INTRODUCTION 
Urinary tract stones are one of the three most common 
diseases in the eld of urology in addition to urinary tract 
infections and benign prostate enlargement. In Indonesia 
urinary tract disease still occupies the largest portion of the 
number of patients in the urology clinic. The incidence and 
denite prevalence of this disease in Indonesia cannot be 
established with certainty. From domestic data published, 
there was an increase in the number of kidney stone patients 
who were treated at CiptoMangunkusumo Hospital from year 
to year starting 182 patients in 1997 to 847 patients in 2002, this 
increase was largely due to the availability of non 
invasivekidney stone breakers. ESWL (Extracorporeal Shock 
Wave Lithotripsy) which covers 86% of all treatments (ESWL, 

1PCNL, and open surgery) .

In the last 3 decades the approach to urinary stone therapy 
has undergone substantial changes. The existence of 
minimally invasive and endourological procedure that can 
directly access visually both the upper urinary tract forces 
conventional surgery to be the second choice.Endourology 
referred to here is percutaneous nephrolithotomy (PCNL) 
which was rst introduced in 1970, is an operation by placing 
a tool in the body to break or take stones. Understanding of the 
anatomy of renal vascularization, good radiological quality, 
and improved access to good punk will reduce the risk of 
complications, especially bleeding, as well as expertise in 
multiple puncture to access the upper part of the kidney, and 

2complex kidney stones.

PCNL monotherapy has the advantage of taking large size 
stones with minimal morbidity, especially stones in the inferior 
kalik, now PCNL is the main choice for the treatment of kidney 
stones that are> 20 mm in size, kidney print stones, and 

3inferior calyx stones of> 10 mm.

Published research usually only shows variables of fever, 
postoperative pain, blood loss, the incidence of urosepsis, or 
the presence of certain preoperative variables that affect 
kidney surgery, including age, obesity, type of nephrostomy 
used. Only one multiple regression analysis of the group 
design showed preoperative hemoglobin, multiple renal 
access, and stone size as predictors of independent 

4perioperative transfusion.  This study aims to compare the 

cost effectiveness of PCNL compared to open surgery seen 
from all aspects.

METHODS
This study is an analytical study with a cross sectional design 
to see a comparison of the Cost Effectiveness between open 
surgery with percutaneous nephrolithotomy (PCNL) in 
patients with nephrolithiasis at H. Adam Malik General 
Hospital, Medan. This research was conducted at the H. Adam 
Malik General Hospital in Medan. Samples were all patients 
with nephrolithiasis who underwent open surgery or 
percutaneous nephrolithotomy (PCNL) in the H. Adam Malik 
Hospital Medan from January to December 2018. Inclusion 
criteria were patients with nephrolithiasis> 2 cm in all renal 
regions or <2 cm in the lower calix. Patients with 
nephrolithiasis that differ between PCNL and open surgery, 
and have concomitant diseases such as diabetes mellitus, 
hypertension, malnutrition, secondary infections, blood 
clotting disorders, and consumption of blood-thinning drugs 
are excluded. Sample collection uses the consecutive method. 
The variables collected were type of surgery, cost of action, 
duration of action, need for blood transfusion, length of stay, 
and complications.

Categorical variables are presented by number or frequency 
(n) and percentage (%). Continuous variables are 
represented by mean ± standard deviation or median value. 
Test the normality of numerical variables in the research 
subjects using the Kolmogorov-Smirnov or Sapphiro-Willk 
test. Unpaired T tests or Mann-Whitney tests were used to 
compare the numerical data of the two groups, while 
categorical data were tested using Chi Square or Fisher test. 
Processing and analysis of statistical data using SPSS 
statistical software, the value of p <0.05 was said to be 
statistically signicant.

RESULTS
Of a total 67 patients, 44 patients underwent percutaneous 
nephrolithotomy (PCNL) while 23 other patients underwent the 
open pyelolithotomy procedure. The mean age in the PCNL 
group was 49.68 (± 10.78) years compared to the open 
pyelolithotomy group of 49.13 (± 8.74) years. Based on gender 
variables, it was found that male and female sexes were 22 
(50%) in the PCNL group compared with 14 men (60.9%) and 9 
women (39.1%) in the open pyelolithotomy group.

