title: Stone attenuation and skin-to-stone distance on computed tomography predicts for stone fragmentation by shock wave lithotripsy.
abstract: OBJECTIVE
  To determine whether stone attenuation and the skin-to-stone distance (SSD) can predict for stone fragmentation by SWL independently. Identifying the factors predictive of shock wave lithotripsy (SWL) outcome would help streamline the care of patients with stones.
  
  
  METHODS
  A retrospective review was performed of 111 patients undergoing initial SWL for a solitary, 5-20 mm, renal calculus. Stone size, location, attenuation value, and SSD were determined on pretreatment noncontrast computed tomography. The outcome was categorized as stone free, complete fragmentation <5 mm, and incomplete fragmentation >or=5 mm or unchanged at 2 weeks on kidney/ureter/bladder radiography.
  
  
  RESULTS
  After SWL, 44 (40%) were stone free, 27 (24%) had complete fragmentation, and 40 (36%) of 111 patients had incomplete fragmentation. The stone attenuation of the successfully treated patients (stone free and complete fragmentation groups) was 837 +/- 277 Hounsfield units (HU) vs 1092 +/- 254 HU for those with treatment failure (incomplete fragmentation; P < .01). The mean SSD also differed: 9.6 cm +/- 2.0 vs 11.1 cm +/- 2.5 for the successful treatment group vs the treatment failure group, respectively (P = .01). On multivariate analysis, the factors that independently predicted the outcome were stone attenuation, SSD, and stone composition. When patients were stratified into 4 risk groups (stone <900 HU and SSD <9.0 cm, stone <900 HU and SSD >or=9.0 cm, stone >or=900 HU and SSD <9.0 cm, and stone >or=900 HU and SSD >or=9.0 cm), the SWL success rate was 91%, 79%, 58%, and 41%, respectively (odds ratio 7.1, 95% confidence interval 1.6-32 for <900 HU and SSD <9.0 cm group vs other 3 risk groups; P = .01).
  
  
  CONCLUSIONS
  The results of our study have shown that a stone attenuation of <900 HU, SSD of <9 cm, and stone composition predict for SWL success, independent of stone size, location, and body mass index. These factors will be considered important in the prospective design of a SWL treatment nomogram at our center.
authors.affiliation: Division of Urology, Department of Surgery, and the Department of Radiology, St. Michael's Hospital and University of Toronto, Toronto, Ontario, Canada.
authors.forename: Alexandra E
authors.initials: AE
authors.lastname: Perks
authors.forename: Trevor D
authors.initials: TD
authors.lastname: Schuler
authors.forename: Jason
authors.initials: J
authors.lastname: Lee
authors.forename: Daniela
authors.initials: D
authors.lastname: Ghiculete
authors.forename: Dae-Gyun
authors.initials: DG
authors.lastname: Chung
authors.forename: R John
authors.initials: RJ
authors.lastname: D'A Honey
authors.forename: Kenneth T
authors.initials: KT
authors.lastname: Pace
mesh_terms: D005260:Female; D006801:Humans; D008096:Lithotripsy; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D012189:Retrospective Studies; D012867:Skin; D014057:Tomography, X-Ray Computed; D014545:Urinary Calculi / Q000000981:diagnostic imaging* / Q000628:therapy*