Gökce MI et al, 2016: External Validation of Triple D Score in an Elderly (≥65 Years) Population for Prediction of Success Following Shockwave Lithotripsy.

Thursday, 16 February 2017

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Gökce MI, Esen B, Gülpınar B, Süer E, Gülpınar Ö.
Department of Urology, Ankara University School of Medicine, Ankara, Turkey.
Department of Radiology, Ankara University School of Medicine, Ankara, Turkey.

Abstract

INTRODUCTION: Triple D score was recently developed for prediction of extracorporeal shockwave lithotripsy (SWL) outcomes. However, it has not been validated. SWL in elderly patients results in lower success and higher complication rates. We aimed at externally validating Triple D score in a population ≥65 years of age.
PATIENTS AND METHODS: We retrospectively analyzed the data of 182 patients ≥65 years of age who underwent SWL for renal or ureteral stones and were evaluated with non-contrast computed tomography before SWL. Stone volume (SV), skin-to-stone distance (SSD), and stone density were measured, and cutoff values were determined with receiver operator characteristic analysis. Triple D scores were calculated, and success rates were determined for each score.
RESULTS: Mean SV, SSD, and stone density values were significantly higher in patients with failed outcomes compared with those with successful outcomes in both renal and ureteral cases. Cutoff values of 187.5 mm(3), 10.5 cm, and 675 HU for renal stones and of 185 mm(3), 11.5 cm, and 785 HU for ureteral stones were detected. Success rates of 95.5% and 95% were detected for patients with a Triple D score of 3 in the renal and ureteral stone groups, respectively. Success rates of patients with a Triple D score of 0 were 20% and 25% in the renal and ureteral stone groups, respectively.
CONCLUSIONS: Triple D score correlated well with SWL outcomes in patients ≥65 years of age, and it is externally validated. Various factors may deal with cutoff levels of involved parameters. Therefore, we suggest that each institution determines its unique cutoff levels for SV, SSD, and stone density parameters and calculates the Triple D score for its patients with respect to these cutoff levels to predict the success after SWL and aid in decision making.

J Endourol. 2016 Sep;30(9):1009-16. doi: 10.1089/end.2016.0328. Epub 2016 Jul 28.

Comments 1

Hans-Göran Tiselius on Thursday, 16 February 2017 13:03

Apart from SWL there are probably few surgical procedures for which so many different scoring systems, indices and nomograms have been developed and suggested for clinical use.

Triple D is another new scoring system described in 2015 by Tran and co-workers [1]. This system requires definition of “cut off” values for stone volume, skin-to-stone distance and stone density. Measurements below the “cut-off” levels results in a score factor of 1. This means that with all three variables below the indicated levels the score is 3 and with all variables above the score is 0!

The authors of the present article have carried out what they refer to as “external validation”, in which the score was calculated for patients > 65 years old and treated with SWL. One of the arguments for using Triple D score was to avoid complications in this specific age group. However, very little is further mentioned about complications and no variable was added for such an outcome. In this regard it needs to be added that for old patients alternative procedures such as URS and PNL might be associated with considerable demand and risks, probably in many cases much more important than the need to repeat SWL. Were the complications more common in patients with high score? This is not discussed.

The success rates were 69% for renal stones and 76% for ureteral stones. In my own experience, these results correspond roughly with one single treatment [2]. The authors present the number of sessions in terms of medians and ranges and it is thus not possible to see how many sessions that actually were required for this result.

I agree with the authors that it is important to use an individualized therapeutic approach for stone removal and thus be aware of treatment efforts for the patient. But, there is, unfortunately, very little information given on the details of SWL such as for instance patient positioning.

Triple D might be one way to review treatment results retrospectively, but inasmuch as stone size, hardness and shockwave path, together with a number of other variables, are well recognized determinants of SWL success, I attempts to predict the treatment outcome with this score is worth the efforts. Particularly not for the age group studied in this article.

References

1. Tran TY, McGillen K, Cone EB, Pareek G.
Triple D Score is a reportable predictor of shockwave lithotripsy stone-free rates.
J Endourol. 2015 Feb;29(2):226-30. doi: 10.1089/end.2014.0212. Epub 2014 Sep 19

2. .Tiselius HG.
How efficient is extracorporeal shockwave lithotripsy with modern lithotripters for removal
of ureteral stones?
J Endourol. 2008; 22:249-255.

