Kaohsiung Journal of Medical Sciences (2017) 33, 516e522

Available online at www.sciencedirect.com

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journal homepage: http://www.kjms-online.com

Original Article

External validation and comparison of the scoring

systems (S.T.O.N.E, GUY, CROES, S-ReSC) for
predicting percutaneous nephrolithotomy
outcomes for staghorn stones: A single center
experience with 160 cases
Serkan Yarimoglu a, Ibrahim Halil Bozkurt b, Ozgu Aydogdu b,
Tarik Yonguc b, Ertugrul Sefik b, Yusuf Kadir Topcu b,*, Tansu Degirmenci b

a
Department of Urology, Igdır Central Hospital, Igdır, Turkey
b
Department of Urology, Bozyaka Training and Research Hospital, Izmir, Turkey

Received 19 December 2016; accepted 21 June 2017

Available online 14 September 2017

KEYWORDS Abstract The aim of this study was validation and comparison of stone scoring systems
Percutaneous (S.T.O.N.E, GUY, CROES, S-ReSC) used to predict postoperative stone-free status and compli-
nephrolithotomy; cations after percutaneous nephrolithotomy (PCNL) for staghorn stones. A total of 160 patients
Guy scoring system; who had staghorn renal stones and underwent PCNL between January 2012 and August 2015
CROES scoring were included in the current retrospective study. Guy, S.T.O.N.E., S-ReSC (Seoul National Uni-
system; versity Renal Stone Complexity) and CROES (Clinical Research Office of the Endourological So-
S.T.O.N.E. scoring ciety) nephrolithometry scores were calculated for each patient, and their potential
system; association with stone-free status, operative and fluoroscopy time, and length of hospital stay
S-ReSC scoring system (LOS) were evaluated. Postoperative complications were graded according to the modified Cla-
vien classification, and the correlation of scoring systems with postoperative complications
was also investigated. The mean CROES, S.T.O.N.E, Guy and S-ReSC scores were
143.5
33.6, 9.7
1.6, 3.5
0.5 and 6.2
2.0 respectively. The overall stone-free rate
was 59%. All scoring systems were significantly correlated with stone-free status in univariate
analysis. However, Guy and S-ReSC scores were the only significant independent predictor in
multivariate analysis. And all four nomograms failed to predict complication rates. Current
study demonstrated that Guy and S-ReSC scoring systems could effectively predict

Conflicts of interest: All authors declare no conflicts of interests.

* Corresponding author. Yusuf Kadir Topcu, Department of Urology, Izmir Bozyaka Training and Research Hospital, Bozyaka/Izmir, Turkey.
E-mail address: yktopcu@gmail.com (Y.K. Topcu).

