SWL literature
SWL Literature
Reviewer's Choice

Wymer KM. et al., 2021: Cost-effectiveness of Retrograde Intrarenal Surgery, Standard and Mini Percutaneous Nephrolithotomy, and Shock Wave Lithotripsy for the Management of 1-2cm Renal Stones.

Wymer KM, Sharma V, Juvet T, Klett DE, Borah BJ, Koo K, Rivera M, Agarwal D, Humphreys MR, Potretzke AM.
Department of Urology, Mayo Clinic, Rochester, MN.
Department of Urology, Mayo Clinic, Rochester, MN; Department of Urology, David Geffen School of Medicine; University of California, Los Angeles, CA; Greater Los Angeles VA, Health Services Research and Development Program, Los Angeles, CA.
Department of Health Services Research, Mayo Clinic, Rochester, MN.
Department of Urology, Indiana University School of Medicine, Indianapolis, IN.
Department of Urology, Mayo Clinic, Phoenix, AZ.
Department of Urology, Mayo Clinic, Rochester, MN.

Abstract

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.
Urology. 2021 Jul 15:S0090-4295(21)00640-3. doi: 10.1016/j.urology.2021.06.030. Online ahead of print. PMID: 34274389

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Commentaires 1

Peter Alken le mercredi 2 mars 2022 08:30

The data on success rates, retreatment rates and complications are derived from 2 recent metaanalyses (1,2).The costs are calculated based on Medicare reimbursement which is a bundled reimbursement not taking into account differences in costs for operating room time or length of hospital stay. Cost, billing or reimbursement differ from country to country and from doctor to doctor. The authors also provide a table with the range of costs obviously not fixed to the medicare system. There e.g. the costs for an emergency room visit vary 3-fold between 1,719-5,156 US $ and cost attributable to a complication like sepsis between 4,280-12,840.

At least in the system chosen by the authors and from a socioeconomic point of view, ESWL is the most expensive way to treat the index stones even if its low complication rate is taken into account. One conclusion is “it is likely SWL is still over-utilized with estimates of the relative frequency of SWL employment ranging from 35%- to 75%.”

ESWL disappears due to the high retreatment rate. It is time to transform the least invasive technique of stone removal into a competitive, contemporary procedure through new technologies.

See also
Herout R, Baunacke M, Groeben C, Aksoy C, Volkmer B, Schmidt M, Eisenmenger N, Koch R, Oehlschläger S, Thomas C, Huber J.
Contemporary treatment trends for upper urinary tract stones in a total population analysis in Germany from 2006 to 2019: will shock wave lithotripsy become extinct?
World J Urol. 2021 Aug 28. doi: 10.1007/s00345-021-03818-y

Peter Alken

The data on success rates, retreatment rates and complications are derived from 2 recent metaanalyses (1,2).The costs are calculated based on Medicare reimbursement which is a bundled reimbursement not taking into account differences in costs for operating room time or length of hospital stay. Cost, billing or reimbursement differ from country to country and from doctor to doctor. The authors also provide a table with the range of costs obviously not fixed to the medicare system. There e.g. the costs for an emergency room visit vary 3-fold between 1,719-5,156 US $ and cost attributable to a complication like sepsis between 4,280-12,840. At least in the system chosen by the authors and from a socioeconomic point of view, ESWL is the most expensive way to treat the index stones even if its low complication rate is taken into account. One conclusion is “it is likely SWL is still over-utilized with estimates of the relative frequency of SWL employment ranging from 35%- to 75%.” ESWL disappears due to the high retreatment rate. It is time to transform the least invasive technique of stone removal into a competitive, contemporary procedure through new technologies. See also Herout R, Baunacke M, Groeben C, Aksoy C, Volkmer B, Schmidt M, Eisenmenger N, Koch R, Oehlschläger S, Thomas C, Huber J. Contemporary treatment trends for upper urinary tract stones in a total population analysis in Germany from 2006 to 2019: will shock wave lithotripsy become extinct? World J Urol. 2021 Aug 28. doi: 10.1007/s00345-021-03818-y Peter Alken
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