Development of S.T.O.N.E.S.

(Stone size, Topography, Obesity, Number of

Stones, Exposure, Skin to Stone Distance) Nephrolithometry Scoring in Predicting the Stone

Free Rate of Extracorporeal Lithotripsy in Uncomplicated Renal Stones

ABSTRACT

BACKGROUND: The development of the S.T.O.N.E.S. (Stone

Size, Topography, Obesity, Number of Stones, Exposure, Skin to Stone

Distance) Nephrolithometry Scoring utilizes specific patient parameters and CT Scan findings.

The STONES Nephrolithometry score is computed, compared and against the outcome of stone-

free rate in patients who underwent ESWL for uncomplicated renal stones. The objective of the

study is to identify if STONES Nephrolithometry score could be utilized to predict or approximate

outcome of stone free rate patients undergoing ESWL that will help improve patient selection,

decision making and treatment success.

METHODS: Retrospective retrieval of data from patients with uncomplicated renal stones who

underwent ESWL using EDAP Sonolith machine with electroconductive technology. Included in

study were patients with complete demographic data and CT scan findings. Specific parameters

retrieved: Stone size up to 2 cm; Topography or location of stone identified as superior, middle or

inferior calyx; Obesity based on BMI-Body Mass Index; Number of Stones, Hounsfield Unit of

Stones and Skin to Stone distance measured. “STONES nephrolithotmetry Score” (SNS) is

computed as the sum of all specific parameters. (SNS = S + T + O + N + E + S). Accuracy ratings

and receiver operator curve analysis to determine the best-predictive cut-off score was

determined.

RESULTS: 66 patients enrolled in the study with 56 patients noted to be stone free and 10

patients who were not stone free post ESWL. 28 of the 46 patients underwent multiple sessions

of ESWL before rendered stone free (Table 1). Weighted score derivations were done using

1
multivariate regression to establish the scoring system. SNS range of 96 to 129 showed the

highest stone free rate (p<0.001). The minimum cut-off that is best predictive of a stone-free rate

is a STONES Nephrolithotomy score of at least 105 with a high sensitivity rating of 98.2%.

Table 1. Number of patients who are stone-free and not-stone-free across the frequency

of ESWL and STONES Score Ranges

STONE FREE

STONES YES NO
Nephrolithometry
Score
1ST Session 2nd Session 3rd Session
n = 28 n = 18 n = 10
54 to 79 0 0 1 5

80 to 105 7 8 3 4

106 to 129 21 10 6 1

Total 28 18 10 10

* Chi-Square, p-value <.001

CONCLUSION: The STONES scoring system is an accurate and reliable tool for predicting stone-

free rate. Its standardized application and interpretation is highly warranted.

KEYWORDS: STONES, nephrolithometry scoring system, stone free rate, extracorporeal

shockwave lithotripsy, uncomplicated renal stones

2
Introduction

Current guidelines, such as the American Urological Association and European

Association of Urology, on the treatment of uncomplicated renal stones only consider the stone

location and size. Recent studies however, showed significant correlation of other independent

parameters such as BMI of the patient, number of stones, stone exposure and skin to stone

distance to stone treatment like ESWL, PCNL or retrograde intrarenal surgery (RIRS). The

development of this Nephrolithometry scoring system will correlate these independent parameters

and will project the probability of stone free rate in ESWL.

Nomograms and scoring systems have been applied as effective tools that helped

physicians and patients on decision making, counseling and management approach. The

development of this STONES Nephrolithometry Scoring System will provide physician, urologist

or not, the patient-friendly guide if the patient is a good candidate for ESWL. In the Philippines

where cost is always a limiting factor, the STONES Nephrolithometry Scoring System will be an

objective tool that can be used to advise the patient of ESWL and its success for each individual

patient or if the patient is not a good candidate, we can offer a better option.

In the Philippines where cost is always a limiting factor, the STONES Nephrolithometry

Scoring System will be an objective tool that can be used to advise the patient of ESWL success

rate or if the patient is not a good candidate, we can offer a better option. Guidelines in the use of

ESWL from Western countries were not updated probably due to the advancement of

endourology. However, in our local setting, ESWL has been popularly used and maybe at times

abused treatment option for the management of renal stones. Thus, STONES Nephrolithometry

Scoring System may be used to inspire local urologist to revisit the guidelines and probably came

up with our local guidelines for ESWL treatment.

