THE CASE FOR PRIMARY ENDOSCOPIC MANAGEMENT OF UPPER URINARY-TRACT CALCULI .2. COST AND OUTCOME ASSESSMENT OF 112 PRIMARY URETERAL CALCULI

Objectives. To compare extracorporeal shock-wave lithotripsy (ESWL) with endoscopic lithotripsy to establish the more efficacious and cost-effective treatment for ureteral caiculi. Methods. The records of 112 patients with primary ureteral calculi treated at one center with either ESWL or endoscopic lithotripsy were retrospectively reviewed. Followup data at 1 and 3 months were obtained in all patients. Success was defined as complete clearance of a stone burden in the endoscopy group. In the ESWL group patients with a residual, asymptomatic 2-mm fragment were also considered successful treatments. The number of auxiliary procedures, retreatments, postoperative office visits, and imaging studies required before a patient was considered stone free was defined. The impact of these variables on global costs was carefully reviewed. Results. Patients with ureteral calculi primarily treated with ESWL or ureteroscopic lithotripsy had stone-free rates after a single session of 45% versus 95% at 1-month follow-up, and 62% versus 97% at 3-month follow-up. Retreatment and auxiliary procedure rates were significantly higher in the ESWL group (31% versus 3%). The mean number of postoperative visits and imaging studies until a patient was stone free was also higher in the ESWL group (2.07 versus 1.13). Operative treatment costs were similar for both modalities, but overall costs weighed heavily against ESWL. Conclusions. ESWL remains the treatment of choice for moderately sized, uncomplicated renal calculi. In skilled hands, ureteroscopic lithotripsy is by far the most expeditious and cost-effective means of clearing a ureteral stone burden.