Cost-effectiveness of universal cystoscopy to identify ureteral injury at hysterectomy

Objective: To evaluate the cost-effectiveness of routine cystoscopy at the time of abdominal, vaginal, and laparoscopically assisted vaginal hysterect omy in terms of cost per ureteral injury identified and treated. Methods: Using a hospital-based perspective, a decision-analysis model was constructed to estimate the outcomes and costs of cystoscopy or no cystosco py at the time of abdominal hysterectomy. A similar model was constructed f or vaginal and laparoscopically assisted vaginal hysterectomy to account fo r the cost of conversion to laparotomy. Cost estimates were based on estima ted costs of Duke University Medical Center and from average Medicare reimb ursements for similar Diagnostic Related Groups from the Health Care Financ ing Administration. The incidence of ureteral injury was obtained from a re view of the literature. Sensitivity analyses were performed for the followi ng variables: ureteral injury rate, silent ureteral injury rate, cost of cy stoscopy, and cost of therapeutic interventions. We assumed a silent renal death rate of 0%. Results: Routine cystoscopy at abdominal hysterectomy was cost-saving above a threshold ureteral injury rate of 1.5%. At a ureteral injury rate of 0.2 %, the marginal increase in the cost of routine intraoperative cystoscopy w as $108 per abdominal hysterectomy, with an associated cost of $54,000 per ureteral injury identified. In comparison, at a ureteral injury rate of 2%, routine cystoscopy gave a marginal cost savings of $44 per hysterectomy, w ith a cost savings of $2200 per ureteral injury identified intraoperatively . At the baseline ureteral injury rate of 0.5%, routine cystoscopy had a ma rginally increased cost of $83 per hysterectomy, with an incremental cost-e ffectiveness of $16,600 spent per ureteral injury identified. The model con structed for vaginal hysterectomy and laparoscopically assisted vaginal hys terectomy yielded a threshold ureteral injury rate of 2%, above which routi ne cystoscopy was cost-saving. In both models, the incidence of ureteral in jury and the cost of readmission were the two variables with the greatest i nfluence on cost-effectiveness. Conclusion: The cost-effectiveness of routine intraoperative cystoscopy dep ends on the rate of ureteral injury independent of the route of hysterectom y. If that rate exceeds 1.5% for abdominal hysterectomy and 2% for vaginal or laparoscopically assisted vaginal hysterectomy, then routine cystoscopy is cost-effective. (Obstet Gynecol 2001;97: 685-92 (C) 2001 by The American College of Obstetricians and Gynecologists.).