Economic evaluation of a Single use Flexible Digital Ureteroscope : Cost Analysis

doi:10.21203/rs.3.rs-5069441/v1

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Economic evaluation of a Single use Flexible Digital Ureteroscope : Cost Analysis

https://doi.org/10.21203/rs.3.rs-5069441/v1

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published 18 Jun, 2025

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Background: The goal of our study is to analyze the possible economic benefits of single-use flexible ureteroscopes (su-fURSs) and compare their cost effectiveness with that of reusable flexible ureteroscopes (re-fURSs) in secondary hospitals with an average patient flow rate.

Methodes: The present study is a single-center, retrospective study conducted at Security Force Hospital, Makkah, Saudia Arabia. The study included data from all flexible ureteroscopy procedures performed in the urology department of the hospitals between June 2021 and December 2023. Karl Storz FLEX-X2S fiber-optic ureteroscopes were used for the procedures involving re-fURS, and the cost assessment took into account the initial cost of purchasing, the cost of reprocessing, and the cost of replacement split by the number of cases. This cost was compared with the costs of using WiScope (OTU Medical Inc.), a digital su-fURS.

Results: Out of the total cases included in the study, 180 utilized su-fURSs, and 59 utilized re- fURSs with one repair exchange done during the observed study period. The average cost of using a re-fURS was approximately SAR 3,668 (USD 975) per case, while the cost of using a su- fURS was approximately SAR 1,650 (USD 438) per case.

Conclusions: Su-fURS is a more cost-effective procedure than re-fURS performed in secondary hospitals with an average patient flow. Su-fURS may be more reliable than re-fURS regarding wear and tear. It is essential to consider different factors such as the cost of sterilization and the time spent in cleaning when determining which scope is most cost-effective for a particular procedure.

Cost

flexible

ureteroscopy

A flexible ureteroscope (fURS) is used frequently in daily urological practice. The flexibility of the device enables the detection and treatment of upper urinary tract diseases, including stones and upper urinary tract urothelial carcinomas [1–3]. A traditional fURS is reusable and must be decontaminated and disinfected before safely reusing. Unfortunately, sterilization methods take time and cost money in terms of products, materials, and labor [4–6].

With the increased usage of fURSs, many urologists face difficulties that may impact their performance, especially when fURSs need repair or exchange [7–10]. Single-use flexible

ureteroscopes (su-fURS) are quickly improving the standard of care in endourology. The main drawbacks of reusable flexible ureteroscopes (re-fURS) are their high purchase and maintenance costs, risk of breakages, immediate availability, and need for reprocessing between procedures [11]. Fortunately, studies have found su-fURSs to have maneuverability, visual quality, and effectiveness comparable to re-fURSs [12–14].

However, due to a lack of competition and limited market share, the cost of su-fURSs is somewhat high, particularly compared to re-fURSs [15]. At the same time, re-fURSs have the added costs of repairing and purchasing. Using su-fURSs also decreases the risk of cross- infections and the need for sterilization between procedures. Moreover, some urologists believe that su-fURSs allow for more torque during the treatment of kidney stones without the increased danger of the device breaking [11]. Thus, the purpose of this study was to compare the costs of employing su-fURSs with re-fURSs in secondary hospitals with average patient volume.

This retrospective study reports the data of a single center that included all flexible ureteroscopic procedures for treating renal stones performed in the urology department of Security Force Hospital, Makkah, Saudi Arabia, between June 2021 and December 2023. The local institutional IRB approval number for the study is 0535-301122.

This study reported and compared the cost of su-fURSs and re-fURSs. It also reported the costs of purchasing both scopes and the costs of sterilization, maintenance, and repair of re-fURSs.

Sample size calculation

Sample size was calculated using G power 3.1.9.4 based on previous studies, we find mean ± SD (11053 ± 7821) $ for group I and mean ± SD (13284 ± 7821) $ for group II. With a power of 80% (using t test and alpha of 0.05). As this study will be carried out on 2 arms. The sample needed for the study was estimated to be 50 patients each arm.

Operating costs of reusable ureteroscopes

When evaluating the cost of re-fURSs, the costs of ureteroscope procurement, maintenance, repair, and operating expenses, which included decontamination and sterilization, were reported.

