes cost beneficial., (Copyright © 2017 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: The 2012 American Urological Association (AUA) Clinical Effectiveness Protocols for Imaging in the Management of Ureteral Calculous Disease recommends routine postoperative imaging after ureteroscopy. We evaluated the cost-effectiveness of routine postoperative imaging after ureteroscopy., Materials and Methods: We searched the literature to determine the risk of complications after routine ureteroscopy for stones, including the incidence of postoperative pain, stricture and silent obstruction. Sequelae of renal loss due to undiagnosed silent obstruction may include chronic kidney disease, end stage renal disease and cardiovascular disease. Imaging and procedure costs were obtained from Medicare reimbursement rates and the literature. The costs and prevalence of lifetime complications associated with silent loss of 1 kidney were obtained from the renal donor transplant literature. A decision tree was constructed to calculate the cost of a strategy of routinely imaging all patients after ureteroscopy vs selective imaging based on postoperative pain. We performed 1-way and 2-way sensitivity analyses., Results: The average cost per patient of a strategy of routine imaging after ureteroscopy in all patients was $5,326 vs $5,196 for a strategy of selective imaging based on postoperative pain. Assuming a 2% rate of silent obstruction, the cost per kidney saved would be $6,262., Conclusions: While routine postoperative imaging carries a $130 per patient incrementally higher cost over that of a strategy of selective imaging in patients with postoperative pain, preventing renal loss and its attendant morbidity justifies the additional modest cost., (Copyright © 2013 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: We evaluated the cost-effectiveness of anti-retropulsion devices used during ureteroscopic lithotripsy., Materials and Methods: A decision analysis model was constructed to compare the cost-effectiveness of ureteroscopic lithotripsy with vs without an anti-retropulsion device. The risk of stone retropulsion was determined from published data in the English language literature. Expected value calculations were used to determine whether the additional cost of a device would be cost-effective to prevent secondary procedures used to treat retropulsed stones. Device cost was determined using the average cost of all commercially available devices., Results: It became cost-effective to use an anti-retropulsion device at or above a 6.3% retropulsion rate. The weighted probability of retropulsion with vs without an anti-retropulsion device was 98.1% vs 83.7%. The estimated costs of secondary procedures needed to treat retropulsed stones were $5,290 for shock wave lithotripsy and $6,390 for ureteroscopy. Average device cost was $278. Thus, the average additional cost of ureteroscopic lithotripsy with vs without an anti-migration device would be $384 vs $952., Conclusions: It is cost-effective to use an anti-retropulsion device at a retropulsion rate of greater than 6.3%., (Copyright © 2013 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: We evaluated the cost-effectiveness of ureteral/renal stone treatment by comparing ureteroscopy, extracorporeal shock wave lithotripsy and percutaneous nephrolithotomy., Materials and Methods: We performed a systematic literature search to identify studies of treatment for adults with ureteral and renal stones that were published between 1995 and 2010. For inclusion in analysis studies had to provide the stone-free rate and the cost of at least 2 therapies., Results: Ten studies were identified, including 8 with an observational design and 2 that synthesized data using decision modeling techniques. Five of 6 studies, including 1 of 2 from the United States, compared ureteroscopy vs shock wave lithotripsy for proximal stones and showed a higher stone-free rate and lower cost for ureteroscopy. Four of the 5 studies, including the only American study, compared ureteroscopy vs shock wave lithotripsy for distal ureteral stones and also showed such an economically dominant result. Studies of shock wave lithotripsy vs percutaneous nephrolithotomy and ureteroscopy vs percutaneous nephrolithotomy for renal stones demonstrated higher cost and a higher stone-free rate for percutaneous nephrolithotomy., Conclusions: Despite the great heterogeneity and limited quality of available cost-effectiveness evaluations most studies demonstrated that ureteroscopy was more favorable than shock wave lithotripsy for ureteral stones in stone-free rate and cost., (Copyright © 2012 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: While percutaneous nephrostolithotomy is the standard of care for renal stones greater than 2 cm, recent studies have shown that staged ureteroscopy/holmium laser lithotripsy may be a reasonable option. Stones 2 to 3 cm may be amenable to ureteroscopy as well as to 1-stage treatment based on their intermediate size. We compared clinical outcomes and the estimated cost of percutaneous nephrostolithotomy vs ureteroscopy for 2 to 3 cm renal stones., Materials and Methods: We retrospectively