title: Cost-effective management of pelvic fracture urethral injuries.
abstract: OBJECTIVE
  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.
authors.affiliation: Department of Urological Surgery, A-1302 Medical Center North, Vanderbilt University Medical Center, Nashville, TN, 37232, USA. niels.v.johnsen@vanderbilt.edu.
authors.forename: Niels V
authors.initials: NV
authors.lastname: Johnsen
authors.affiliation: Department of Urological Surgery, A-1302 Medical Center North, Vanderbilt University Medical Center, Nashville, TN, 37232, USA.
authors.forename: David F
authors.initials: DF
authors.lastname: Penson
authors.affiliation: Department of Urological Surgery, A-1302 Medical Center North, Vanderbilt University Medical Center, Nashville, TN, 37232, USA.
authors.forename: W Stuart
authors.initials: WS
authors.lastname: Reynolds
authors.affiliation: Department of Urological Surgery, A-1302 Medical Center North, Vanderbilt University Medical Center, Nashville, TN, 37232, USA.
authors.forename: Douglas F
authors.initials: DF
authors.lastname: Milam
authors.affiliation: Department of Urological Surgery, A-1302 Medical Center North, Vanderbilt University Medical Center, Nashville, TN, 37232, USA.
authors.forename: Roger R
authors.initials: RR
authors.lastname: Dmochowski
authors.affiliation: Department of Urological Surgery, A-1302 Medical Center North, Vanderbilt University Medical Center, Nashville, TN, 37232, USA.
authors.forename: Melissa R
authors.initials: MR
authors.lastname: Kaufman
mesh_terms: D000328:Adult; D003362:Cost-Benefit Analysis; D050723:Fractures, Bone / Q000150:complications*; D006801:Humans; D059411:Lower Urinary Tract Symptoms / Q000175:diagnosis / Q000209:etiology; D008297:Male; D018803:Models, Economic; D010346:Patient Care Management / Q000191:economics / Q000379:methods; D010384:Pelvic Bones / Q000293:injuries*; D019651:Plastic Surgery Procedures / Q000191:economics / Q000379:methods; D014481:United States; D014521:Urethra / Q000000981:diagnostic imaging / Q000293:injuries / Q000503:physiopathology / Q000601:surgery; D014525:Urethral Stricture / Q000175:diagnosis / Q000209:etiology / Q000601:surgery; D013520:Urologic Surgical Procedures / Q000191:economics / Q000379:methods; D014949:Wounds, Nonpenetrating / Q000150:complications
keywords: Pelvic fracture; Realignment; Trauma; Urethra; Urethral stricture