http://dx.doi.org/10.1016/j.kjms.2017.06.017
1607-551X/Copyright ª 2017, Kaohsiung Medical University. Published by Elsevier Taiwan LLC. This is an open access article under the
CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Comparison of the Scoring Systems
postoperative stone-free status for staghorn stones. However all four scoring systems failed to
predict complication rates.
Copyright ª 2017, Kaohsiung Medical University. Published by Elsevier Taiwan LLC. This is an
open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/
by-nc-nd/4.0/).
Introduction
Percutaneous nephrolithotomy (PCNL) is the standard
treatment method for patients with large renal stones.
There are several variables that may affect the post-
operative outcomes of PCNL including renal anatomy, stone
burden, location of the stone, skeletal abnormalities and
surgeon’s experience [1]. The requirement for the stan-
dardization of reporting the outcomes of PCNL led to
development of nephrolithometry scoring systems [2]. The
most commonly used scoring systems are Guy’s stone score
[3], S.T.O.N.E (stone size (S), tract length (T), obstruction
(O), number of involved calices (N), and essence or stone
density (E)) nephrolithometry score [4], S-ReSC (Seoul Na-
tional University Renal Stone Complexity) scoring system
[5] and CROES (Clinical Research Office of the Endouro-
logical Society) nephrolithometry nomogram [6]. Besides
imaging characteristics, the patient’s characteristics
including obesity, history of previous renal surgery, spinal
cord injury, spina bifida and surgeon’s experience were
used in these nomograms. Scoring systems allow us to
accurately predict the outcomes of PCNL and give chance
to inform the patient about the success of surgery and
possible complications pre-operatively [3e5].
GSS (Guy scoring system) categorizes PCNL complexity
into four grades (grade I, II, III, IV) according to the patient’s
and imaging characteristics [3]. S.T.O.N.E score is calculated
using five variables including stone size, tract length (skin-to-
stone distance), degree of obstruction, number of calyces
involved and stone essence (density) [4]. In 2013, Smith and
associates on behalf of the Clinical Research Office of the
Endourological Society (CROES) PCNL Study Group proposed
a new nephrolithometric nomogram using patient factors
besides preoperative radiologic findings [6]. In this nomo-
gram, all variables correspond to a numeric value including
the case volume per year. S-ReSC scoring system was
developed by Jeong et al. to predict the outcomes of PCNL
that had been performed using only one access [5].
Staghorn calculi are the most complex stone type in
clinical practice. PCNL is the standard treatment for stag-
horn stones [7]. Recent studies reported that high stone-free
rates (74e83%) and low morbidity rates (7e27%) after stan-
dard PCNL for the treatment of the staghorn calculi [8].
However, it was reported that the patients who underwent
PCNL for staghorn stones had longer length of hospital stay
and operation time, higher complication rates and lower
stone-free rates compared to non-staghorn stones [9].
Therefore, preoperative evaluation of the patient with
scoring systems is important to predict the success rate and
proper preoperative counseling of the patient. There is a
lack of agreement about the best scoring system for staghorn
stones. In the recent study we aimed to compare the efficacy
517
of the four most used scoring systems for staghorn stones. As
far as we know our study is the first one to evaluate and
compare all four stone scores for staghorn calculi.
Materials and methods
A total of 160 patients who had staghorn renal stones and
underwent PCNL between January 2012 and August 2015
were included in the current retrospective study. The study
has been conducted in accordance with the ethical princi-
ples of Declaration of Helsinki. All stones were evaluated
with computerized tomography (CT) pre-operatively. There
is no globally accepted consensus for definition of staghorn
calculi. For the present study, a renal stone occupying the
renal pelvis and 2 calyces was defined as partial staghorn
[10]. A renal stone filling the renal pelvis and the entire
collecting system (>80%) was considered as complete
staghorn calculus [10].
All procedures were performed in a tertiary referral
center by two experienced endourologists (IHB and TD). All
PCNLs were performed under general anesthesia with the
patient in the prone position. Access was obtained under C-
arm fluoroscopy using an 18 gauge needle with the patient
in the prone position. The tract was dilated with amplatz
dilatators. Fragmentation of the stone was accomplished
using a pneumatic lithotripter (Vibrolith, Elmed, Ankara,
Turkey). Fluoroscopy was used for access guidance and
Amplatz dilators used for dilation. Fluoroscopy time was
measured for the entire procedure beginning from access to
nephrostomy tube placement. A 14F nephrostomy tube was
inserted at the end of the procedure. The operative time
was measured after the patient was turned to the prone
position. The patients’ demographic characteristics, stone
burden, number of tracts and location, operative time,
fluoroscopy time, presence of residual stones, and esti-
mated blood loss (EBL) were recorded prospectively in all
patients postoperatively. Stone burden was calculated in
square millimeters, using the ellipsoid formula [11]:
length  width  p  0.25, where p is a mathematical
constant equal to 3.14.
At the 1-month follow-up visit, patients were evaluated
with plain kidneys-ureters-bladder (KUB) radiography. Pa-
tients with asymptomatic residual fragments <4 mm were
accepted as stone free. In our institution, KUB radiography
is used for routine evaluation of post-PCNL stone status,
because of the cost. CT is reserved for only symptomatic
patients, radiolucent stones, and/or suspicion of residual
fragments seen on KUB radiography.
Guy, S.T.O.N.E, S-ReSC and CROES nephrolithometry
scores were calculated for each patient and their correla-
tion with stone-free status, operative and fluoroscopy time
and length of hospital stay (LOS) was evaluated. Patients
518 S. Yarimoglu et al.