Hospital staff centrally prepared and sterilized all re-fURS using a steam sterilization unit. Inspection, preliminary cleaning, disinfection, and sterilization were all part of the reprocessing protocol. If damage to the re-fURS was discovered during inspection, the re- fURS was sent

back to the original manufacturer for assessment and repair, and a replacement re-fURS made available by the original manufacturer was put into use.

The central services billing division reported the reprocessing expenses of re-fURS per case. The hourly salaries of the sterilization technicians and an assessment of the average time needed to reprocess the re-fURS were used to estimate labor expenses.

The next step in re-fURS processing is sterilization and repacking. This procedure, which involved cleaning, rinsing, disinfecting, drying, and reconditioning brushes, was carried out in the hospital's sterilization room. The last step is transporting the scope to the operating room. In all, the cost of materials and labor for decontamination, repackaging, and transport for each re- fURS was calculated.

The total cost of re-fURS used per procedure was calculated using the following formula:

Total cost per case = (total purchase and exchange costs/number of cases) + (cost of reprocessing or recycling each case).

Operating expenses included costs for decontamination, transportation, and storage. After each procedure, a ureteroscope is first treated in the operating room with wiping, aspiration, and

tightness tests. In the sterilizing room, ureteroscopes are cleaned, rinsed, disinfected with

peracetic acid, dried, and repackaged as the second stage in processing. The final step in reusable fURS processing is transportation from the decontamination room to the operation room.

Cost of single-use ureteroscopes

Su-fURSs don't need to be cleaned or reconditioned before use because they come in sterile packs. The only expense reported is the cost of buying them. In the present study, the waste processing of su-fURSs should have been considered.

The cost of digital su-fURS was based on market data as of June 2021 (approximately SAR 1,650 (USD 438) per su-fURS. The total cost of a su-fURS was calculated using the following formula:

Total cost (y) = (cost of purchase of each su-fURS + 15% VAT) × (number of procedures (x)). The currency of choice for cost comparison was the Saudi Arabian Riyal (SAR).

Thanks to this study, our hospital improved its practices by utilizing a hybrid strategy that mixes re-fURSs and su-fURSs. In this strategy, su-fURSs take the role of traditional re-fURSs in circumstances where there is a high danger of infection transmission or a high risk of scope damage (complex stones, stones in the inferior calyx, urine diversion, etc.).

The study included 239 ureteroscopic procedures performed in the Security Force Hospital, Makkah, in the period between June 2021 and December 2023. A fiber-optic (Flex X2S, Storz®) re-fURS was used in 59 procedures (Group A) and WiScope (OTU Medical Inc.) su- fURSs were used in 180 cases (Group B).

No stastistical significant differences were observed between both groups regarding preoperative demographic data and regarding stone burden (20±14 mm, vs 27± 9 mm , P= 0.63). Equivalent Stone free rate was reported in both groups ( 48 cases in group A and 151 case in group B , P= 0.8). As regard re operation of residual stones, 15 patients were re-operated in group A and 29 patients were re-operated in group B , P=0.16. Twelve patients in group A had renal pelvic stone and 30 patients in group B had stones located in renal pelvis (P= 0.95). (Table 2)

One new re- fURS was used at the beginning of the study. The original purchase price of the re- fURS was SAR 98,876 ($26,296). This re- FURS was damaged during the study and was replaced with a new one. The cost of exchanging a broken re-fURS with a new one was SAR 82,178 (USD 21,855). There were no significant differences in patient demographics or stone

characteristics between the two groups. ( Table 1).

The reprocessing of re- fURS includes scope cleaning, rinsing, disinfecting, drying, and reconditioning brushes. The last step is transporting the scope to the operating room. The cost of materials and labor for decontamination, repackaging, and transport for each re-fURS was also calculated, and it was determined to be approximately SAR 600 (USD 159) per procedure.

The overall cost of a re-fURS, including the initial purchase cost, the cost of exchanging a broken re-fURS, and reprocessing and labor charges, was 216,454 (USD 57,567) throughout the study period.

June 2021, our institution purchased 180 WiScope® su-fURSs for SAR 297,000 (USD 78,989), including a 15% sales tax. The average cost of using a su-fURS was calculated to be approximately SAR 1,650 (USD 438) per case, while the cost of using a re-fURS was calculated to be approximately SAR 3,668 (USD 975) per case. Thus, su-fURSs are more cost-effective than re-fURSs. Table (1,2).

In present study, in the re- FURS group, the scope was damaged in one case that was completed with another new Su- FURS. In the Su FURS group, the scope was damaged in two cases that were completed by another new Su FURS scopes.

