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Costs of urodynamic testing
LETTERS TO THE EDITOR
COSTS
OF URODYNAMIC
To the Editor: This
TESTING
letter might be considered as “equal time for the practicing clinical urologist” and is directed toward the thrust of Dr. Frank Hinman’s editorial comments on Dr. Edward McGuires’ article, “Patient Costs for Urodynamic Testing,” published in the October issue (vol. 14, pages 425, 426-427) of UROLOGY. Dr. McGuires’ statistical presentation was interesting because, in part, it explains the recent migration of Canadian physicians to the United States. He then makes a quantum argumentative leap to conclude that urodynamics testing should be largely confined to university laboratories where equipment costs can be defrayed from sources other than patient fees. The logic of this conclusion escapes me, since it might be too simplistic to assume that ultimately, in one way or another, the consumer does not “foot the bill” because of either tax consideration which partially motivates contributions or funding of this equipment through federal grants. Dr. Hinman, on the other hand, has been for several years an advocate for restraint in the clinical application of urodynamics testing outside of university centers and is the author of several editorials on this subject which have appeared in other journals. In this most recent editorial, Dr. Hinman suggests that too many instruments are in the hands of physicians who may not know how to use them properly and whose indications for their use might be motivated by an attempt to amortize rapidly the cost of this expensive equipment. I am sure that in some instances and perhaps in many situations he has surveyed in his area, Dr. Hinman’s observations hold some validity. However, I am compelled to offer another aspect of urodynamics testing which should be considered. First and foremost, we should define “urodynamics testing” in a nonuniversity-center setting. At the risk of seeming anecdotal, this can be accomplished by describing one who might be considered an average clinical urologist engaged in full-time private practice. I became intrigued with the intellectual aspects and clinical applications of urodynamics testing several years ago and have closely followed the advances in neurophysiology and pharmacology in this area. At that time, I began doing electronic urinary flow rates when indicated and find this study very helpful in evaluating many of my patients. For example, I know of no other study that can objectively and simply evaluate the progression of infravesical obstructive problems and their response to indicated management. Granted, a graduated flask and stopwatch could be used and less information regarding the pat-
652
tern of voiding might be obtained. However, such an argument might also be employed to discourage the physician from obtaining a fiberoptic system when an incandescent light cystoscope might suffice. Cystometrics are certainly of value in bladder testing and when interpreted within the framework that what it is measuring is not necessarily a physiologic process, a rapid-flow carbon dioxide study can give valuable information and is easy to do. A twochannel unit will also allow the possibility of obtaining some manifestation of external sphincter electromyographic (E MC) potential without increasing the time or expense of the study. However, except in rare instances I am not convinced EMG has helped in the evaluation of these patients, and this study must be interpreted with caution. Because of this, I am not inclined to charge a patient for EMG when doing cystometrics, since I have incurred no expense and it has taken me no more time to include this parameter. Urethral profilimetry is an elegant study, but I am not sure that it has helped me very much with my patients. Therefore, I will occasionally perform this study because of intellectual curiosity or on rare occasions when I think it will be helpful in a clinical situation. Conceivably, a true reason for this study may be found someday. Until then, I will continue not to charge a fee for this. My fees for flow rate studies and cystometrics are less than the mean charges outlined by Dr. McGuire. How then do I increase my income by doing these studies? In fact, this equipment generates very little income for me. But it does help me in my evaluation of a certain segment of my practice. At the risk of seeming too altruistic, I must, however, point out that with depreciation and investment tax credit, there is little need to overutilize an $8,000 investment so that it pays for itself within a reasonable time. If this equipment is not making me rich, what then is it doing? Basically, it is helping me in the management of some of my patients and stimulating my interest in this exciting and rapidly advancing aspect of our specialty. It would be profoundly unfair to expect the practicing urologist to keep up with these advances and deny him the opportunity of using the information he is expected to absorb from the scientific publications. I do not advocate the presence of more sophisticated equipment, such as pressure tlow with tine, outside a urodynamics center; neither do I feel that every urologist in town needs urodynamics testing equipment. However, I think it would be unfortunate to deny those who are interested in this field the opportunity to study our patients with this modality when indicated. This, in
