Wymer Kevin, Plunkett Beth A, Park Sangtae
Division of Biological Sciences, Pritzker School of Medicine, University of Chicago, Chicago, IL.
Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Evanston, IL.
Am J Obstet Gynecol. 2015 Nov;213(5):691.e1-8. doi: 10.1016/j.ajog.2015.07.024. Epub 2015 Jul 26.
The purpose of this study was to determine the cost-effectiveness of serial stenting vs ureteroscopy for treatment of urolithiasis during pregnancy as a function of gestational age (GA) at diagnosis.
We built decision analytic models for a hypothetical cohort of pregnant women who had received a diagnosis of symptomatic ureteral calculi and compared serial stenting to ureteroscopy. We assumed ureteral stent replacement every 4 weeks during pregnancy, intravenous sedation for stent placement, and spinal anesthetic for ureteroscopy. Outcomes were derived from the literature and included stent infection, migration, spontaneous kidney stone passage, ureteral injury, failed ureteroscopy, postoperative urinary tract infection, sepsis, and anesthetic complications. Four separate analyses were run based on the GA at diagnosis of urolithiasis. Using direct costs and quality-adjusted life years, we reported the incremental costs and effectiveness of each strategy based on GA at kidney stone diagnosis and calculated the net monetary benefit. We performed 1-way and Monte-Carlo sensitivity analyses to assess the strength of the model.
Ureteroscopy was less costly and more effective for urolithiasis, irrespective of GA at diagnosis. The incremental cost of ureteroscopy increased from -$74,469 to -$7631, and the incremental effectiveness decreased from 0.49 to 0.05 quality-adjusted life years for a kidney stone diagnosed at 12 and 36 weeks of gestation, respectively. The net monetary benefit of ureteroscopy progressively decreased for kidney stones that were diagnosed later in pregnancy. The model was robust to all variables.
Ureteroscopy is less costly and more effective relative to serial stenting for urolithiasis, regardless of the GA at diagnosis. Ureteroscopy is most beneficial for women who received the diagnosis early during pregnancy.
本研究旨在确定在妊娠期间根据诊断时的孕周（GA），序贯支架置入术与输尿管镜检查治疗尿路结石的成本效益。
我们为一组假设的已诊断为有症状输尿管结石的孕妇建立了决策分析模型，并比较了序贯支架置入术与输尿管镜检查。我们假设在妊娠期间每4周更换一次输尿管支架，支架置入采用静脉镇静，输尿管镜检查采用脊髓麻醉。结局数据来自文献，包括支架感染、移位、肾结石自然排出、输尿管损伤、输尿管镜检查失败、术后尿路感染、败血症和麻醉并发症。根据尿路结石诊断时的孕周进行了四项独立分析。使用直接成本和质量调整生命年，我们报告了基于肾结石诊断时孕周的每种策略的增量成本和有效性，并计算了净货币效益。我们进行了单因素和蒙特卡洛敏感性分析以评估模型的稳健性。
无论诊断时的孕周如何，输尿管镜检查治疗尿路结石的成本更低且更有效。对于分别在妊娠12周和36周诊断出的肾结石，输尿管镜检查的增量成本从-$74,469增加到-$7631，增量有效性从0.49质量调整生命年降至0.05质量调整生命年。对于在妊娠后期诊断出的肾结石，输尿管镜检查的净货币效益逐渐降低。该模型对所有变量均具有稳健性。
对于尿路结石，相对于序贯支架置入术，输尿管镜检查成本更低且更有效，无论诊断时的孕周如何。输尿管镜检查对在妊娠早期接受诊断的女性最有益。