Due to improvements in the production of fURSs, flexible ureteroscopy is the preferred method of treating upper urinary tract stones [1, 16]. However, there have consistently been worries about the high price [17]. The price of the flexible ureteroscope technique includes the cost of the laser used for stone fragmentation, the pay of the staff members responsible for cleaning and sterilization procedures, and all accessory tools used during the treatment. Institutions may also encounter severe delays in repairing or exchanging broken re-fURS [16, 17].

On the other hand, su-fURSs may offer solutions for the problems mentioned above, particularly in reducing the cost of repairing and replacing re-fURSs [18]. According to a few randomized controlled trials, FURSs are brittle and necessitate high maintenance and repair expenses [19, 20]. A digital fURS is typically used 21 times before requiring a repair, and a fiber-optic ureteroscope is typically used 6 to 15 times before being returned to its maker [7, 21].

Legemate et al. [22] reported that digital re-fURSs had more extended durability (mean: 27; 20–56) compared to fiber-optic fURSs (mean: 24; 10–37), but the average durability of re-fURSs ranged from 3 to 11 cases [9, 23–25]. Another study concluded that not only are new fURSs

more resistant to malfunction (mean: 44) than refurbished devices, but the new re-furs last longer if they are maintained and repaired by the original maker (mean: 11.1) than by outside contractors (mean: 6.9) [9].

Previous studies have tested the first generation of su-fURSs, but suboptimal surgical effects prevent their inclusion into daily practice [26–28]. However, newer su-fURS provide similar clinical efficacy and maneuverability to reusable scopes and are now part of routine daily practice in urology [13, 29–34]. Since su-fURSs don't need to be repaired, maintained, or sterilized, and the stock is managed by a hospital's pharmacy, one of their key benefits is accessibility and availability [18, 35].

Despite adherence to the decontamination and sterilization processes of reusable ureteroscopes, risks of infection and cross-contamination exist. Ofstead et al. analyzed 16 re-fURS procedures in two different centers, finding that despite disinfection procedures, all the re-fURSs had visible damage and were contaminated with hemoglobin, protein, or microbial growth. There is no such risk with su-fURSs [5].

Various studies have reported on the incidence rate of re-fURS breakage that occurs during storage or processing, finding that 7.7–22% of the time, re-fURSs are damaged even in the hands of qualified staff [8, 21, 26, 29]. Abraham et al. studied two identical fiber-optic re-fURSs that undergo sterilization through different sterilization processes. The first ureteroscope, sterilized with the Steris system, had 297 broken fibers, a 12-mm tear on its shaft, and a 37% loss in resolution after 100 sterilization cycles, according to the authors. Ten damaged fibers were found in the second re-fURS, which had been Cidex sterilized [36].

In our hospital, re-fURS re-sterilization involves three hours of labor and three paramedical personnel, while su-fURSs are stored in a sterile package in the operating room. The su-fURS are delivered to a burning device after each treatment.

The price of buying, repairing, and sterilizing the scope must be factored into the total cost of re- fURSs. A modern re-fURS (Flex-X, Karl Storz, Germany) costs USD 13,611, according to a recent study [37].

In a recent Australian study, the digital Olympus URF-V was purchased for USD 20,200 [15]. The cost of reprocessing this device includes paying employees (nurses, technicians, etc.) and buying supplies for cleaning, sterilization, packaging, and leakage testing. Recent cost analyses indicated that the cost of reprocessing ranged from USD 19.90 to USD 108.00 per case if the price of purchasing a STERRAD machine (a system that uses low-temperature hydrogen peroxide gas plasma technology to sterilize) is not taken into account [15, 37–39].

In the present study, the average cost for re-FURS was approximately SAR 3,668 (USD 975) per case, and the price for su-fURS was approximately SAR 1,650 (USD 438) per case, that did not change from 2022 till end of 2024. Tagushi et al. reported a USD 3.65 recycling cost per re-fURS of the type used in their study [40].

The purchase cost of a su-fURS is always a concerning issue. The business agreement between the manufacturer and the hospital has the most significant impact. LithoVueTM [15, 33, 41], PolyscopeTM [42], and SemiFlexTM [30] have reported purchase prices ranging from USD 1,300 to USD 3,180, USD 700, and USD 800, respectively. More su-fURSs will be well-spent as production technology develops, perhaps lowering final retail pricing. As more manufacturers vie for market share, sales prices could also drop (Sales prices may decrease as more manufacturers compete for market share).

