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Office-Based Endourology Using Fluoroscopic Guidance: Clinical Outcomes and Cost-Effectiveness
Boris Gershman, MD, Brian H. Eisner, MD, Dianne E. Sacco, MD.
Massachusetts General Hospital, Boston, MA, USA.

BACKGROUND: Endourologic procedures are increasingly being performed in the office. We examined the clinical outcomes and cost-effectiveness of endourologic procedures performed in the office using standard fluoroscopy under local anesthesia.
METHODS: We performed a retrospective review of all patients who underwent primary ureteral stent placement, ureteral stent exchange, or ureteral catheterization with retrograde pyeolography or BCG instillation under fluoroscopic guidance in the office from 9/2008 - 12/2009. All patients were given topical 1% lidocaine jelly for local anesthesia and a dose of pre-procedural antibiotics. Select cases received oral ativan for anxiolysis. Cost data was estimated from Medicare 2010 non-facility physician fees and Ambulatory Payment Classification (APC) reimbursements.
RESULTS: Endourologic procedures were attempted in 65 renal units in 38 patients (13 male, 25 female) with a mean age of 62.2 years (range 29.1 - 95.4 years). Of these procedures, there were 24 primary ureteral stent placements, 22 ureteral stent exchanges, and 19 ureteral catheterizations with retrograde pyelography or BCG instillation. No patient developed a urinary tract infection after the procedure. No procedure was terminated due to patient discomfort. Primary ureteral stent placement was successful in 23/24 (95.8%) renal units (2 bilateral). One (1/24, 4.2%) was unsuccessful in a patient with a long-standing impacted ureteral stone and ureteral stricture. Ureteral stent exchange was successful in 19/22 (86.4%) renal units. Three (3/22, 13.6%) were unsuccessful due to stent encrustation, ureteral stricture, or stent migration into the distal ureter. Of the 30 patients who underwent stent placement or exchange, indications were ureteral stone in 14 (46.7%), malignant extrinsic ureteral compression in 8 (26.7%), benign extrinsic ureteral compression in 3 (10%), ureteral stricture in 2 (6.7%), ureteropelvic junction obstruction in 2 (6.7%), and hydronephrosis of unknown etiology in 1 (3.3%). Ureteral catheterization with retrograde pyelography or BCG instillation was performed successfully in 19/19 renal units (3 bilateral). The cost of stent placement/stent exchange/retrograde pyelography is $599.74/$599.74/$346.11 when performed in the office compared with $2,306/$2,306/$2,279 when performed in the ambulatory surgical suite (respectively). The total cost savings for the 38 patients in this study was approximately $95,601, including excess cost from failure in the office.
CONCLUSIONS: Primary ureteral stent placement, ureteral stent exchange, and ureteral catheterization with ancillary procedures can be performed safely and effectively in the office in a majority of cases and in both men and women. This avoids general anesthesia, provides convenience to patient and clinician, and represents a substantial cost-savings for the healthcare system.


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