Ureteral Stenting and Retrograde Pyelography in the Office: Clinical Outcomes,Cost Effectiveness,and Time Savings

Introduction

E ndourologic procedures are increasingly being performed in the office. Ureteral stent removal in the office is routine, ¹ and a number of studies have questioned the need for general anesthesia for various ureteroscopic procedures. ^{2 –10} There have even been reports of ureteroscopic retrieval of migrated stents, ¹¹ surveillance ureteroscopy, ¹² upper tract Bacillus Calmette-Guerin (BCG) instillation, ¹³ and ureteroscopic lithotripsy ¹⁴ all performed in the office. Performing such procedures in the office offers potential advantages to the patient, clinician, and healthcare system in the way of convenience, avoidance of general anesthesia, cost-savings, and time-savings. Nonetheless, there has been little enthusiasm among the urologic community for these more complicated endourologic office procedures due to concerns of safety and patient tolerance. ¹⁴ In addition, there has been no analysis of the potential cost savings to the healthcare system or time savings to the patient.

At our institution, we perform ureteral stent placement, ureteral stent exchange, and ureteral catheterization with retrograde pyelography or BCG instillation in the office in select patients. We examined the clinical outcomes, cost-effectiveness, and time savings of these endourologic procedures performed in the office with topical anesthesia using standard fluoroscopy.

Materials and Methods

After obtaining Institutional Review Board (IRB) approval, we performed a retrospective review of all patients who underwent primary ureteral stent placement, ureteral stent exchange, or ureteral catheterization with retrograde pyeolography or BCG instillation under fluoroscopic guidance in the office from 9/2008–12/2009. Procedures were identified using billing data and electronic medical records were reviewed for each patient to examine technical elements and clinical outcomes. For an evaluation of potential time savings, we compared this to a cohort of similar procedures performed in the operating room during the same time period. Of note, routine stent placement at our institution is done with general anesthesia via laryngeal mask airway.

Office procedures were performed by two clinicians (D.E.S., B.H.E.) using standard endourologic techniques under fluoroscopic guidance (GE OEC 9900 Elite; GE Healthcare, Piscataway, NJ). All procedures in men were performed using the flexible cystoscope, while procedures in women were performed with either the flexible or rigid cystoscope at the surgeon's discretion. All patients were given 1% lidocaine jelly for topical anesthesia and select cases received oral ativan for anxiolysis. Patients received a single dose of preprocedural antibiotics.

Cost data for office procedures was estimated from Medicare 2010 nonfacility physician fees based on Current Procedure Terminology codes 52332 and 52205. Medicare Ambulatory Payment Classification reimbursements were used to estimate the cost of procedures performed in the ambulatory surgical suite. Excess costs for failed procedures were estimated based on hospital billing data for admission with nephrostomy tube placement and Medicare fees for relevant ambulatory surgical procedures.

Procedure, periprocedure, and total hospital time data was obtained from outpatient clinic patient tracking software for office procedures and from operating room department logs for ambulatory surgical procedures. Procedures were limited to unilateral stent placement or unilateral stent exchange for the time analysis. Procedure time was total time spent in the operating room or procedure room (i.e., from patient entry until exit–for office-based procedures this also includes changing clothes, which is done in the procedure suite). Periprocedure time included time spent in the waiting room for office-based procedures, and time spent in the preoperative area and recovery room for ambulatory surgical procedures. Total hospital time included the time spent from arrival until departure from the outpatient clinic or hospital. One-way analysis of variance was performed to compare procedure, periprocedure, and total hospital times using JMP-SAS version 9 (SAS Institute, Cary, NC) with statistical significance set at p<0.05.

Results

Procedures were attempted in 65 renal units in 38 patients (13 male, 25 female) with a mean age of 62.2 years (29.1–95.4 years). Primary ureteral stent placement was attempted in 24 renal units, ureteral stent exchange in 22 renal units, and ureteral catheterization with retrograde pyelography or BCG instillation in 19 renal units (Table 1). No patient developed a urinary tract infection as a result of the procedure. No procedure was terminated due to patient discomfort. A variety of stents of different sizes were employed based on surgeon preference, including Kwart (Cook Urological, Spencer, IN), Percuflex (Boston Scientific, Marlborough, MA), Polaris loop (Boston Scientific), and InLay Optima (Bard Urological, Covington, GA). All ureteral stents were 6 or 7F in diameter.

Primary ureteral stent placement was successful in 23/24 (95.8%) renal units (2 bilateral). One (1/24, 4.2%) procedure was unsuccessful in a patient with a stone located at the site of a ureteral stricture. Pyuria was noted during one (1/24, 4.2%) procedure in a patient who was subsequently admitted for intravenous antibiotics. In patients who underwent ureteral stent placement for stones, mean stone size was 5.8 mm (range 3–8.8 mm). Stones were located in the proximal ureter (i.e., above the sacroiliac vessels) in nine renal units and in the distal ureter in six renal units.