Martin et al. conducted a cost-benefit analysis on all available fURSs to determine the cost of re- fURSs. They reported a cost of USD 848.10 per case and favored the purchase of re-fURSs when more than 99 procedures a year were being performed at a hospital, suggesting that re-fURSs are more cost-effective in high-volume institutions [43]. Similarly, Mager et al. conducted a cost- analysis study to evaluate the expenses of fURSs. The study reported that the cost of re-fURS ranged between USD 436 and USD 708 per case. When the initial purchasing costs were added, the total cost increased to $1,212–USD 1,743 per case. Based on data and studies, LithoVueTM procedures range in price from USD 1,300 (market pricing) to USD 3,180 (manufacturer's recommended wholesale price) per case. Mager et al. discovered in a prediction model that the routine use of su-fURSs would be more costly than the routine usage of re-fURSs after executing 61 to 118 examples [38].

In a German case series, Ozimek et al. reported 321 cases of kidney stone treatment and 102 diagnostic fURS surgeries. On average, 14.4 incidents resulted in scope damage, and all operations cost a total of USD 261,332. The calculated average cost per fURS procedure was USD 617.40. Ozimek et al. concluded that the use of re-fURSs was cost-effective when compared to the use of su-fURSs since the price of a LithoVueTM device was USD 1,227.50 [44].

According to Hennessey et al., the mean cost per case for seven new digital re-fURSs utilized over 30 months was USD 533 (USD 276-USD 904), and the overall repair cost for these devices was USD 124,800. The increasing cost of 28 cases using re-fURSs was USD 38,360. For a su- fURS (LithoVueTM) that costs USD 1,918, the total cost would be USD 55,239 for the same 28 cases; thus, the re-fURSs would be more economical. Conversely, if the cost of su-fURSs were USD 920, then the cost for 28 cases would be USD 26,850, which would be a considerable economic, saving [15].

Study limitation

The present study has some limitation including, the expense of maintaining room sterilization was not considered in the current analysis, which would have increased the price of processing re-fURSs. Another limitation of this study is that the waste processing of su-fURSs was not included in the cost analysis. Additionally, post operative possible infection and its treatment cost that may include hospital readmission were not evaluated in the study.

Several factors affect the cost analysis of su-fURSs compared to re-fURSs, such as the number and type of procedures and equipment cost. When considering the cost of sterilization and the time spent in cleaning, su-fURS may be more cost-effective than re-fURS in secondary hospitals with an average flow rate of patients. Moreover, su-fURS may be more reliable than re-fURS regarding wear and tear. Finally, it is essential to consider all these factors when determining which scope is most cost-effective for a particular procedure.

fURS: flexible ureteroscope

SAR: Saudi Arabian Riyal USD: United States Dollar

su-fURS: single-use flexible ureteroscope re-fURS: reusable flexible ureteroscope

Ethics approval : IRB approval number (0535301122- Security Force Hospital / Makkah. Saudia Arabia) Consent for publication: Consent for publication was obtained

Funding: None

Conflict of interrest : there are no financial or institutional conflicts of interest influencing the present study.

Author Contribution

A. I. A.: Idea owner, helped in writing the manuscript, data collectionA. A: helped in writing manuscriptS. A. K.: writing the manuscript and data collectionA. T.: data collectionA. A. : Data collectionW. A.: Data collectionA. M.: writing manuscriptA. B: data collectionS. A.: data collectionA.H.: writing manuscript, data collection

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Table 1 and 2 are available in the Supplementary Files section.

No competing interests reported.

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Journal Publication

published 18 Jun, 2025

Read the published version in African Journal of Urology →

Editorial decision: Accepted
02 Jun, 2025
Reviews received at journal
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Reviewers agreed at journal
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You are reading this latest preprint version

Economic evaluation of a Single use Flexible Digital Ureteroscope : Cost Analysis

Status:

Journal Publication

Version 1

Abstract

Introduction

Patients and methods

Sample size calculation

Operating costs of reusable ureteroscopes

Cost of single-use ureteroscopes

Results

Discussion

Study limitation

Conclusions

Abbreviations

Declarations

Author Contribution

References

Tables

Additional Declarations

Supplementary Files

Status:

Journal Publication

Version 1