were categorized into four grades according to the points

Table 1 Demographic and preoperative characteristics of
calculated in the CROES scoring system (grade 1: 0e100,
patients.
grade 2: 101e150, grade 3: 151e200, grade 4: 201e350).
Postoperative complications were graded according to the Mean
SD Range
modified Clavien classification [1], and the correlation of Age (years) 50.3
12.5 19e82
scoring systems with postoperative complications was also BMI (kg/m2) 26.5
4.6 18e43
evaluated. Stone burden (mm2) 952.9
674.7 102e2869
Operation time (minute) 124.5
44.1 45e300
Statistical analysis Scopy time (second) 78.5
49.5 3e300
Length of hospital stay (days) 4.3
2.8 2e20
Statistical analyses were performed with statistical package Nephrostomy time (days) 2.4
0.8 0e5
of social sciences version 21 (SPSS, Chicago, IL). Categorical CROES score 143.5
33.6 79e201
variables were presented as numbers and percentages and S.T.O.N.E score 9.7
1.6 7e13
compared with Chi-square test and Fisher’s exact test. Guy score 3.5
0.5 3e4
Continuous variables were presented as means and standard S-ReSC score 6.2
2.0 1e9
deviations and compared with independent sample-t test. n %
Multivariate logistic regression analysis was used to identify
Stone free rate 94/160 59
potential independent predictors for postoperative stone-
Female/Male 111/49 69.4/30.6
free status and complications. Receiver operating charac-
Previous ESWL 17 10.6
teristic (ROC) curves were generated to assess the predictive
Complete/partial staghorn 76/84 47.5/52.5
role of scoring systems on stone free rate. The cut-off value
Left/Right 89/71 55.6/44.4
was calculated using Youden index method. Statistical sig-
Clavien
nificance was set at a p value of 0.05.
0 102 63.8
1 20 12.5
Results 2 15 9.4
3a 20 12.5
Eighty four patients had partial staghorn calculi and 76 3b 3 1.9
patients had complete staghorn calculi. However we did Renal anomaly 12 7.5
not evaluate the efficacy of the four scoring systems with Bleeding (>250 cc) 68 42.5
subclassification of renal staghorn stone in the current _ Body Mass Index;
SD, standard deviation; BMI, _ ESWL, Extracor-
study. The demographic and perioperative characteristics poreal Shock Wave Lithotripsi.
of the patients were summarized in Table 1. Mean stone
burden was 952.9
674.7 (102e2869) mm2. Mean operation
time and fluoroscopy time were 124.5
44.1 (45e300) min anomalous morphology making their management
and 78.5
49.5 (3e300) sec, respectively. Residual frag- demanding and challenging. There were significantly lower
ments were detected in 66 (41%) patients. success rates for staghorn stones group in comparison be-
The mean CROES, S.T.O.N.E, Guy and S-ReSC scores tween staghorn and non-staghorn stones from the large
were 143.5
33.6, 9.7
1.6, 3.5
0.5 and 6.2
2.0 CROES PCNL database [9]. Desai et al. [9] reported that the
respectively. The overall stone-free rate was 59%. Table 2 patients with staghorn calculi had lower stone free rates,
shows the distribution of clinical and imaging data more frequent complications and longer operative time and
regarding postoperative stone-free status. All scoring sys- length of hospital stay than those with non-staghorn calculi.
tems were significantly correlated with stone-free status in Preoperative imaging methods have critical importance
univariate analysis. However, Guy and S-ReSC scores were to decide for the accurate diagnosis and optimum surgical
the only significant independent predictors in multivariate management in patients with renal stones [13]. Multiplanar
analysis (Table 3). All four nomograms failed to predict imaging has been the preferred one to detect the stone
complication rates (CR) (Tables 4 and 5). The complications complexity including stone size, location, pelvicaliceal
graded according to modified Clavien classification system anatomy and association with adjacent organs [14,15].
were shown in Table 6 in detail. The overall CR was 36.2%. Postoperative stone free status can be predicted using
Receiver operating characteristic (ROC) analysis of four preoperative imaging methods [16e18]. In the recent
scoring systems to predict stone-free status was shown in years, several scoring systems have been developed to
Fig. 1. The cut-off point calculated with Youden index for standardize the terminology regarding stone complexity
stone-free status for CROES was 134.5 (sensitivity, 65% and and for preoperative counseling of the patients [3e6].
specificity, 56%). Ideal scoring system should be repeatable, easily used in
daily practice, include the findings of imaging methods and
predict postoperative stone free rate and CR [3]. There’s no
Discussion universally accepted scoring system yet. Staghorn calculi
represents a unique group of renal stones with large size
Although PCNL is the standard and efficacious treatment and anomalous morphology making their management
method for patients with large renal stones, the success demanding and challenging. Thus, the question promoted
rate is significantly decreasing in case of staghorn stones our research was whether preoperative nomograms can
[12]. Staghorn calculi are characterized by large size and effectively and equally predict stone-free results after
Comparison of the Scoring Systems 519