3
 Kidney stones had been increasing worldwide unbounded with race, sex and age with an

annual prevalence of about 3-5% and approximate lifetime prevalence of about 15-25%1.

Evolution of management of kidney stones from medical to open renal surgery to minimally

invasive procedures, such as endourologic procedures and shockwave lithotripsy, had been seen

in the past decades. Despite the recent advancement in the field of endourology, with

Percutaneous Nephrolithotomy (PCNL) and Retrograde Intrarenal Surgery (RIRS) battling their

role in the gold standard for complicated urinary stones, extracorporeal shock wave lithotripsy

(ESWL) still remains among the options for the management of uncomplicated renal stones less

than 2 cm. ESWL’s success rate had varying results from different large number studies which

may also be attributed to patient selection. Proper patient selection is the key for the success of

any procedure and this could be maximized with identifying objective reproducible findings such

as BMI and non-contrast CT scan measurement in decision making and management in ESWL.

Both American (American Urological Association) and European (European Association

of Urology) Guidelines agreed on the role of ESWL as a first line of treatment for stones less than

20 mm, however EAU highlighted the need to assess the factors that affects the stone free rate

of ESWL such as stone size, location, and composition of the stones, patient’s habitus and

performance of SWL 2,3. AUA also emphasize that for lower pole stone more than 10 mm, ESWL

should not be offered as the first line of treatment admitting the limitation of ESWL in this location

however, it is still considered as an acceptable second line of treatment.

We have seen the value of predictive models for treatment and management of diseases

like cancer which helped clinicians and patients alike in treatment decision making and

management course. Likewise, in the management of renal stones, there were models and

nomogram proposed which could predict the stone free rate of procedures like PCNL,

Ureteroscopy and ESWL.

4
 Onal et al, proposed a scoring system and nomogram for children4. In this study, they

have cited that previous history of ipsilateral stone treatment, stone burden, stone location, gender

and age at presentation were significant variables in predicting stone free rate in children.

Previous history of stone treatment was noted to negatively affect the stone free rate probably

due to scarring from previous ESWL which prevents good peristalsis and adequate contraction

resulting to delays in urinary drainage and subsequent passage of the stone fragments after

ESWL treatment

Kim et al recognized the need for validated prediction model for stone free rate for patient

counseling and decision-making of treatment strategies5. Using CT information from 3028

patients who underwent ESWL, a graphical nomogram was developed and validated to predict

the stone free rate at first and within the third session of ESWL. They found that sex, stone

location, stone number, and maximal stone diameter, mean Hounsfield unit (HU) and grade of

hydronephrois (HN) were significant parameters of stone-free rate.

Kent et all created a nomogram that predicts the stone free rate at 3 months after 1 session

of ESWL6. They found that size, location and number of stones are independent significant

indexes that predicts the stone free rate at 3 months following 1 session of ESWL in renal and

ureteral stones.

In 2014, Molina et al introduced The S.T.O.N.E. Score, an assessment tool to predict SFR

in patients who require ureteroscopy for ureteral and renal stone disease7. The features of

S.T.O.N.E. that are relevant in predicting SFR with URS include the Size, location, and degree of

hydronephrosis, number of stones and Hounsfield unit. This has been the inspiration of the author

to use the same acronym but a different set of parameters to predict the stone free rate for ESWL.

The author had an approval to use the STONES acronym from the author of this previous study.

5
 The author used the independently studied parameters, namely stone size (S), stone

location(T), BMI(O), number of stones(N), Stone Exposure (E), and stone to skin distance(S),

which were significantly affecting stone free rate and combine them to produce the

Nephrolithometry Scoring System with the acronym STONES. The STONES Nephrolithometry

Scoring System will be used to identify the probability of stone free rate of patients who underwent

ESWL. This study is the first to the best of our knowledge to combine these parameters to develop

a scoring system that will predict the probability of stone free rate of patients undergoing ESWL

that can be applied in our local setting.

SCOPE AND LIMITATIONS

The study is limited in that it utilized only a fixed-sample size of sixty-six patients. No

subgroup of patients with complicated urolithiasis was included, hence the generalizability to this

group will be limited.

