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Akinci A. et al., 2022: Predicting ESWL success by determination of Hounsfield unit on non-contrast CT is clinically irrelevant in children.

Akinci A, Akpinar C, Babayigit M, Karaburun MC, Soygur T, Burgu B.
Department of Pediatric Urology, Ankara University School of Medicine, Cebeci Children's Hospital, Ankara, Turkey.
Department of Urology, Cubuk State Hospital, Ankara, Turkey.
Department of Urology, Ankara University School of Medicine, Ankara, Turkey.
Department of Pediatric Urology, Ankara University School of Medicine, Cebeci Children's Hospital, Ankara, Turkey.

Abstract

The necessity of determining stone density by non-contrast computerized tomography (NCCT) before extracorporeal shock wave lithotripsy (ESWL) is a controversial topic due to the radiation exposure. We aimed to investigate whether stone density is helpful in predicting the success of ESWL in pediatric patients or not. In this retrospective study, database of a single center was used to identify 232 children aged between 2 and 16 years. Patients with abnormal renal anatomy, distal obstruction, a known cystine stone disease, a previous history of an intervention regarding stone, and an insufficient follow-up period (< 3 months) were excluded from the study. A total of 209 patients were included in the study (94 with NCCT, 115 without NCCT). Groups were compared in terms of stone size, stone location, and stone-free rate at 3 months after a single ESWL session. The mean age was 6.17 ± 3.27 years and 120 (57.4%) of the patients were male and 89 (42.6%) were female. Mean stone size was 11.7 mm in NCCT group and 12.3 mm in non-NCCT group (p 0.128). The complete stone clearance rate in NCCT and non-NCCT group at 3 months after ESWL was 57.4% (54/94) and 54.7% (63/115), respectively, and there was no statistically significant difference (p 0.316). In conclusion, unnecessary NCCT use should be avoided before ESWL considering the similar success rates after ESWL and the risk of exposure to radiation.

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Comments 1

Peter Alken on Friday, 12 August 2022 11:30

An interesting study with important messages.
1. The information offered by a pre-ESWL NCCT, does not improve the one-session success rate.
2. If the slight, statistically insignificant higher SFR of the NCCT group - causes unknown - would translate into a routine pre-ESWL NCCT, “37 patients needed to be screened with NCCT to achieve 1 additional patient success with ESWL. In other words, it was determined that 36 children were unnecessarily exposed to NCCT”.
3. The SFR of stones with a density of > or nder if more clinical parameters, like urine analysis, a more detailed evaluation of the stone image and a correlation with a post-ESWL stone analysis - which is missing - could change the success rate of the non-NCCT group.

Regardless of any criticism, the following statement in the discussion remains important: “Clinicians have supported the ALARA (As low as reasonably achievable) principle to reduce the radiation exposure, especially for the pediatric population. This principle means that if receiving that dose has no direct benefit, the clinician should try to avoid it regardless of the dose.”

Peter Alken

An interesting study with important messages. 1. The information offered by a pre-ESWL NCCT, does not improve the one-session success rate. 2. If the slight, statistically insignificant higher SFR of the NCCT group - causes unknown - would translate into a routine pre-ESWL NCCT, “37 patients needed to be screened with NCCT to achieve 1 additional patient success with ESWL. In other words, it was determined that 36 children were unnecessarily exposed to NCCT”. 3. The SFR of stones with a density of > or nder if more clinical parameters, like urine analysis, a more detailed evaluation of the stone image and a correlation with a post-ESWL stone analysis - which is missing - could change the success rate of the non-NCCT group. Regardless of any criticism, the following statement in the discussion remains important: “Clinicians have supported the ALARA (As low as reasonably achievable) principle to reduce the radiation exposure, especially for the pediatric population. This principle means that if receiving that dose has no direct benefit, the clinician should try to avoid it regardless of the dose.” Peter Alken
Saturday, 18 May 2024