requires the proprietary software which is not openly

Table 2 Comparison of patients’ characteristics accord-
available. Additionally, surgical difficulty in the extraction
ing to postoperative stone free status.
of renal stones has usually been associated with the com-
Stone free Not stone free p plex anatomy of renal collecting system, which is not
(n Z 94) (n Z 66) necessarily related to the volume of stone.
Mean
SD In a previous study, the authors revealed a significant
correlation between S.T.O.N.E nephrolithometry score and
Age (years) 52.6
12.1 47.1
12.5 0.006*
SFR and bleeding [23]. Farhan et al. found significant asso-
BMI (kg/m2) 26.6
4.7 26.4
4.5 0.855*
ciation between S.T.O.N.E score and SFR and operation time
Stone burden 870.6
666.3 1070.1
674.2 0.06*
respectively [24]. However the authors showed no associa-
(mm2)
tion between S.T.O.N.E score and CR. Similarly, Akhavein
Operation time 120.1
40.4 130.8
48.6 0.13*
et al. advocated that although S.T.O.N.E scoring system was
(minute)
highly effective to predict postoperative SFR, it was not
Scopy time 73.7
48.3 85.3
50.8 0.145*
sufficient to predict CR [25]. In contrast Kumsar et al. found
(second)
significant association between S.T.O.N.E score and SFR,
Hospitalization 4.2
2.6 4.4
3.1 0.721*
operation time and Clavien complication scores [22]. In the
time (days)
recent study, a positive correlation was not found between
Nephrostomy 2.3
0.7 2.4
0.9 0.439*
S.T.O.N.E score and SFR, CR. We think the S.T.O.N.E. neph-
time (days)
rolithometry uniquely includes variables that have been
CROES score 149.1
31.4 135.5
35.1 0.011*
shown to have significant impact on postoperative outcomes.
S.T.O.N.E score 9.5
1.6 10.0
1.7 0.049*
Furthermore, because it stratifies patients into low-, mod-
Guy score 3.4
0.5 3.6
0.5 0.002*
erate-, and high-risk groups, it is practical for decision
S-ReSC score 5.7
1.8 6.9
2.1 <0.001*
making and surgical planning. One limitation is that
n (%) S.T.O.N.E. was validated with a small cohort. This may limit
Female/Male 27/67 (29/71) 22/44 (33/67) 0.533y its applicability to a wider patient population.
Previous ESWL 11 (12) 6 (9) 0.598y Labadie et al. revealed a significant relation between
Complete/partial 35/59 (37/63) 41/25 (62/38) 0.002y CROES nomogram and postoperative SFR after PCNL [21].
staghorn Similarly previous validation studies showed that CROES
Left/Right 49/45 (52/48) 40/26 (61/39) 0.288y nomogram is an effective and reliable scoring system to
Renal anomaly 8 (9) 4 (6) 0.762z predict SFR [21,26]. In a recent study, Bozkurt et al. inves-
Bleeding 38 (40) 30 (45) 0.526y tigated the results of 437 patients who underwent PCNL and
(>250 cc) compared Guy and CROES scoring systems [27]. In this study,
both scoring systems were significantly associated with SFR,
Bold text indicates values are statistically significant.
_ Body Mass _Index; ESWL, Extracor- bleeding rate, operation time and CR. In the recent study, a
SD, standard deviation; BMI,
positive correlation was not found between CROES score and
poreal Shock Wave Lithotripsi.
*, independent sample t test. SFR, CR. We think there are two important limitation of
y, Chi-square test. CROES scoring system. First, the CROES database was not
z, Fisher’s exact test. created specifically for the development of a predictive
model for classification of stone disease prior to PCNL and,
therefore, lacks important variables affecting the outcomes
PCNL for staghorn calculi. We think that it’s essential to such as radiologic data on hydronephrosis and other pelvi-
compare existing scoring systems and find out deficient calyceal abnormalities. It also does not take into account the
parts to improve the ideal scoring system for staghorn stone density or composition. Secondly, the CROES nomo-
stones. In the present study, we investigated the potential gram is complex, requiring a more time consuming evalua-
role of Guy, S.T.O.N.E, S-ReSC and CROES scoring systems tion of preoperative variables. Many physicians feel that the
to predict postoperative SFR and CR for staghorn stones. CROES nomogram is impractical in the clinical setting.
Previous studies revealed significant correlation be- S-ReSC is a scoring system which was developed to pre-
tween SFR, CR and Guy score [3,19e21]. Kumsar et al. dict postoperative SFR following PCNL. S-ReSC scoring sys-
showed significant association between Clavien score, tem mainly uses the complex localization of the stone in the
operation time and Guy score [22]. However the authors renal collecting system as the most important factor to
revealed no correlation between SFR and Guy score. In a predict SFR. However this system is not solely dependent on
previous study, the authors advocated that although Guy the distribution of the stone in the collecting system since
scoring system (GSS) was highly effective in predicting this is closely related with the size and number of the
stone free status, it was inefficient to predict CR [23]. In stones. In the original study, cut-off value for S-ReSC score
the current study, a positive correlation was found between to predict stone free status was calculated as 0.86 [5]. In a
Guy and SFR in multivariate analysis. There were not sta- different study, Choo et al. investigated the outcomes of
tistically significant correlation between Guy and CR. 327 PCNL operations which were performed in two clinics by
However, we think Guy scoring system does not appear to four different surgeons and their findings revealed a sig-
be widely used because it does not allow for an immediate nificant correlation between S-ReSC scoring system and SFR
determination of the grades. Staghorn morphometry is a [28]. In the current study, a positive correlation was found
new prediction model for PCNL, which was based on ac- between Guy and SFR in multivariate analysis and no sta-
curate measurement of stone volume. However, that model tistically significant correlation was detected between Guy
520 S. Yarimoglu et al.

