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| Reliability of nephrolithometric nomograms in patients treated with minimally invasive percutaneous nephrolithotomy: A precision study |
a Department of Urology, San Bassiano Hospital, Bassano del Grappa, Italy
b Department of Urology, University of Trieste, Trieste, Italy
c Institute of Urology, University College Hospitals London, London, UK
d Department of Urology, Minimally Invasive Centre, the first affiliated hospital of Guangzhou Medical University, Guangzhou, China |
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Abstract Objectives: The study aimed to evaluate quality of nephrolithometric nomograms to predict stone-free rates (SFRs) and complication rates (CRs) in case of minimally invasive percutaneous nephrolithotomy (PNL). In the last decade, nomograms have been introduced to estimate the SFRs and CRs of PNL. However, no data are available regarding their reliability in case of utilization of miniaturized devices. Herein we present a prospective multicentric study to evaluate reliability of Guy’s stone score (GSS), the stone size, tract length, obstruction, number of involved calyces, and essence of stone (S.T.O.N.E.) nephrolithometry score and Clinical Research Office of the Endourological Society (CROES) score in patients treated with minimally invasive PNL. Methods:We evaluated SFRs and CRs of 222 adult patients treated with miniaturized PNL. Patients were considered stone-free if no residual fragments of any size at post-operative unenhanced computed tomography scan. Patients demographics, SFRs, and CRs were reported and analyzed. Performances of nomograms were evaluated with the area under the curve (AUC). Results:We included 222 patients, the AUCs of GSS, CROES score, and S.T.O.N.E. nephrolithometry score were 0.69 (95% confidence interval [CI] 0.61-0.78), 0.64 (95% CI 0.56-0.73), and 0.62 (95% CI 0.52-0.71), respectively. Regarding SFRs, at multivariate binomial logistic regression, only the GSS had significance with an odds ratio of 0.53 (95% CI 0.31-0.95, p=0.04). We did not find significant correlation with complications, with only a trend for GSS. Conclusion:This is the first study evaluating nomograms in miniaturized PNL. They still show good reliability; however, our data showed lower performances compared to standard PNL. We emphasize the need of further studies to confirm this trend. A dedicated nomogram for minimally invasive PNL may be necessary.
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Received: 10 August 2021
Available online: 20 January 2023
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| Type of nomogram | Variable evaluated | Nomogram’s subgroup | | GSS [12] | -
Grade 1: solitary stone in the mid- or lower pole; pelvis with normal anatomy | -
Grade 1 | -
Grade 2: solitary stone in upper pole; multiple stones with simple anatomy; any solitary stone with abnormal anatomy | -
Grade 2 | -
Grade 3: multiple stones with abnormal anatomy; stone in diverticulum; partial staghorn | -
Grade 3 | -
Grade 4: staghorn stone; any stone in patient with spina bifida or spinal injury | -
Grade 4 | | S.T.O.N.E. nephrolithometry score [13] | -
Stone size | -
Low complexity [5,6] | -
Tract length | -
Medium complexity [7,8] | -
Presence of obstruction | -
High complexity (>9) | -
Number of calices involved | | -
Mean stone density (essence) | | | CROES score [14] | -
Stone volume | -
Grade 1 (0-100) | -
Stone location | -
Grade 2 (101-150) | -
Prior treatments | -
Grade 3 (151-200) | -
Presence of staghorn | -
Grade 4 (201-350) | -
Number of stones | | -
Case volume per year of the center | |
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Characteristics of GSS, S.T.O.N.E. nephrolithometry score, and CROES score.
