JOURNAL OF ENDOUROLOGY

Volume 23, Number 9, September 2009 Imaging

ª Mary Ann Liebert, Inc.
Pp. 1383–1385
DOI: 10.1089=end.2009.0394

Skin to Stone Distance Is an Independent Predictor

of Stone-Free Status Following Shockwave Lithotripsy

Trushar Patel, M.D., Kristin Kozakowski, M.D., Greg Hruby, M.S., and Mantu Gupta, M.D.

Abstract
Introduction: In recent years several new parameters such as Hounsefield unit density and skin to stone distance
(SSD) have been determined to correlate with successful extracorporeal shockwave lithotripsy (SWL). SSD has
been shown to independently predict successful SWL for lower pole calculi. The objective of this study was to
determine which stone characteristics on noncontrast computed tomography (NCCT), including SSD, inde-
pendently predict for SWL success regardless of stone location within the kidney.
Materials and Methods: A retrospective review of all 1282 SWL procedures between 2004 and 2007 at a single
institution revealed 83 patients meeting inclusion criteria for current study. All patients were treated using a
single electromagnetic lithotriptor (DoLi 50; Dornier Medical Systems, Marrieta, GA) with a single technician.
Stone-free (SF) status was determined by NCCT or abdominal plain film radiographs at 6 weeks post-SWL.
Logistic regression analysis was computed to assess SF rates using SSD, stone size, location, and Hounsefield
unit density as predictors.
Result: Of the 83 patients, 51 were SF and 32 had residual stones at a mean follow-up of 2.3 months. The mean
SSD in the SF group was 83.3
21.9 mm in comparison to those in the residual stone group who had a mean SSD
of 107.7
28.9 mm ( p  0.05). Multivariate logistic regression analysis revealed that SSD was the only significant
independent predictor of treatment outcome.
Conclusion: SSD is an easily measured parameter on NCCT that independently correlates with SWL efficacy in
treating stones in all locations.

Introduction Materials and Methods

T he advent of noncontrast computed tomography

(NCCT) as the imaging modality of choice to diagnose
and plan the treatment of renal calculi has focused attention
to the study of parameters easily measured on NCCT that
can reliably predict the efficacy of extracorporeal shockwave
lithotripsy (SWL). Calculi size, shape, location, and density
measured by Hounsefield unit (HU) have all been previously
studied in an attempt to better predict success with SWL.1–4
Studies reporting improved efficacy of SWL in thin patients
and young children have resulted in body mass index and
skin to stone distance (SSD) as parameters that might help
predict success.1,5,6 With respect to preoperative planning,
these factors can help select for patients who are more ame-
nable to SWL, therefore limiting unnecessary and ineffective
treatments.
Previous studies have shown that SSD predicts SWL suc-
cess for lower pole stones. We sought to determine whether it
is a predictor of successful SWL for stones independent of
stone size, location, and the HU density.
With institutional review board approval, a retrospective
review of clinical records was performed on 1282 consecutive
patients undergoing SWL at a single institution from 2004 to
2007. Inclusion criteria included the following: 6 to 15 mm,
single, radiopaque calculus located within the kidney with
preoperative NCCT within 1 month of treatment, and no
evidence of stone migration=movement. Patients with multi-
ple stones or those with indwelling stents were not included
in the analysis. A total of 83 patients were included in the
study.
All patients were treated using the same electromagnetic
lithotriptor (DoLi 50; Dornier Medical Systems, Marrieta, GA)
at a single institution by a single technician. The calculi were
fragmented under fluoroscopic guidance, and the number of
shockwaves delivered and energy level (in kilovolts) were
recorded. All patients underwent post-SWL radiographic
imaging at 6 weeks by NCCT or abdominal plain film radi-
ography. The mean follow-up was 2.3 months. Patients were
then categorized into a stone-free (SF) or residual fragment

Department of Urology, Columbia University College of Physicians and Surgeons, New York, New York.

1383
1384 PATEL ET AL.

