Presented by: Amit Shemesh MD
Samson Assuta Ashdod University Hospital

Introduction

Surgical interventions play a significant role in the direct treatment costs associated with urolithiasis. This study aims to evaluate the expenditure related to surgical treatment in patients presenting with ureteral stones at the Emergency Department (ED).

 

Materials

A retrospective analysis was conducted on all patients admitted to the ED and found to have a ureteric stone on CT. Clinical, laboratory, and imaging parameters were collected, along with data regarding admissions, ED readmissions, surgical procedures, and the total cost of treatment. The different cost rates were compared with regard to different stone parameters and characteristics, patient clinical presentation, laboratory results, admissions and surgical intervention.

Results

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Between 2018 and 2020, a total of 805 patients visiting a single institution's ED were identified with CT-proven ureteral stone. Of them, 296 patients underwent surgical procedures. Eleven patients (3.7%) underwent kidney drainage (KD) only (ureteral stent/nephrostomy), 260 (87.8%) ureteroscopy (URS) with or without retrograde internal renal surgery (RIRS), 4 (1.4%) percutaneous nephrolithotomy (PCNL), 4 (1.4%) extracorporeal shockwave lithotripsy (ESWL) and 17 (5.7%) patients underwent multiple procedure (MP). PCNL patients had the highest treatment cost (30,776$), followed by MP (21,016$), KD (16,326$), URS (12,435$) and ESWL (11,165$) [p<0.001]. The average hospital stay was longest for PCNL patients with 15.75 days, followed by KD (15.7 days), MP (8.4 days), URS (6 days) and ESWL (4.25 days) [p<0.001]. PCNL patients had larger stones (p<0.001) and higher rate of proximal stone (0.003). Patients underwent KD, had higher inflammatory markers (CRP p<0.001, WBC p=0.02), positive urine culture rate (p=0.026) and ICU admissions (p<0.001). On logistic regression, length of stay was the sole parameter correlating with treatment costs (pearson correlation 0.937). A number of 188 patients underwent kidney drainage prior surgery. 171 (91%) ureteral stent (US), 11 (6%) nephrostomy (PCN), 3 (1.5%) multiple PCN and 3 (1.5%) multiple US and PCN. Pre-drainage increased the total treatment cost, with patient underwent multiple PCN having the highest expenditure (52,290$), followed by multiple US and PCN (29,503$), PCN (18,893$), US (13,257$) and without drainage (11,274$) [p<0.001].

Conclusion

Surgical treatment costs for ureteral stone are chiefly affected by hospital length of stay, which is dictated by stone burden, infectious state, and patient general health.

Funding

None

Co-Authors

Dor Golomb, MD
Samson Assuta Ashdod University Hospital

Hanan Goldberg, MD, MSc
SUNY Upstate Medical University

Eyal Hen, MD
Samson Assuta Ashdod University Hospital

Fahed Atamna, MD
Samson Assuta Ashdod University Hospital

Amir Cooper, MD
Samson Assuta Ashdod University Hospital

Orit Raz, MD
Samson Assuta Ashdod University Hospital