Cost-effective management of pelvic fracture urethral injuries.

Johnsen NV, Penson DF, Reynolds WS, Milam DF, Dmochowski RR, Kaufman MR
World J Urol. 2017 35 (10): 1617-1623

PMID: 28229209 · DOI:10.1007/s00345-017-2022-8

PURPOSE - To compare the cost-effectiveness of various treatment strategies in the management of pelvic fracture urethral injuries using decision analysis.

METHODS - Five strategies were modeled from the time of injury to resolution of obstructed voiding or progression to urethroplasty. Management consisted of immediate suprapubic tube (SPT) placement and delayed urethroplasty; primary endoscopic realignment (PER) followed by urethroplasty in failed patients; or PER followed by 1-3 direct vision internal urethrotomies (DVIU), followed by urethroplasty. Success rates were obtained from the literature. Total medical costs were estimated and incremental cost-effectiveness ratios (ICERs) were generated over a 2-year follow-up period.

RESULTS - PER was preferred over SPT placement in all iterations of the model. PER followed by a single DVIU and urethroplasty in cases of failure was least costly and used as the referent approach with an average cost-effectiveness of $17,493 per unobstructed voider. The ICER of a second DVIU prior to urethroplasty was $86,280 per unobstructed voider, while the ICER of a third DVIU was $172,205. The model was sensitive to changes in the success rate of the first DVIU, where when the probability of DVIU success is expected to be less than 32% immediate urethroplasty after failed PER is favored.

CONCLUSIONS - Management of pelvic fracture urethral injuries with PER is the preferred management strategy according to the current model. For those who fail PER, a single DVIU may be attempted if the presumed success rate is >32%. In all other cases, urethroplasty following PER is the preferred approach.

MeSH Terms (15)

Adult Cost-Benefit Analysis Fractures, Bone Humans Lower Urinary Tract Symptoms Male Models, Economic Patient Care Management Pelvic Bones Reconstructive Surgical Procedures United States Urethra Urethral Stricture Urologic Surgical Procedures Wounds, Nonpenetrating

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