Comparison of Extracorporeal Shock Wave Lithotripsy versus Ureteroscopy Holmium Laser Lithotripsy in the Management of Ureteral Stones: A Cost-effectiveness Analysis

Abstract

Objective: To determine the better cost-effective treatment strategy for ureteral stones in a health district of Eastern Spain. Methods: A total of 180 patients were treated between June 2012 and December 2013 for ureteral stones using two different strategies (SWL as initial treatment and URS as rescue technique vs URS and laser lithotripsy (up to 2 procedures). We performed an economic evaluation through a cost effectiveness analysis comparing costs and outcome. We performed a differentiating model in patients with lithiasis less than 1 cm or equal to or larger than 1 cm. The effectiveness parameter was the stone free rate (SFR), defined as the absence of lithiasis fragments or the presence of clinically insignificant residual fragments (CIRFs) - less than 3 mm at the 3 month follow up. A decision tree was developed and a Monte Carlo simulation was performed to establish uncertainty. Results: The SWL as first line was equally or more effective and cheaper than URS as first line of treatment for ureteral stones regardless of location or size. The overall cost for SWL (plus URS as second line) was 1,445,86 € and its SFR was 99.7%, and 2,369,21 and 97.62% for URS group. After the Montecarlo sensitivity analysis, the SWL showed dominance or cost-effectiveness in the vast majority of times, for each position and size. Conclusions: SWL as first line of treatment was more efficient in terms of cost effectiveness than first line URS with Ho: YAG laser lithotripsy for ureteral stones. Given its level of stone clearance, a non-invasive, outpatient based treatment like lithotripsy should remain the first-line treatment option for ureteral stones