Economics of stone management

Objective: Cost has become an important factor, in addition to efficacy and morbidity, in determining the best therapeutic modality for a variety of disease states. We sought to evaluate the role of cost in the management of urolithiasis. Methods: A comprehensive literature search was performed to identify articles addressing the issue of cost in the medical and surgical management of renal and ureteral calculi. Published cost analyses and cost comparisons were critically reviewed to arrive at conclusions regarding the most cost-effective approach to acute stone events, surgical treatment and prophylaxis. Results: The cost of medical care, surgical treatment and medication varies widely across health care systems, resulting in differing conclusions with regard to cost-effective treatment strategies. In general, for renal calculi, percutaneous nephrostolithotomy (PCNL) is more cost effective than shock wave lithotripsy (SWL) for stones, while SWL may be cost-effective for smaller stones. For ureteral stones, observation is the least costly treatment strategy, but among surgical options, URS is less costly than SWL. For single and recurrent stone formers, prophylactic strategies involving drug therapy are more costly than conservative therapy involving dietary measures alone, but yield fewer stone recurrences. Conclusions: To determine the most cost-effective treatment strategy for the management of renal or ureteral calculi, the efficacy, cost and complication rates of each procedure, as well as the cost of retreatment for failures must be taken into consideration. International cost comparisons are limited by differing degrees of subsidization of components of health care, such as medication or surgery. Decision tree modeling allows determination of the most cost-effective treatment approach in any given health care system or institution.