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| Variable | Total | Stone-free case | Residual stone | p-Value | | Patienta | 222 (100) | 173 (77.9) | 49 (22.1) | NA | | Ageb, year | 54 (42-63) | 53 (42-63) | 55 (47-74) | 0.47 | | Gendera | | | | 0.33 | | Female | 93 (41.9) | 69 (39.9) | 24 (49.0) | | | Male | 129 (58.1) | 104 (60.1) | 25 (51.0) | | | Sidea | | | | 0.45 | | Right | 108 (48.6) | 87 (50.3) | 21 (42.9) | | | Left | 114 (51.4) | 86 (49.7) | 28 (57.1) | | | ASA scorea | | | | 0.367 | | 1 | 98 (44.1) | 78 (45.1) | 20 (40.8) | | | 2 | 111 (50.0) | 87 (50.3) | 24 (49.0) | | | 3 | 13 (5.9) | 8 (4.6) | 5 (10.2) | | | 4 | 0 (0.0) | 0 (0.0) | 0 (0.0) | | | Stone burdenb, mm2 | 157 (61-372) | 125 (48-337) | 324 (153-588) | <0.001 | | Stone densityb, HU | 1032 (745-1231) | 1011 (727-1217) | 1093 (771-1276) | 0.18 | | Tract lengthb, mm | 85 (71-100) | 85 (72-102) | 83 (69-96) | 0.16 | | Renal pelvic obstructiona | | | | 0.22 | | None or mild | 160 (72.1) | 126 (72.8) | 34 (69.4) | | | Moderate or severe | 62 (27.9) | 47 (27.2) | 15 (30.6) | | | Calyxes involveda,c | | | | 0.16 | | 1 | 125 (56.3) | 102 (59.0) | 23 (46.9) | | | 2 | 44 (19.8) | 34 (19.7) | 10 (20.4) | | | 3 | 24 (10.8) | 15 (8.7) | 9 (18.4) | | | Multiple (staghorn) | 23 (10.4) | 16 (9.2) | 7 (14.3) | | | Stone locationa,d | | | | 0.03 | | Pelvis | 45 (20.3) | 40 (23.1) | 5 (10.2) | | | Lower calyx | 59 (26.6) | 50 (28.9) | 9 (18.4) | | | Medium calyx | 15 (6.8) | 10 (5.8) | 5 (10.2) | | | Upper calyx | 15 (6.8) | 13 (7.5) | 2 (4.1) | | | Multiple sites | 86 (38.7) | 58 (33.5) | 28 (57.1) | | | Stonea | | | | 0.004 | | Single | 87 (39.2) | 77 (44.5) | 10 (20.4) | | | Multiple | 135 (60.8) | 96 (55.5) | 39 (79.6) | | | Presence of staghorn stonea | | | | <0.001 | | Yes | 54 (24.3) | 31 (17.9) | 23 (46.9) | | | No | 168 (75.7) | 142 (82.1) | 26 (53.1) | | | Prior treatmenta | | | | 0.34 | | None | 181 (81.5) | 137 (79.2) | 44 (89.8) | | | PNL | 20 (9.0) | 16 (9.2) | 4 (8.2) | | | ESWL | 6 (2.7) | 6 (3.5) | 0 (0.0) | | | Endoscopic | 5 (2.3) | 5 (2.9) | 0 (0.0) | | | Multiple | 10 (4.5) | 9 (5.2) | 1 (2.0) | | | S.T.O.N.E. nephrolithometry scoreb | 6 (6-7) | 6 (6-7) | 7 (6-9) | <0.001 | | Guy’s stone scoreb | 2 (1-3) | 2 (1-2) | 3 (2-3) | <0.001 | | CROES nomogramb | 211 (156-269) | 218 (160-270) | 169 (131-230) | 0.004 | | CROES gradeb | 4 (3-4) | 4 (3-4) | 3 (2-4) | <0.001 |
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Demographic and pre-operative data of 222 patients who have undergone minimally invasive PNL.
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| Nephrolithometric nomogram | Patienta, n (%) | SFR | 30-day CR | | n (%) | p-Value | n (%) | p-Value | | S.T.O.N.E. nephrolithometry score | | | 0.005 | | 0.59 | | 5-6 | 125 (56.3) | 102 (81.6) | | 17 (13.6) | | | 7-8 | 66 (29.7) | 53 (80.3) | | 19 (28.8) | | | 9-13 | 28 (12.6) | 15 (53.6) | | 10 (35.7) | | | GSS | | | <0.001 | | 0.04 | | Grade 1 | 72 (32.4) | 67 (93.1) | | 9 (12.5) | | | Grade 2 | 88 (39.6) | 73 (83.0) | | 13 (14.8) | | | Grade 3 | 38 (17.1) | 21 (55.3) | | 14 (36.8) | | | Grade 4 | 21 (9.5) | 12 (57.1) | | 10 (47.6) | | | CROES system | | | 0.007 | | 0.02 | | Grade 1 (0-100) | 15 (6.8) | 8 (53.3) | | 6 (40.0) | | | Grade 2 (101-150) | 34 (15.3) | 23 (67.6) | | 16 (47.1) | | | Grade 3 (151-200) | 52 (23.4) | 38 (73.1) | | 11 (21.2) | | | Grade 4 (201-350) | 118 (53.2) | 101 (85.6) | | 13 (11.0) | |
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GSS, S.T.O.N.E. nephrolithometry score and CROES score association with SFRs and 30-day CRs.