UROLOGY
/
DECEMBER
1979
/
VOLUME
XIV,
NUMBER
6
turn, would help us to ascertain which of our patients need referral for more sophisticated studies without subjecting all of them to the inconvenience and expense of traveling to a center when a detailed evaluation may not be necessary. In this age of federal guidelines which increasingly dictate the nature of our medical practice, it is conceivable that the opinions of such a distinguished urologist as Dr. Hinman could be used to justifji the limitation of some of our procedures to university centers. Since the quality and sophistication of the clinical urologist is constantly improving, thanks to educators such as Dr. Hinman, I believe it would be sad if they were not able to practice at their level of competence. Steven B. Roberts, M.D. 1017 E. Idel Street Tyler, Texas 75701
MORE
“PEARLS”
To the Editor:
This letter is in response to “Pearls,” by Paul Lemer, M.D., which appeared in the “Letters to the Editor” section of the August issue (vol. 14, page 211) of UROLOGY. Dr. Lemer criticized the tendency for the two main urology journals to concentrate on technical articles which were lacking in practical application and literary style. He hoped that other urologists would echo his sentiments, and that some day practical articles such as his would become a regular feature. It is in this spirit that more “pearls” are offered. Reanastomosis
of Vas
An excellent way of stenting the anastomosis is to use a lacrimal duct stent. This tubing is easy to insert because it comes with a needle-introducer at each end. After leading the plastic tubing into the lumen for a reasonable distance, the straight needle is thrust through the wall of the vas, and then through the scrotal wall, both above and below the anastomosis. At this point the needles are cut off, and the ends of the tubing are sutured together to prevent their retraction. Subsequent removal of the tubing presents no difficulty. (I am indebted to my senior associate, Dr. Ernest R. Gentile, for this suggestion.) He has had excellent success (i.e., pregnancy) utilizing this type of stent, without a need for microsurgical techniques. Ureteral
Calculi
1. Avoid “double booking” fbr distal ureteral calculi. If the stone is low enough fbr basketry, it is low enough to be a most difficult ureterolithotomy. After unsuccessful basketry, many of these stones will pass spontaneously in a few days. If not, it is worth a second basket attempt before considering an open procedure.
UROLOGY
I
DECEMBER
1979
i
VOLUME
XIV,
NUMBER
2. If you are performing a ureterolithotomy on a very distal calculus, it is sometimes helpful to place a ureteral catheter alongside the calculus one or more days before. Th e catheters help to “fix” the calculus, as well as make localization of the ureter less difficult. In a female patient, the catheter can be placed easily with local anesthesia. 3. Laugh if you will, but in my book there is one very solid indication for the use of oral enzymes in ureteral calculus disease. It is in the 25O-pound woman who has a matrix calculus, which is not only nonopaque but associated with a fever. This patient is the last one on whom you want to make an incision. The enzymes can break up the matrix stone and promote spontaneous passage. 4. In a stone wedged at the ureteropelvic junction, do not operate “on” the ureteropelvic junction. You may get away with it a hundred times, but there will come the time when you push it into the pelvis and thence into a calyx. To avoid this potential disaster, operate instead on the renal pelvis. Open the pelvis, and lift out the stone from above. (Another lesson learned the hard way.) 5. If your ureterolithotomy patients are still in the hospital after the seventh postoperative day, consider this approach. Place the tip of your index finger just beneath the stone, so that the stone is firmly fixed. The knife blade incises only that ureter which is just over the calculus. The stone is removed through this small ureterotomy not only by grasping it with vascular forceps (Randall forceps are too large), but also by pushing it out from within by the index finger that lies beneath the stone. This ureterotomy is approximated, not closed, with a single adventitial stitch, which avoids muscle as well as mucosa. 6. Despite improvements in the Jackson-Pratt type of drain, the tried-and-tested Penrose drain is still superior. It cannot become clogged because the drainage is around it and not through it. And if drainage stops because of inspissated secretions, drainage can be restarted easily by gentle advancement. 7. Removing the drain before the drainage has stopped is a good way to convert a one-stage operation into a two-stage one, the second being at the very least the drainage of a collection. (This caveat was derived from a negative personal experience.) 8. When operating on an upper ureteral calculus, I recommend making the incision higher than you think is necessary, removing some part of the twelfth rib without the slightest hesitation. The purpose is to come down on the ureter above the supposed position of the stone. Personal experience, again, is the basis for this recommendation. 9. When the patient is septic and you are desperate to get a ureteral catheter by the stone to buy some time, and you cannot, consider injecting anesthetic lubricant at the level of the stone through the ureteral catheter to permit relaxation of the spastic
