Reviewer's Choice

Owen K. et al., 2023: Role of Noncontrast Computed Tomography Parameters in Predicting the Outcome of Extracorporeal Shock Wave Lithotripsy for Upper Urinary Stones Cases: A Meta-analysis.

Monday, 01 July 2024

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Owen K, Joe W, Ivander A, Palgunadi IN, Adhyatma KP.
Bangli General Hospital, Bangli, Indonesia (K.O.). Electronic address: This email address is being protected from spambots. You need JavaScript enabled to view it..
Regional Public Hospital dr.M. Thomsen Nias, Gunungsitoli, Indonesia (W.J.).
Faculty of Medicine, Universitas Sumatera Utara, Medan, Indonesia (A.I.).
Urology Division, Bangli General Hospital, Bangli, Indonesia (I.P.).
Department of Surgery, Urology Division, Universitas Sumatera Utara, Medan, Indonesia (K.P.A).

Abstract

Rationale: Extracorporeal shock wave lithotripsy (ESWL) is widely considered the primary approach for managing urinary tract stones. This study aimed to assess the predictive factors associated with non-contrast computed tomography (NCCT)-based parameters of upper urinary stones in relation to the outcomes of ESWL.

Materials and methods: A systematic search was conducted in PubMed, ScienceDirect, Web of Science, and Cochrane Library to identify all relevant studies published up to June 3, 2023. Several NCCT-based parameters to predict ESWL outcomes, comprised of mean stone density (MSD), skin-to-stone distance (SSD), and stone size, were extracted and analyzed using Review Manager software.

Results: Out of 979 publications screened, a total of 39 publications, involving 7869 patients, were enrolled in the analysis. The pooled estimate demonstrated significant differences between MSD, and stone size between successful and failure of stone fragmentation groups, in which lower values of these parameters are associated with successful ESWL outcomes.

Conclusion: The results from the current study suggested that lower NCCT parameters, notably MSD, SSD, and stone size, are significantly associated with successful ESWL outcome. However, additional large-scale prospective studies are required to utilize these parameters effectively, and the optimal cutoff value should be determined.

Acad Radiol. 2023 Nov 18:S1076-6332(23)00556-1. doi: 10.1016/j.acra.2023.10.021. Online ahead of print. PMID: 37985292

Comments 1

Peter Alken on Monday, 01 July 2024 11:00

My comment to this paper is divided in two parts. Part 1 consists of a citation of the core statements of this publication. Part 2 is my opinion on the message and significance of this publication.
Part 1
“DISCUSSION
In general, higher mean stone attenuation, SSD, and stone size
often indicate a poor response to ESWL therapy.
MSD
Evidence suggest that the MSD may not be reliable and has certain limitations in predicting the success of ESWL … Thus, physicians should be cautious in interpreting this parameter.”
SSD
… In further inspection we also found a discrepancy regarding stone-to-skin distance role in multiple literature.”
STONE SIZE
… is essential to note that discrepancies in stone size measurements can arise due to variations in the imaging modalities used to evaluate stone size across different studies ...
Based on the findings from the current study, it is challenging to reconcile the differences in the measured values of NCCT parameters obtained using various measurement methods. Consequently, conducting a meta-analysis to determine the optimal cut-off values for these parameters is not feasible. Nevertheless, this study holds significance as it brings attention to the issue of inconsistent measurement methods. Therefore, there is a need to establish a precise and replicable method for measuring these NCCT parameters, as evidenced by the diverse outcomes observed in our study.
CONLUSION
… MSD, SSD, and stone size, have a significant association with successful ESWL outcomes. Therefore, these parameters should be considered when selecting and planning the treatment for patients with upper urinary stones. Nevertheless, in order to utilize these parameters more effectively, further large-scale prospective studies are necessary. Once an appropriate method for measuring these NCCT parameters has been established, the optimal cutoff value must be determined accordingly.”
COMMENT Part 2
This is a highly significant publication.
It is a long overdue and necessary summary of what has been said so far about the use of CT imaging to predict the success or failure of ESWL. It documents the useless radiation exposure of 7869 patients, the waste of time, labour, money and paper and a disappointment based on 39 carefully selected publications published between 2006 and 2022.
The next plague will be ruminating on the same theme with the help of AI!
Probably, but hopefully not, a similar study on pancreatic stones will be published in a few years (1).
I have no intention of reviewing further publications on this subject unless new points of view arise in comparison with the criticism expressed in this publication. Hopefully there will be reasons to change this intention.
1 Assessment of pancreatic ductal stone density on non-contrast computed tomography for predicting the outcome of extracorporeal shock wave lithotripsy.
Dalal A, Kamat N, Maydeo A, Patil G, Vadgaonkar A, Parekh S, Vora S.
Endosc Int Open. 2024 Feb 28;12(2):E274-E281. doi: 10.1055/a-2226-1464. eCollection 2024 Feb.
PMID: 38420153
Free PMC article.