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| Variable | Total | Stone-free case | Residual stone | p-Value | | Patienta | 222 | 173 (77.9) | 49 (22.1) | NA | | Maximum tract diameterb, Fr | 16 (14-18) | 16 (14-18) | 18 (14-18) | 0.002 | | Maximum tract diametera, Fr | | | | 0.003 | | 14 | 85 (38.3) | 72 (41.6) | 13 (26.5) | | 16 | 42 (18.9) | 37 (21.4) | 5 (10.2) | | 18 | 94 (42.3) | 64 (37.0) | 30 (61.2) | | 22 | 1 (0.5) | 0 (0.0) | 1 (2.0) | | Puncturea | | | | 0.14 | | 1 | 199 (89.6) | 157 (90.8) | 42 (85.7) | | 2 | 22 (9.9) | 16 (9.2) | 6 (12.2) | | 3 | 1 (0.5) | 0 (0.0) | 1 (2.0) | | Active suctiona | | | | 0.9 | | Yes | 196 (88.3) | 152 (87.9) | 44 (89.8) | | No | 26 (11.7) | 21 (12.1) | 5 (10.2) | | Level of upper puncturea,c | | | | 0.03 | | Below 12th | 134 (60.4) | 112 (64.7) | 22 (44.9) | | Below 11th | 75 (33.8) | 52 (30.1) | 23 (46.9) | | Below 10th | 8 (3.6) | 5 (2.9) | 3 (6.1) | | Patient’s positiona | | | | 0.16 | | Prone | 142 (64.0) | 106 (61.3) | 36 (73.5) | | Supine | 80 (36.0) | 67 (38.7) | 13 (26.5) | | Stone biochemistrya,d | | | | 0.8 | | Calcium oxalate | 150 (67.6) | 116 (67.1) | 34 (69.4) | | Calcium phosphate | 45 (20.3) | 36 (20.8) | 9 (18.4) | | Urates | 9 (4.1) | 8 (4.6) | 1 (2.0) | | Struvite | 10 (4.5) | 7 (4.0) | 3 (6.1) | | Cystine | 5 (2.3) | 3 (1.7) | 2 (4.1) | | Drug-related stone | 1 (0.5) | 1 (0.6) | 0 (0.0) | | Type of drainagea | | | | 0.02 | | Stent plus nephrostomy | 101 (45.5) | 72 (41.6) | 29 (59.2) | | Tubeless | 70 (31.5) | 54 (31.2) | 16 (32.7) | | Totally tubeless | 48 (21.6) | 44 (25.4) | 4 (8.2) | | Length of stayb, day | 3 (2-4) | 3 (1-4) | 4 (3-5) | 0.03 | | 30-day complicationa,d | | | | 0.83 | | Clavien I | 34 (15.3) | 21 (12.1) | 13 (26.5) | | Clavien II | 4 (1.8) | 4 (2.3) | 0 (0.0) | | Clavien IIIa | 3 (1.4) | 2 (1.2) | 1 (2.0) | | Clavien IIIb | 1 (0.5) | 1 (0.6) | 0 (0.0) | | Clavien IVa | 4 (1.8) | 3 (1.7) | 1 (2.0) |
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Peri-operative data of 222 patients who have undergone minimally invasive percutaneous nephrolithotomy included in the study.
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| Modified Clavien-Dindo | n (%) | | Grade I | 34 (15.3) | | Pain requiring higher analgesia | 21 (9.5) | | Fever | 9 (4.1) | | Diarrhea | 1 (0.5) | | Self-resolving dyspnea | 1 (0.5) | | Clot retention requiring prolonged catheterization | 1 (0.5) | | Urinoma | 1 (0.5) | | Grade II | 4 (1.8) | | Fever requiring antibiotic therapy change | 4 (1.8) | | Grade IIIa | 3 (1.4) | | Hydrothorax | 1 (0.5) | | Displaced stent requiring repositioning under general anesthesia | 1 (0.5) | | Sepsis without organ failure requiring supportive therapy | 1 (0.5) | | Grade IIIb | 1 (0.5) | | Angio-embolization | 1 (0.5) | | Grade IVa | 4 (1.8) | | Sepsis requiring ICU stay | 3 (1.4) | | Pulmonary embolism requiring ICU stay | 1 (0.5) |
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Complications occurred in our study group (n=222) according to Clavien-Dindo classification modified for PNL.