GENERAL OBJECTIVE

To develop and validate the STONES Nephrolithometry Scoring System that will

predict the stone free rate of ESWL for patients with uncomplicated renal stones

SPECIFIC OBJECTIVES

1. To determine the accuracy of the STONES Nephrolithometry Scoring System using

six independent parameters from BMI and NCCT measurements

2. To determine the best minimum cut-off score that is predictive of stone-free rate.

3. To determine the range of STONES scores and their corresponding stone-free rates.

6
ETHICAL CONSIDERATION

The protocol was prepared by the authors. The protocol was submitted to the review

process of the institution’s Ethics Committee. The research was conducted in accordance

with this protocol, which was consistent with the ethical principles that have their origin in the

Declaration of Helsinki and the National Guidelines for the Biomedical/Behavioral Research of

the National Ethics Committee (NEC) Philippines. All study participants of the study were given

clear and complete instructions about the goal and study design. Withdrawal from the study for

any reasons was allowed at any time. The investigators made themselves available for any

questions or clarifications raised. Study participants were not being given remuneration but were

rewarded by the medical attention and treatment.

All study participants who passed the Criteria for inclusion were given information on the

basic elements of the REC- approved Protocol. When understood and accepted, participants

were then asked to sign a detailed Informed Consent Form.

MATERIALS AND METHODS

This is a retrospective cohort study of patients with uncomplicated renal stones (< 2 cm)

treated with ESWL using standard shockwave lithotripsy protocol. All patients were diagnosed

using non-contrast enhanced CT scan of the KUB. Patient who underwent previous stone

treatment, such as ESWL, PCNL, RIRS or open stone surgery, on the ipsilateral kidney were

excluded on the study.

All patients were treated at a single institution using EDAP Sonolith 4000 (Technomed,

France) with a standard protocol (Fig. 1). Patients received prophylactic antibiotics and IV

sedation. The shock wave was delivered at an asynchronized rate of 100 shocks per minute or at

electrocardiogram triggering mode with a power of 80% initially which was increased up to 100%.

7
The positioning of the stone was checked by fluoroscopy after every 500 shocks. Treatment

ended after a maximum of 1000kJ was given. All the staffs, nurse and technicians, were trained

and were the only personnel who gave the treatment to our patients.

At 95% confidence level and 10% confidence interval, the minimum required number of

patients was at least 69 patients. This was based on the results of the previous study of (2012),

where 76.7% were considered as stone-free after ESWL.

The ESWL treatment protocol consist of up to 3 ESWL procedure and follow up with plain

kidney-ureter-bladder X-ray (PKUB) to be performed 2-3 weeks post treatment. Patients with

PKUB X-ray showing presence of radiopaque lesion were schedule for another treatment. The

interval of re-assessment was set at 2 weeks and repeat treatment was scheduled at 3-4 weeks

from the last treatment to give ample amount of time for the kidney to recover and resolve possible

hematomas. Patients with persistence of radiopaque density on PKUB on 3 month follow up was

classified as treatment failure. Patient’s with PKUB showing no radiopaque lesion at the previous

stone site was confirmed with KUB Ultrasound. The primary outcome of the study was the stone-

free rate at 3 months. Stone free was defined as no visible or up to 3 mm radiopaque focus on

good plain KUB X-ray on the 3rd month follow up comparing with the pre-operative plain KUB.

Measurement of stone size (S), stone location/topography (T), number of stones(N), stone

exposure /Hounsfield unit (E) and stone to skin distance were reported (S). NCCTs were reviewed

by a single radiologist who was blinded with the clinical results. Data were collated by the authors

and processed using statistical analysis software to identify the predictiveness for stone free rate

of each parameters. A multivariate analysis is performed to generate the regression equation that

is used to develop the scoring system. Calibration of the scoring system and validation through

the sample population was also performed. Range and its probability of stone free rate was then

established.

In this study, six parameters were used which showed predictiveness for stone free rate

from previous studies. Stone was measured in 3 planes and the longest measurement was used

8
as representative for the stone size (S). Stone size of 5 to 10 mm was assigned with 80 points

while 11 to 15 mm and 16 mm to 20mm were given 54 and 27 points respectively. The stone

location/topography (T) was identified by the location where the stone is noted either in the

calyces or renal pelvis. Superior calyx and renal pelvis stones were given 9 points, middle calyx

was 8 points and inferior calyx with 7 points.

