World J Urol DOI 10.1007/s00345-015-1489-4
ORIGINAL ARTICLE
Ultra‑mini PCNL versus flexible ureteroscopy: a matched analysis of treatment costs (endoscopes and disposables) in patients with renal stones 10–20 mm Martin Schoenthaler · Konrad Wilhelm · Simon Hein · Fabian Adams · Daniel Schlager · Ulrich Wetterauer · Azad Hawizy · Andreas Bourdoumis · Janak Desai · Arkadiusz Miernik
Received: 3 November 2014 / Accepted: 9 January 2015 © Springer-Verlag Berlin Heidelberg 2015
Abstract Purpose Latest publications state equal efficacy of a recently introduced new percutaneous technique (“ultramini PCNL”, UMP) and flexible ureteroscopy (fURS) in the treatment of medium-size urinary stones. Today we face challenges concerning cost-effectiveness and reduction of in-hospital length of stay. In this retrospective study, we compare clinical outcome parameters and costs of treatment (endoscopes and disposables) of both techniques. Methods Thirty patients treated by UMP at two tertiary university centres were matched to 30 fURS patients from previously recorded databases. Data analysis included operating time, length of stay, stone-free rates (SFR), complications (>Clavien II), ancillary procedures (presurgical ureteral stenting, secondary ureteral stenting or placement of a nephrostomy tube, secondary procedures) and costs for
German Clinical Trial Register ID DRKS00006957. The work has been presented at German Urology Congress in Düsseldorf, Germany, September 2014 (partial results), 4th International Meeting “Challenges in Endourology and Functional Urology” June 2014, Paris, France (partial results). M. Schoenthaler · K. Wilhelm · S. Hein · F. Adams · D. Schlager · U. Wetterauer · A. Miernik (*) Department of Urology, University Medical Centre Freiburg, Hugstetterstr. 55, 79106 Freiburg, Germany e-mail: arkadiusz.miernik@uniklinik‑freiburg.de A. Hawizy · A. Bourdoumis Department of Urology, Endourology and Stone Services, Royal London Hospital, Bartshealth NHS Trust, London E1 1BB, UK J. Desai Department of Urology, Samved Hospital, Nr. Stadium Circle, Navrangpura, Ahmedabad 380 009, Gujarat, India
disposable materials and instruments (endoscopes, as calculated per procedure). Results We found no significant differences in operating times (UMP vs. fURS: 121/102 min), hospital length of stay (2.3/2.0 days), SFR (84/87 %) and complications (7/7 %). Costs for disposable materials and endoscopes were 656 euro (UMP) and 1,160 euro (fURS) per procedure. Conclusions UMP and fURS are both safe and effective in the treatment of medium-size urinary stones. Costs for endoscopes and disposable materials are significantly lower in UMP. Keywords Costs of treatment · Flexible ureteroscopy · Nephrolithiasis · Ultra-mini percutaneous nephrolithotomy Abbreviations fURS Flexible ureteroscopy PCNL Percutaneous nephrolithotomy SFR Stone-free rate(s) SWL Shock wave lithotripsy UMP Ultra-mini PCNL URS Ureteroscopy
Introduction The EAU guidelines on urolithiasis update 2013 upgraded endourology to first-line therapy (together with shock wave lithotripsy (SWL)) for medium-size renal stones 10–20 mm [1]. This decision was based on continuously improving clinical outcomes as a result of technological and surgical advances in endourological techniques over the last years. Both ureteroscopy (URS) and percutaneous nephrolithotomy (PCNL) are minimally invasive techniques using
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a natural orifice and route or a tiny artificial tract to reach the target organ, i.e. the kidney. Hence, surgical trauma is minimal and resulting complications are potentially low. However, standard PCNL (24–30F) bears a considerable risk of significant bleeding and blood transfusions [2]. This observation prompted efforts to further reduce trauma by both stretching the limits of flexible ureteroscopy (fURS) and minimizing access diameters in PCNL. In medium-size renal stones, flexible ureteroscopy and miniaturized PCNL may reach stone-free rates up to 97 % at equally low complications rates [3–6]. Today physicians are challenged by healthcare providers and employing institutions not only to provide patient care at the highest standards but also to respect the necessity of cost-effectiveness and reduced length of stay. This retrospective cohort study compares clinical outcome parameters and costs of treatment (endoscopes and disposables) of ultra-mini percutaneous nephrolithotomy (UMP) [5] and fURS.
