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Jaime Landman: Hi, this is Jaime Landman. I'm the Chair of the Department of Urology over at UC Irvine and welcome to another installment of Endourology Today, which is, of course, a collaboration by our great partners at UroToday and the Endourology Society. Today, we have a really fun and important topic and a great guest. So Thomas, welcome.

Thomas Tailly is a great colleague, a great friend, and a graduate of Catholic University in Belgium. Of course, he also did his residency there. He then did his fellowship in London, Ontario at Western University with doctors Denstedt, Pöttler, and Razvi. And has, since then, become quite the world expert on all things endourology, particularly stone disease. He then took his post-op consultant position at The University Hospital of Ghent. And I was really pleased that you accepted a position recently as Assistant Editor of The Journal of Endourology, and has been, quite frankly, one of the best reviewers that we have, both in terms of the number of manuscripts you review and the quality.

So thank you so much for that. But as we do with Endourology Today, we take the manuscripts that are going to be published in the near future that are accepted, and we give our viewers great insight as to what the impact of the manuscript is. And yours just struck me as incredibly important. Dr. Dries Van Compernolle was the first author. You are, of course, the senior author of the manuscript, which was entitled, "Reusable, Single-Use or Both: A Cost-Efficiency Analysis of Flexible Ureterorenoscopes After 983 Cases."



So with a thousand cases under your belt, you are probably one of the biggest experts in the world. I'm going to start because this is a tech issue, do you have any disclosures in terms of support you got for this study or for yourself or from any of the companies?


Thomas Tailly: I didn't get any support from any of the companies to do this study.

Jaime Landman: It makes you particularly objective. And I'm sorry, you didn't get any support, but hopefully, they can support you in the future.

So over five years, you did about a thousand cases. Why don't you just go through, in brief, what you did so that the viewers can understand?


Thomas Tailly: So first of all, thank you for the invitation, and it is a real honor to be here. Thank you so much, and an honor to be part of the journal, by the way.


We thought of this concept or this project, really, when Dries, the first author, was my resident and then fellow because we were considering working on a hybrid model for a flexible ureteroscope because ureteroscopy reusable scopes are quite costly. And we were thinking about how to move towards a complete disposable project or a hybrid system, really.


So we looked at all of our cases. We did a cost-efficiency analysis, and then a friend of mine who is an economist, made us a formula to see how we could make a hybrid model or a hybrid system cost-efficient, really.


Jaime Landman: That is remarkably important. And what I love about your work, here, is that we have such protean healthcare systems that are funded so differently, but after looking at your formula... and if you don't mind, I'd love to go through it with you. I really think it's adaptable to European systems, American systems, Asian systems, South American systems. So this has a global impact, which is what caught my eye. And I'm hoping people will find great value in this. So do you mind sharing, for example, the formula and some examples of how we might calculate costs?

Thomas Tailly: Not at all. It will be my pleasure.

It was exactly the goal, really, to make something completely adaptable to each center, because when we look at all the papers that are out there, they are quite center-specific, and they tell us, well, after so many cases and what are cost-efficient, after so many cases, and so on.


What I wanted to do is make something that everybody could really use, and see whether or not the hybrid system would be useful for them in any country, in any system. So this is basically the model that my friend developed. And what we see here, is the different cost rates of a repair, if it is under warranty or insurance, it doesn't cost anything. Now we have repair costs for type one, type two, and type three, which are different costs. And the different percentages of the number of repairs that we had.


Like for instance, in our study, we had about 50-55% of our repairs were out of the highest cost. Then the formula gives you, or this sheet, really, gives you an average repair cost. And if you look at the average amount of procedures that we do with our reusable scopes, we put that here. This, here, is the cost of our sterilization of one cycle. And then we want to compare that to the cost of the single-use scope that we want to see whether or not the hybrid system would be useful in. And if you use a scope, let's say 650 euros, which is the Pearson scope in our case, and we would use it, let's say in 15% of the cases... we would have to go from 22 uses to 28 uses out of a reusable scope before we have a cost analysis that brings us to a breakeven.


So if you use this reusable scope 29 times, it is cost-efficient in a hybrid system where we use 15% single-use scopes.


If our single-use scope is more expensive, let's say it's 950 euros, but all the rest stays the same, all the numbers change right away. And we see that the same reusable scope would have to go for 38 times before it's cost-neutral with the 15% single-use scopes. So 8 extra times or 6 extra times or 16 extra times makes a big difference. And that, for me, makes a single-use scope of 650 euros feasible in our cost-efficiency analysis. But the other one, not so much.


But let's say that you are in a system where you use your scope only 15 times, and your sterilization cycle is maybe 100 euros. There you go. Or your repair costs are, even more, let's say at 65%. So your average cost of repair goes up, and your average cost of one use goes up as well. And then your cost efficiency is a lot easier. Because instead of 15 times, you have to use it only 15-and-a-half times to be cost-neutral. And it's quite feasible or probable that you will use your scope more than 16 times if you are using a single-use scope for 15% of the cases. And you may even go up to 30% with the single-use scope, and only have to use it 16-and-a-half times to be cost-neutral.


So that is where this formula can be adaptable to each and every center around the globe, really.


Jaime Landman: I think this is utterly fantastic for this very reason. You've actually given us a wonderful tool. I will have to say I am very impressed by your 22 uses per repair for your reusable ureterscopes, because that is, I think pretty close to double what we are getting. And faculty blames the residents. Residents like to blame the faculty. Everyone likes to blame SPD, which is our reprocessing team. But in the end, I don't care as long as we keep our costs down. Or I do care if our costs are way up.

