Society For Pediatric Urology

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Cost analysis of pediatric ureteral stent removal with and without a string
Hoang-Kim Le, MD1, Ryan Gleber, BS2, Kelly Swords, MD1.
1University of California San Diego/Rady Children's Hospital, San Diego, CA, USA, 2University of California San Diego, San Diego, CA, USA.

BACKGROUND: Placement of ureteral stents is often a necessary component of various urologic surgeries. This proposes several unique challenges in the pediatric population. Most notably this includes operating room costs and exposure to anesthesia associated with the removal of an indwelling stent. This, however, can be mitigated through the use of stents with retrieval strings and an in office removal. Fears of increased rate of infection have prevented widespread adoption of this practice by pediatric urologists. The aim of this study was to examine overall cost incurred by the removal of stent with strings and without.
METHODS: Cost data was obtained from Rady Children’s Hospital for patients undergoing both operative and in office stent removal. Fixed costs included lost wages for a clinic visit and charges for an operative case. Variable costs included those dependent on anesthesia time, case length and disposable equipment use. A retrospective chart review was performed for the last 20 operative stent removals prior to March 15, 2018 to obtain information regarding total in facility time (potential time for lost wages), anesthesia time, and presence of UTI. In addition, a thorough PubMed search was conducted containing the search terms “ureteral” AND “stent” AND “string” OR “complications” OR “pediatric” OR “pyeloplasty.”
RESULTS: The total average cost for operative removal was $16,452.29 compared to $564.48 for in office retrieval if the stent was removed during the global coverage period. Costs that factored into this average included parental lost wages, procedure costs (anesthesia, facility and surgeon fees, medications and equipment), and the cost of potential complications including urinary tract infections, hospital/ER visits, and medications. Stents with strings proved to be the most cost effective intervention by a differential of $15,887.81. Average anesthesia time for operative stent removal was 30 + 6 minutes. Average in facility time was 4 hours 11 minutes + 1 hour 1 minute, compared to an average estimated clinic visit time of 50 minutes. It is important to note that upon literature review and in our own patient population stents with strings had equivalent complication rates compared to stents without strings.
CONCLUSIONS: While the literature suggests there is no difference in complication rates (including UTIs), quality of life, or patient morbidity, there is a significant cost savings of more than $10,000 when comparing stents on a string removed in clinic versus surgically removed stents without a string. Ureteral stents placed with a string does not sacrifice outcomes and should be strongly considered as the preferred intervention in the pediatric population in order to decrease healthcare costs, anesthesia exposure, and parental burden.

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