Materials and methods The study was approved by the local ethics committees. In a retrospective data analysis, thirty consecutive patients treated by UMP at two tertiary university centres (University Medical Centre Freiburg and Royal London Hospital, April 2013 to March 2014) were matched to 30 fURS patients from previously recorded databases. Matching criteria were stone characteristics [size, number and location of unilateral renal stones 10–20 mm (single or cumulative)]. Cumulative stone size was calculated by summing up maximum diameters in cases of multiple stones. Data analysis included patient and stone characteristics, operating times, hospital length of stay, stone-free rates (SFR, as assessed by intraoperative inspection/fluoroscopy and post-operative sonography), complications (>Clavien II), ancillary procedures (presurgical ureteral stenting, secondary ureteral stenting or placement of a nephrostomy tube, secondary procedures). Routine stenting after fURS (usually for 2 days, removal of the stent by pulling of an attached string) was not considered an ancillary procedure. Costs were calculated for disposable materials and instruments (endoscopes, as calculated per case). Results were compared using the Student’s t test. Statistical significance was defined as p
ORIGINAL ARTICLE
Ultra‑mini PCNL versus flexible ureteroscopy: a matched analysis of treatment costs (endoscopes and disposables) in patients with renal stones 10–20 mm Martin Schoenthaler · Konrad Wilhelm · Simon Hein · Fabian Adams · Daniel Schlager · Ulrich Wetterauer · Azad Hawizy · Andreas Bourdoumis · Janak Desai · Arkadiusz Miernik
Received: 3 November 2014 / Accepted: 9 January 2015 © Springer-Verlag Berlin Heidelberg 2015
Abstract Purpose Latest publications state equal efficacy of a recently introduced new percutaneous technique (“ultramini PCNL”, UMP) and flexible ureteroscopy (fURS) in the treatment of medium-size urinary stones. Today we face challenges concerning cost-effectiveness and reduction of in-hospital length of stay. In this retrospective study, we compare clinical outcome parameters and costs of treatment (endoscopes and disposables) of both techniques. Methods Thirty patients treated by UMP at two tertiary university centres were matched to 30 fURS patients from previously recorded databases. Data analysis included operating time, length of stay, stone-free rates (SFR), complications (>Clavien II), ancillary procedures (presurgical ureteral stenting, secondary ureteral stenting or placement of a nephrostomy tube, secondary procedures) and costs for
German Clinical Trial Register ID DRKS00006957. The work has been presented at German Urology Congress in Düsseldorf, Germany, September 2014 (partial results), 4th International Meeting “Challenges in Endourology and Functional Urology” June 2014, Paris, France (partial results). M. Schoenthaler · K. Wilhelm · S. Hein · F. Adams · D. Schlager · U. Wetterauer · A. Miernik (*) Department of Urology, University Medical Centre Freiburg, Hugstetterstr. 55, 79106 Freiburg, Germany e-mail: arkadiusz.miernik@uniklinik‑freiburg.de A. Hawizy · A. Bourdoumis Department of Urology, Endourology and Stone Services, Royal London Hospital, Bartshealth NHS Trust, London E1 1BB, UK J. Desai Department of Urology, Samved Hospital, Nr. Stadium Circle, Navrangpura, Ahmedabad 380 009, Gujarat, India
disposable materials and instruments (endoscopes, as calculated per procedure). Results We found no significant differences in operating times (UMP vs. fURS: 121/102 min), hospital length of stay (2.3/2.0 days), SFR (84/87 %) and complications (7/7 %). Costs for disposable materials and endoscopes were 656 euro (UMP) and 1,160 euro (fURS) per procedure. Conclusions UMP and fURS are both safe and effective in the treatment of medium-size urinary stones. Costs for endoscopes and disposable materials are significantly lower in UMP. Keywords Costs of treatment · Flexible ureteroscopy · Nephrolithiasis · Ultra-mini percutaneous nephrolithotomy Abbreviations fURS Flexible ureteroscopy PCNL Percutaneous nephrolithotomy SFR Stone-free rate(s) SWL Shock wave lithotripsy UMP Ultra-mini PCNL URS Ureteroscopy
Introduction The EAU guidelines on urolithiasis update 2013 upgraded endourology to first-line therapy (together with shock wave lithotripsy (SWL)) for medium-size renal stones 10–20 mm [1]. This decision was based on continuously improving clinical outcomes as a result of technological and surgical advances in endourological techniques over the last years. Both ureteroscopy (URS) and percutaneous nephrolithotomy (PCNL) are minimally invasive techniques using
13
a natural orifice and route or a tiny artificial tract to reach the target organ, i.e. the kidney. Hence, surgical trauma is minimal and resulting complications are potentially low. However, standard PCNL (24–30F) bears a considerable risk of significant bleeding and blood transfusions [2]. This observation prompted efforts to further reduce trauma by both stretching the limits of flexible ureteroscopy (fURS) and minimizing access diameters in PCNL. In medium-size renal stones, flexible ureteroscopy and miniaturized PCNL may reach stone-free rates up to 97 % at equally low complications rates [3–6]. Today physicians are challenged by healthcare providers and employing institutions not only to provide patient care at the highest standards but also to respect the necessity of cost-effectiveness and reduced length of stay. This retrospective cohort study compares clinical outcome parameters and costs of treatment (endoscopes and disposables) of ultra-mini percutaneous nephrolithotomy (UMP) [5] and fURS.
Materials and methods The study was approved by the local ethics committees. In a retrospective data analysis, thirty consecutive patients treated by UMP at two tertiary university centres (University Medical Centre Freiburg and Royal London Hospital, April 2013 to March 2014) were matched to 30 fURS patients from previously recorded databases. Matching criteria were stone characteristics [size, number and location of unilateral renal stones 10–20 mm (single or cumulative)]. Cumulative stone size was calculated by summing up maximum diameters in cases of multiple stones. Data analysis included patient and stone characteristics, operating times, hospital length of stay, stone-free rates (SFR, as assessed by intraoperative inspection/fluoroscopy and post-operative sonography), complications (>Clavien II), ancillary procedures (presurgical ureteral stenting, secondary ureteral stenting or placement of a nephrostomy tube, secondary procedures). Routine stenting after fURS (usually for 2 days, removal of the stent by pulling of an attached string) was not considered an ancillary procedure. Costs were calculated for disposable materials and instruments (endoscopes, as calculated per case). Results were compared using the Student’s t test. Statistical significance was defined as p
