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Geraghty RM et al, 2018: Ureteroscopy is more cost effective than shock wave lithotripsy for stone treatment: systematic review and meta-analysis.

Geraghty RM, Jones P, Herrmann TRW, Aboumarzouk O, Somani BK.
Department of Urology, University Hospital Southampton NHS Trust, Southampton, SO16 6YD, UK.
Clinic of Urology, Spital Thurgau AG, Frauenfeld, Switzerland.
Department of Urology, Queen Elizabeth University Hospital, Glasgow, UK.

Abstract

INTRODUCTION: A rising incidence of kidney stone disease has led to an increase in ureteroscopy (URS) and shock wave lithotripsy (SWL). Our aim was to compare the cost of URS and SWL for treatment of stones.
METHODS: A systematic review and meta-analysis based on Cochrane and PRISMA standards was conducted for all studies reporting on comparative cost of treatment between URS and SWL. The cost calculation was based on factual data presented in the individual studies as reported by the authors. English language articles from January 2001 to December 2017 using Medline, PubMed, EMBASE, CINAHL, Cochrane library and Google Scholar were selected. Our study was registered with PROSPERO (International prospective register of systematic reviews)-registration number CRD 42017080350.
RESULTS: A total of 12 studies involving 2012 patients (SWL-1243, URS-769) were included after initial identification and screening of 725 studies with further assessment of 27 papers. The mean stone size was 10 and 11 mm for SWL and URS, respectively, with stone location in the proximal ureter (n = 8 studies), distal ureter (n = 1), all locations in the ureter (n = 1) and in the kidney (n = 2). Stone free rates (84 vs. 60%) were favourable for URS compared to SWL (p < 0.001). Complication rates (23 vs. 30%) were non-significantly in favor of SWL (p = 0.11) whereas re-treatment rates (11 vs. 27%) were non-significantly in favor of URS (p = 0.29). Mean overall cost was significantly lower for URS ($2801) compared to SWL ($3627) (p = 0.03). The included studies had high risk of bias overall. On sub-analysis, URS was significantly cost-effective for both stones  < 10 and  ≥ 10 mm and for proximal ureteric stones.
CONCLUSION: There is limited evidence to suggest that URS is less expensive than SWL. However, due to lack of standardization, studies seem to be contradictory and further randomized studies are needed to address this issue.

World J Urol. 2018 May 5. doi: 10.1007/s00345-018-2320-9. [Epub ahead of print] Review.

 

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Commenti 1

Hans-Göran Tiselius il Venerdì, 14 Settembre 2018 08:26

Like many reports today this article is a ”systematic review and meta-analysis” based on reports of comparisons between SWL and URS. In the current report there was a focus on economics.

In view of the great variations in principles applied in different health care systems, it is doubtful what kind of information and conclusions that can be extracted from reviews of this kind.

From the data presented in the article the cost for SWL in average was higher than that for URS (U$ 3637 vs. U$ 2810). It needs to be emphasized, however, that the range of costs for SWL varied from U$ 120 to U$ 16900 and that for URS from U$ 630 to U$ 10000. For SWL the cost was lower than that for URS in seven out of the 17 studies referred to. Moreover, the cost was at approximately the same level in six of the reports.

There are indeed as number of problems that needs attention for cost analyses. Such factors are for instance which kind of anaesthesia that was used, whether an anaesthetist was present, operator experience, extent of out-patient treatment and radiological methods used for follow-up.

To exemplify the problems with this kind of analyses, I looked at three of the articles, two with the highest cost for SWL [1,2] and one with the lowest cost [3].

In the article by Parker and co-workers [1] patients were treated for proximal ureteral stones and the cost was based on “billing costs” rather than on “actual costs”. It is also important to note that general anaesthesia was used for 59% of patients treated with SWL (65/111). Although general anaesthesia still appears to be commonly used with SWL in USA, I personally stopped using general or regional anaesthesia in 1987, at that time with the unmodified Dornier HM3 lithotripter. In this article [1] the lithotripters used were Dornier HM4 and Doli, but none of the more recently developed lithotripters. The total average cost for all patients treated with SWL was U$ 15583 and for URS U$ 9378. Surprisingly the majority of SWL-treated patients were pre-stented (89%). This high frequency of stenting was most certainly not necessary. Nothing is mentioned in the article about hospital stay or how the equipment cost was incorporated in the calculations.

In the article by Pearle and co-workers [2], SWL and URS were used for treating patients with distal ureteral stones. The calculation of cost was based on charges and there was obviously a high professional cost. SWL was carried out with the HM3 lithotripter. Intravenous contrast was used in 44% of the cases. General anaesthesia was used for 31% of the SWL-treated patients of whom 94% were discharged the same day.

Article [3] by Cui and co-workers comprised a summary of patients treated for stones in the proximal, mid and distal ureter. General anaesthesia was used for URS but not for SWL. There was no hospital stay after SWL but 1-2 days after URS. The authors claimed that the difference in cost between the two procedures (U$ 120 vs. U$ 1180) mainly was explained by the procedural time.

It is correctly stated by the authors of the preset article that lack of standardization calls for large randomized prospective studies. For such studies it is strongly recommended that the actual cost is recorded for every procedure and every patient, step by step. This will be enabled only by carful, detailed and continuous computerized recordings.