Baseline height and weight were recorded prior to the first treatment by the SWL nurse to

calculate for the BMI (O). Patients were categorized as normal (9 points), overweight (5 points)

and obese (4 points). Number of stones (N) was used instead of the total stone burden because

multiple stones need to be targeted separately and the need to refocus the treatment is essential.

Solitary stone was assigned with 3 points while multiple stones were given 2 points.

The Exposure/Hounsfield unit (E) was the mean of the spherical ruler pointed on the stone.

The mean stone exposure was 827. Stone exposure less than 827 was designated with 9 points

and those equal or more than 827 has 4 points. Stone skin distance/SSD (S) was measured in 3

planes from the stone with perpendicular line to the skin at 90, 45 and 30 degrees. The average

of the 3 measurements was used as the stone to skin distance. The mean SSD was 85mm. SSD

with less than 85 was assigned with 20 points while equal or more than 85 mm was given 9 points.

The sum of the values of the S-T-O-N-E-S is the STONES Nephrolithometry score. The

accuracy of the scoring system was confirmed using statistical analysis presented.

STATISTICAL ANALYSIS
All analyses were done using the Statistical Package for the Social Sciences (SPSS

Version 23, with license). Numerical summaries were done using mean and their standard

deviations for continuous numerical variables and percentages for categorical data. Multivariate

analysis of the different variables in the STONES criteria was done using binary logistic regression

by forward technique. Variables with odd ratios of above 1, with p-values less than 05 were

considered statistically significant. Statistical precision of the OR estimates was pegged at 95%

9
confidence level. For factors with more than two categories in the encoding, a categorical analysis

was separately performed to determine the individual odd ratios for each level. To formulate the

scoring model, a multivariate analysis was conducted to derive the beta-coefficients. A weighted

point was computed by dividing the specific beta-coefficient by the lowest beta-coefficient in the

predictor set multiplied by the regression constant. The resultant weighted score was rounded off

to the nearest whole integer. The regression equation was derived to determine the probability of

stone-free status using the six variables in the scoring tool. The Hosmer-Lemeshow's goodness

of fit test was utilized to determine any significant variation in the scoring model that can be

explained by factors that are not significant and to test for significant calibration or discriminative

power of each score set. Each score was applied to the same set of subjects (validation set). The

sum of all scores was utilized to run a receiver operator curve analysis to determine the accuracy

of the scoring model, and to determine the minimum best score that is predictive of a stone-free

status. The sensitivity and false-positive rate were plotted against each score. Three ranges of

scores were calculated by subtracting the lowest score from the highest score divided by three to

come up with specific range of STONES scores. Stone free rates in each range were determined

and compared using Chi-Square Test. An area under the curve with p-value of less than .05 was

considered statistically significant.

RESULTS
A total of sixty-six patients who underwent lithotripsy were included in this validation study

with their profile shown (Table-2). The mean age was 47 years old, with male predominance

(63.6%). Nine patients were classified as obese (13.6%). In terms of stone topography, twelve

(18.2%) were categorized as superior, 23 (34.8%) were in the middle region and 31 (47%) in the

inferior region. In terms of laterality, left sided stones were slightly more common (54.5% versus

45.5%). More than half of the stones were between 5 to 10 millimeters (53%). The average

10
Hounsfield units and skin-to-stone distance was 827.9 and 85.1 cm respectively. Stones were

commonly solitary (77.3%). Overall average of “shocks” utilized was 3178. A total of 56 patients

(84.8%) were eventually categorized as “stone-free”.

