Economic Considerations in the Management of Nephrolithiasis - Beyond the Abstract

The increasing global incidence of nephrolithiasis coupled with constantly evolving technology has made it important for all urologists to understand the economic impact of this disease. In this review paper we considered the contemporary economics of urolithiasis, with an emphasis on important takeaways for the practicing urologist. 

The United States (US) spent 2.1 billion dollars on stone disease in 2000.1 This is in comparison to the 1.83 billion dollars the US spent on the same disease five years prior.1 In 2030, the projected amount of spending on nephrolithiasis in the US is set to be 4.1 billion dollars.2 These numbers only include direct costs. 

Surgical therapy for the treatment of nephrolithiasis is the primary driver for these high direct costs. Studies that have focused on the economic efficacy of surgical stone therapy have largely concluded that flexible ureteroscopy for stone treatment is economically superior for all stones with the exception of larger and lower pole stones, where percutaneous nephrolithotomy remains economically most efficient.3 In our paper we also explore the following question: do disposable flexible ureteroscopes offer an economic advantage when treating kidney stones? The simple answer is yes, they have a role, but context is important. One setting where disposable ureteroscopes are more economically efficient that reusable is in lower volume practices where the overhead required to purchase and maintain reusable ureteroscopes makes them too expensive to obtain and maintain as compared to simply using disposable scopes for all cases.  Another setting is for higher volume practices, during cases where the risk of damage to the flexible ureteroscope is high such as in lower pole stones and staghorn calculi that necessitate sustained hard flexion of the scope.4,5

We highlight that the emergency department and inpatient care are economically inefficient settings to treat the majority of stone patients. Transitioning appropriate stone evaluation and treatment to the outpatient setting presents an opportunity for health systems and individual providers to increase financial efficiency. Supported through our findings, we make the argument that medical treatment of kidney stones, in the form of medical expulsive therapy (MET), and metaphylaxis for the prophylaxis of kidney stones are cost-effective when applied to select populations, not broadly.6

Adding indirect costs increases these figures substantially. Indirect costs include such things as missed time off work and while much harder to quantify, they are just as, if not more, economically burdensome. For example, one study found the total indirect cost of stone disease per year in the United States was $775 million, based on a privately insured population who miss an average of 3.1 million workdays per year due to stone disease.7

This field is developing fast with the increasing prevalence of kidney stones and the rapid technological advancements that are making their way into practice. Subsequently, this means that the economics of the field is ever-changing. It will be exciting and worthwhile for all urologists to follow the economic considerations of stone disease in the future.   

Written by: Dan Roberson, MD, Twitter: @DSRoberson93, Colin Sperling, MD, and Ankur Shah, MD, MBA, Twitter: @Uroshah, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania

Corresponding Author: Justin Ziemba, MD, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, Twitter: @Justin_Ziemba


  1. Pearle, Margaret S., Elizabeth A. Calhoun, Gary C. Curhan, and Urologic Diseases of America Project. "Urologic diseases in America project: urolithiasis." The Journal of urology 173, no. 3 (2005): 848-857.
  2. Kittanamongkolchai, Wonngarm, Lisa E. Vaughan, Felicity T. Enders, Tsering Dhondup, Ramila A. Mehta, Amy E. Krambeck, Cynthia H. McCollough, Terri J. Vrtiska, John C. Lieske, and Andrew D. Rule. "The changing incidence and presentation of urinary stones over 3 decades." In Mayo Clinic Proceedings, vol. 93, no. 3, pp. 291-299. Elsevier, 2018.
  3. Matlaga, Brian R., Jeroen P. Jansen, Lisa M. Meckley, Thomas W. Byrne, and James E. Lingeman. "Economic outcomes of treatment for ureteral and renal stones: a systematic literature review." The Journal of urology 188, no. 2 (2012): 449-454.
  4. Martin, Christopher J., Sean B. McAdams, Haidar Abdul-Muhsin, Victoria M. Lim, Rafael Nunez-Nateras, Mark D. Tyson, and Mitchell R. Humphreys. "The economic implications of a reusable flexible digital ureteroscope: a cost-benefit analysis." The Journal of urology 197, no. 3 (2017): 730-735.
  5. Taguchi, Kazumi, Manint Usawachintachit, David T. Tzou, Benjamin A. Sherer, Ian Metzler, Dylan Isaacson, Marshall L. Stoller, and Thomas Chi. "Micro-costing analysis demonstrates comparable costs for lithovue compared to reusable flexible fiberoptic ureteroscopes." Journal of endourology 32, no. 4 (2018): 267-273.
  6. Lotan, Yair, Jeffrey A. Cadeddu, Claus G. Roerhborn, Charles YC Pak, and Margaret S. Pearle. "Cost-effectiveness of medical management strategies for nephrolithiasis." The Journal of urology 172, no. 6 Part 1 (2004): 2275-2281.
  7. Saigal, Christopher S., Geoffrey Joyce, Anga R. Timilsina, and Urologic Diseases in America Project. "Direct and indirect costs of nephrolithiasis in an employed population: opportunity for disease management?." Kidney international 68, no. 4 (2005): 1808-1814.
Read the Abstract