Table 3 Multivariate analysis of potential independent Table 5 Multivariate analysis of potential independent
predictors for postoperative stone-free outcomes. predictors for postoperative complication.
OR p 95% CI OR p 95% CI
Age 0.963 0.010 0.936e0.991 Stone burden 1.000 0.286 1.000e1.001
Complete/partial staghorn 0.736 0.204 0.459e1.181 Operation time 1.006 0.205 0.997e1.015
CROES score 0.997 0.760 0.975e1.019 Hospitalization time 1.558 <0.001 1.220e1.989
S.T.O.N.E score 0.933 0.794 0.608e1.429 Nephrostomy time 0.768 0.351 0.442e1.336
Guy score 2.765 0.002 1.444e5.295 Bleeding (>250 cc) 1.638 0.186 0.788e3.405
S-ReSC score 1.317 0.006 1.083e1.600 CROES score 0.985 0.164 0.965e1.006
Bold text indicates values are statistically significant. S.T.O.N.E score 0.855 0.448 0.570e1.282
OR, Odds ratio; CI, confidence interval. Guy score 0.957 0.925 0.385e2.381
S-ReSC score 1.050 0.600 0.876e1.258

and CR. We think, S-ReSC scoring system was developed
with that the distributional complexity of stones was the
most powerful predictor of SFR. However, this system is not
based solely on these factors because stone distributions
are closely related to stone size, volume and stone number.
Sfoungaristos et al. [29] reported that all three nomo-
grams (Guy, CROES, STONE) had a significant association
with postoperative stone free status. However, multivar-
iate analysis showed that STONE nephrolithometry repre-
sents the only significant independent predictor of post-
PCNL stone-free status. Choi et al. [30] reported that
multiple involved calyces, high grades of S.T.O.N.E. neph-
rolithometry, and pre-existent UTIs (Uriner tract infections)
were associated with lower SFR after PCNL for staghorn
calculi.
In the current study, we found that there was positive
correlation between Guy, S-ReSC and stone free rates. We
Bold text indicates values are statistically significant.
OR, Odds ratio; CI, confidence interval.
think the most important parameter to predict stone free
rate is the distribution pattern of stones in the pelvicaly-
ceal space for staghorn stones. Because the main param-
eter to calculate Guy and S-ReSC score is the stone
distribution.
The main limitation of the present study is its retro-
spective design which could possibly cause some bias. All of
the patients were not evaluated postoperatively with CT as
a standard imaging method and patients were evaluated
with plain kidneys-ureters-bladder (KUB) radiography for
financial constraints. The overall stone-free rate was 59%.
We think these stone free rates may affect negatively the
stone scoring system prediction accuracy. However, to the
best of our knowledge, the recent study is the first one in