identified patients who underwent percutaneous nephrostolithotomy and ureteroscopy at our institution from 2004 to 2008 with a maximal renal stone diameter of 2 to 3 cm. Demographic information, disease characteristics, intraoperative and postoperative data, and complications were recorded. Stone clearance was reported as a residual stone burden of 0 to 2 mm and less than 4 mm. Cost was estimated using local Medicare reimbursements for surgeon, anesthesia, hospital and outpatient services., Results: A total of 20 patients underwent percutaneous nephrostolithotomy and 19 underwent ureteroscopy for 2 to 3 cm renal stones. The estimated cost of percutaneous nephrostolithotomy was significantly greater than that of ureteroscopy ($19,845 vs $6,675, p <0.0001). There were significantly more second stage procedures among percutaneous nephrostolithotomy cases (11 vs 1, p = 0.003). Stone clearance (0 to 2 mm) was superior for percutaneous nephrostolithotomy vs ureteroscopy (89% vs 47%, p = 0.01). Using a less than 4 mm threshold stone clearance improved to 100% vs 95% (p not significant). Two patients (10.5%) with ureteroscopy required subsequent ipsilateral stone surgery. They were noncompliant with medical/dietary therapy or radiographic surveillance., Conclusions: While percutaneous nephrostolithotomy achieves superior stone clearance, ureteroscopy achieves acceptable treatment outcomes with a low risk of subsequent stone related events or interventions. The lower relative cost of ureteroscopy in this population may have implications for the development of treatment guidelines.

Purpose: Recent collective reviews show that ureteral stenting provides a decrease in ureteroneocystostomy anastomotic complications following renal transplantation. We identified the specific morbidity associated with urinary complications following renal transplantation and quantified the health care resources required to treat these patients at a high volume center., Materials and Methods: Prospective databases were used to identify patients with a renal transplant who had urinary complications and track postoperative hospital readmissions and admission diagnostic codes. Financial models were used to estimate the variable direct costs of prophylactic stent placement and removal. Cost based analysis was performed to assess the financial feasibility of routine stenting following renal transplantation., Results: Patient specific morbidity and hospital readmissions were significantly increased in patients with a transplant who had a urinary complication. The incremental hospital costs incurred in a patient with a renal transplant who had urinary leakage during the first 12 months postoperatively was $20,121. Routine placement of an anastomotic stent was inexpensive. Approximately 22 or 23 stents could be placed at the same incremental cost of treating 1 patient with a urinary complication in the hospital., Conclusions: Urinary anastomotic complications following renal transplantation are highly morbid. Even with modest decreases in urinary complications prophylactic ureteral stent placement is financially advantageous.

Purpose: We determined the optimal treatment for primary ureteropelvic junction obstruction based on cost using a decision tree model., Materials and Methods: A comprehensive literature search for articles addressing surgical correction of ureteropelvic junction obstruction was performed and data were abstracted on operative time, hospital stay, complications and success rate. The overall cost and individual cost centers at our institution for antegrade endopyelotomy, retrograde ureteroscopic endopyelotomy, Acucise (Applied Medical Resources, Laguna Hills, California) endopyelotomy, laparoscopic pyeloplasty and open pyeloplasty were compared. A decision tree model estimated the cost of treatment and followup for each modality using commercially available software. Sensitivity analyses were performed to evaluate the effect of individual treatment variables on overall cost., Results: Based on cost center review retrograde ureteroscopic endopyelotomy was the least costly procedure ($2,891). In the decision tree model the rank order of overall treatment costs was: retrograde ureteroscopic endopyelotomy ($3,842), Acucise endopyelotomy ($4,427), antegrade endopyelotomy ($5,297), laparoscopic pyeloplasty ($7,026) and open pyeloplasty ($7,119). Despite various hospital stay, operative time, equipment cost and success rate data 1-way sensitivity analysis revealed that antegrade endopyelotomy, laparoscopic pyeloplasty and open pyeloplasty were never cost effective compared with retrograde ureteroscopic endopyelotomy or Acucise endopyelotomy, while 2-way sensitivity analysis favored retrograde ureteroscopic endopyelotomy., Conclusions: Primary cost variables for ureteropelvic junction obstruction treatments include operative time, hospital stay, equipment cost and success rate. Decision tree analysis showed that retrograde ureteroscopic or Acucise endopyelotomy is the most cost-effective treatment modality at our institution. However, cost is only 1 of a number of factors that are considered when deciding on an optimal course of treatment.

