Screening recommendations for prostate cancer remain controversial, and no specific guidelines exist for screening in renal transplant candidates. To examine whether the use of prostate-specific antigen (PSA)-based screening in patients with ESRD affects time to transplantation and transplant outcomes, we retrospectively analyzed 3782 male patients $18 years of age undergoing primary renal transplant evaluation during a 10-year period. Patients were grouped by age per American Urological Association screening guidelines: group 1, patients ,55 years; group 2, patients 55-69 years; and group 3, patients .69 years. A positive screening test result was defined as a PSA level .4 ng/ml. We used univariate analysis and Cox proportional hazards models to identify the independent effect of screening on transplant waiting times, patient survival, and graft survival. Screening was performed in 63.6% of candidates, and 1198 candidates (31.7%) received kidney transplants. PSA screening was not associated with improved patient survival after transplantation (P=0.24). However, it did increase the time to listing and transplantation for candidates in groups 1 and 2 who had a positive screening result (P,0.05). Furthermore, compared with candidates who were not screened, PSA-screened candidates had a reduced likelihood of receiving a transplant regardless of the screening outcome (P,0.001). These data strongly suggest that PSA screening for prostate cancer may be more harmful than protective in renal transplant candidates because it does not appear to confer a survival benefit to these candidates and may delay listing and decrease transplantation rates.

The difference in cost for the 2 procedures was largely driven by the cost and method of ureteral stent removal. Sensitivity analysis shows that the cost difference can be minimized, but not eliminated, by increasing the rate of patient self-stent removal via string.CONCLUSIONS: Our decision analysis model demonstrates superior cost-effectiveness for URS without stent placement with an estimated savings of $2,940 per procedure. The increased costs associated with higher complication rates for stentless URS do not add increased costs to the healthcare system. Although stent omission is not recommended for every patient, careful stratification and selection of stone patients may enable surgeons to improve cost-effectiveness of URS lithotripsy.

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