COST EFFECTIVENESS COMPARISON OF OPEN SURGERY WITH 
PERCUTANEOUS NEPHROLITHOTOMY (PCNL) IN NEPHROLITHIASIS 

PATIENTS IN H. ADAM MALIK HOSPITAL MEDAN

Original Research Paper

M. Bob Muharly 
Rambe

Department of Surgery, Medical Faculty of Universitas Sumatera Utara, Haji 
Adam Malik General Hospital Medan

  X 27GJRA - GLOBAL JOURNAL FOR RESEARCH ANALYSIS

Surgery

Urinary tract stones are one of the three most common diseases in the eld of urology in addition to 
urinary tract infections and benign prostate enlargement. Percutaneous nephrolithotomy (PCNL) 

monotherapy has the advantage of taking large stones with minimal morbidity, especially stones in the inferior calyx. This study 
aims to compare the cost effectiveness of PCNL compared to open surgery seen from all aspects. This study is an analytical 
study with a cross sectional design to see the comparison of the Cost Effectiveness between open surgery with percutaneous 
nephrolithotomy (PCNL) in patients with nephrolithiasis in the H. Adam Malik General Hospital Medan in the period of January - 
December 2018. Based on the results, it was found that PCNL procedures are superior in terms of cost-effectiveness compared to 
open pyelolithotomy with relatively shorter duration of action, shorter duration of treatment and less complication of action than 
open pyelolithotomy.

ABSTRACT

KEYWORDS : PCNL, Open surgery, nephrolithiasis, cost effectiveness

Ramlan Nasution*
Department of Surgery, Medical Faculty of Universitas Sumatera Utara, Haji 
Adam Malik General Hospital Medan*Corresponding Author

SyahMirsya Warli
Department of Surgery, Medical Faculty of Universitas Sumatera Utara, Haji 
Adam Malik General Hospital Medan

VOLUME-8, ISSUE-9, SEPTEMBER-2019 • PRINT ISSN No. 2277 - 8160 • DOI : 10.36106/gjra



28 X GJRA - GLOBAL JOURNAL FOR RESEARCH ANALYSIS

Table 1. Patient' Characteristics

The factors assessed in this study were complications when 
intraoperative and postoperative. Based on the data it was 
found that complications occurred in 20 cases of PCNL (45.5%) 
and 15 cases of open pielolitotomy. A common complication is 
bleeding, which occurred in 14 cases of PCNL (31.8%) and 12 
cases of open pielolitotomy (52.1%).

In table 2 we conduct a cost-effectiveness analysis to compare 
the effectiveness of PCNL compared to open pielolitotomi. 
There are several variables that are measured and analyzed 
to determine the effectiveness of the PCNL procedure against 
the open pyelolithotomy procedure.

Table 2.Cost-effectiveness Analysis

aUsing the Mann-Whitney test because data is not normally 
distributed
bUsingChi Square

In table 2, an analysis between PCNL and open pielolitotomy 
is presented. For variable duration of operation, there was a 
statistically signicant difference between the PCNL 
procedure and open pielolitotomi, where the average duration 
of PCNL surgery was shorter, namely 172.39 (± 52.94) minutes 
compared to open pielolitotomy for 217.39 (± 80.96) minute. P 
value obtained in this variable is 0.015.

Furthermore, the length of treatment days comparison was 
seen in patients who underwent the PCNL procedure and open 
pielolitotomy. The result was that patients who underwent 
PCNL had a shorter duration of treatment with 4.20 (± 0.97) 
days compared to open pielolitotomy with 7.26 (± 1.25) days. 
There is a statistically signicant difference in this variable, 
with a P value of 0.001.

While based on the variable transfusion needs, there were 14 
patients who underwent PCNL and needed blood transfusion 
(31.8%) compared with 14 people in the open pielolitotomy 
group (60.9%) who needed blood transfusion. There is no 
statistically signicant difference in this variable with a P 
value of 0.766.

Fewer complications occurred in the group of patients who 
underwent PCNL where there were 20 people in the PCNL 
group who had complications (45.5%) compared to 15 people 
in the open pielolitotomy group (65.2%). The result, there is a 
statistically signicant difference in this complication 
variable, as evidenced by the P value of 0.034.

Table3. Cost-effectiveness Analysis by Average Cost-
Effectiveness Ratio (ACER)

Based on the results of ACER calculations, it was found that 
PCNL had a lower ACER on both the hourly duration of the 
operation and the length of stay, with ACER Rp. 3,500,000 per 
hour of operation and Rp. 1,100,000 per day.

