# Cost Comparison of Percutaneous Nephrolithotomy With and Without Intraoperative Cone-beam Computed Tomography: 18-month Postoperative Analysis

## TL;DR

Using CT scans during kidney stone surgery increases initial costs but reduces later expenses and complications, making it a cost-effective option.

## Contribution

Demonstrates that higher initial costs of CBCT-PCNL are offset by reduced postoperative expenses and complications.

## Key findings

- CBCT-PCNL had 40.2% higher procedural costs but 38.3% lower follow-up and complication costs.
- Total costs for CBCT-PCNL and standard PCNL were nearly comparable (€8725 vs. €8564 per patient).
- CBCT-PCNL reduces unplanned care and shifts expenses to planned care pathways.

## Abstract

Intraoperative cone-beam computed tomography (CBCT) during percutaneous nephrolithotomy (PCNL) increases postoperative stone-free rates and reduces postoperative stone-related events (SREs), but widespread adoption depends on costs. Our results show that the higher procedural costs for CBCT-PCNL are offset by lower follow-up and SRE costs. Thus, CBCT-PCNL represents a clinically effective and financially viable strategy, and can also shift expenses from unplanned to planned care pathways.

Residual fragments (RFs) after percutaneous nephrolithotomy (PCNL) increase the risk of stone-related events (SREs) such as reinterventions and emergency department (ED) visits. Intraoperative cone-beam computed tomography (CBCT) facilitates detection and removal of RFs to improve stone-free rates and potentially reduce SREs. To determine whether the initial increase in surgical costs for CBCT in a hybrid operating room (OR) is offset by a reduction in overall expenses by minimizing SREs, we compared the total in-hospital health care costs of standard PCNL versus CBCT-PCNL over an 18-mo period.

Data from a previous randomized controlled trial including 80 patients undergoing CBCT-PCNL and 80 undergoing conventional PCNL were analyzed. Procedural costs were calculated by multiplying operative duration by the Dutch reference price per minute, and adding disposable costs. Follow-up costs included costs for complications, SREs (reinterventions, ED visits, drainage, admissions), imaging, and consultations during 18 mo.

Assuming utilization rates of 42% for a hybrid OR and 92% for a conventional OR and following reference prices, we calculated mean total costs per patient of €8725 for the CBCT group and €8564 for the control group, with a difference of €167. The 40.2% higher procedural costs for hybrid-OR PCNL were nearly offset by 38.3% lower follow-up, complication, and SRE costs. Limitations include the single-center design, incomplete cost standardization, and the exclusion of non-hospital costs such as productivity loss.

While PCNL with CBCT in a hybrid OR increases operative costs, it lowers SREs and unplanned care expenses. Even at a significantly lower hybrid OR utilization rate, total health care costs remain comparable, so PCNL-CBCT can facilitate predictable resource use and efficient care, with potential benefits for patients and health care systems.

A new technique using CT (computed tomography) scans during surgery may help in more complete extraction of kidney stone fragments. Our study shows that even though this procedure is more expensive, it reduces the need for postoperative appointments, scans, emergency department visits and additional operations.