Young JA, 0 Garden EB, Al-Alao O et al: Disposable versus reusable cystoscopes: a micro-costing value analysis in high-volume and low-volume urology practices. Urol Pract 2021; 8: 466.

Cystourethroscopy is one of the most commonly utilized procedures by urologists worldwide and has traditionally been performed with reusable equipment that is sterilized between procedures. However, in recent years, single-use disposable cystoscopes have grown in popularity.^1,2 As these tools become increasingly available, it is important for clinicians to understand the economic implications of integrating this technology into their practices.

Advocates of single-use equipment cite theoretical economic advantages derived from eliminating sterilization and maintenance costs for reusable scopes, as well as the potential for increased workplace efficiency and decreased post-procedural infections.³ Whereas reusable equipment costs are largely incurred with the up-front purchase of capital goods, disposable equipment requires regular restocking, which could be costlier in the long term. These dynamics may also manifest differently based on specific practice locations. Studies comparing Coloplast’s Isiris® disposable cystoscope with built-in grasper against traditional reusable equipment have yielded mixed results, suggesting a breakeven point of 704 procedures until the reusable equipment becomes cost-effective.⁴ The recently released Ambu® aScope™ 4 Cysto cystoscope was evaluated for cost and value analysis.⁵

We retrospectively reviewed cystoscopy procedures performed at two outpatient clinics in New York City: one high-volume multi-provider practice (HVP), which performed 1,984 procedures, and one low-volume single-provider practice (LVP), which performed 245 procedures.⁵ For each practice, we performed a micro-costing analysis evaluating the real-world per-case costs of cystoscopy using reusable Olympus® equipment compared to the theoretical per-case costs of procedures with the Ambu aScope 4 Cysto disposable cystoscope.

For reusable equipment, the analysis factored in the amortized costs of the cystoscopes and towers, sterilization and reprocessing pathways, annual service contracts and repairs, and medical assistant labor costs. Meanwhile, for single-use equipment, in addition to labor costs, the analysis incorporated the tiered pricing model offered by Ambu for their disposable cystoscopes, with manufacturer’s suggested retail price (MSRP) bulk pricing varying based on facility volume. For instance, the HVP analysis used the price point used for bulk purchasing of >1,000 scopes, while the LVP was studied at the price point used for bulk purchasing of 1-249 cystoscopes.

In 2019, the HVP used the Olympus reusable cystoscope annual service contract 4 times for minor repairs, while the LVP required only 1 cystoscope repair over the past 5 years. The average labor time spent per case with reusable cystoscopy was 32 minutes, while the average time spent with single-use cystoscopy was 10 minutes. This reclaimed full-time equivalent (FTE) time is represented by the difference in indirect fixed costs between models. Based on our micro-costing analysis, the per-case cost using nine Olympus CYF-VHR reusable cystoscopes and two towers at the HVP was $65.98, compared to $227.18 for the Ambu single-use cystoscope. The per-case cost at the LVP was $232.62 using two Olympus CYF-V2 cystoscopes and $461.18 for the Ambu single-use cystoscope. At the HVP, reusable equipment was more cost-effective after 294 cystoscopies (fig. 1). At the LVP, reusable equipment was more cost-effective after only 19 cystoscopies (fig. 2). Accordingly, for high- and low-volume practices performing >294 and >19 procedures annually, respectively, the Olympus reusable cystoscope is more cost-beneficial.

Figure 1. Olympus reusable vs Ambu disposable cystoscope annual cost analysis at HVP with identification of cost-equivalent point.

Figure 2. Olympus reusable vs Ambu disposable cystoscope annual cost analysis at LVP with identification of cost-equivalent point.

Given the findings of this cost analysis, we recommended using the Ambu aScope 4 Cysto cystoscope as an adjunct rather than as a complete replacement for reusable cystoscopes in the outpatient setting. In particular, there are several noted advantages to using the Ambu aScope 4 Cysto. The scope has excellent portability and is particularly convenient when visiting satellite clinics or offices with no access to reusable equipment. Busy practices can improve throughput in office procedures by using the disposable scope during very busy portions of the day, for “add-on” procedures, end of day procedures, or particularly difficult procedures concerning for scope breakage. In addition, although not studied in this evaluation, the Ambu aScope 4 Cysto seems ideal to use in the inpatient setting for performing bedside examinations and consults in the emergency room or operating room. Provided the higher reimbursements obtainable in an Article 28 hospital setting, the Ambu aScope 4 Cysto seems very well suited for this environment and has the potential to be more economical and practical in this setting. In these ways, single-use cystoscopes may improve workflow and productivity.

There are limitations to this study. First, the results cannot be directly generalizable across all institutions and time. Equipment pricing is based on individual contracts made between organizations and product ordering specific for our facilities in 2019. The costs of Olympus and Ambu supplies may vary based on volume purchased, promotional agreements, and fiscal year. While we showed that a hypothetical cost-benefit of the disposable cystoscope is affording medical assistants more time for other revenue generating activities, this benefit is not meaningfully accounted for in our fixed case volume model. Further studies incorporating variable case volume models are necessary to elucidate savings with reclaimed FTE time. Our study does not include data comparing patient or provider satisfaction with each type of device, nor clinical data evaluating performance and safety of disposable vs reusable cystoscopes.

Finally, we have limited understanding of the environmental costs between the reusable and disposable cystoscopes. Ambu has advertised a sustainability partnership with Sharps Compliance, Inc. (Houston, Texas) to provide a pathway to recycle their single-use cystoscopes, although to the best of our knowledge there are no real-world data regarding the impact of participation in these programs. Therefore, further research is warranted to assess the ecological costs of reusable and disposable cystoscopes, as well as the efficacy of existing initiatives to optimize the sustainability of disposable equipment.

The Ambu aScope 4 Cysto cystoscope appears to augment flexibility and efficiency in urology outpatient practices. However, until costs of single-use technology abate, its use in both high- and low-volume clinics requires further evaluation.