ORIGINAL PAPER

The cost analysis of flexible ureteroscopic lithotripsy in 302 cases

Cenk Gurbuz • Gokhan Atıs • Ozgur Arikan •

Ozgur Efilioglu • Asıf Yıldırım • Onur Danacıoglu •

Turhan Caskurlu

Received: 5 July 2013 / Accepted: 6 November 2013

� Springer-Verlag Berlin Heidelberg 2013

Abstract The objective of this study was to audit the cost

of flexible ureterorenoscopic lithotripsy. The data for 302

consecutive flexible ureteroscopic lithotripsy (FURSL)

procedure undertaken in our department for renal stone

treatment were collected retrospectively. The costs asso-

ciated with performing FURSL, including the cost of

ancillary equipment were analyzed. This includes the cost

of the initial purchase of the ureterorenoscopes and the

holmium laser equipment. The cost of flexible ureterore-

noscopy for each lithotripsy procedure (for a total of 302

FURSL) was $118. Additional cost of ancillary equipment

including laser device, ureteral acces sheath and stone

retrival catheter were $156, $231 and $611, respectively. In

this series, the costs of the ancillary equipment including

laser exceeded the purchase and maintenance of the flexi-

ble ureteroscope. The cost of disposables rather than flex-

ible ureteroscope itself should be considered in planning

the budget.

Keywords Laser � Lithotripsy � Flexible ureteroscopy �Cost

Introduction

The advances in flexible ureteroscopy and intracorporeal

lithotripsy have revolutionized the treatment of intrarenal

calculi. Current technology allows access to and treatment

of calculi throughout the intrarenal calyceal system using a

single procedure, with stone-free rates up to 88 % [1].

However, there is some reluctance to accept this procedure

due to high equipment costs. The basic mandatory instru-

ments for flexible ureteroscopic lithotripsy (FURSL) are

laser lithotriptor and flexible ureteroscope. Equipments are

expensive to buy and flexible instruments have limited

lifespan. Not all departments have lasers and some need to

hire them. When equipment is broken, there are long delays

for replacement and repair.

Although technical efforts were made to increase ureter-

oscope durability, Afane et al. [2] reported an average of

6–15 procedures in the first generation of small-caliber

ureteroscopes before requiring some sort of repair. The loss

of deflection during treatment of lower pole stone was the

most frequent defect. These repairs are expensive, and the

durability of these instruments represents a major financial

concern [3]. During procedure, a disruption in the laser fiber

during a lower pole stone fragmentation with full deflection

damaged the working channel of one ureteroscope. Lower-

pole ureteronephroscopy requires transmission of hol-

mium:YAG energy along a deflected fiber. There is also a

risk of fiber fracture from thermal breakdown and laser-

energy transmission to the endoscope. The performance and

safety of laser fibers differ both between manufacturers and

as regards manufacturer’s line of fibers [4].

We aimed to audit the cost of FURSL undertaken in our

department.

Materials and methods

Between March 2010 and March 2013, data for 302 con-

secutive FURSL procedure for renal stone treatment were

C. Gurbuz (&) � G. Atıs � O. Arikan � O. Efilioglu �A. Yıldırım � O. Danacıoglu � T. Caskurlu

Department of Urology, Istanbul Medeniyet University Goztepe

Training and Research Hospital, Kısıklı mahallesi, Resat Bey

Sokak, Ilkkent Camlık sitesi , B Blok, D 12, Uskudar,

Istanbul, Turkey

e-mail: gurbuzcenk@yahoo.com

123

Urolithiasis

DOI 10.1007/s00240-013-0628-x

collected retrospectively. Our technique has been described

previously [5], we start the procedure with semirigid ure-

teroscope and introduce two safety guide wires and dila-

tation is done under visual control and then attempt to

insert ureteral access sheath (UAS) to the related renal unit.

All costs are presented in United States of American

Dollar ($). The cost of a new conventional flexible ure-

teroscope (Flex-X, Karl Storz, Germany) is $13.611. With

our business contract, with each major repair, the old

flexible ureterorenoscope is replaced with a new scope with

a cost $8477. Minor repair cost depending on the damage

was added. The cost of ancillary equipment, including

disposables, such as guidewire, ureteric stent, ureteric

access catheter, stone retrieval basket, and ureteric access

sheath were also included for individual procedures. The

laser generator and probes were used for multiple proce-

dures and their mean cost was based on the total number of

procedures carried out before it needed replacement.

In this audit, we only look at the costs associated with

performing FURSL, including the cost of ancillary equip-

ment. This includes the cost of the initial purchase of the

ureterorenoscopes and the holmium laser equipment. Costs

associated with staffing and hospital stay were not ana-

lyzed. Majority of the procedures were performed by high

volume (over 50 cases experience) surgeons.