DISCUSSION
Of the 67 patients, 44 patients underwent PCNL and 23 
patients underwent the open pielolitotomy procedure with an 
average age in the PCNL group of 49.68 (± 10.78) years 
compared to the open pielolitotomy group of 49.13 (± 8.74) 
years. The average age obtained in this study is quite similar 
to that of Zhang et al., Namely 54.3 ± 411.6 (19-80) for PCNL 

5and 50.5 ± 11.1 (28-66) for open pielolitotomy  according to 
nakamon et al average age obtained for PCNL 51.42 ± 8,80 
and 48,3 (20-66) for open pielolitotomy.

The duration of PCNL in the study was found to be similar to 
Zhang et al., Namely 172.39 (± 52.94) minutes and 156.6 ± 
41.2 (85-285) minutes. Whereas the duration of surgery on 
open pielolitotomy in the study was found to be faster than that 
of Zhang et al, namely 217.39 (± 80.96) vs. 282,1 ± 54,5 (187-
340). And compare to study by nakamon et al, namely 52,62 (± 
20,68) minutes and open pielolitotomi 84 (57-124) minutes for 
study by Cakici et al the duration was faster. The duration of 
surgery more signicant in these studies, Zhang et al, 
Nakamon et al and Cakici et al (p=0,015 and <0,001). 

In this study, length of stay in PCNL patients was 4.20 (± 0.97) 
and open pielolitotomi 7.26 (± 1.25), where Zhang et al. found 
a longer treatment time of 6.2 ± 2.7 (2-17) for PCNL,according 
to Nakamon et al found the length of stay longer,namely 4,78 
(2,65) whereas for open pielolitotomy the time of treatment 
was found to be 10.3 ± 1.8 (8-14) (Zhang 2019), and shorter in 
Cakici et al 5,5 (3-8)

The number of blood transfusions in open pielolitotomy was 
found to be more than for PCNL, ie 60.9% (n = 14) vs. 31.8% (n 
= 14), although not signicantly different (p = 0.237). In the 
study of Zhang et al., There were more blood transfusions in 
the open pielolitotomy group, namely 4/11 (36.4%) vs. 12/61 
(19.7%). However, contradictory results were found where total 
bleeding in PCNL was higher than in open pielolitotomy, 695.5 
± 531.8 (10-2512) ml and 613.6 ± 528.7 (100-1800) ml. the 
different result show in Cakici et al for open pielolitotomi no 
need of tranfusion with the decrease of hemoglobin 1,8 (0,3-
4,7) mg/dl with estimation blood loss 400-600 cc. 

In this study complications were found in 20 people in the 
PCNL group (45.5%) and 15 in the open pielolitotomy group 
(65.2%), with no statistically signicant differences. The most 
common complication in the open pielolitotomy group was 
bleeding (52.1%, n = 12).

According to the UAE algorithm, kidney stone therapy based 
on location and stone size, for upper and middle pole stones or 
renal pelvis with for stones more than 20 mm PCNL is the main 
therapeutic choice. While open surgery is generally 

VOLUME-8, ISSUE-9, SEPTEMBER-2019 • PRINT ISSN No. 2277 - 8160 • DOI : 10.36106/gjra

Characteristics PCNL Open 
Pyelolithotomy

Age (year) 49,68 (±10,78) 49,13 (±8.74)

Gender

Male 22 (50%) 14 (60.9%)

Female 22 (50%) 9 (39.1%)

Diagnosis

Pyelumst 23 (52,3%) 3 (13.0%)

Print st 14 (31,8%) 18 (78.3%)

Inferior Calyx st 4 (9,1%) 0 (0%)

Multiple calyx st 3 (6,8%) 2 (8.7 %)

Complication

Bleeding 14 (31,8%) 12 (52.1%)

Fever 6 (13,6%) 8 (34.7%)

Sepsis 0 (0%) 4 (17.3%)

Wound infection 0 (0%) 2 (%)

Without 24 (54,5%) 8 (34.7%)

Variable PCNL Open 
Pielolitotomi

P

Duration (minute) 172,39 (±52,94) 217,39 (±80,96) a0,015

Length of stay 
(day)

