Medical and economic justification of the use of micropercutaneous nephrolithotripsy in clinical practice
Authors:   American Medical Center St.Petersburg, Russia, Emelianenko A.V. , Dunets K.A. ,   St. Petersburg City Hospital No. 15, St. Petersburg, Russia, Startsev V.Yu. ,   St. Petersburg State Pediatric Medical University of the Ministry of Health of the Russian Federation, St. Petersburg, Russia
Published: September 2021

Introduction. Percutaneous nephrolithotripsy (PNL) is traditionally used in the surgical treatment of patients with kidney stones. The use of retrograde intrarenal surgery using a flexible endoscope (RIRS) and micropercutaneous nephrolithotripsy (micro PNL) in the treatment of kidney stones with a diameter of 10-15 mm allows minimizin renal bleeding and reducing the period of hospitalization of the patient. Despite the development of urolithiasis treatment methods, the results of a comparative study of the medical and economic aspects of various surgical options for kidney stones treatment were not described. Materials and methods. We carried out a retrospective analysis of 654 cases of PNL and RIRS for the period of 2015-2019. We analyzed the results of surgical and medical material costs in 15 patients whom micro PNL was done according to the standard protocol. All patients underwent an assessment of the blood hemoglobin level and the frequency of complications according to Clavien-Dindo classification, as well as a control examination to exclude residual stones was done. Results. According to the data of the planning and economic service of healthcare institutions, the costs under the mandatory medical insurance tariff for RIRS and PNL amounted to 47,743.10 rubles and 71,300.00 rubles, respectively, without differences in hardware. The cost of endoscopes used for RIRS and PNL differed significantly (1,045,185. 00 rubles and 886,203. 00 rubles, respectively). Taking into account labor costs and general anesthesia, the cost of surgical treatment of kidney stone in PNL increased by 7,429. 78 rubles (74.9%). For fragmentation of the stone with micro PNL, a thulium or YAG laser was used, without nephrostomic drainage. The duration of the PNL was longer-on average 113 minutes (62-186 minutes), than with micro PNL – on average 83 minutes (42-122 minutes,). After micro PNL, there was a slight decrease in the level of hemoglobin and a minimal degree of complications (I-II Grade Clavien-Dindo), compared with PNL. The transition to the RIRS was required in three cases: during the mobilization of the migration of the stone into the middle calyx and during the removal of residual fragments of the upper and lower calyx. The duration of hospitalization of patients decreased after micro PNL to 2 days. Conclusions. Micro PNL for small (up to 2 cm) kidney stones treatment is more advantageous compared to traditional PNL in a number of positions: less the duration of the operation, reduced blood loss, lack of drainage, reduced costs for hospital observation of the patient. From a medical and economic point of view, the RIRS is the most preferable, but it requires initially large costs for the purchase of flexible endoscopes with a small working resource and a relatively high cost. The development of surgical equipment and production capacities, as well as the accumulation of clinical experience of micro PNL will allow us fairly assess the feasibility of this technique with a personalized approach.