(RF) group based on the presence of absence of visible stone Table 1. Patient Characteristics
fragments. Patients were classified with RF if they had any
evidence of stone fragments on postoperative imaging re- Characteristic Stone free Residual fragments p-Value
gardless if they were clinically significant. Patients (n) 51 32 n=a
Stone size, density (in HU), and stone location were re- Age 51.3 52.0 0.813
corded using the preoperative NCCT. The images showing Laterality
the calculus in the largest dimension were analyzed. The Left 28 21 0.334
images were viewed and measured using the Centricity En- Right 23 11
terprise Web Version 2.1 radiology image viewer available at Stone location
our institution. Adapted from Pareek and associates,5 the SSD Lower pole 32 21 0.106
was calculated by measuring the distance from the skin to the Central region 6 1
leading edge of the stone at its largest diameter at a 458 angle Pelvis 5 8
Upper pole 8 2
from the horizontal, which represents the normal coupling
Stone size (mm) 8.2 8.8 0.209
angle on the lithotripter. SSD (mm) 83.3 107.7 < 0.05
The mean SSD, HU density, size, and the location for each HU 787.7 803.2 0.410
stone were compared between the SF and RF groups. A lo- Shocks delivered 2242.7 2344.8 0.178
gistical regression model was computed to predict SF rates
using SSD, stone size, location, and HU density as variables. SSD ¼ skin to stone distance; HU ¼ Hounsefield unit; n/a ¼ non-
Data regarding stone composition were limited in this cohort applicable.
and therefore excluded from the analysis. Statistical analysis
was performed using chi-square tests, two-tailed t tests, and Discussion
logistic regression analysis (SPSS, Chicago, IL). All variables
As NCCT has become the standard modality by with which
were considered statistically significant at p  0.05.
urolithiasis is diagnosed and evaluated, there have been
multiple studies investigating the value of stone location, size,
Results shape, number, and composition with respect to SWL success.
Previously published work has shown stone location and size
A total of 83 patients reviewed met the inclusion criteria for
to be significant predictors of SWL success,7–13 whereas others
the study. The mean patient age at the time of treatment was
have correlated HU measurement on preoperative NCCT
51.6
13.3 years. At a mean follow-up of 2.3 months, the
with stone fragmentation.2–4,6,14 Saw et al2 demonstrated
overall SF rate was 61.4%, with 32 (39.6%) patients with RF.
within an in-vitro model that a greater number of shocks is
All patients had a solitary stone with a mean stone size of
required for fragmentation in stones with higher attenuation
8.5
3.2 mm. Of the 83 patients, 27 (32.5%) had stones greater
measured in HUs. They observed that the shocks needed for
than 10 mm in size. More patients (61%) had stones located
95% fragmentation were generally less than half the measured
within the left kidney. All patients underwent SWL with the
stone HU. In this current series, though the mean HU for
same Dornier lithotripter (DoLi 50) with the same SWL
patients with RFs was slightly higher than those of SF patients
technician. The mean number of shocks administered was
(738 vs. 779), it was not found to be a significant predictor of
2281.2
464.1. Fifty-three patients (64.9%) had stones located
SWL success.
within the lower pole of the kidney, with the remaining 30
Shockwaves produced by electrohydraulic lithotriptors are
patients (35.1%) having stones located within the upper pole,
generated at a focal point of an ellipsoid (level of electrode)
central region, and renal pelvis. There was no significant
that travels to a second focal point (level of stone).15 This focal
difference in the modality by which patients were followed,
distance that a shockwave must propagate through is signif-
with 12 (23.5%) patients found to be SF having NCCT on
icant in the fact that large patients may have stones at a dis-
follow-up imaging, compared with 11 (34.3%) patients found
tance from the skin that is larger than the defined focal length
with RF ( p ¼ 0.321). The remaining patients were all followed
for each individual lithrotriptor, thereby compromising the
with plain film abdominal radiographs.
efficacy of stone fragmentation by SWL. This has been clini-
Table 1 lists the comparison of patient characteristics be-
cally studied by Pareek et al,5 who have described SSD to be
tween patients found to be SF and those with RFs. No sig-
significantly associated with SWL success, with observations
nificant difference was found with respect to age, laterality,
stone location, stone size, HU, and number of shocks deliv-
ered between the two cohorts. The mean stone size was Table 2. Logistic Regression Model
8.2
2.9 mm for SF patients, compared with 8.81
3.7 mm for Predicting Stone-Free Rate
those with RFs ( p ¼ 0.209). The number of shocks delivered
95% Confidence
to SF and RF patients was 2344.8
464.9 and 2242.7
469.2, Odds ratio interval p-Value
respectively ( p ¼ 0.178). The mean SSD in the SF group was
83.3
21.9 mm in comparison to those in the RF group who Stone size 1.03 0.85, 1.25 0.721
had a mean SSD of 107.7
28.9 mm ( p  0.05). SSD 0.96 0.95, 0.98 0.001
A logistic regression model predicting SF rates was devel- HU 0.99 0.99, 1.00 0.808
oped using stone size, location, SSD, and HU attenuation Stone location
(Table 2). This analysis found SSD to be the only significant Lower pole 1 Reference
predictor of outcome following SWL independent of stone Central region 2.44 0.21, 28.4 0.474
Pelvis 0.43 0.10, 28.4 0.256
location (odds ratio 0.96; 95% confidence interval 0.95, 0.98;
Upper pole 1.61 0.15, 16.4 0.687
p < 0.005).
SSD-INDEPENDENT PREDICTOR OF SF STATUS
suggesting that a threshold of less than 10 cm should be used
as a predictor of success. Of note, all patients included in their
analysis had only lower pole stones. In this current analysis
we found SSD to be independently predictive of SWL success,
regardless of stone location, size, and HUs. However, previ-
ous work by Weld et al16 found that SSD was only a signifi-
cant predictor when renal pelvic=ureteropelvic junction (UPJ)
stones were excluded and suggested that SSD be only appli-
cable in the treatment of calyceal stones. Our analysis found
that SSD was predictive irrespective of location of the stone.
Conclusion
SSD is an easily measured parameter on NCCT which
correlates with SWL efficacy in the treatment of stones in all
locations independent of other factors. SSD is a valuable tool,
easily accessible to clinicians, which can be used to predict the
success of SWL.
Disclosure Statement
No competing financial interests exist.
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Address correspondence to:
Mantu Gupta, M.D.
Department of Urology
Columbia University College of Physicians and Surgeons
161 Fort Washington Ave., 11th Floor
New York, NY 10032
E-mail: mg392@columbia.edu
Abbreviations Used
HU ¼ Hounsefield unit
n=a ¼ non-applicable
NCCT ¼ noncontrast computed tomography
RF ¼ residual fragment
SF ¼ stone free
SSD ¼ skin to stone distance
SWL ¼ extracorporeal shockwave lithotripsy