Ghani KR, Rojanasarot S, Cutone B et al: The economic burden of cystoscopy-based ureteral stent removal in the United States: an analysis of nearly 30,000 patients. Urol Pract 2021; 9: 40.

Ureteroscopy is the most common therapeutic modality to treat upper urinary tract stone disease¹ and one of the most frequently performed procedures by urologists.² Stents are routinely placed by urologists in nearly 75% of ureteroscopy procedures to help maintain the outflow of urine from the kidney to the bladder.³ Removing the ureteral stent often requires a return visit to a medical facility and a subsequent cystoscopic procedure. Cystoscopy-based stent removal (CBSR) can be a painful procedure for the patient and may entail a high cost for the health care system. Patients undergoing CBSR may also experience procedure-related complications such as infection or encrustation of the stent due to long stent indwell times.⁴

Given the potential burden of CBSR, the rate of CBSR following ureteroscopy for stone disease and its economic burden among working-age adults in the United States was examined.⁵ This retrospective cohort study included privately insured adults who underwent ureteroscopy and stent placement for upper urinary tract stones between 2014 and 2018 using the IBM^® MarketScan® Commercial Database, a nationally representative health care claims database of U.S. workers with employer-provided health insurance. Patients were categorized as those with CBSR or without CBSR within 6 months post-index ureteroscopy and examined the medical costs paid by insurers at 6 months post-index surgery.

Figure. Medical costs at 6 months post-ureteroscopy in patients with CBSR (n=16,682) versus without CBSR (n=12,853).⁵

The key findings of this study were 1) more than half of the patients (57%) in this claims data study had a CBSR procedure within 6 months following ureteroscopy and stenting for stone disease, and 2) medical costs for CBSR patients were significantly higher than for nonCBSR patients in this large working-age population.⁵ Approximately 70% of the CBSR patients had their stent removed in a physician’s office setting, and the remaining 30% had their stents removed in either a hospital setting or ambulatory surgical center. The average 6-month medical costs for patients undergoing CBSR were significantly higher than those for nonCBSR patients ($7,808 vs $6,231, p <0.0001; see figure).⁵ An incremental $1,500 was spent on CBSR per patient, indicating a substantial economic burden associated with stent removal. The findings provided insight into the economic burden of CBSR and are consistent with prior single-institution studies examining the costs and medical resource utilization associated with ureteral stent removal showing that CBSR patients were more costly than nonCBSR patients.^6,7

A key strength of this study was the identification of nearly 30,000 patients who underwent ureteroscopy with stent placement and more than 16,000 patients with CBSR. The analysis represented all settings of care and all U.S. geographic regions, which improves the generalizability of these findings compared to single-institution studies. Additionally, this study employed a unique methodological approach that established a patient comorbidity profile prior to the index surgery and then followed these patients longitudinally over 6 months to capture their costs and medical resource utilization. A key limitation of this study is the lack of data in the IBM MarketScan database for stents removed either by the patients themselves or by providers without the use of cystoscopy. This information is not available in the IBM MarketScan database as these types of encounters are not reimbursed and paid for by insurers. Therefore, the economic burden from this study is only applicable to CBSR.

The findings of this study underscore the importance of stent selection by urologists. Stents that facilitate an easy extraction with an extraction string (ie via self-removal at home) instead of a cystoscopic procedure may decrease the costs of care to the health care system by potentially avoiding a procedure at a medical facility and freeing up urologists’ time for other patient care activities. Stent designs that offer biocompatible materials, promote optimal drainage, improve tolerability and mitigate some of the complications related to CBSR such as encrustation may provide an economic benefit to the health care system as well. Given the growing emphasis on value-based health care among payers and providers, the findings of this study suggest shifting to a less costly treatment pathway for stone patients undergoing ureteroscopy with stent placement may lead to cost-savings for the health care system.