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| Variable | Univariate | Multivariate | | OR (95% CI) | p-Value | OR (95% CI) | p-Value | | Agea, years | 0.99 (0.97-1.01) | 0.48 | | | | Sex | | Male | 1.00 (Ref.) | | | | | Female | 0.69 (0.36-1.31) | 0.26 | | | | Side | | Left | 1.00 (Ref.) | | | | | Right | 1.35 (0.71-2.58) | 0.36 | | | | Stone burdena, mm2 | 0.99 (0.99-1.00) | <0.001 | 1.00 (0.99-1.00) | 0.04 | | Tract lengtha | 1.01 (0.99-1.02) | 0.16 | | | | Renal pelvic obstruction | | None or mild | 1.00 (Ref.) | | | | | Moderate or severe | 0.83 (0.42-1.67) | 0.83 | | | | Number of calyxes involveda | 0.75 (0.56-1.00) | 0.05 | 1.36 (0.98-2.65) | 0.21 | | Stone density (HU)a | 0.99 (0.99-1.00) | 0.18 | | | | Prior treatment | | No | 1.00 (Ref.) | | | | | PNL | 1.28 (0.41-4.63) | 0.67 | | | | ESWL | 1.31 (0.08-NA) | 0.99 | | | | Endoscopic | 1.36 (0.24-NA) | 0.99 | | | | Multiple | 1.82 (0.52-54.36) | 0.33 | | | | Presence of staghorn | | No | 1.00 (Ref.) | | | | | Yes | 0.25 (0.12-0.48) | <0.001 | 0.30 (0.11-0.72) | 0.01 | | Number of stones | | Single | 1.00 (Ref.) | | | | | Multiple | 0.32 (0.14-0.66) | 0.03 | 0.42 (0.18-0.91) | 0.03 | | Guy’s stone scorea | 0.47 (0.33-0.67) | <0.001 | 0.53 (0.31-0.95) | 0.04 | | S.T.O.N.E. nephrolithometry scorea | 0.71 (0.57-0.86) | 0.001 | 0.95 (0.66-1.34) | 0.69 | | CROES scorea | 1.71 (1.24-2.37) | 0.001 | 0.89 (0.41-1.74) | 0.68 | | AUC of the model | | | 0.72 (0.70-0.76) | |
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Univariate and multivariate binomial logistic regression analysis to assess predictors of stone-free status.
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The receiver-operating curves for GSS, S.T.O.N.E. score and CROES score. GSS, the Guy’s stone score; S.T.O.N.E., the stone size, tract length, obstruction, number of involved calyces, and essence of stone; CROES, the Clinical Research Office of the Endourological Society; AUC, the area under the curve; CI, confidence interval.
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| Parameter | GSS | S.T.O.N.E. nephrolithometry score | CROES score | | AUC (95% CI) | 0.69 (0.61-0.78) | 0.62 (0.52-0.71) | 0.64 (0.56-0.73) | | Accuracy (95% CI) | 0.75 (0.50-0.81) | 0.76 (0.61-0.81) | 0.61 (0.55-0.77) | | Best threshold | 2.5 | 7.5 | 202 | | Sensitivity (95% CI) | 0.81 (0.75-0.88) | 0.87 (0.62-0.98) | 0.59 (0.53-0.86) | | Specificity (95% CI) | 0.53 (0.41-0.68) | 0.37 (0.18-0.61) | 0.65 (0.31-0.78) | | NPV (95% CI) | 0.44 (0.29-0.55) | 0.45 (0.31-0.71) | 0.32 (0.27-0.47) | | PPV (95% CI) | 0.86 (0.83-0.93) | 0.83 (0.80-0.86) | 0.86 (0.80-0.91) |
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GSS, S.T.O.N.E. nephrolithometry score and CROES score performances.
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