Cost-effectiveness of percutaneous nephrostomy vs JJ stent in obstructive urolithiasis: economic evaluation alongside the STent Or NEphrostomy (STONE) randomised controlled trial

Objective: To evaluate whether percutaneous nephrostomy (PCN) is cost-effective compared to JJ ureteric stent in the acute treatment of obstructive urolithiasis. Patients and methods: A randomised controlled non-inferiority trial with 204 patients with obstructive urolithiasis requiring decompression. Participants were randomly assigned to either PCN or JJ stent, with follow-up until the stone was surgically removed or passed spontaneously. Effectiveness outcomes included time to recovery and quality-adjusted life years (QALYs). Costs were assessed from a societal perspective, incorporating healthcare, patient-related, and lost productivity costs. Results: Weighted mean procedure costs were €685 for PCN and €792 for JJ. Mean total societal costs were €8468 for PCN and €7122 for JJ. Largest cost differences were in productivity loss and home care. Time to recovery and QALYs were similar between groups. The probability that JJ was cost-effective compared to PCN was 0.74 for quicker recovery time and 0.74 for QALYs at a willingness-to-pay threshold of €0. Some cost and quality-of-life data were self-reported, and the analysis reflects the Dutch healthcare system, which may limit generalisability. Conclusion: The JJ ureteric stent was found to be the likely cost-effective option compared to PCN, despite higher procedural costs. Procedural costs can be lowered by performing procedures outside of an operating theatre. Most societal costs were made during the waiting period for definitive stone removal; future research should investigate whether total cost can be lowered by reducing waiting times.