TABLE-2 Clinical Profile of Patients for the Validation of The STONES

Nephrolithometry Scoring System

00Characteristic No. %
Total patients 66 --
Mean age (SD) 47 (11.4) --
Sex
Male 42 63.6
Female 24 36.4
BMI
Normal 9 13.6
Overweight 28 42.4
Obese 29 43.9
Topography of stone
Superior (Calyx, Pelvis) 12 18.2
Middle Calyx 23 34.8
Inferior Calyx 31 47.0
Laterality
Left 36 54.5
Right 30 45.5
Mean stone size
5-10 35 53.0
11-15 23 34.8
16-20 8 12.1
Number of stones
1 51 77.3
2 15 21.7
Mean Hounsfield Units (SD) 827.9 (297) --
Mean skin-to-stone distance (SD) cm 85.1 (13.1) --
Mean shocks (SD)
First session 3248 (523) --
Second session 3213 (532) --
Third session 3051 (526) --
Overall mean 3178 (521) --
Stone-free status
Yes 56 84.8
No 10 15.2
SD-standard deviation

11
MULTIVARIATE AND CATEGORICAL ANALYSIS OF “S-T-O-N-E-S” CRITERIA IN
PREDICTING STONE-FREE STATUS

Of all the variables analyzed, only stone size was predictive of a stone free status (OR=

.081, p=.008). Other variables in the criteria were not predictive. (p-values were >.05) (Table-3)

TABLE-3 Regression Analysis of the STONES Nephrolithometry Scoring

System as Predictors of Stone-Free Status

FACTOR OR 95% CI p
Stone Size (S) .081 .013-0.52 .008*
Stone Topography (T) 1.25 0.31-5.0 0.75
Obesity (O) 0.171 .008 -3.46 0.17
Number of stones (N) 0.35 0.039-3.3 0.36
Exposure (Hounsfield Units) (E) 0.996 0.99-1.0 .086
Skin-to-stone distance (S) 1.058 0.96-1.16 .23
*significant predictor if p-value is < .05

Categorical analysis was done in three variables having more than two categories. These

are the stone sizes, topography and the body mass index categories. Patients with smaller stone

sizes (5-10 mm) had a higher probability of stone-free status than those above this range

(OR=20,95% CI 12-34, p=.001). For stone topography, similar odds ratios were reported, whether

the stone was lodged in the superior pole (OR=0.99), in the middle region (OR=.0.84) or in the

inferior region (OR=0.94). Those who had normal BMI was 1.87 times associated with stone free

status (OR 1.87, 95% CI 0.44-2.87, p=.07), while those who were either overweight or obese had

a slightly lower association (OR 1.78, 95% CI 0.27-11.8 and OR 1.71, 95% CI 0.26- 11.4, p=.57

respectively). (Table-4)

12
 TABLE-4 Categorical Analysis for Variables with more than Two Categories in
the STONES Nephrolithometry Scoring System for Predicting Stone-
Free Status
FACTOR OR 95% CI p
Stone Size (S)
5-10 20.0 12 -34 .001
11-15 6.1 0.56-66.2 .14
16-20 3.1 0.44 – 5.4 .23
Stone Topography (T)
Superior (Calyx, Pelvis) 0.91 0.04-2.8 0.71
Middle Calyx 0.84 .05-14.4 0.91
Inferior Calyx 0.94 .094-9.38 0.96
BMI Category
Normal 1.87 0.44 – 2.87 .07
Overweight 1.78 0.27 – 11.8 .55
Obese 1.71 0.26 – 11.4 .57
*OR with values less than 1 were rounded off the nearest integer
The two factors above have more than 2 encoding categories

Proposed STONES Nephrolithometry Scoring System

The proposed STONES scoring system below categorizes each variable and a weighted

point is assigned (Table-5). The equation for defining the chances of a “stone-free” state is

determined by summing up the weighted points. Hence, the Probability of Stone Free is = 1.5

multiplied by the sum of [stone size + stone topography + obesity + number of stones + Hounsfield

Units + Skin-to-stone distance].

The test of the goodness of fit of this model is shown to be well calibrated (Hosmer-

Lemeshow's goodness of fit test, Chi-square=8.3, p=.30).