6
653
COSTS
OF URODYNAMIC
To the Editor: This
TESTING
letter might be considered as “equal time for the practicing clinical urologist” and is directed toward the thrust of Dr. Frank Hinman’s editorial comments on Dr. Edward McGuires’ article, “Patient Costs for Urodynamic Testing,” published in the October issue (vol. 14, pages 425, 426-427) of UROLOGY. Dr. McGuires’ statistical presentation was interesting because, in part, it explains the recent migration of Canadian physicians to the United States. He then makes a quantum argumentative leap to conclude that urodynamics testing should be largely confined to university laboratories where equipment costs can be defrayed from sources other than patient fees. The logic of this conclusion escapes me, since it might be too simplistic to assume that ultimately, in one way or another, the consumer does not “foot the bill” because of either tax consideration which partially motivates contributions or funding of this equipment through federal grants. Dr. Hinman, on the other hand, has been for several years an advocate for restraint in the clinical application of urodynamics testing outside of university centers and is the author of several editorials on this subject which have appeared in other journals. In this most recent editorial, Dr. Hinman suggests that too many instruments are in the hands of physicians who may not know how to use them properly and whose indications for their use might be motivated by an attempt to amortize rapidly the cost of this expensive equipment. I am sure that in some instances and perhaps in many situations he has surveyed in his area, Dr. Hinman’s observations hold some validity. However, I am compelled to offer another aspect of urodynamics testing which should be considered. First and foremost, we should define “urodynamics testing” in a nonuniversity-center setting. At the risk of seeming anecdotal, this can be accomplished by describing one who might be considered an average clinical urologist engaged in full-time private practice. I became intrigued with the intellectual aspects and clinical applications of urodynamics testing several years ago and have closely followed the advances in neurophysiology and pharmacology in this area. At that time, I began doing electronic urinary flow rates when indicated and find this study very helpful in evaluating many of my patients. For example, I know of no other study that can objectively and simply evaluate the progression of infravesical obstructive problems and their response to indicated management. Granted, a graduated flask and stopwatch could be used and less information regarding the pat-
652
tern of voiding might be obtained. However, such an argument might also be employed to discourage the physician from obtaining a fiberoptic system when an incandescent light cystoscope might suffice. Cystometrics are certainly of value in bladder testing and when interpreted within the framework that what it is measuring is not necessarily a physiologic process, a rapid-flow carbon dioxide study can give valuable information and is easy to do. A twochannel unit will also allow the possibility of obtaining some manifestation of external sphincter electromyographic (E MC) potential without increasing the time or expense of the study. However, except in rare instances I am not convinced EMG has helped in the evaluation of these patients, and this study must be interpreted with caution. Because of this, I am not inclined to charge a patient for EMG when doing cystometrics, since I have incurred no expense and it has taken me no more time to include this parameter. Urethral profilimetry is an elegant study, but I am not sure that it has helped me very much with my patients. Therefore, I will occasionally perform this study because of intellectual curiosity or on rare occasions when I think it will be helpful in a clinical situation. Conceivably, a true reason for this study may be found someday. Until then, I will continue not to charge a fee for this. My fees for flow rate studies and cystometrics are less than the mean charges outlined by Dr. McGuire. How then do I increase my income by doing these studies? In fact, this equipment generates very little income for me. But it does help me in my evaluation of a certain segment of my practice. At the risk of seeming too altruistic, I must, however, point out that with depreciation and investment tax credit, there is little need to overutilize an $8,000 investment so that it pays for itself within a reasonable time. If this equipment is not making me rich, what then is it doing? Basically, it is helping me in the management of some of my patients and stimulating my interest in this exciting and rapidly advancing aspect of our specialty. It would be profoundly unfair to expect the practicing urologist to keep up with these advances and deny him the opportunity of using the information he is expected to absorb from the scientific publications. I do not advocate the presence of more sophisticated equipment, such as pressure tlow with tine, outside a urodynamics center; neither do I feel that every urologist in town needs urodynamics testing equipment. However, I think it would be unfortunate to deny those who are interested in this field the opportunity to study our patients with this modality when indicated. This, in
UROLOGY
/
DECEMBER
1979
