1104 TRAUMA, AND GENITAL AND URETHRAL RECONSTRUCTION

Public Employees’ Retirement System on payments for joint replacement and per enrollee use of joint
replacement. The reference pricing intervention set a price for total joint replacement that was
accepted by designated facilities. If an individual elected to use a nondesignated facility, he or she
paid any charge above the set reference price. The center of excellence (COE) intervention required
enrollees to use a facility that was designated a COE for joint replacement by the Blue Cross Blue
Shield Association. If an individual elected to undergo surgery at a facility not deemed to be a COE,
he or she paid the full facility charge out of pocket.
After these policies were enacted the use of facilities accepting the reference price increased
154.2% and the use of centers of excellence increased 638.2%. Interestingly while both approaches
decreased the cost of joint replacement per enrollee, the effect of each intervention was different.
The reference pricing intervention reduced average payments to facilities by 26.7%, whereas the
center of excellence intervention decreased utilization rates of joint replacement among members
by 29.2%.
This interesting study of 2 insurance designs for surgical care found that both were effective at
reducing per capita costs. However, they did so in different ways. Whereas the reference pricing
design decreased variation in price, the COE design reduced variation in service utilization. As we
continue to evolve toward value based care, we will undoubtedly be subject to interventions such as
those evaluated in this study. Understanding the menu of levers to reduce health care spending in the
United States will be critically important as we continue to deliver the right care to the right patient
at the right time.

Matthew J. Resnick, MD, MPH, MMHC

Trauma, and Genital and Urethral Reconstruction

Re: Natural History of Low-Stage Urethral Strictures

R. S. Purohit, R. Golan, F. Copeli, J. Weinberger, M. Benedon, G. Mekel and J. G. Blaivas

Department of Urology, Icahn School of Medicine at Mount Sinai, Department of Urology, New York-Presbyterian Hospital/Weill Cornell Medical Center,
Department of Urology, SUNY Downstate College of Medicine, and Institute for Bladder and Prostate Research, New York, New York, and University of
California, Los Angeles School of Medicine, Los Angeles, California
Urology 2017; 108: 180e183. doi: 10.1016/j.urology.2017.05.025

Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/28552818

Editorial Comment: Scars generally contract with time and this phenomenon applies to urethral
strictures as well. This is a small but novel series of men with urethral strictures graded according to
endoscopic appearance. Admittedly the literature is poor regarding the staging and stratification of
stricture disease, although great strides have recently been made concerning reconstructive tech-
niques. Another way of thinking about it is to consider when radiographic irregularities in the urethra
become significant strictures that warrant treatment. My general rule has always been that if I can get
a flexible cystoscope through a stricture, then I do not consider it to be appropriate for reconstructive
surgery. These data indicate I was right.
This study examines the fate of 42 men with negligible wide bore (stage 1) strictures easily passable
with the scope. Not surprisingly, the entire group managed to avoid reconstructive surgery during a
median followup of nearly 2 years, although 12% had progression to slightly tighter strictures. The
results shed new light on previous data indicating that urethrotomy is more successful than
cystoscopy in wide caliber stricturesdperhaps it is no better. The other side of this coin is that we
need to consider the fate of more obliterative strictures. Should they be excised or grafted? The au-
thors offer a practical syntax for staging stricture severity that makes good sense and is sorely
needed.

Allen F. Morey, MD
 UROLITHIASIS/ENDOUROLOGY 1105

Re: Primary Realignment for Pelvic Fracture Urethral Injury is Associated with
Prolonged Time to Urethroplasty and Increased Stenosis Complexity

A. Horiguchi, M. Shinchi, A. Masunaga, K. Okubo, K. Kawamura, K. Ojima, K. Ito, T. Asano

and R. Azuma
Departments of Urology and Plastic Surgery, National Defense Medical College, Saitama, Japan
Urology 2017; 108: 184e189. doi: 10.1016/j.urology.2017.06.001

Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/28606774

Editorial Comment: This study from Japan demonstrates, as we reported 3 years ago, that men treated
with primary realignment for pelvic fracture urethral injuries tend to experience much longer delays to
definitive urethroplasty (mean time 133 months in this series!). Repeated transurethral procedures were
common in the realignment group, as were false passage and iatrogenic scar formation. Stricture length
and operative time, technique and outcomes were similar.

Allen F. Morey, MD

Urolithiasis/Endourology

Re: Composition of Urinary Calculi in Infants: A Report from an

Endemic Country
M. N. Zafar, S. Ayub, H. Tanwri, S. A. A. Naqvi and S. A. H. Rizvi
Departments of Pathology and Urology, Sindh Institute of Urology and Transplantation, Karachi, Pakistan
Urolithiasis 2017; Epub ahead of print. doi: 10.1007/s00240-017-1010-1

Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/29101428

Editorial Comment: Stone disease is endemic in Pakistan. This study demonstrated that the majority
of stones in younger children in this country are composed of ammonium acid urate. This finding held
true across anatomical sites including the bladder, kidney and ureter. Several things can induce for-
mation of these stones, including chronic diarrhea, infection and diet. Diarrhea can lead to bicarbonate
loss, promoting acidosis. The latter results in increased urinary ammonium excretion, with ammonium
serving as a buffer. Urinary ammonium can also be generated from urinary tract infection with urease
producing organisms. Diets low in animal protein result in decreased amounts of phosphate, which
would normally be a Hþ proton acceptor prompting increased ammonium to be generated for buffering.
Such responses produce a favorable milieu for generation of ammonium acid urate stones. Ammonium
acid urate stones may also be a sign of laxative abuse, something that should be suspected in otherwise
normal patients.

Dean G. Assimos, MD

Suggested Reading

Smith CR, Poindexter JR, Meegan JM et al: Pathophysiological and physicochemical basis of ammonium urate stone formation in dolphins. J Urol 2014; 192:
260.
Rizvi SA, Naqvi SA, Hussain Z et al: Pediatric urolithiasis: developing nation perspectives. J Urol 2002; 168: 1522.
Soble JJ, Hamilton BD and Streem SB: Ammonium acid urate calculi: a reevaluation of risk factors. J Urol 1999; 161: 869.
Dick WH, Lingeman JE, Preminger GM et al: Laxative abuse as a cause for ammonium urate renal calculi. J Urol 1990; 143: 244.