Decision Analysis Model Comparing Cost of Management Strategies for Pelvic Fracture Urethral Injuries

Introduction We compare the costs associated with primary endoscopic realignment vs delayed elective bulbomembranous anastomotic urethroplasty after initial management of pelvic fracture urethral injuries with suprapubic tubes. Methods Decision analysis was performed comparing the costs associated with suprapubic tube placement with a definitive bulbomembranous urethroplasty performed 2 to 3 months after injury to those associated with primary endoscopic realignment. Model assumptions based on literature review included success rates of 30% for primary endoscopic realignment, 92% for bulbomembranous urethroplasty and 50% for direct vision internal urethrotomy. Using an institutional patient database of patients undergoing suprapubic tube placement, bulbomembranous urethroplasty and direct vision internal urethrotomy, costs were estimated based on hospital and operating room costs and Medicare reimbursement rates. Sensitivity analyses were performed by varying model assumptions. Using data from the Nationwide Inpatient Sample and the National Trauma Data Bank®, the annual incidence of pelvic fracture urethral injuries nationwide was estimated. Results The total average cost of treating a pelvic fracture urethral injury with attempted primary endoscopic realignment is $11,043 vs $9,743 for suprapubic tube with elective bulbomembranous urethroplasty, for a savings of $1,300 (12%) per patient. For primary endoscopic realignment to be preferred, a success rate of 40% or better would be necessary. In addition, cost analysis calculation revealed that when bulbomembranous urethroplasty demonstrates an efficacy of 78% or greater, then suprapubic tube and elective bulbomembranous urethroplasty become more cost-effective than primary endoscopic realignment. Conclusions Given the added costs and variable outcomes of primary endoscopic realignment and subsequent endoscopic interventions, the durability of definitive urethroplasty appears to be cost-effective in treating men with pelvic fracture urethral injuries.