Ureteral stent exchange was successful in 19/22 (86.4%) renal units. Three procedures (3/22, 13.6%) were unsuccessful as follows: a single case of stent encrustation for which the stent could not be removed, a single case of stent migration into the distal ureter upon replacement, and a single case of severe ureteral stricture preventing stent replacement. Hospitalization for nephrostomy tube placement was required after two of these procedures (2/22, 9.1%). Pyuria was noted during one procedure (1/22, 4.5%) in a patient who was subsequently admitted for intravenous antibiotics.

Of the 46 renal units in which stent placement or exchange was attempted, indications were malignant extrinsic ureteral compression in 17 (37.0%), ureteral stone in 15 (32.6%), ureteropelvic junction obstruction in 6 (13.0%), benign extrinsic ureteral compression in 5 (10.9%), ureteral stricture in 2 (4.3%), and hydronephrosis of unknown etiology in 1 (2.2%) (Table 2).

Ureteral catheterization with retrograde pyelography or BCG instillation was performed successfully in 19/19 renal units (3 bilateral). Indications included upper tract imaging for patients with hematuria, a history of urothelial carcinoma, or hydronephrosis (10/19, 52.6%), and upper tract BCG instillation for urothelial carcinoma in a single patient with a solitary kidney (9/19, 47.4%).

Based on Medicare 2010 reimbursement data, the total cost of stent placement/stent exchange/retrograde pyelography was $599.74/$599.74/$346.11 when performed in the office, compared with $2,306/$2,306/$2,279 when performed in the ambulatory surgical suite (respectively). After accounting for estimated excess cost incurred from failures in the office (i.e., one failed primary stent placement and three failed stent exchanges), the total cost savings for the 38 patients in this study was approximately $91,496 (Table 3) with an average cost savings of $1,551 per procedure.

To determine whether office-based procedures were associated with time savings, we compared procedure, periprocedure, and total hospital times for office-based and ambulatory surgical procedures (Table 4). Periprocedure time included time spent in the waiting room for office-based procedures, and time spent in the preoperative area and recovery room for ambulatory surgical procedures. Procedure time included time spent in the procedure room, which includes patients changing their clothes and preparation time by nursing staff for office-based procedures and anesthesia time for operating room-based procedures. Total hospital time was the total time spent from arrival to the hospital or outpatient clinic until departure. Unilateral ureteral stent placement and stent exchange were associated with nearly three-fold reduction in total hospital time when performed in the office compared with the ambulatory surgical suite (106.2±31.2 minutes vs. 275.0±33.5 minutes, p<0.001 for stent placement; and 120.4±44.4 minutes vs. 346.1±63.1 minutes, p<0.001 for stent exchange). This was due to reduced periprocedure waiting time (32.9±28.6 minutes vs. 226.4±21.6 minutes, p<0.001 for stent placement; and 37.1±29.5 minutes vs. 302.6±62.2 minutes, p<0.001 for stent exchange) as procedure time was slightly longer for those performed in the office setting (65.0±27.5 minutes vs. 45.1±17.6 minutes, p=0.048 for stent placement; and 80.4±22.5 minutes vs. 41.5±8.6 minutes, p<0.001 for stent exchange).

Discussion

Urologic procedures are increasingly being performed in the office setting. Since the advent of the flexible cystoscope, diagnostic cystoscopy has become one of the most common office procedures with good patient tolerability and safety. ^{15 –17} We hypothesized that performing ureteral stent placement/exchange and ureteral catheterization with retrograde pyelography in the office would represent a significant cost and time savings to the patient and healthcare system and reviewed our experience with these procedures.

In our study, we performed procedures in the office using standard fluoroscopy with only local anesthesia. Overall success rates were 95.8% and 86.4% for primary ureteral stent placement and ureteral stent exchange, respectively, and both male and female patients tolerated the procedures. No procedure was stopped due to patient discomfort, and the majority of failures were cases which were not amenable to uncomplicated primary stent change in the ambulatory surgical suite either–severe ureteral stricture and an encrusted stent. The office procedures also demonstrated versatility in both the diversity of indications as well as variety of stents employed. Furthermore, the procedures were safe: no urinary tract infection developed as a result of the procedure, and there were no acute complications, such as ureteral injury.

A total of four patients required admission after their procedures. Two patients were noted to have cloudy urine after stent placement/exchange and were admitted for antibiotics–this would have been our practice even if the procedures were performed in the operating room. In the stent exchange group, two patients required admission for nephrostomy tube placement due to inability to replace the ureteral stent. It is unclear if different outcomes would have been achieved in the operating room.

