Elsevier

Urology

Volume 67, Issue 5, May 2006, Pages 889-893
Urology

Adult urology
What is the most cost-effective treatment for 1 to 2-cm bulbar urethral strictures: Societal approach using decision analysis

https://doi.org/10.1016/j.urology.2005.11.003Get rights and content

Abstract

Objectives

Direct vision internal urethrotomy (DVIU) and urethroplasty are the primary methods of managing urethral stricture disease. Using decision analysis, we determine the cost-effectiveness of different management strategies for short, bulbar urethral strictures 1 to 2 cm in length.

Methods

A decision tree was constructed, with the number of planned possible DVIUs before attempting urethroplasty defined for each primary branch point. Success rates were obtained from published reports. Costs were estimated from a societal perspective and included the costs of the procedures and office visits and lost wages from convalescence. Sensitivity analyses were conducted, varying the success rates of the procedures and cost estimates.

Results

The most cost-effective approach was one DVIU before urethroplasty. The incremental cost of performing a second DVIU before attempting urethroplasty was $141,962 for each additional successfully voiding patient. In the sensitivity analysis, urethroplasty as the primary therapy was cost-effective only when the expected success rate of the first DVIU was less than 35%.

Conclusions

The most cost-effective strategy for the management of short, bulbar urethral strictures is to reserve urethroplasty for patients in whom a single endoscopic attempt fails. For longer strictures for which the success rate of DVIU is expected to be less than 35%, urethroplasty as primary therapy is cost-effective. Future prospective, multicenter studies of DVIU and urethroplasty outcomes would help enhance the accuracy of our model.

Section snippets

Model

The decision tree constructed (Fig. 1) graphically represents the components of the problem. It consisted of four types of nodes: a decision node (squares) at which the treatment strategy was chosen; chance nodes (circles), at which an event was out of the decision maker’s control and requires the probability of outcomes to be estimated; label nodes (bowties), which are placeholders marking the progression of patients from one surgical procedure to the next; and terminal nodes (triangles),

Results

In the base case of a 1 to 2-cm bulbar urethral stricture with an estimated success rate of 95% for urethroplasty, 50% for a first DVIU and 20% for a second DVIU, the strategy of one DVIU before proceeding to urethroplasty was the least costly ($8575) and three DVIUs before urethroplasty had the greatest cost ($10,466; Table II). The average cost per successfully voiding patient of the “one DVIU before urethroplasty” strategy was $8795, and it achieved a 97.5% success rate. The ICERs for the

Comment

Using decision analysis, we found that across a wide range of success rates for DVIU, and assuming a very high success rate for urethroplasty, an approach of endoscopic therapy first is more cost-effective for strictures less than 1 to 2 cm in length.

Disagreement exists on the appropriate management algorithm for short urethral strictures. Urethroplasty has been advocated as a primary therapy16 after one failed DVIU6, 13 or after multiple failed DVIUs.3 A recent survey reported that 74% of

Conclusions

The most cost-effective strategy for the management of short urethral stricture disease is to reserve urethroplasty for patients in whom one attempt at DVIU fails. Urethroplasty, as the primary therapy, is only cost-effective if the expected success of a first DVIU is less than 27% to 35%. Two endoscopic treatments before urethroplasty would be the most cost-effective if the expected success rate of a second DVIU were greater than 28% to 34%. Future prospective, multicenter studies of DVIU and

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This study was supported by grant R49-CE000197 from the Centers for Disease Control.

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