The bottom-line of my comment is that meta-analyses carried out in an uncritical way on studies published over a long period of time give very little information on the cost effectiveness. Although complications following URS were few, I would personally consider a ureteral avulsion with chronic stent treatment (although rare today) as more problematic than minor residual fragments. Moreover, and in view of different results with the two methods, it needs to be decided to which extent repeat or auxiliary procedures are necessary in a short-term and long-term perspective.

References
1. Parker BD, Frederick RW, Reilly TP, Lowry PS, Bird ET.
Efficiency and cost of treating proximal ureteral stones: shock wave lithotripsy versus ureteroscopy plus holmium:yttrium-aluminum-garnet laser.
Urology. 2004 Dec;64(6):1102-1106
2. Pearle MS, Nadler R, Bercowsky E, Chen C, Dunn M, Figenshau RS, Hoenig DM, McDougall EM, Mutz J, Nakada SY, Shalhav AL, Sundaram C, Wolf JS Jr, Clayman RV
Prospective randomized trial comparing shock wave lithotripsy and ureteroscopy for management of distal ureteral calculi.
J Urol. 2001 Oct;166(4):1255-1260
3. Cui Y, Cao W, Shen H, Xie J, Adams TS, Zhang Y, Shao Q.
Comparison of ESWL and ureteroscopic holmium laser lithotripsy in management of ureteral stones.
PLoS One. 2014 Feb 3;9(2):e87634. doi: 10.1371/journal.pone.0087634. eCollection 2014.

Like many reports today this article is a ”systematic review and meta-analysis” based on reports of comparisons between SWL and URS. In the current report there was a focus on economics. In view of the great variations in principles applied in different health care systems, it is doubtful what kind of information and conclusions that can be extracted from reviews of this kind. From the data presented in the article the cost for SWL in average was higher than that for URS (U$ 3637 vs. U$ 2810). It needs to be emphasized, however, that the range of costs for SWL varied from U$ 120 to U$ 16900 and that for URS from U$ 630 to U$ 10000. For SWL the cost was lower than that for URS in seven out of the 17 studies referred to. Moreover, the cost was at approximately the same level in six of the reports. There are indeed as number of problems that needs attention for cost analyses. Such factors are for instance which kind of anaesthesia that was used, whether an anaesthetist was present, operator experience, extent of out-patient treatment and radiological methods used for follow-up. To exemplify the problems with this kind of analyses, I looked at three of the articles, two with the highest cost for SWL [1,2] and one with the lowest cost [3]. In the article by Parker and co-workers [1] patients were treated for proximal ureteral stones and the cost was based on “billing costs” rather than on “actual costs”. It is also important to note that general anaesthesia was used for 59% of patients treated with SWL (65/111). Although general anaesthesia still appears to be commonly used with SWL in USA, I personally stopped using general or regional anaesthesia in 1987, at that time with the unmodified Dornier HM3 lithotripter. In this article [1] the lithotripters used were Dornier HM4 and Doli, but none of the more recently developed lithotripters. The total average cost for all patients treated with SWL was U$ 15583 and for URS U$ 9378. Surprisingly the majority of SWL-treated patients were pre-stented (89%). This high frequency of stenting was most certainly not necessary. Nothing is mentioned in the article about hospital stay or how the equipment cost was incorporated in the calculations. In the article by Pearle and co-workers [2], SWL and URS were used for treating patients with distal ureteral stones. The calculation of cost was based on charges and there was obviously a high professional cost. SWL was carried out with the HM3 lithotripter. Intravenous contrast was used in 44% of the cases. General anaesthesia was used for 31% of the SWL-treated patients of whom 94% were discharged the same day. Article [3] by Cui and co-workers comprised a summary of patients treated for stones in the proximal, mid and distal ureter. General anaesthesia was used for URS but not for SWL. There was no hospital stay after SWL but 1-2 days after URS. The authors claimed that the difference in cost between the two procedures (U$ 120 vs. U$ 1180) mainly was explained by the procedural time. It is correctly stated by the authors of the preset article that lack of standardization calls for large randomized prospective studies. For such studies it is strongly recommended that the actual cost is recorded for every procedure and every patient, step by step. This will be enabled only by carful, detailed and continuous computerized recordings. The bottom-line of my comment is that meta-analyses carried out in an uncritical way on studies published over a long period of time give very little information on the cost effectiveness. Although complications following URS were few, I would personally consider a ureteral avulsion with chronic stent treatment (although rare today) as more problematic than minor residual fragments. Moreover, and in view of different results with the two methods, it needs to be decided to which extent repeat or auxiliary procedures are necessary in a short-term and long-term perspective. References 1. Parker BD, Frederick RW, Reilly TP, Lowry PS, Bird ET. Efficiency and cost of treating proximal ureteral stones: shock wave lithotripsy versus ureteroscopy plus holmium:yttrium-aluminum-garnet laser. Urology. 2004 Dec;64(6):1102-1106 2. Pearle MS, Nadler R, Bercowsky E, Chen C, Dunn M, Figenshau RS, Hoenig DM, McDougall EM, Mutz J, Nakada SY, Shalhav AL, Sundaram C, Wolf JS Jr, Clayman RV Prospective randomized trial comparing shock wave lithotripsy and ureteroscopy for management of distal ureteral calculi. J Urol. 2001 Oct;166(4):1255-1260 3. Cui Y, Cao W, Shen H, Xie J, Adams TS, Zhang Y, Shao Q. Comparison of ESWL and ureteroscopic holmium laser lithotripsy in management of ureteral stones. PLoS One. 2014 Feb 3;9(2):e87634. doi: 10.1371/journal.pone.0087634. eCollection 2014.
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