ENDOUROLOGY & LAPAROSCOPY

Evaluation of overall costs of currently available small flexible ureteroscopes
Landman J, Lee DI, Lee C, Monga M
From the Division of Urology, Washington University School of Medicine, St. Louis, Missouri; and Department of Urology, University of Minnesota School of Medicine, Minneapolis, Minnesota, USA
Urology. 2003; 62: 218-22

• Objectives: To perform a meta-analysis of the currently available data regarding the durability of flexible ureteroscopes to establish cost estimates for the purchase and use of five currently available, smaller than 9F, ureteroscopes. Healthcare costs have become increasingly germane to the determination of disease management strategies. Improved ureteroscope technology has expanded the role of these instruments. However, the initial purchase costs and high maintenance costs have become problematic with these fragile instruments.
• Methods: Ureteroscope durability data on the Storz 11274AA, Olympus URF-P3, Wolf 7325.172, ACMI AUR-7, and ACMI DUR-8 were collected from three prior studies. Combining the durability data and cost data regarding the initial purchase price and maintenance costs of these instruments, we calculated the overall costs associated with the use of each of the ureteroscopes for 25, 50, 75, and 100 cases during the first year (warranties included) and with subsequent use.
• Results: The variability in the costs associated with the use of the currently available smaller than 9F ureteroscopes was significant. The initial instrument purchase price, durability, repair costs, and associated warranties all contributed to large discrepancies in the cost of performing ureteroscopy. In this model, during the first year of ownership, the projected cost of performing 100 ureteroscopic cases varied by a difference of 95% depending on the ureteroscope used.
• Conclusions: Physicians and institutions that perform ureteroscopy should strongly consider the purchase price, durability, repair cost, and associated warranties before the purchase of small flexible ureteroscopes.
  
  
• Editorial Comment
  The most impressive advances in the surgical treatment of urolithiasis over the past decade have been in ureteroscopy. The holmium:YAG laser is a significantly superior flexible lithotrite, and ancillary instruments such as tip less nitinol baskets and improved ureteral access sheaths have contributed greatly as well. Certainly, however, the most prominent improvements have been with regards to the size and capabilities of flexible ureteroscopes. The 7 to 8F flexible ureteroscopes, with working channels in excess of 3F, allow routine access to all portions of the upper urinary tract. As pointed out in this article, these instruments come at a considerable price. Although the initial purchase price of these ureteroscopes are similar, ranging from $11,995 to $15,000 (USD), there is greater variability in the cost of major repairs, the degree of damage covered by the warranties, and – most importantly – the durability of the scopes. With the exception of the ACMI DUR-8 (the new Storz ureteroscope was not included in this analysis), the other four ureteroscopes have been shown in a previous study to last only 9.4 to 14.5 cases before repair is required. These figures were drawn from a head-to-head comparison of these ureteroscopes published previously, while the durability of the ACMI DUR-8 (25 cases before repair) was obtained from a meeting abstract that examined only that instrument. As such, the markedly improved figure for the DUR-8 could be due in part to other factors, but the concept that durability (as well as repair cost and warranty coverage) makes a large difference in the overall cost of using a small-caliber ureteroscope is valid. The authors give us the very interesting figure “on the basis of consistent data provided by all four manufacturers” that 70% of ureteroscopes sent in for repair have been damaged by user error - usually holmium:YAG laser damage to the working channel. The take-home message is: if you want to minimize the cost of flexible ureteroscopy, then determine the repair cost and warranty coverage of a ureteroscope, consider its reported durability, and be careful with the lithotrite.

Dr. J. Stuart Wolf Jr.
Associate Professor of Urology
University of Michigan
Ann Arbor, Michigan, USA