The cost analysis in this study demonstrated a significant benefit to the office procedures. We found per patient cost savings of $1,706 for ureteral stent placement or exchange and $1,933 for retrograde pyelography. Even after accounting for excess cost incurred from failures in the office (which included cost of admission and nephrostomy tube placement), there was a substantial cost savings of $91,496 for the 38 patients, or a net cost-reduction of $1,551 per procedure. For patients who are managed with serial stent exchanges (e.g., those with malignant extrinsic compression of the ureter due to abdominal malignancies), the economic benefit of performing these procedures in the office can be expected to grow with time. Furthermore, assuming the cost estimates in this study, it would only take approximately three office stent changes or placements to offset the cost of one failure requiring admission for nephrostomy tube placement.

The evaluation of the time-cost associated with these procedures revealed a nearly three-fold reduction in total hospital time for office procedures compared with ambulatory surgical procedures. This was largely due to significantly reduced periprocedure waiting time—patients are routinely required to arrive several hours before operating room procedures, and must recover from general anesthesia afterwards. In the office setting, these times are significantly reduced. It should be noted that we cannot exclude potential selection bias in the time analysis–it is conceivable that case complexity or patient preference may have caused select cases to be performed in the ambulatory surgery setting. However, ambulatory surgical procedure times were shorter than office procedure times, and the increase in total hospital time was instead due to greater periprocedure times. In other words, the differences in time were due to waiting times rather than procedure times.

To our knowledge, there has been only one other report of ureteral stent placement in the office under local anesthesia. In an analysis of pain associated with endoscopic procedures and extracorporeal shockwave lithotripsy performed in an outpatient setting, Jeong, et al ¹⁴ evaluated 127 patients who underwent retrograde ureteral stent placement using lidocaine jelly in males and no anesthetic in females. The study found no statistically significant difference in visual analog pain scale scores among endoscopic procedures. However, the authors examined only patient reported pain and did not evaluate clinical outcomes, cost-effectiveness, or time-cost. Our study demonstrated both the efficacy and feasibility of ureteral stent placement in the office and found similar results for ureteral stent exchange.

Performing urologic procedures in the office offers a number of important benefits. It avoids the use of general anesthesia, which can save considerable morbidity for patients that is difficult to fully quantify. It also provides convenience to both the patient and clinician, who may schedule the procedures at their mutual convenience rather than negotiate a busy operating room schedule. Moreover, office procedures are associated with a significant reduction in time-cost as a result of reduced periprocedure waiting times, as well as a substantial cost savings to the healthcare system.

There are several drawbacks to performing upper tract endourologic procedures in the office. It requires an office fluoroscopy unit, which may be an unrealistic expense for some practices. However, a C-arm used for fluoroscopy-based urodynamics may be available in many office practices and could be used for these procedures as well. The use of a flexible cystoscope for male patients may also place the office urologist at a mechanical disadvantage, although it did not appear to affect success rates in our study. There have also been some safety concerns with performing other ureteroscopic procedures under local anesthesia ¹⁴ ; however, stent placement, stent exchange, and ureteral catheterization pose minimal risk of ureteral injury with patient movement.

This study has a number of limitations. First, it is retrospective and subject to the inherent pitfalls of this design. We did not assess subjective pain perceived by patients during the procedure, and tolerance was inferred from procedure and office notes. Also, we cannot exclude selection bias on the basis of patient preference or case complexity affecting choice of procedure setting, although such considerations would reflect factors that may be generalized to most clinical practices. We also acknowledge a selection bias insofar as we perform office endourologic procedures in patients who we feel will tolerate the procedure. We do not have an algorithm, per se, to identify these specific patients, but through preprocedure counseling, we attempt to determine who will be a suitable candidate for the procedures without general anesthesia or sedation. At our institution, ureteral stent placement and exchange are most often performed with laryngeal mask airway due to Anesthesia practice patterns. We acknowledge that performing these cases using monitored anesthesia care may change the outcome of our cost analysis. We also understand that these office procedures may be performed with greater confidence if the office building is in the vicinity of the main hospital should the procedure fail and the patient require admission, although we do perform these types of procedures in our outpatient satellite clinics. Lastly, although the cost analysis evaluated cost to the patient/healthcare system using Medicare reimbursement, we did not attempt to capture the material costs incurred by the physician when performing office procedures.

Conclusions

Primary ureteral stent placement, ureteral stent exchange, and ureteral catheterization with retrograde pyelography or upper tract BCG instillation can be performed safely and effectively in both men and women. This avoids general anesthesia, provides convenience to patient and clinician, reduces hospital time, and represents a substantial cost savings for the healthcare system.