4.20(±0.97) 7.26 (±1.25) a0,001

Transfusion
b0,237

Yes 14 (31,8%) 14 (60.9%)

No 30 (68,2%) 9 (39.1%)

Complication b0,034

Yes 20 (45,5%) 15 (65.2%)

No 24 (54,5%) 8 (34.7%)

Cost-Effectiveness 
Variable

ACER 
PCNL
(in 1000 rupiah)

ACER
Open Pyelolithotomy
(in 1000 rupiah)

Surgery duration 3.500 per hour 4.100 per hour

Length of stay 1.100 per day 1.272 per day



performed on indications of unavailability of PCNL facilities, 
failure of ESWL and PCNL measures, large size of multiple 
stones that require repeated ESWL and PCNL, presence of 
urinary anatomical abnormalities, extreme obesity, and 
contraindications to PCNL.

Cost-effectiveness analysis, which is a comparative analysis 
of effective intervention or treatment taking into account the 
costs incurred for conducting an intervention, is conducted to 
compare which procedure are taken to obtain maximum 
effects with minimal costs. Costs included in the INA-CBG's 
package that are calculated in costs include the direct 
medical costs which consist of drug costs, hospitalization fees, 
doctor fees (services), administration fees, laboratory fees, 
and medical equipment costs. Cost-effectiveness calculation 
is stated in ACER value (Average Cost-Effectiveness Ratio). 
Results from ACER were interpreted as average costs per 
clinical outcome unit.

Based on the rates of INA-CBG's Regional 1, type A hospitals, 
PCNL and open pyelolithotomy belong to the same category, 
namely the upper urinary tract procedure. This category has a 
package of costs ranging from Rp. 22,979,300 to Rp. 
31,916,200. Whereas in terms of rates, the two procedures 
have different rates of Rp. 13,324,000 for PCNL and Rp. 
18,653,000 for open pyelolithotomy.

Based on the results of the ACER calculation, it was found that 
PCNL had lower ACER both on the aspect of hourly duration of 
operation and length of stay, with ACER Rp. 3,700,000 per hour 
of operation and Rp. 1,100,000 per day of care. Based on the 
ACER value, it was found that the PCNL was more cost-
effective than the open pyelolithotomy because the ACER 
value was more and with consideration PCNL had lighter side 
effects in terms of bleeding, fever, sepsis and surgical wound 
infection. Therefore, PCNL can be recommended as an option 
in the treatment of kidney stones measuring over 2 cm both 
based on medical indications and the cost effectiveness of 
actions.

CONCLUSION:
Based on the results of Cost-Effectiveness Analysis studies, it 
was found that PCNL procedures were superior in terms of 
cost-effectiveness compared to open pyelolithotomy with 
relatively shorter duration of action, shorter duration of 
treatment and less complication of action than open 
pyelolithotomy.

Suggestions for future research are to conduct studies with a 
wider sample and more homogeneous data to assess the cost-
effectiveness of both actions, and study can continue to 
compare other therapeutic modalities so as to achieve 
modalities with high cost-effectiveness in channel stone 
therapy urinary tract.

REFERENCES:
[1] Jayaraman, UC., and Gurusamy, A. (2018), “Review on Uro-Lithiasis 

Pathophysiology and Aesculapian Discussion” IOSR Journal Of Pharmacy. 
8(2), 30-42.

[2] Bawari S, Sah AN, Tewari D. (2016),“Urolithiasis: An Update on Diagnostic 
Modalities and Treatment Protocols.” Indian Journal of Pharmaceutical 
Sciences. Apr 30;79(2):164-74.

[3] Bartoletti R, Cai T., (2008), “Surgical approach to urolithiasis: the state of art. 
Clinical cases in mineral and bone metabolism.” May;5(2):142.

[4] Ganpule AP, Vijayakumar M, Malpani A, Desai MR. (2016), “Percutaneous 
nephrolithotomy (PCNL) a critical review.” International Journal of Surgery. 
Dec 1;36:660-4.

[5]  Zhang FBY, Lin WR, Yang S, Hsu JM, Chang HK, et al. (2017), “Outcomes of 
percutaneous nephrolithotomy versus open stone surgery for patients with 
staghorn calculi.”Urological Science.

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VOLUME-8, ISSUE-9, SEPTEMBER-2019 • PRINT ISSN No. 2277 - 8160 • DOI : 10.36106/gjra