Results

Of the 302 cases, renal stones were located in the renal

pelvis, upper pole or mid calyx in 10, 25 and 31.7 %,

respectively, and 33.3 % in the lower pole. The mean stone

size was 18.60 ± 11.20 mm. The success rate was 80.8 %

both immediately after the operation and 1 month later.

With an increase in the use of FURS in our department,

we now have three flexible ureterorenoscopes. Four major

and two minor repairment were required for each damage.

The cost analysis was performed only for unilateral FURSL

procedure. At the time of purchase, the ureteroscope was

listed at $13.611 and each repair/exchange currently costs

$33.908 (4 9 0.8477). Two minor repairments were

required with a cost of $1833 and technical report showed

that there was a pressure deficit in the instrument.

Initial purchase of holmium laser (Sphinx, LISA, Ger-

many) was $38.333. Two minor repairments and purchase

of new laser probes were required between 2008 and 2013.

The holmium laser and probes were used also in one

hundred rigid ureteroscopic laser lithotripsy procedures.

The mean laser cost was based on the total number (402

case) of the laser lithotripsy procedures.

The cost of flexible ureterorenoscopy for each procedure

(for a total of 302 FURSL) was $118 (A total amount of

major/minor repairment cost which is $35,741 divided to

302 cases). Additional costs of ancillary equipment

including laser device are presented in Tables 1 and 2.

Discussion

In this audit, we only look at the costs associated with

performing FURSL procedures, including the cost of

ancillary equipment. Routine use of a ureteral access

sheath appears to facilitate semirigid and flexible ureter-

oscopy by allowing direct visualization of ureteroscope

insertion with simple ureteral re-entry and assisting renal

and ureteral access with minimal associated morbidity but

the cost should be considered. In our cost analysis, almost

half of the price of FURSL procedure was from UAS

usage. Cost studies reported to favor UAS use, although a

formal cost-effectiveness analysis has not been performed

[6]. There is no consensus in the literature whether the

routine use of a ureteral access sheath is necessary [7].

Controversy in the literature regarding flexible urete-

rorenoscopy (F-URS) durability, with a variable expected

number of uses from a new F-URS. The need for repair

occurs less frequently with the new generation of URSs,

especially when they are used by an experienced endou-

rologist [8]. In our department, majority of the procedures

were performed by high volume (over 50 cases experience)

surgeons. This may partly explain the lower repair rate in

our unit, with a mean of 50 (302 procedures/6 repairs)

Table 1 Cost of flexible FURSL

Product Cost ($)

Flexible URS/302 case

Replaced with a new ureterenoscope at each major

repair

118

LASER (Hol-YAG)/402 case 132

Laser Probe (3)/402 case 24

Port seal/20 case 45

UAS (two different companies price) 140, 278

Stone Retrival catheter (1.5–1.7 FR) 611

Open-ended ureteral catheter 3.75

Double J stent (two different companies price) 12, 18

Guide/glide wire (various companies prices) 18, 78, 138

Urograffin 16

Table 2 Cost for standard

FURSL per caseCost ($)

Flexible URS 118

LASER 156

UAS 231

Guide wire 38

Total 543

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procedures before the need for repair. Binbay et al. [9]

reported their average number of uses for conventional

flexible ureteroscope before repair necessity was 17. Ka-

raolides reported the average number use as 21.6 before

damage [10]. Following the proposed guidelines for safe

use and with monitored training of new users, these

instruments can have a significantly longer lifespan. Patel

A et al. were able to use the same flexible ureteroscope

over 100 cases, the indications for F-URS were therapeutic

in 75.4 % [11]. For lower pole calculi, the stone was

relocated in 65.2 % and managed with the nonflexed

flexible instrument 90 % of the time. We rarely used stone

retrival catheter, the cost reported in current study was

$611. Mentioned article above suggested that the increased

durability of F-URS was from a variety of factors, a key

element of which was the method of sterilization, while

routine use of the semirigid instrument initially further

contributed significantly to increase the number of F-RS

procedures, saving overall costs. The cleaning and sterili-

zation process can also cause great damage. Our policy in

our department, all flexible ureteroscopes and laser probes

were processed by the well-trained urology nursing staff

rather than central staff. We believe, it is a reasonable

means to reduce processing-related damages.