Peter Alken

My comment to this paper is divided in two parts. Part 1 consists of a citation of the core statements of this publication. Part 2 is my opinion on the message and significance of this publication. 
Part 1 
“DISCUSSION 
In general, higher mean stone attenuation, SSD, and stone size 
often indicate a poor response to ESWL therapy. 
MSD 
Evidence suggest that the MSD may not be reliable and has certain limitations in predicting the success of ESWL … Thus, physicians should be cautious in interpreting this parameter.” 
SSD 
… In further inspection we also found a discrepancy regarding stone-to-skin distance role in multiple literature.” 
STONE SIZE 
… is essential to note that discrepancies in stone size measurements can arise due to variations in the imaging modalities used to evaluate stone size across different studies ... 
Based on the findings from the current study, it is challenging to reconcile the differences in the measured values of NCCT parameters obtained using various measurement methods. Consequently, conducting a meta-analysis to determine the optimal cut-off values for these parameters is not feasible. Nevertheless, this study holds significance as it brings attention to the issue of inconsistent measurement methods. Therefore, there is a need to establish a precise and replicable method for measuring these NCCT parameters, as evidenced by the diverse outcomes observed in our study. 
CONLUSION 
… MSD, SSD, and stone size, have a significant association with successful ESWL outcomes. Therefore, these parameters should be considered when selecting and planning the treatment for patients with upper urinary stones. Nevertheless, in order to utilize these parameters more effectively, further large-scale prospective studies are necessary. Once an appropriate method for measuring these NCCT parameters has been established, the optimal cutoff value must be determined accordingly.”
COMMENT Part 2 
This is a highly significant publication. 
It is a long overdue and necessary summary of what has been said so far about the use of CT imaging to predict the success or failure of ESWL. It documents the useless radiation exposure of 7869 patients, the waste of time, labour, money and paper and a disappointment based on 39 carefully selected publications published between 2006 and 2022. 
The next plague will be ruminating on the same theme with the help of AI! 
Probably, but hopefully not, a similar study on pancreatic stones will be published in a few years (1). 
I have no intention of reviewing further publications on this subject unless new points of view arise in comparison with the criticism expressed in this publication. Hopefully there will be reasons to change this intention. 
1 Assessment of pancreatic ductal stone density on non-contrast computed tomography for predicting the outcome of extracorporeal shock wave lithotripsy. 
Dalal A, Kamat N, Maydeo A, Patil G, Vadgaonkar A, Parekh S, Vora S. 
Endosc Int Open. 2024 Feb 28;12(2):E274-E281. doi: 10.1055/a-2226-1464. eCollection 2024 Feb. 
PMID: 38420153 
Free PMC article.

Peter Alken

My comment to this paper is divided in two parts. Part 1 consists of a citation of the core statements of this publication. Part 2 is my opinion on the message and significance of this publication. Part 1 “DISCUSSION In general, higher mean stone attenuation, SSD, and stone size often indicate a poor response to ESWL therapy. MSD Evidence suggest that the MSD may not be reliable and has certain limitations in predicting the success of ESWL … Thus, physicians should be cautious in interpreting this parameter.” SSD … In further inspection we also found a discrepancy regarding stone-to-skin distance role in multiple literature.” STONE SIZE … is essential to note that discrepancies in stone size measurements can arise due to variations in the imaging modalities used to evaluate stone size across different studies ... Based on the findings from the current study, it is challenging to reconcile the differences in the measured values of NCCT parameters obtained using various measurement methods. Consequently, conducting a meta-analysis to determine the optimal cut-off values for these parameters is not feasible. Nevertheless, this study holds significance as it brings attention to the issue of inconsistent measurement methods. Therefore, there is a need to establish a precise and replicable method for measuring these NCCT parameters, as evidenced by the diverse outcomes observed in our study. CONLUSION … MSD, SSD, and stone size, have a significant association with successful ESWL outcomes. Therefore, these parameters should be considered when selecting and planning the treatment for patients with upper urinary stones. Nevertheless, in order to utilize these parameters more effectively, further large-scale prospective studies are necessary. Once an appropriate method for measuring these NCCT parameters has been established, the optimal cutoff value must be determined accordingly.” COMMENT Part 2 This is a highly significant publication. It is a long overdue and necessary summary of what has been said so far about the use of CT imaging to predict the success or failure of ESWL. It documents the useless radiation exposure of 7869 patients, the waste of time, labour, money and paper and a disappointment based on 39 carefully selected publications published between 2006 and 2022. The next plague will be ruminating on the same theme with the help of AI! Probably, but hopefully not, a similar study on pancreatic stones will be published in a few years (1). I have no intention of reviewing further publications on this subject unless new points of view arise in comparison with the criticism expressed in this publication. Hopefully there will be reasons to change this intention. 1 Assessment of pancreatic ductal stone density on non-contrast computed tomography for predicting the outcome of extracorporeal shock wave lithotripsy. Dalal A, Kamat N, Maydeo A, Patil G, Vadgaonkar A, Parekh S, Vora S. Endosc Int Open. 2024 Feb 28;12(2):E274-E281. doi: 10.1055/a-2226-1464. eCollection 2024 Feb. PMID: 38420153 Free PMC article. Peter Alken

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