Purpose: Medical management is generally recommended for recurrent calcium stones to prevent future episodes. However, in this era of extracorporeal shock wave lithotripsy and outpatient ureteroscopy it is not known whether medical prophylaxis is more cost-effective than treatment of recurrent stone episodes. The cost of medical prophylaxis was compared with the cost of clinically managing recurrent stone episodes, and the stone recurrence rate without prophylaxis (stone frequency) at which these 2 treatment approaches became cost equivalent was determined., Materials and Methods: An international cost survey was conducted in 10 countries to compare costs of medical prophylaxis and managing recurrent acute stone episodes. Costs of an acute stone episode included an emergency room visit, associated radiographic imaging to confirm diagnosis of a symptomatic stone and outpatient treatment of upper urinary tract stones that did not pass spontaneously. Costs of medical management included an initial limited metabolic evaluation, drug therapy, a followup office visit every 6 months that included a 24-hour urinalysis and radiographic imaging of the kidneys, ureters and bladder once a year., Results: Costs of medical prophylaxis and managing an acute stone episode varied significantly from country to country. The stone frequency at which costs of these management options became equivalent ranged from 0.3 to 4 stone episodes a year., Conclusions: Medical management of a first stone episode is not cost-effective. Cost analysis should be individualized for specific health care plans to determine which practice patterns are most cost-effective for a particular patient with recurrent calcium stone formation.

Purpose: We prospectively compared plain film radiography and noncontrast, thin cut helical computerized tomography (CT) to flexible nephroscopy for detecting residual stones after percutaneous nephrostolithotomy., Materials and Methods: We prospectively evaluated 36 patients (41 renal units) undergoing percutaneous nephrostolithotomy for large (greater than 3 cm., 23 renal units) or staghorn (18 renal units) calculi. All patients underwent postoperative imaging with plain film of the kidneys, ureters and bladder and noncontrast helical CT, and flexible nephroscopy on postoperative day 2 or 3. The size and location of residual fragments determined radiographically and identified by flexible nephroscopy were compared., Results: Plain film radiography and CT detected an average of 0.7 and 3.4 stones per renal unit, respectively. With a mean operating time plus or minus standard deviation of 77.3+/-35 minutes and a mean fluoroscopy time of 7.6+/-6.7 minutes, an average of 2.3 stones per renal unit were retrieved at flexible nephroscopy. In 90.2% of renal units all calices could be directly inspected. The sensitivity and specificity were 46% and 82% for plain film radiography, and 100% and 62% for CT, respectively, using flexible nephroscopy as the gold standard for detecting residual stones. The overall stone-free rate after flexible nephroscopy was 92.6%. The cost of this procedure is $5,625.13 compared to $220 for CT, including the interpretation fee, at our institution., Conclusions: Selective use of flexible nephroscopy after percutaneous nephrostolithotomy based on positive CT findings will avoid an unnecessary operation in 20% of patients. The rate of unnecessary procedures is 32% if all patients undergo flexible nephroscopy, regardless of radiographic findings. At our institution this strategy will result in a cost savings of $109,687 per 100 patients.