13
 TABLE-5 Weighted Points in the STONES Nephrolithometry Scoring System
for Predicting Stone-Free Status

FACTOR Beta-coefficient Weighted Points*

Stone Size (S) of
5-10 mm 9.0 80
11-15 6.1 54
16-20 3.1 27
Stone Topography (T)
Superior (Calyx, Pelvis) 0.99 9
Middle Calyx 0.84 7
Inferior Calyx 0.94 8
BMI (Obesity)
Normal 0.17 9
Overweight 0.58 5
Obese 0.54 4
Solitary stones (N) 0.35 3
> 2 Stones 0.24 2
Mean Exposure (Hounsfield Units) (E)
>/= 827 0.45 4
<827 0.99 9
Mean Skin-to-stone distance (S)
< 85 2.3 20
>85 1.05 9
Constant 1.5 13
Calibration assessment Chi-square=8.3,
(Hosmer-Lemeshow's goodness of fit test, final p=.30
model)
*Weighted points of a risk factor were calculated using a linear transformation of the corresponding β coefficient was
divided by the smallest β coefficient (0.17, Normal BMI), multiplied by a constant (1.5), and rounded to the nearest
integer

Obtaining an overall STONES Score is summing up all the individual scores of the 6 domains.

Regression Equation for Probability of Stone Free Rate= 1.5 * [stone size + stone topography + BMI Category +
number of stones + Hounsfield Units + Skin-to-stone distance]

VALIDATION OF THE SCORING SYSTEM

Accuracy Rating
For the validation set involving the same 66 participants, the minimum score was the 54

and the maximum score was 129 points, with an average score of 108 (± 21).

Figure-1 displays the receiver operator curve (ROC) of the STONE Scoring System in

predicting stone-free status as validated in the set of sixty-six patients. The overall accuracy (area

14
under the curve-AUC) of the tool is 88% with a standard error of 5.2%. (95% CI 77.9, 98.2%,

p<.001)

Based on the validation set, the minimum cut-off that is best predictive of a stone-free rate

is a STONES score of at least 105 with a high sensitivity rating of 98.2%.

Figure-1 Receiver Operator Curve of the STONE Scoring System in Predicting Stone-Free
Status

STONE-FREE RATES ACCORDING TO PREDICTIVE CUT-OFF SCORE

When applied to the validation set, the minimum score was the 54 and the maximum score

was 129 points, with an average score of 108 (± 21). If the STONE score is between 54 to 79,

the stone-free rate was 16.6%. When STONE scores approach the range of 80 to 105, the stone

15
free rate was 81.8%; while scores between 106 to 129, the stone-free rate was 97.3% (Table-5).

Overall percentage of patient who were stone-free and not stone free across each range is

presented in Figure 2.

TABLE-6 Stone-Free Rates According to Range of the STONES Score, Validation Set
Involving 66 Patient

STONES SCORE STONE FREE RATE

RANGE
(Sum of the 6 YES NO
Components)
No., (%) No., (%)
54 to 79 1 (16.6) 5 (83.3)
80 to 105 18 (81.8) 4 (18.2)
106 - 129 37 (97.3) 1(2.6)
Total 56 (84.8) 10 (15.2)
Chi-Square, p-value <.001

Distribution of Patient with Stone Free and Not Stone Free Status Post
ESWL
2%
15%
27%

56%
SNS 54-79 SNS 80-105 SNS 106-109 Not Stone Free

Figure 2: The distribution of patient STONES Scores who were Stone-Free and Not-
Stone-Free Across STONES Score Ranges

STONE FREE RATES ACROSS ESWL SESSIONS

Of the 66 cases, 56 or 84.8% were stone free after ESWL. The distribution of stone free across

the frequency of ESWL session is displayed. (Table-6)

16
 TABLE-6 Stone Free Rates Across Frequency of ESWL Sessions

Number of ESWL Sessions STONE FREE Total

Yes No
No. (%) No. (%) No. (%)
One 29 (96.7) 1 (3.3) 30 (100)
Two 17 (94.4) 1 (5.6) 18 (100)
Three 10 (55.6) 8 (44.4) 18 (100)
Total 56 10 66
*Significant distribution p<.05 by Chi-Square Test

DISCUSSION
The present study investigates the validity and reliability of the STONES tool in predicting

stone free status in patients with nephrolithiasis post-lithotripsy. The validation sample is

composed of sixty-six patients with data retrospectively collated from medical records using a

standardized data collection form. Verification of the successful extracorporeal shockwave

lithotripsy (ESWL) procedures was done by examining the PKUB X-rays upon follow up. The

population consist mostly of physically fit men compared to general population.