I think that is remarkable work. And just so you know, everyone has to convert euros. But today, the day we are recording this, the euro is 1.2 dollars, so for those in the US or are using US dollars, you can take all those numbers and multiply them by 1.2.


You know, Thomas, it is just fantastic work, and kind of, as you were talking, and even before I prepped for this call, I realized I didn't think of it, we really need to create a website. And I'm happy to work with you. Or you can do it because this is a resource that I think people are going to need, just to have it in a place where you can plug in your numbers, might be easier than-


Thomas Tailly: Fully agree.

Jaime Landman: So you could put this on your site or I am happy to work with you. The only thing I didn't see there was, you said that if you have a warranty, and very few of these I think are under warranty, but if you have a repair contract, did you have that in yours, in your system here? I didn't see that.

Thomas Tailly: So the repair contract is such that we have a certain repair cost, and we get a refurbished scope in exchange for the scope that we give.

Jaime Landman: Correct.

Thomas Tailly: That's the contract that we have. It doesn't come with an extra cost on top of the repairs.

Jaime Landman: All right. But where did that go in? Into the capital cost?

Thomas Tailly: So actually the service contract, as such or in itself, does not cost anything. We only pay for the repairs, an agreement that we have with the company.

Jaime Landman: So that's the difference between some of the centers I know here in the US. I'd love to talk to... we will do that offline because I think that would be important if we want this to have a universal application, which of course it should.


So let's just get down to your bottom line. You said that if you use a reusable scope, it is more cost-efficient after 155 to 274 cases, in your experience with your numbers. Obviously, results will vary as they say, in disclaimers. But that gives people a general idea at a high-volume center like yours, what they might encounter. But the beauty of the manuscript is that they will be able to personalize this for themselves.


Thomas Tailly: Exactly.

Jaime Landman: So I'm going to take us away from this. You know, back to your being a high-volume expert, globally. 40% of my life, I'm an administrator currently, and 60%, I'm a doctor. The administrator in me thinks your manuscript is impeccable and perfect. The doctor in me says, gosh, when I use a flexible ureteroscope that is reusable, I feel sometimes the quality, especially when they are working well, is maybe a little better.

So switching... You are completely off your finance mode into your doctor mode. What are the differences? Obviously, our objective with most ureteroscopies is a stone-free rate, and we want to do that without complications. I would argue that if I have a better ureteroscope with better flow, better vision, I may use a little less fluoro and respect ALARA, better. Can you put your manuscript in the bigger picture?


Thomas Tailly: So the quality of the scope is definitely very, very important when you are treating the stone. And I do know that there are a lot of our colleagues that use an analog scope and not a digital scope to treat stones. I honestly like my digital scopes so much that I only use the analog scope in cases where I can't get my digital scope up the ureter. For instance, in kids, I have a 7.5 French analog, flexible ureterscope, which I use in my pediatric cases or in very narrow ureters. But in all the other cases I use my digital scopes. And for sure, the digital scopes that we have are of great, great quality. The vision is great, the irrigation is great, you can pass any instrument in there and still have quite a good flow. For irrigation and flow, I think we are quite comparable with the single-use scopes because it is a 3.6 French working channel in both the reusable and disposable scopes.

Regarding the quality of the view, I think our digital, reusable scopes are still somewhat better done than our disposable scopes. They will probably get there in the next few years, but for now, I think the digital scopes that we have from all the different companies are still better in quality than the disposable scopes that we have.


And I do agree that if your view is not as impeccable as you would like it to be, then the disposable scope just may not cut it, and you may not get the same results. And you are right, that is most likely the most important aspect of our job: getting the patient stone-free with as little radiation as possible. But if you compare the single-use scopes to the analog scopes that a lot of our colleagues are still using for treating stones... and I have to say, they are actually better. Because with an analog scope, you don't get the view that you get with the disposable, digital scope. So if you compare those, then my personal opinion would be, that a disposable scope is at least as good as an analog, flexible scope, but not at the same level as a reusable, digital scope.


Jaime Landman: Almost entirely agree with you. My only comment would be that we tend to favor Dual Lumen scopes. And the Dual Lumen I like allows a completely empty channel with the complete flow. But you are spot on, and those Dual Lumen scopes are not widely used to my knowledge.

So the only thing I will end up with is, essentially, a landfill. You know, it just breaks my heart every time I use an endoscope... and your father is a great endourologist. Think of the thousands of cases he did. I can see a huge pile in your backyard that your children and mine will have to deal with. My father was a urologist, and I can't imagine what his pile would have looked like. So as much as I kind of see this great vision, because there are some really wonderful things about disposable endoscopes, it is a little bit heartbreaking, and I'm hopeful that someday we can find a balance of some kind of a reposable solution that allows us to get the best of all worlds. But we'll see if that innovation is yet to be around.


Well, with that I'll end this episode. And I want to thank you, Thomas. You are a great partner and friend, and I think this is an important manuscript. I do think you should consider a website, and allow us all to have a great resource for use of your formula. And maybe even incorporate something about the cost of these contracts that many places in the US have, which is just a fixed contract that's annual, and you can maybe plug that in, should be very easy. Especially for a brilliant economist, like your buddy, who helped you with this.


Anyway, have a wonderful evening, and thanks to all our listeners and viewers for always paying attention. And thanks as always to UroToday for allowing us the opportunity to create this content.


Thomas Tailly: And thanks for the opportunity to be here.