Cost effectiveness in the transition from open to percutaneous nephrolithotomy in a low and middle-income country public hospital setting

Background: In high income countries, minimally invasive surgical techniques such as percutaneous nephrolithotomy (PCNL) to treat kidney stone disease have demonstrated better health outcomes and lower costs. However, open surgery is still commonplace in low- and middle-income countries (LMICs) due to inequities in access to equipment, training and resources. PCNL was introduced at Georgetown Public Hospital Corporation (GPHC) in Guyana in 2023. We analyzed open pyelolithotomy and PCNL cases for complex kidney stone disease at GPHC and quantified the theoretical change in costs if open cases were entirely replaced with PCNL. Methods: Case logs of urology patients at GPHC from January 2018 to December 2024 were retrospectively reviewed. A total of 59 patients treated by open pyelolithotomy and 20 patients treated by PCNL with complex kidney stones were identified. A decision tree analysis was performed to ascertain the potential cost savings by replacing open pyelolithotomy with PCNL. The analysis included surgical, hospital, complication and transfusion costs. Results: Prior to the introduction of PCNL at GPHC (2018-2022), 46% of urinary stone procedures were open surgery. Pyelolithotomy was the most common open procedure. A decision tree analysis showed that open pyelolithotomy was 1.4 times more expensive ($4160 versus $2974) than PCNL. Conclusion: This study shows that PCNL is a cost saving alternative to open pyelolithotomy at GPHC and demonstrates an opportunity to improve standards of care for urological disease in LMICs.