Apart from SWL there are probably few surgical procedures for which so many different scoring systems, indices and nomograms have been developed and suggested for clinical use.

Triple D is another new scoring system described in 2015 by Tran and co-workers [1]. This system requires definition of “cut off” values for stone volume, skin-to-stone distance and stone density. Measurements below the “cut-off” levels results in a score factor of 1. This means that with all three variables below the indicated levels the score is 3 and with all variables above the score is 0!

The authors of the present article have carried out what they refer to as “external validation”, in which the score was calculated for patients > 65 years old and treated with SWL. One of the arguments for using Triple D score was to avoid complications in this specific age group. However, very little is further mentioned about complications and no variable was added for such an outcome. In this regard it needs to be added that for old patients alternative procedures such as URS and PNL might be associated with considerable demand and risks, probably in many cases much more important than the need to repeat SWL. Were the complications more common in patients with high score? This is not discussed.

The success rates were 69% for renal stones and 76% for ureteral stones. In my own experience, these results correspond roughly with one single treatment [2]. The authors present the number of sessions in terms of medians and ranges and it is thus not possible to see how many sessions that actually were required for this result.

I agree with the authors that it is important to use an individualized therapeutic approach for stone removal and thus be aware of treatment efforts for the patient. But, there is, unfortunately, very little information given on the details of SWL such as for instance patient positioning.

Triple D might be one way to review treatment results retrospectively, but inasmuch as stone size, hardness and shockwave path, together with a number of other variables, are well recognized determinants of SWL success, I attempts to predict the treatment outcome with this score is worth the efforts. Particularly not for the age group studied in this article.

References

1. Tran TY, McGillen K, Cone EB, Pareek G.
    Triple D Score is a reportable predictor of shockwave lithotripsy stone-free rates.
      J Endourol. 2015 Feb;29(2):226-30. doi: 10.1089/end.2014.0212. Epub 2014 Sep 19

2. .Tiselius HG.
    How efficient is extracorporeal shockwave lithotripsy with modern lithotripters for removal   
    of ureteral stones?
    J Endourol. 2008; 22:249-255.

Apart from SWL there are probably few surgical procedures for which so many different scoring systems, indices and nomograms have been developed and suggested for clinical use. Triple D is another new scoring system described in 2015 by Tran and co-workers [1]. This system requires definition of “cut off” values for stone volume, skin-to-stone distance and stone density. Measurements below the “cut-off” levels results in a score factor of 1. This means that with all three variables below the indicated levels the score is 3 and with all variables above the score is 0! The authors of the present article have carried out what they refer to as “external validation”, in which the score was calculated for patients > 65 years old and treated with SWL. One of the arguments for using Triple D score was to avoid complications in this specific age group. However, very little is further mentioned about complications and no variable was added for such an outcome. In this regard it needs to be added that for old patients alternative procedures such as URS and PNL might be associated with considerable demand and risks, probably in many cases much more important than the need to repeat SWL. Were the complications more common in patients with high score? This is not discussed. The success rates were 69% for renal stones and 76% for ureteral stones. In my own experience, these results correspond roughly with one single treatment [2]. The authors present the number of sessions in terms of medians and ranges and it is thus not possible to see how many sessions that actually were required for this result. I agree with the authors that it is important to use an individualized therapeutic approach for stone removal and thus be aware of treatment efforts for the patient. But, there is, unfortunately, very little information given on the details of SWL such as for instance patient positioning. Triple D might be one way to review treatment results retrospectively, but inasmuch as stone size, hardness and shockwave path, together with a number of other variables, are well recognized determinants of SWL success, I attempts to predict the treatment outcome with this score is worth the efforts. Particularly not for the age group studied in this article. References 1. Tran TY, McGillen K, Cone EB, Pareek G. Triple D Score is a reportable predictor of shockwave lithotripsy stone-free rates. J Endourol. 2015 Feb;29(2):226-30. doi: 10.1089/end.2014.0212. Epub 2014 Sep 19 2. .Tiselius HG. How efficient is extracorporeal shockwave lithotripsy with modern lithotripters for removal of ureteral stones? J Endourol. 2008; 22:249-255.

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