Increased knowledge of the etiology of flexible ureter-

oscope damage should aid urologists in prolonging the

lives of these delicate instruments. In the present study, the

major causes of flexible ureteroscope damage were work-

ing channel damage from laser burn or instrument passage

and extreme scope deflection with an indwelling instru-

ment. The primary reasons for ureteroscope repair includ-

ing improper handling in the operating room and during

sterile processing should be differentiated from intraoper-

ative inappropriate use. By this way, departments can take

precautions to maximize the longevity of these commonly

used instruments.

The major damaged scope has been replaced with a new

scope instead of being repaired. Although this may be pos-

sible currently in the Turkey, variability in contractual

arrangements in different markets must be considered. These

agreements may not be universally accepted. Our business

contract with the manufacturers of replacing the major

damaged ureteroscopes with a new ureteroscope seems to be

cost-effective for maintaining this expensive equipment.

In this series, the costs of the ancillary equipment

including laser exceeded the purchase and maintenance of

the ureteroscope, and we expect this trend to continue in

the long term. For laser, not all departments have their laser

and some need to hire them. In the current study, the cost

for laser for individual case was $148. If it was hired from

laser company, the cost would be $333 for individual case.

The initial cost, durability, and warranty and expected

frequency of the procedure must be considered before

purchasing the laser device. From our record, the cost

benefit would be provided over 60 procedures per year.

Somani [12] reported their cost of FURS and lasertripsy

for stones is between $444 and $644. The cost variation is

based on the number of ancillary equipment used for a par-

ticular procedure. Based on their business model, they only

look at the costs associated with performing flexible urete-

rorenoscopic procedures, including the cost of ancillary

equipment. Koo [13] presented a useful comparative report

within the UK setting of cost analysis and effectiveness

between the SWL and FURS in the treatment of lower pole

renal calculi. The mean perceived cost of each FURS and

SWL procedure was similar (£249 vs. £292, respectively);

however, when all other costs were considered, the FURS

group was significantly more costly (£2602 vs. £426). In both

studies, they excluded the cost of the initial purchase of the

ureterorenoscopes or the holmium laser equipment and

maintenance/service outcomes which might be very impor-

tant. The purchase and installation costs of a hol-

mium:yttrium-aluminium-garnet lasertripsy unit are varied

in different laser companies and the costs are also related

with energy powers (20–100 W). Shared usage of laser

device in the different departments may be reasonable to

reduce the cost. Health care system in Turkey is mainly

provided by the government through several institutions.

The cost discrepancies might be expected from country to

country due to the variation of price regulation.

The limitations of our study were, we excluded the costs

associated with staffing and hospital stay. Ureteral Access

Sheath was attempted to introduce for each case, if not, the

second attempt was performed without UAS. The formal

cost analysis for the procedure with and without UAS from

the start could give us more clear answer. However, our

analysis included the cost of initial purchase of the urete-

rorenoscopes and the holmium laser equipment whereas

previous studies excluded these major cost [12–14]. The

other limitation of this study is we did not mention the need

of secondary procedures which might be important to

evaluate the cost analysis.

Cost-effectiveness analysis is a decision-making assis-

tance tool. It identifies the economically most efficient way

to fulfill an objective. But, this study only aimed to audit

the cost of flexible ureterorenoscopic lithotripsy.

In high-volume centers, to decrease the cost, the con-

tractual negotiations can be done, not only for uretero-

scopes, but also for the other ancillary equipment used. The

advent of more durable ureteroscopes may ultimately

reduce the frequency of costly repairs. It is important to

address the causes of ureteroscope damage, to develop

techniques that increase durability. In addition, UAS and

stents range in cost enormously and there is little evidence

that the most expensive UAS and stents are the best; this is

an area which requires further research. The use of routine

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UAS may not be necessary for all cases. When purchasing

a laser to facilitate flexible ureterorenoscopy, one that

permits the use of a reusable fiber is preferable. In the

present series, the laser fibers were reusable but there is no

reusable product for UAS, stone retrival catheter etc.

In our department, Laser lithotripsy is only used for

micro-percutaneous nephrolithotomy (PCNL) procedures

and not for the standard PCNL. Laser can also be used for

endopyelotomy and tumor ablation procedures but we had

limited number of case (\5). We did not involve this small

population for cost audit.

Comment and conclusion

Success with endourological procedures requires expertise

and instrumentation. Despite technical advances in urete-

roscopic design, the scopes continue to have problems with

durability. As the cost of equipment increases, in the face

of limited financial resources, there will be increasing

pressure to perform minimally invasive surgery in an

economical fashion. The cost of disposable instrumentation

used in this study was considerable and eventually over-

took the cost of the ureteroscope. We expect the costs of

ancillary equipment to continue to exceed ureteroscope

costs and the proportion of expenditure on disposable items

to increase in the long term.

Conflict of interest In this study, there are no potential or actual

competing interests.

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