Disposable or reusable flexible ureterorenoscopy for renal calculi: cost remains as the deciding factor

Abstract

We read with interest the paper published by Göger et al. [1], detailing a prospective comparison of reusable and disposable flexible ureterorenoscopy (fURS) in the management of lower pole stones. Baseline, intra-operative and post-operative outcomes were analyzed accordingly, most of which revealed no significant differences between both groups [stone-free rate (SFR), post-operative complication rate, and hospitalization time]. However, the disposable fURS group was notably seen to have lower operation time compared to the reusable group (p = 0.012), with further univariate analysis depicting the use of disposable fURS as an independent predictor of shorter operative time. This is contrasted to the reusable group, which was determined on multivariate analysis to be associated with increased operative time. We acknowledge the authors’ findings and would cordially like to introduce a similarly previous prospective case–control study by Salvadó et al. [2] that bore the same study objectives. Albeit the incorporation of a different brand of reusable fURS (Cobra® Endoscope, Richard Wolf, Knittlingen, Germany) for the study, the same disposable digital scope as Göger and colleagues (Uscope 3022®, Pusen Medical) was utilized. Likewise, they reported a congruent lower operative time demonstrated by the disposable fURS group compared to its reusable counterpart (Uscope 3022®, Pusen Medical) (56.1 ± 34.8 vs. 77 ± 37.4, p = 0.01). In addition, disposable fURS also clocked a lower fluoroscopy time (66.1 ± 60.9 vs. 83.4 ± 44.90, p = 0.02). This was not seen in the said study of discussion, surfacing another potentially insightful benefit of disposable fURS. Overall, equivalent and comparable outcomes were seen across both groups in both papers in the management of lower pole stones. Although not specific to lower pole calculi, two metaanalyses [3, 4] comparing disposable vs. reusable fURS in various aspects (stone free rate, periand post-operative complication rate, safety comparison) also corroborated the findings to be akin across both groups. Interestingly though, in the pooled analysis by Li et al., disposable fURS demonstrated longer operative time compared to reusable fURS (MD 7.39 min; 95% CI 1.75–13.03; p = 0.01). However, a caveat was made that operative time was variably defined across studies included for analysis, potentially contributing to inconsistently recorded times. The aforementioned studies are all generally in unison of the stance that disposable fURS can be safely and effectively incorporated in today’s era of retrograde intra-renal surgery (RIRS), as an alternative to reusable fURS. However, the only longstanding unresolved shortcoming of disposable scopes is that of a distinct difference in cost-effectiveness [5, 6]. Although the financial implication is largely heterogeneous in nature and very much dependent on the country’s specific healthcare system jurisdiction and institution-based utilization, reusable scopes are generally concluded to be more cost-effective in high volume centres. Therefore, even if the clinical performance of both types of scopes is onpar with each other, it is imperative for cost concerns to be considered before transitioning to a greater adoption of disposable fURS for routine clinical practice.