比較多次手術處理近端輸尿管結石先使用輸尿管鏡碎石或先使用體外震波碎石兩組臨床與經濟上的差異
高銘鴻1,2, 王炯珵1,3
恩主公醫院泌尿科1; 台大醫院泌尿部2; 中原大學醫學工程系3
The comparison of economic and clinical outcome in dealing with proximal ureteral stone requiring multiple procedures between initial ureteroscopic lithotripsy or extracorporeal shock wave lithotripsy
Ming-Hong Kao1,2, Cheng-Chung Wang1,3
Department of Urology, En Chu Kong Hospital, New Taipei City, Taiwan1 ;
Department of Urology, College of Medicine, National Taiwan University, Taipei, Taiwan 2 ; Department of Biomedical Engineering, Chung Yuan Christian University, Taoyuan, Taiwan 3
Purpose: To investigate the real-world clinical and economical feature of dealing with difficult proximal ureteral stones, we compared the total cost and clinical outcome in treating proximal ureteral stones requiring multiple procedures with initial ureteroscopic lithotripsy(URS-L) or extracorporeal shock wave lithotripsy(ESWL)
Materials and Methods: 213 patients undergoing both URS-L and ESWL for the same proximal ureteral stone were included in this study. The patient medical records, images, and billing statements of all patients for proximal ureteral stones between January 2011 and September 2015 at a regional hospital were reviewed. These patients had at least one episode of URS-L and ESWL during the whole course of managing the same proximal ureteral stone. Two groups were compared according to the initial treatment URS-L or ESWL. Furthermore, we divided these patients in different stone size groups (> 1cm and < 1 cm ).
Results: A total of 81 patients were in the URSL first group and 112 patient in the ESWL first group. The URSL first group seemed to had higher total cost (80147+27224 versus 67683+11229 TWD, p<0.0001), longer hospital days (3.81+3 versus 2.7+0.8 days, p=0.002 ), longer DBJ placement days(17.8+11.1 versus 13.8+10.2 days, p<0.001), larger stone sizes (1.48+0.56 versus 1.04+0.47 cm , p <0.001), more pre-operative urosepsis(12.4% versus 0%,p<0.0001), chronic kidney disease (9.8% versus 0%,p<0.0001), and pre-OP acute kidney injury (19.6% versus 0%,p<0.001). The complication rate was comparable (1.2% versus 0%,0=0.038). For stone smaller than 1 cm , 16 patients were in URSL first group and 68 patients were in ESWL group. The total cost of URSL first was statistically comparable (65271+9030 TWD versus 63926+8545 TWD , p= 0.065) . For stone 1 cm or larger, 65 patients were in URSL first group and 64 patients were in ESWL first group. The total cost of URSL first was statistical higher than ESWL first group(83809+28995 versus 71674+12374 TWD, p<0.001) and hospital days of URSL first were longer (3.97+3.31 versus 2.86+0.71 fays). The URSL first group also had more chronic kidney disease patient (12.6% versus 0%, p=0.006), pre-OP AKI (20% versus 0%, p<0.001) and pre-OP sepsis (12.6% versus 0%, p=0.006).
Conclusion: The urologists tended to use URS-L first to manage larger proximal ureteral stone and more complicated patients. The URSL first groups seemed to deal with larger proximal ureteral stones and more complicated patients. The total costs of URSL first were higher in stone size 1 cm or larger. The larger and complicated proximal stones accompanied with higher cost.