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| Morphometry scores: Clinical implications in the management of staghorn calculi |
Jared S. Winoker,Ryan A. Chandhoke,William Atallah,Mantu Gupta( )
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| Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA |
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Abstract Due to their large size, rapid growth, and attendant morbidity, staghorn calculi are complex clinical entities that impose significant treatment-related challenges. Moreover, their relative heterogeneity—in terms of both total stone burden and anatomic distribution—limits the ability to standardize their characterization and the reporting of surgical outcomes. Several morphometry systems currently exist to define the volumetric distribution of renal stones, in general, and to predict the outcomes of percutaneous nephrolithotomy; however, they fall short in their applicability to staghorn stones. In this review, we aim to discuss the clinical utility of morphometry systems and the influence of pelvicalyceal anatomy on the management of these complex calculi.
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Received: 13 January 2019
Available online: 12 June 2019
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Corresponding Authors:
Mantu Gupta
E-mail: mantu.gupta@mountsinai.org
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Computerized comography-based three-dimensional reconstruction of a staghorn calculus with volumetric analysis.
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| Scoring system | Pertinent staghorn criteria | Limitations to applicability in staghorn patients | | GSS [19] | Grades I/II: Not applicable
Grade III: Partial staghorn (or calyceal or multiple stones in a patient with abnormal anatomy)
Grade IV: Complete staghorn (or any stone in a spinal injury or spina bifida patient) | -
No standardized definitions of “partial” or “complete” staghorn stones
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Inclusion of other clinical variables within staghorn grading categories (grades III/IV) obscures interpretation of outcomes
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Does not account for staghorn volume or stone hardness | | S.T.O.N.E.score [20] | Maximum 3 points are assigned under “n” (number of calyces) for presence of a staghorn calculus | -
No clinical definition of “staghorn” provided
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Pools all staghorn stones together; does not subdivide by size and/or shape | | CROES nomogram [21] | “Presence of staghorn” represents 1 of 6 nomogram parameters; reduces probability of being stone-free after PCNL | -
No clinical definition of “staghorn” provided
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Pools all staghorn stones together; does not subdivide by size and/or shape
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Does not account for stone hardness or variant/complex renal anatomy | | S-ReSC [22] | No specific criteria. Staghorn morphometry is indirectly accounted for by number of calyces involved by stone | -
Does not specifically characterize staghorn complexity
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Does not account for variant/complex renal anatomy, stone hardness, or stone volume |
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Comparison of stone scoring systems on the basis of staghorn classification.
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| Studiesa | Stone-free definition | Key study features | Scoring systems | Major findings | | Sfoungaristos et al. [34] | No fragments >4 mm on CT at 4-6 weeks | •
73 patients
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Complete 26 (35.6%)
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Partial 47 (64.4%)
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Single-stage PCNL
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Mean stone burden: 1 253.5 mm2 | GSS
S.T.O.N.E.
CROES | •
Overall SFR = 65.8%
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Overall complications rate = 42.5%
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S.T.O.N.E. score was the only independent predictor of SFR
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AUCs
GSS = 0.635
CROES = 0.687
S.T.O.N.E. = 0.743 | | Choi et al. [35] | No fragments >4 mm on KUB on postoperative day 1 (or CT if radiolucent stones) | •
217 patients
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Complete 106 (48.8%)
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Partial 111 (51.2%)
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Some patients underwent staged procedures
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Mean stone burden: 1 358.3 mm2 | GSS
S.T.O.N.E.
CROES | •
Overall SFR = 70.1%
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Overall complications rate = 32.7%
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Independent predictors of SFR:
NIC, pre-existent UTI, S.T.O.N.E. score
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AUCs
GSS = 0.678,
CROES = 0.627
S.T.O.N.E. = 0.746 | | Yarimoglu et al. [36] | No fragments ≥4 mm on KUB at 1 month (or CT if radiolucent stones) | •
160 patients
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Complete 76 (47.5%)
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Partial 84 (52.5%)
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Mean stone burden: 952.9 mm2 | GSS
S.T.O.N.E.
CROES
S-ReSC | •
Overall SFR = 58.8%
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Overall complications rate = 36.2%
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GSS and S-ReSC were independently predictive of SFR
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Did not calculate AUC for scoring systems |
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Comparative studies evaluating morphometry systems in staghorn patients.
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Influence of infundibular angle on nephroscope maneuverability during percutaneous nephrolithotomy. (A) Computerized tomography (CT) urogram with a theoretical supracostal upper pole access showing aninfundibular angle into an interpolar calyx of 55°, indicating low likelihood of entry by rigidnephroscopy; (B) CT urogram with a theoretical supracostal upper pole access showing an infundibular angle into a lower pole calyx of 130°, indicating high likelihood of entry by rigid nephroscopy.
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Influence of renal pelvis shape on percutaneous nephrolithotomy. (A) Singular renal pelvis draining all upper, lower, and interpolar calyces of the kidney; (B) Divided renal pelvis with one portion draining the upper pole and anotherdraining both the lower and interpolar calyces.
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