Economic analysis: SURE reduces downstream stone costs

A cost-focused analysis using data from the ASPIRE randomized trial suggested that the steerable ureteroscopic renal evacuation (SURE) procedure—which uses the CVAC device to actively aspirate stone fragments during ureteroscopy—may generate meaningful downstream savings compared to standard ureteroscopy (URS).¹

The ASPIRE trial followed 123 patients with renal stones over 2 years, tracking emergency department visits, surgical retreatments, and hospitalizations. The new analysis, presented at the 41st Annual Congress of the European Association of Urology (EAU) in London, UK, combined those event frequencies with 2025 Medicare fee schedule estimates and IBM MarketScan commercial claims data to project health care resource utilization costs over the same horizon.

SURE was associated with a relative risk of 0.16 for ED visits, 0.85 for retreatments, and 0.30 for hospitalizations compared with standard URS—yielding a combined 64% reduction in total event-related costs. Applied to real-world claims data, that translates to an estimated per-patient savings of $3464 in kidney stone–related follow-up costs over 2 years ($1958 vs $5422).

In this interview, lead investigator Brett Johnson, MD, an associate professor of urology at UT Southwestern Medical Center, noted that the analysis intentionally excludes the incremental index procedure cost of SURE relative to standard URS, as those costs vary too widely by payer, setting, and contracting structure to model cleanly. Instead, the data are designed to give hospital value analysis committees a downstream benchmark they can weigh against their own cost structures.

Please provide an overview of this study and its notable findings.

The idea is we're looking at steerable ureteroscopic renal evacuation using the CVAC system. There was a randomized trial we did several years ago called the ASPIRE trial, and we have all sorts of surgical outcomes from that. We followed these patients very closely for 2 years. We know who went back to the emergency room, who needed additional visits, who had these downstream health care utilizations over that 2-year period. The ASPIRE study showed that the SURE procedure substantially lowered residual stone volume and was associated with fewer downstream health care touchpoints over that 2-year period.

The idea for this study was, using some modeling, we did an analysis that basically analyzed what we expect the cost of those downstream health encounters would be, to determine if there was any cost savings for the SURE procedure if you look at their follow-up as a whole. Ultimately, we estimated a savings of around $2700 to $3900 per patient in a cost reduction for kidney stone–related events during that follow-up period. The idea is we have kind of an economic argument to make that says we should be offering this procedure to improve stone clearance and offset some costs that may be associated with the index procedure with downstream benefits.

The analysis explicitly excludes the incremental index treatment cost of SURE vs standard ureteroscopy—framing the $3,464 in downstream savings as a basis to "amortize" that difference. What is the actual cost differential at index treatment, and at what price point does the math work in favor of SURE for a hospital, an ambulatory surgical center, or a payer?

That's an excellent question and definitely one that was brought up at the EAU [Congress]. The short answer is it's a little bit too hard to do that because each situation—each procedure—will vary so greatly based on the payer, based on whether it's an inpatient, whether it's in a hospital setting, whether it's in an ambulatory surgery center, what the contracting structure is, what the reimbursement payment is. It doesn't really make sense to say, “Well, this is the cost of the procedure.” The way the math was done, we used data from ASPIRE, which was a different generation of device with different costs. We can't really use direct costs. It's too complicated to bake all that into one analysis. The purpose of the study was, here are the follow-up data, and you can take these and go to your own value committee and go through your contracting and your payer mix and all that and say, “This is what the value committee will estimate it will cost, and this is what we would expect for an outcome.” So, the short answer is we really wanted to define this downstream value, and it would get too messy. I think we would lose the thread a little bit if we said, “The index costs procedure does this, unless the payer is this, unless you're doing it here.” So, we really wanted to frame it in that way. It's a very valid question. It just wasn't really what we were trying to answer with the study.

MarketScan commercial claims data reflects a privately insured, largely working-age population. How generalizable is that cost baseline to the broader kidney stone population urologists actually treat—including Medicare patients, uninsured patients, and those in health systems with very different utilization patterns?

This comes up with pretty much any of these population-style studies using Medicare data or these IBM MarketScan studies. We’re including both commercial and Medicare supplements in the claims data, so that's a pretty wide distribution. There are a lot of supplemental Medicare patients and private payers. Baseline follow-up costs varied a lot, but when we looked at our data, it was very consistent with other studies that looked at just the cost. There are all these studies on the cost of stone disease in general, and our data were very consistent with previously published work.

The clinical driver of cost—emergency room visits, needing surgery—is essentially payer agnostic. Going to the ER is going to cost money. Those are all generalizable for no matter who the payer is. And absolutely, uninsured and underinsured patients are challenging. We're certainly missing that piece of the pie in this type of data. But that's also challenging because those patients, the claims data is different, but also the way they behave clinically is sometimes different. They often delay their care, and those costs can be shifted downstream. Ultimately, when it becomes emergent—you may have a patient who has an obstructing ureteral stone that could have been treated, but they wait 2 years and now it's a robotic nephrectomy, or they get an XGP [xanthogranulomatous pyelonephritis] kidney, and there's some clinical complication from a delay in care. That makes it hard to consider them within the same group for the analysis.

Anytime we do this population-level thing, we are certainly giving up some granularity, with the benefit that we get a much larger data set to analyze with. But I think, looking at both facets of how the analysis was done, it is generalizable for the vast majority of patients a urologist would see.

For a urologist or hospital administrator trying to make a real procurement decision about SURE vs standard ureteroscopy today, what does this analysis actually tell them—and what additional data would you want to have before making that case to a value analysis committee?

I talk with the value analysis people all the time for various things. The first thing I say to them is, “My job ultimately is to offer the best operation for the situation that is clinically warranted, and that should be your goal too. I understand we've got to keep the lights on and keep the nurses paid and make it all work and make sense. We don't want to do anything frivolous, but ultimately, we have clinical data that say this is a better operation. This can reduce downstream emergency room visits that in and of themselves have burdens on patients—financial burden, financial toxicity.”

But the idea of this study is, you can't just look at what is the equipment cost to do a given case—or you can, but it's probably not the right way to do it. And if you do a better operation up front, what you end up with is potentially either net-net neutral costs or maybe even some favorable decrease in costs downstream. The value analysis committee may or may not care about that, frankly. They have their budget, and saving an ER visit in 9 months may not necessarily make their books. So, I think when you're talking about the hospital system as a whole, it's a very strong argument that it's a clinically and economically meaningful outcome. And then you have to figure out what the situation is. What is our payer mix, what is our reimbursement, what is the cost going to be, is this going to be feasible long term?

But the other side I would also say is that patients are becoming more and more educated. They're asking ChatGPT about these surgeries, they're getting summaries of scientific articles, and they'll bring it to you and say, “I want this,” or, “Tell me about this.” And so there may also be kind of a branding component where some percentage of patients will say, “I want this procedure because I've read this study.” And if we don't offer that, that patient's going to go somewhere else. So ultimately, I think we're trying to say that there is value downstream by doing a better operation. But I would also say to the committee: “Our goal should be to do a better operation because that's our job. And then your goals and my goals should align.”

REFERENCE

1. Matlaga B, Chi T, Stern K, et al. Health-Economic Implications of the SURE procedure in Kidney Stone Removal: A Claims Data Analysis based on Two-Year Results of the ASPIRE Study. Presented at: 41st Annual Congress of the European Association of Urology. London, UK. March 13-16, 2026. Abstract LB016