Using Helical CT to Predict Stone Fragility in Shock Wave Lithotripsy (SWL)

Abstract

Great variability exists in the response of urinary stones to SWL, and this is true even for stones composed of the same mineral. Efforts have been made to predict stone fragility to shock waves using computed tomography (CT) patient images, but most work to date has focused on the use of stone CT number (i.e., Hounsfield units). This is an easy number to measure on a patient stone, but its value depends on a number of factors, including the relationship of the size of the stone to the resolution (i.e., the slicewidth) of the CT scan. Studies that have shown a relationship between stone CT number and failure in SWL are reviewed, and all are shown to suffer from error due to stone size, which was not accounted for in the use of Hounsfield unit values. Preliminary data are then presented for a study of calcium oxalate monohydrate (COM) stones, in which stone structure -rather than simple CT number values-is shown to correlate with fragility to shock waves. COM stones that were observed to have structure by micro CT (e.g., voids, apatite regions, unusual shapes) broke to completion in about half the number of shock waves required for COM stones that were observed to be homogeneous in structure by CT. This result suggests another direction for the use of CT in predicting success of SWL: the use of CT to view stone structure, rather than simply measuring stone CT number. Viewing stone structure by CT requires the use of different viewing windows than those typically used for examining patient scans, but much research to date indicates that stone structure can be observed in the clinical setting. Future clinical studies will need to be done to verify the relationship between stone structure observed by CT and stone fragility in SWL.

Fragility of Brushite Stones in Shock Wave Lithotripsy: Absence of Correlation with Computerized Tomography Visible Structure

“…This variability would not, however, completely rule out the use of Hounsfield units in low-resolution CT for identifying fragile stones, as in that mode low attenuation values could correlate with small size in brushite stones, as it does for any stone type. 17 …”

Heterogeneity in calcium nephrolithiasis: A materials perspective

“…The determination of HU without accounting for the stone size relative to the sampling volume can lead to inaccurate estimates of stone density, and many studies have questionable reporting of HUs. 3,5 Clinicians appreciate this when they place the small cursor over a stone on a clinical CT scan and move it to various locations within the stone and obtain at times markedly different values. In practice, one takes an eye-balled average to determine clinical HUs.…”

“…For decades, urologists and radiologists have used stone density, as estimated by Hounsfield units (HU) on clinical CT scans, to help predict stone type, stone hardness, and how stones will respond to lithotripsy. [2][3][4][5] This approach is based on the assumption that stone mineral density is related to hardness, but this overlooks the underlying effects of marked heterogeneity in the structure, mineral density, and elemental composition of nephroliths. When stones are fractured and examined in detail, the stone interior reveals more complex compositions, growth patterns, and architecture than those previously understood.…”

Lithotripsy

“…It has long been recognized that certain stones do not respond well to shock waves [191]. X-ray or CT scanning can be employed to assess the structure of kidney stones, and has the potential to predict their response to SWL [192][193][194]. In addition, patient factors, such as skin-to-stone distance, have also been shown to impact on SWL [195].…”