LAUSR

BACKGROUND Intraoperative evaluation of ureteral patency is often performed in gynecologic and urogynecologic surgery. There are many agents used to help assess patency, each with its own associated cost, ease of use, and adverse reactions. Some agents, such as dextrose, are used as instillation fluid to create a viscosity difference and aid visualization of a ureteral jet. Others, such as oral phenazopyridine or intravenous use of sodium fluorescein and indigo carmine, cause a color change of the urine to directly aid visualization of ureteral jets. Recently, numerous studies have examined the efficacy and surgeon satisfaction of these agents. Studies have also emphasized certain options as being associated with lower cost, however, there have not been any cost studies comparing these agents. OBJECTIVE To compare cost-effectiveness of four agents 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. 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. Costs of agents, adverse effects, and ureteral obstruction work-ups were obtained from the University of North Carolina - 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 $9,755 for intraoperative evaluation with retrograde pyelograms and stents to $29,034 for hospitalization. Our primary outcome was the incremental cost-effectiveness ratio (ICER) per unnecessary work-up for ureteral obstruction avoided. Sensitivity analyses were performed to identify 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 slight improvement in avoiding unnecessary ureteral obstruction work-ups, and higher cost associated with adverse reactions (ICER $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 most effective agents to aid in visualization of ureteral patency during intraoperative cystoscopy, though dextrose is associated with higher cost due to a higher rate of adverse reactions (primarily UTI). 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 visualization of ureteral jets is unclear with initial use of phenazopyridine or dextrose.