Table 4 Comparison of patients’ characteristics according to postoperative complication.

Complication (þ) Complication () p
(n Z 58) (n Z 102)
Mean
SD
Age (years) 49.8
13.2 50.6
12.2 0.681*
BMI (kg/m2) 26.5
4.7 26.5
4.5 0.912*
Stone burden (mm2) 1097.6
750.7 870.6
616.2 0.04*
Operation time (minute) 138.1
52.3 116.8
36.8 0.003*
Scopy time (second) 85.1
50.7 74.7
48.6 0.203*
Hospitalization time (days) 5.7
3.7 3.5
1.6 <0.001*
Nephrostomy time (days) 2.6
0.9 2.2
0.8 0.003*
CROES score 137.2
36.4 147.1
31.5 0.073*
S.T.O.N.E score 9.9
1.7 9.6
1.6 0.249*
Guy score 3.5
0.5 3.4
0.5 0.259*
S-ReSC score 6.4
2.0 6.0
2.0 0.226*
n (%)
Female/Male 17/41 (29/71) 32/70 (31/69) 0.786y
Previous ESWL 6 (10) 11 (10) 0.931y
Complete/Partial staghorn 31/27 (53/47) 45/57 (44/56) 0.256y
Left/Right 31/27 (53/47) 58/44 (57/43) 0.676y
Renal anomaly 3 (5) 9 (8) 0.539z
Bleeding (>250 cc) 31 (53) 37 (36) 0.035y
Bold text indicates values are statistically significant.
_ Body Mass Index;
SD, standard deviation; BMI, _ ESWL, Extracorporeal Shock Wave Lithotripsi.
*, independent sample t test.
y, Chi-square test.
z, Fisher’s exact test.
Comparison of the Scoring Systems 521

Table 6 Complications according to the modified Clavien classification system.

Grade Complications No %
0 e 102 63.8
1 - Postoperative pain managed by opioid with or without adjunct 5 12.5
analgesic regimen
- Deranged renal function that requires IV fluid management only 4
- Bleeding that requires a single episode of nephrostomy clamping 7
- Bleeding managed using IV fluid without need for blood transfusion 4
– Total 20
2 - Bleeding requiring blood transfusion 10 9.4
- Postoperative fever (>38.0 8C) managed with antibiotics in the ward 2
- Symptomatic UTI managed using antibiotics 3
– Total 15
3A - Febrile UTI or suspected sepsis without organ failure requiring supportive 11 12.5
therapy and enhanced monitoring
- Bleeding managed by postoperative ureteric stenting without general anesthesia 2
- Hydrothorax managed by intercostal draining under local anesthesia 1
- Renal pelvic perforation managed by prolonged nephrostomy tube or postoperative 4
placement of nephrostomy
- Urine leakage managed by ureteric stenting without general anesthesia 2
– Total 20
3B - Bleeding managed by angioembolisation 1 1.9
- Ureteric stricture managed by balloon dilation 2
– Total 3
4A
4B
5

Figure 1. Receiver operating characteristic (ROC) curves of scoring systems to predict postoperative stone-free status.
522
the literature comparing the all four stone scoring systems
for staghorn calculi.
Conclusion
We think that scoring systems can be potentially used to
standardize the postoperative outcomes of different
studies and these systems can guide the clinician to predict
postoperative PCNL outcomes. Our findings revealed that
Guy and S-ReSC scoring systems can be effectively and
reliably used to predict SFR for staghorn stones. In addition
GSS and S-ReSC can be more easily used in clinical practice.
However all four scoring systems failed to predict CR.
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