Panthier F. et al., 2023: How to estimate stone volume and its use in stone surgery: a comprehensive review

Wednesday, 06 March 2024

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Panthier F, Kutchukian S, Ducousso H, Doizi S, Solano C, Candela L, Corrales M, Chicaud M, Traxer O, Hautekeete S, Tailly T.
Grupo de Investigación Clínica en Litiasis Urinaria, Hospital Tenon, Paris, France; Servicio de Urología, Asistencia Pública Hospitales de París, Hospital Tenon, Universidad de La Sorbona, Paris, France. Electronic
Grupo de Investigación Clínica en Litiasis Urinaria, Hospital Tenon, Paris, France; Servicio de Urología, Asistencia Pública Hospitales de París, Hospital Tenon, Universidad de La Sorbona, Paris, France; Servicio de Urología, Hospital Universitario de Poitiers, Poitiers, France.
Servicio de Urología, Hospital Universitario de Poitiers, Poitiers, France.
Grupo de Investigación Clínica en Litiasis Urinaria, Hospital Tenon, Paris, France; Servicio de Urología, Asistencia Pública Hospitales de París, Hospital Tenon, Universidad de La Sorbona, Paris, France.
Grupo de Investigación Clínica en Litiasis Urinaria, Hospital Tenon, Paris, France; Universidad de La Sorbona, París, Francia; Servicio de Endourología, Uroclin SAS Medellín, Colombia.
Grupo de Investigación Clínica en Litiasis Urinaria, Hospital Tenon, Paris, France; Servicio de Urología, Asistencia Pública Hospitales de París, Hospital Tenon, Universidad de La Sorbona, Paris, France; Divisiónde Oncología Experimental, Unidad de Urología, URI. IRCCS Hospital San Raffaele, Universidad Vita-Salute San Raffaele, Milán, Italy.
Grupo de Investigación Clínica en Litiasis Urinaria, Hospital Tenon, Paris, France; Servicio de Urología, Asistencia Pública Hospitales de París, Hospital Tenon, Universidad de La Sorbona, Paris, France; Servicio de Urología, CHU Limoges, Limoges, France.
Servicio de Radiología, Hospital Universitario de Gante, Gante, Belgium.
Servicio de Urología, Hospital Universitario de Gante, Gante, Belgium.

Abstract

Objective: Current interventional guidelines refer to the cumulative stone diameter to choose the appropriate surgical modality (ureteroscopy [URS], extracorporeal shockwave lithotripsy [ESWL] and percutaneous nephrolithotomy [PCNL]). The stone volume (SV) has been introduced recently, to better estimate the stone burden. This review aimed to summarize the available methods to evaluate the SV and its use in urolithiasis treatment.

Material and methods: A comprehensive review of the literature was performed in December 2022 by searching Embase, Cochrane and Pubmed databases. Articles were considered eligible if they described SV measurement or the stone free rate after different treatment modalities (SWL, URS, PCNL) or spontaneous passage, based on SV measurement. Two reviewers independently assessed the eligibility and the quality of the articles and performed the data extraction.

Results: In total, 28 studies were included. All studies used different measurement techniques for stone volume. The automated volume measurement appeared to be more precise than the calculated volume. In vitro studies showed that the automated volume measurement was closer to actual stone volume, with a lower inter-observer variability. Regarding URS, stone volume was found to be more predictive of stone free rates as compared to maximum stone diameter or cumulative diameter for stones >20 mm. This was not the case for PCNL and SWL.

Conclusions: Stone volume estimation is feasible, manually or automatically and is likely a better representation of the actual stone burden. While for larger stones treated by retrograde intrarenal surgery, stone volume appears to be a better predictor of SFR, the superiority of stone volume throughout all stone burdens and for all stone treatments, remains to be proven. Automated volume acquisition is more precise and reproducible than calculated volume.

Actas Urol Esp (Engl Ed). 2023 Aug 30:S2173-5786(23)00107-5. doi: 10.1016/j.acuroe.2023.08.009. Online ahead of print. PMID: 37657708 Review. English, Spanish.