Our initial analysis shows that among all factors in the STONES Nephrolithometry Scoring

analyzed, only stone size showed a significant regression coefficient and odds. Increasing stone

size as depicted in three categories, was highly associated with a lower rate of stone-free status.

This supports the external validation study of Noureldin et.al.7, involving 155 percutaneous

nephrolithotomy procedures, where stone size and the number of involved calyces were still the

most predictive of all factors combined for a given procedure. However, there was not significant

difference in the calculated odds whether the stone was lodged in the superior, middle, inferior

calyces or renal pelvis in this study.

Obesity (BMI), categorically speaking, was not a predictor of stone-free rate in our scoring

model. This is partly explained by the fewer subjects falling within the body mass index range of

above 30 kg/m2. Majority of the participants in this study are soldiers and hence obesity was

17
underrepresented in this study. The study of Yarimoglu et.al.9 demonstrated that stone-free

patients had significantly lower BMI (<0.001).

In our predictive model, the stone-to-skin distance average of three angle measurements,

contributed to a higher weighted score than the stone exposure (Hounsfield units), although both

parameters were not strongly predictive. This again is due to the disproportionate distribution of

subjects falling in the categories for stone exposure and stone-to-skin distance. The study of Niwa

et.al.10 showed that stone size, maximum HU of the stone, and SSD at 90° were significant

predictors of successful shock wave lithotripsy outcome in patients with a proximal ureteral stone.

In our study, we utilized the average of SSD to categorize patients. An arbitrary cut-off of

less than 85 mm stone-to-skin distance was associated with a higher odd of stone-free rate. One

study showed that a median SSD of 125 mm (range 81-165 mm) were associated with successful

stone-free outcomes while those 141 mm (range 108-172 mm) had treatment failure.11 When

examining stone exposure, the study of Sugino et.al.12 revealed that maximum HU and mean HU

have equivalent predictive accuracy, and maximum HU is easier to measure and less biased than

mean HU.

The overall derived accuracy for the STONES predictive scoring index was fairly high

(87.1%). As depicted above, the STONES nephrolithometry scoring tool is an easy, fast and

accurate tool. One of the drawbacks for its use is the weighted scores assignment that needs to

be simplified. Because of the inherent small sample size of this study, the weighted scores in

some variables were overinflated like the stone size and skin-to-stone distance which makes it

cumbersome to remember. But the ease of summing up the scores is the same mathematical

procedure in determining the probability of stone-free rates as seen in the other scoring models

presented. A comparison of the area under the receiver operating characteristic (ROC) curves for

stone burden, the Guy's, STONE score, CROES core and S-ReSC scores showed good results

(0.737/0.674/0.762/0.746/0.710) respectively. 15

18
 The STONES score is based on factors determined through CT imaging, which is the

currently preferred imaging modality for patients with nephrolithiasis. The potential problem will

probably stem from inaccurate reporting of the imaging results. The discriminative power

(calibration) of this tool is highly dependent partly on the specific CT measurements on high

resolution, the degree and the body morphology of obesity, the ability to detect the multiplicity of

stones in relation to their site in the pelvo-calyceal regions, the variability in reading the HU and

the SSD.

The development of this STONES scoring system has its own limitations. Due to the

inherently small sample size, some categories were underrepresented. The skewed frequency

distribution in the mentioned categories of the scoring system explains the lack of significant

association. We presented an arbitrary range of scores and their corresponding stone free rates.

The predictive accuracy of the tool even at low scores could have been improved by enrolling

more participants. The retrospective nature of the study is prone to recall bias; hence validation

must be done in another independent sample of participants employing a prospective recruitment

design.

CONCLUSION:

• The STONES nephrolithometry scoring system composed of stone size, topography, obesity,

number of stones, exposure and skin-to-stone distance is accurate in predicting stone-free

rates at 87.1%, with a minimum best-predictive cut-off of 105 points (98.2%).

RECOMMENDATIONS:

• To offset recall bias, it is recommended to perform a cross-sectional validation study using

independent and blind personnel doing the scoring and determining the stone free rate.

• It is useful to validate the scoring system using a higher sample size. This will adjust the

weighted scores assigned to each variable and make it easier to remember.

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• There is a need to standardize the utilization of the STONES prediction tool by training

urologists in its use and interpretation.

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