AUA 2018: Controlling the Costs of Flexible Ureteroscopy

San Francisco, CA (  Vernon Pais, MD from Dartmouth-Hitchcock moderated the Plenary session on “Controlling the Costs of Flexible Ureteroscopy” with Michael Lipkin, MD, Ben Chew, MD, Brian Matlaga, MD and Eduardo Mazzucchi, MD as the panelists. Lipkin advocated for thoughtful pre-operative assessments prior to flexible ureteroscopy. He stated that urine analysis is required prior to any ureteroscopic procedure but that urine cultures should only be performed if there was a concern for infection. He reiterated that AUA guidelines recommended post-ureteroscopy imaging; however, given the costs of computed tomography (CT) that renal ultrasound and plain films were recommended instead. Additionally, he mentioned that ureteral stents that are placed during the case are responsible for significant costs as it is associated with an office visit and may also require cystoscopy for removal. He advocated leaving the ureteral stent on a string in the appropriately selected patient as the patients themselves could remove the stent and if an office visit was required that cystoscopy would then not be necessary. Lastly, he mentioned that studies have shown that the dusting technique may be associated with decreased costs secondary to decreased operative time.

Mazzucchi explained that costs associated with flexible ureteroscopy are significantly different in the developing world. The main sources of increased expenditure are increased costs of the devices and poor surgical/paramedic staff training. He mentioned that there were costs associated with transportation, storage, and repair of the flexible ureteroscopes and that some governments also levy a tax on the utilization of these devices. He suggested several ways to reduce these costs including utilizing portable laser devices, considering using low-cost single use flexible ureteroscopes, reducing the number of disposables (using one wire, not always using a ureteral access sheath, etc), and performing more procedures in an outpatient setting. Additional cost-saving measures are found in educating surgeons, residents and staff to properly handle and clean the flexible ureteroscopes. He also mentioned altering surgical technique by considering starting with rigid ureteroscopy and if not able to treat the stone in that manner to then switch to flexible ureteroscopy. 

Chew concluded the panel session by advocating the use of shock wave lithotripsy (SWL) as a way to reduce costs associated with flexible ureteroscopy. He mentioned that in his practice in Canada they routinely use SWL for distal ureteral stones and that these patients were rendered stone free after the first SWL in 77.6% of cases and after a second SWL in 90.2% of cases. 

Pais’ take home messages were to use thoughtful pre- and post-op testing, reduce disposable inventory, improve handling of the flexible ureteroscopes by providing better education for the surgeons along with the staff and to consider modifying surgical technique. 

Presented by: Vernon Pais, MD, Dartmouth-Hitchcock
Panelists: Ben Chew, MD Brian Matlaga, MD Michael Lipkin, MD Eduardo Mazzucchi, MD

Written by: Roshan Patel, Department of Urology, University of California-Irvine, medical writer for at the 2018 AUA Annual Meeting - May 18 - 21, 2018 – San Francisco, CA USA