Outcomes of percutaneous nephrolithotomy in a resource-limited setting: a retrospective study

BACKGROUND: Percutaneous nephrolithotomy (PCNL) is the gold standard for managing large renal calculi; however, data on its long-term efficacy in resource-limited settings such as Yemen are scarce. We evaluated the outcomes and complications of PCNL surgery in resource limited settings over a nine-year period in a high-volume centre in Ibb City, Yemen. METHODS: We conducted a retrospective analysis of 1,458 patients who underwent PCNL between October 2016 and June 2025. Data included patient demographics, stone characteristics, surgical techniques (standard, mini-PCNL, and supine), and outcomes. The stone-free rate (SFR) was defined as the absence of fragments greater than 4 mm on follow-up imaging at three months. Complications were classified using the Clavien-Dindo system. RESULTS: The cohort comprised 763 (52.3%) males and 695 (47.7%) females with a mean age of 43.8±17.5 years (range: 2-87 years). Staghorn calculi were present in 647 cases (44.4%). Prone lower-pole access was the predominant approach (58.2%), with a progressive institutional shift toward mini-PCNL (5.7%), supine PCNL (3.1%), and ultrasound-guided access (1.4%) in later years. The primary stone-free rate after a single session was 76.0%, increasing to a final SFR of 92.6% following auxiliary interventions including repeat PCNL, ureteroscopy (2.8%), ESWL (1.5%), and conservative management of clinically insignificant residual fragments (6.0%). Major complications (Clavien-Dindo Grade III-V) occurred in 1.44% of cases, including colonic perforation (0.41%) and conversion to open surgery (0.62%). Mortality rate was 0.14% (n=2). Minor complications (Grade I-II) affected 17.4% of patients, predominantly postoperative pain (7.3%) and transient fever (5.3%). CONCLUSIONS: This large series demonstrates that PCNL can be performed with high stone-free rates and acceptable morbidity in resource-limited settings despite a high prevalence of complex staghorn calculi. The progressive adoption of miniaturized and supine techniques reflects institutional adaptability and confirms the feasibility of implementing contemporary endourological standards in low-resource environments.