Ureteroscopy increasingly used for pediatric stones

Los Angeles-Ureteroscopy (URS) is being increasingly used for surgical management of nephrolithiasis in pediatric patients, and that trend appears to be associated with cost benefits, a recent study indicates.

RELATED: Flexible URS found safe, effective in stones <2 cm

Study authors Steve Kim, MD, assistant professor of urology, and Jamal Nabhani, MD, urology resident at Keck School of Medicine, University of Southern California, Los Angeles, queried the administrative databases for two national private insurers (Humana and Ingenix) to identify surgical procedures for nephrolithiasis performed in pediatric patients during the years 2004 to 2012. In addition, they extracted data on costs for the procedures, medications, and post-treatment outpatient and emergency room (ER) visits.

After excluding a few cases of percutaneous nephrolithotomy, the review identified 618 patients who underwent 1,100 procedures. Overall, URS accounted for 368 (59.5%) of the primary procedures.

Although there was some variation from year to year in patterns of usage, there was a trend for growing primary utilization of URS over time. URS accounted for just 42% of primary procedures performed in 2004, but for 74% of primary procedures performed in 2012.

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The cost analysis showed that URS was associated with a significantly lower total cost than ESWL ($2,671 vs. $3,709), which was primarily attributable to URS having a significantly lower procedural cost ($1,637 vs. $2,861).

“URS has been shown to result in higher stone-free rates than ESWL in studies of adults with nephrolithiasis, but it is only more recently with advances in endoscopic instrumentation that URS became feasible as a surgical management option for children,” said Dr. Nabhani.

“Just as a number of other studies have shown the use of ESWL is declining while URS is increasing for management of stone disease in adults, our study points to greater uptake of URS in the pediatric population.”

Dr. Nabhani noted there have been some previous reports examining patterns of surgical management for pediatric nephrolithiasis. However, they have been in smaller populations, representing either single-center or smaller multi-institution studies. The current study was designed to provide a higher altitude view of trends at a national level.

Lower procedural cost for URS

In addition, the authors say they believe it is one of the first papers to analyze costs. Aside from finding that URS carried a roughly $1,200 lower procedural cost compared to ESWL, the study showed the mean outpatient/ER cost was significantly higher in the URS group than for ESWL ($891 vs. $689). Mean cost for medications was similar in the URS and ESWL groups ($143 vs. $159).

“The higher procedural cost of ESWL was related to both higher charges for the primary procedure and the fact that secondary procedures were more common in the ESWL cohort than in the URS group-19.2% vs. 11.4%,” Dr. Nabhani told Urology Times.

“The explanation for the higher outpatient/ER costs with URS is unclear, but it may reflect a higher rate of ER urologic consultation for ureteral stones (in contrast to renal stones) that are more likely to be treated ureteroscopically.”

Dr. Nabhani reported that the patients had a mean age of about 14 years, but the population showed a bimodal age distribution with one large group of patients in the first year of life and a second large group ranging between 16 and 18 years of age.

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