Background

Intraoperative evaluation of ureteral patency is often performed in gynecologic and urogynecologic surgery. Many agents are used to help assess the patency, each with its own associated cost, ease of use, and adverse reactions. Some agents, such as dextrose, are used as an instillation fluid to create a viscosity difference and aid the visualization of a ureteral jet. Others, such as oral phenazopyridine or the intravenous use of sodium fluorescein and indigo carmine, cause a color change of the urine to directly aid the visualization of ureteral jets. Recently, numerous studies have examined the efficacy and surgeon satisfaction of these agents. The studies have also emphasized certain options as associated with a lower cost. However, there have not been any cost studies comparing these agents.

Objective

To compare the cost-effectiveness of the following 4 agents that are commonly used in assessing ureteral patency intraoperatively: oral phenazopyridine, dextrose instillation, intravenous sodium fluorescein, and intravenous indigo carmine.

Study Design

We constructed a decision-analytic model to compare cystoscopy using oral phenazopyridine, dextrose instillation, intravenous sodium fluorescein, and intravenous indigo carmine. Failure to see efflux resulted in work-ups for ureteral obstruction. The probabilities were obtained from published studies, and the probability of successfully seeing efflux ranged from 0.92 with oral phenazopyridine to 0.99 with intravenous indigo carmine. The costs of the agents, adverse effects, and ureteral obstruction work-ups were obtained from the University of North Carolina at Chapel Hill Department of Pharmacy, the Healthcare Cost and Utilization Project 2016 database and the FAIR Health Consumer database. The cost of a ureteral obstruction work-up used in our model ranged from $9755 for intraoperative evaluation with retrograde pyelograms and stents to $29,034 for hospitalization. Our primary outcome was the incremental cost-effectiveness ratio per unnecessary work-up for ureteral obstruction avoided. Sensitivity analyses were performed to identify the key uncertainties.

Results

Oral phenazopyridine, followed by an intravenous agent if needed, had a mean cost of $110 per patient. Dextrose averaged $151 more per patient, with only a slight improvement in avoiding unnecessary ureteral obstruction work-ups and a higher cost associated with adverse reactions (incremental cost-effectiveness ratio, $62,000). Intravenous agents cost approximately $1000 more per patient and were less effective at preventing unnecessary work-ups. Sensitivity analyses did not identify any thresholds that would significantly change the outcomes.

Conclusion

Our model suggests that oral phenazopyridine and dextrose instillation are the least expensive and the most effective agents to aid in the visualization of ureteral patency during intraoperative cystoscopy, although dextrose is associated with higher costs owing to a higher rate of adverse reactions (primarily urinary tract infections). Intravenous sodium fluorescein and indigo carmine are historically popular first-choice agents. However, they were found to be more expensive and less effective as primary agents in our model and should likely be reserved for use as secondary agents in the event that the visualization of ureteral jets is unclear with the initial use of phenazopyridine or dextrose.

中文翻译：

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妇科和泌尿科手术术中膀胱镜检查中用于评估输尿管通畅性的药物的成本效益

背景

输尿管通畅的术中评估通常在妇科和泌尿妇科手术中进行。许多药物用于帮助评估通畅性，每种药物都有其相关的成本、易用性和不良反应。一些药剂，例如葡萄糖，用作滴注液以产生粘度差异并有助于输尿管射流的可视化。其他药物，例如口服非那吡啶或静脉使用荧光素钠和靛蓝胭脂红，会导致尿液颜色变化，从而直接帮助观察输尿管喷射。最近，许多研究检查了这些药物的疗效和外科医生满意度。这些研究还强调了与较低成本相关的某些选择。然而，还没有任何成本研究来比较这些药物。

客观的

比较以下 4 种常用于评估术中输尿管通畅的药物的成本效益：口服非那吡啶、葡萄糖滴注、静脉注射荧光素钠和静脉注射靛胭脂。

学习规划

我们构建了一个决策分析模型来比较使用口服非那吡啶、葡萄糖滴注、静脉注射荧光素钠和静脉注射靛胭脂的膀胱镜检查。未能看到流出物导致输尿管阻塞的检查。概率是从已发表的研究中获得的，成功看到外排的概率范围从口服非那吡啶的 0.92 到静脉注射靛胭脂的 0.99。药物、不良反应和输尿管阻塞检查的成本来自北卡罗来纳大学教堂山分校药学系、2016 年医疗保健成本和利用项目数据库和 FAIR 健康消费者数据库。我们模型中使用的输尿管梗阻检查的费用从 9755 美元（用于逆行肾盂造影和支架的术中评估）到 29 美元不等，034住院。我们的主要结果是每次不必要的输尿管阻塞检查增加的成本效益比。进行敏感性分析以确定关键的不确定性。

结果

口服非那吡啶，然后根据需要静脉注射药物，每位患者的平均费用为 110 美元。葡萄糖平均每位患者增加 151 美元，在避免不必要的输尿管梗阻检查和与不良反应相关的更高成本方面仅略有改善（增量成本效益比，62,000 美元）。静脉注射药物每位患者的成本大约高出 1000 美元，并且在防止不必要的检查方面效果较差。敏感性分析没有确定任何会显着改变结果的阈值。

结论

我们的模型表明，口服非那吡啶和葡萄糖滴注是帮助术中膀胱镜检查期间输尿管通畅可视化的最便宜和最有效的药物，尽管由于不良反应率较高（主要是尿路感染），葡萄糖与较高的成本相关）。静脉注射荧光素钠和靛蓝胭脂红是历史上流行的首选药物。然而，在我们的模型中，发现它们作为主要药物更昂贵且效果更差，并且在最初使用非那吡啶或葡萄糖时输尿管射流的可视化不清楚的情况下，可能应保留用作次要药物。