Comments 1

Hans-Göran Tiselius on Wednesday, 06 March 2024 10:00

One factor that has remained crucial for predicting and evaluating the outcome of active stone removal is the stone burden. This was not a problem when open surgery was the major or only surgical procedure. Information on the stone burden came into focus with the introduction of SWL, but is also of fundamental importance for URS, RIRS and PCNL. Different ways of expressing the stone burden over time has been determined by the available imaging techniques. Based on measurements on KUB the information was restricted to what could be measured in the frontal view. This information resulted in the common use of the longest diameter, the width and occasionally the calculated stone surface area [1]. The use of sum of diameters, in my mind, has been the least attractive estimate, particularly when the range of size distribution is wide.

With the availability of NCCT it became possible to measure not only the surface area, but also to get an estimate of the stone volume. This can be made manually, semi-automated or automated as shown and discussed in this article.

It seems both logical and of great interest to note that the stone volume is one of the best predictors. In the conclusion the authors state that “large scale, rigorous studies are needed to help answer this question”. Although this might be true, it is doubtful how necessary such research is, because stone volume is only one factor that determines the outcome of non-or low-invasive stone removal. Stone hardness and stone structure are other factors. In view of the importance of operator skill, methodological differences, and anatomical prerequisites, it is my personal view that a reasonable estimate of the stone volume with any of the described techniques is sufficient.

References
1. Tiselius HG, Andersson A. Stone burden in an average Swedish population of stone formers requiring active stone removal: how can the stone size be estimated in the clinical routine? Eur Urol. 2003 Mar;43(3):275-81. doi: 10.1016/s0302-2838(03)00006-x.PMID: 12600431

Hans-Göran Tiselius

With the availability of NCCT it became possible to measure not only the surface area, but also to get an estimate of the stone volume. This can be made manually, semi-automated or automated as shown and discussed in this article.

It seems both logical and of great interest to note that the stone volume is one of the best predictors. In the conclusion the authors state that “large scale, rigorous studies are needed to help answer this question”. Although this might be true, it is doubtful how necessary such research is, because stone volume is only one factor that determines the outcome of non-or low-invasive stone removal. Stone hardness and stone structure are other factors. In view of the importance of operator skill, methodological differences, and anatomical prerequisites, it is my personal view that a reasonable estimate of the stone volume with any of the described techniques is sufficient.

References
1.	Tiselius HG, Andersson A.  Stone burden in an average Swedish population of stone formers requiring active stone removal: how can the stone size be estimated in the clinical routine? Eur Urol. 2003 Mar;43(3):275-81. doi: 10.1016/s0302-2838(03)00006-x.PMID: 12600431

Hans-Göran Tiselius

One factor that has remained crucial for predicting and evaluating the outcome of active stone removal is the stone burden. This was not a problem when open surgery was the major or only surgical procedure. Information on the stone burden came into focus with the introduction of SWL, but is also of fundamental importance for URS, RIRS and PCNL. Different ways of expressing the stone burden over time has been determined by the available imaging techniques. Based on measurements on KUB the information was restricted to what could be measured in the frontal view. This information resulted in the common use of the longest diameter, the width and occasionally the calculated stone surface area [1]. The use of sum of diameters, in my mind, has been the least attractive estimate, particularly when the range of size distribution is wide. With the availability of NCCT it became possible to measure not only the surface area, but also to get an estimate of the stone volume. This can be made manually, semi-automated or automated as shown and discussed in this article. It seems both logical and of great interest to note that the stone volume is one of the best predictors. In the conclusion the authors state that “large scale, rigorous studies are needed to help answer this question”. Although this might be true, it is doubtful how necessary such research is, because stone volume is only one factor that determines the outcome of non-or low-invasive stone removal. Stone hardness and stone structure are other factors. In view of the importance of operator skill, methodological differences, and anatomical prerequisites, it is my personal view that a reasonable estimate of the stone volume with any of the described techniques is sufficient. References 1. Tiselius HG, Andersson A. Stone burden in an average Swedish population of stone formers requiring active stone removal: how can the stone size be estimated in the clinical routine? Eur Urol. 2003 Mar;43(3):275-81. doi: 10.1016/s0302-2838(03)00006-x.PMID: 12600431 Hans-Göran Tiselius

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