/
VOLUME
XIV,
NUMBER
6
turn, would help us to ascertain which of our patients need referral for more sophisticated studies without subjecting all of them to the inconvenience and expense of traveling to a center when a detailed evaluation may not be necessary. In this age of federal guidelines which increasingly dictate the nature of our medical practice, it is conceivable that the opinions of such a distinguished urologist as Dr. Hinman could be used to justifji the limitation of some of our procedures to university centers. Since the quality and sophistication of the clinical urologist is constantly improving, thanks to educators such as Dr. Hinman, I believe it would be sad if they were not able to practice at their level of competence. Steven B. Roberts, M.D. 1017 E. Idel Street Tyler, Texas 75701
MORE
“PEARLS”
To the Editor:
This letter is in response to “Pearls,” by Paul Lemer, M.D., which appeared in the “Letters to the Editor” section of the August issue (vol. 14, page 211) of UROLOGY. Dr. Lemer criticized the tendency for the two main urology journals to concentrate on technical articles which were lacking in practical application and literary style. He hoped that other urologists would echo his sentiments, and that some day practical articles such as his would become a regular feature. It is in this spirit that more “pearls” are offered. Reanastomosis
of Vas
An excellent way of stenting the anastomosis is to use a lacrimal duct stent. This tubing is easy to insert because it comes with a needle-introducer at each end. After leading the plastic tubing into the lumen for a reasonable distance, the straight needle is thrust through the wall of the vas, and then through the scrotal wall, both above and below the anastomosis. At this point the needles are cut off, and the ends of the tubing are sutured together to prevent their retraction. Subsequent removal of the tubing presents no difficulty. (I am indebted to my senior associate, Dr. Ernest R. Gentile, for this suggestion.) He has had excellent success (i.e., pregnancy) utilizing this type of stent, without a need for microsurgical techniques. Ureteral
Calculi
1. Avoid “double booking” fbr distal ureteral calculi. If the stone is low enough fbr basketry, it is low enough to be a most difficult ureterolithotomy. After unsuccessful basketry, many of these stones will pass spontaneously in a few days. If not, it is worth a second basket attempt before considering an open procedure.
UROLOGY
I
DECEMBER
1979
i
VOLUME
XIV,
NUMBER
2. If you are performing a ureterolithotomy on a very distal calculus, it is sometimes helpful to place a ureteral catheter alongside the calculus one or more days before. Th e catheters help to “fix” the calculus, as well as make localization of the ureter less difficult. In a female patient, the catheter can be placed easily with local anesthesia. 3. Laugh if you will, but in my book there is one very solid indication for the use of oral enzymes in ureteral calculus disease. It is in the 25O-pound woman who has a matrix calculus, which is not only nonopaque but associated with a fever. This patient is the last one on whom you want to make an incision. The enzymes can break up the matrix stone and promote spontaneous passage. 4. In a stone wedged at the ureteropelvic junction, do not operate “on” the ureteropelvic junction. You may get away with it a hundred times, but there will come the time when you push it into the pelvis and thence into a calyx. To avoid this potential disaster, operate instead on the renal pelvis. Open the pelvis, and lift out the stone from above. (Another lesson learned the hard way.) 5. If your ureterolithotomy patients are still in the hospital after the seventh postoperative day, consider this approach. Place the tip of your index finger just beneath the stone, so that the stone is firmly fixed. The knife blade incises only that ureter which is just over the calculus. The stone is removed through this small ureterotomy not only by grasping it with vascular forceps (Randall forceps are too large), but also by pushing it out from within by the index finger that lies beneath the stone. This ureterotomy is approximated, not closed, with a single adventitial stitch, which avoids muscle as well as mucosa. 6. Despite improvements in the Jackson-Pratt type of drain, the tried-and-tested Penrose drain is still superior. It cannot become clogged because the drainage is around it and not through it. And if drainage stops because of inspissated secretions, drainage can be restarted easily by gentle advancement. 7. Removing the drain before the drainage has stopped is a good way to convert a one-stage operation into a two-stage one, the second being at the very least the drainage of a collection. (This caveat was derived from a negative personal experience.) 8. When operating on an upper ureteral calculus, I recommend making the incision higher than you think is necessary, removing some part of the twelfth rib without the slightest hesitation. The purpose is to come down on the ureter above the supposed position of the stone. Personal experience, again, is the basis for this recommendation. 9. When the patient is septic and you are desperate to get a ureteral catheter by the stone to buy some time, and you cannot, consider injecting anesthetic lubricant at the level of the stone through the ureteral catheter to permit relaxation of the spastic
6
653