1. How do you measure stone heterogeneity?

A: Stone heterogeneity is measured using the stone heterogeneity index (SHI), which is the
standard deviation of stone density on NCCT. This index can represent the internal diversity of
the stone and also reflect the structural and morphological heterogeneity of the stone. This can
used to predict SWL outcomes in patients with ureteral stones. It can be measured using the
PACS (picture archiving and communication system) from NCCT. A research by Lee et.al that
was published last April 2016 claims that their study is the first report in dealing with this
clinical factor, and this paper revealed that SHI was an independent predictor of SWL outcomes
in ureteral stones. SHI is used to measure the stone’s fragility and the higher the SHI, the more
favorable the outcome after SWL will be.
2. What is the RIRS scoring system?
A: It is an innovative scoring system by Xiao et.al, which was published last 2017. This can be
used to preoperatively assess treatment success after RIRS. The components for this scoring
system is obtained by a CT urogram and measures the following parameters: renal calculus
density, renal infundibulopelvic angle (RIPA) of the inferior pole, renal infundibulopelvic length
(RIL), and stone burden. A minimum of 4 points, which indicates the simplest stone, and a
maximum of 10 points, which indicates the most complex situation, is given depending on the
parameters measured.
3. What is the Guy’s Stone Scoring (GSS) system?
A: The GSS is a 4-grade system designed by Thomas et.al and published last 2011 to predict
success rate after PNL. A KUB film, IV urography, or CT scan can be used to measure the
parameters.
Grade 1: a solitary stone in the middle and/or lower pole, or in the pelvis with a normal
anatomy and simple collecting system.
Grade 2: a solitary stone in the upper pole; multiple stones in patients with simple
anatomy; or a solitary stone in a patient with abnormal anatomy
Grade 3: multiple stones in a patient with abnormal anatomy; or in a calyceal
diveriticulum or partial staghorn calculus
Grade 4: a complete staghorn calculus; or any stone in a patient with spina bifida or a
spinal injury; calculus in a patient with clinical neurological alterations (SCI,
myelomeningocoele)
4. How do you give methylene blue during PNL?
A: The Blue Spritz Technique uses methylene blue that is administered thru the nephroscope or
ureteroscope into the collecting system, then aspirated back out thru the working channel.
Once the collecting system is irrigated again by saline solution, a stream of residual blue dye
effluxing from the ostium of the diverticulum can be observed which would aid in identifying
the diverticular neck. The concentration of methylene blue should be very dilute; 1-2 drops per
10cc saline solution.
5. How is infundibulotomy done during PNL?
A: Infundibulotomy is done in patients with symptomatic calyceal diveruticulum. This can be
achieved by a retrograde ureteroscopic approach, percutaneous approach, and laparoscopy.
Only the 1st 2 methods will be discussed.
The indications for doing a retrograde ureteroscopic approach are upper or middle pole
calyceal diverticula with or without stones 15 mm or less in size. An RGP is first done to have an
overview of the calyceal anatomy and identification of the location of the diverticulum. Flexible
ureteroscopy is then done. If a thin membrane or a pinhole opening cannot be identified, the
Blue Spritz technique is done. Once the opening is visualized, a guidewire is passed and coiled in
the diverticulum. The infundibulum can be dilated or incised. For the former, a dilating balloon
is used and dilation is done under fluoroscopic guidance until the narrowed infundibulum is no
longer seen. For the latter, if the infundibular neck is short, incision by direct vision can be done
using a 200-μ Holmium: YAG laser fiber or a 2- or 3-Fr electrosurgical probe. Optimal settings
for incision are 1 J at 10–15 Hz for the Holmium: YAG laser and 50 W pure cutting current for an
electrosurgical probe. Shallow, radial cuts are made to avoid bleeding from a single, deep
incision. A double-J stent is placed and its proximal end is positioned inside the diverticulum. If
the diverticulum is small, the coil is placed in the pelvis. Removal of the stent is done after 7
days or sooner if the proximal end is in the pelvis.
The indications for doing a percutaneous approach are peripherally-located calyceal diverticula
containing large stones measuring >15 mm cumulative size and posteriorly-located calyceal
diverticula. A 22 Fr. chiba needle is used to directly access the diverticulum under fluoroscopic
guidance. Confirmation of proper position of tip of the access needle is done by aspirating fluid
or injecting contrast to opacify the diverticulum. Then a guidewire is inserted and coiled inside.
Careful dilatation is done to avoid diverticular rupture and once the opening is identified, the
nephroscope is inserted carefully in the diverticulum with subsequent further passage of the
sheath into the diverticular cavity. A nephrostomy tube is inserted and left in place for 2-7 days
to allow the diverticular walls and the diverticular neck to heal with a larger caliber lumen.
Another method called “neoinfundibulotomy” can be done if the neck of the diverticulum
cannot be identified or intubated with a guidewire. Auge et.al published a review last 2002
which gives a detailed illustration of this technique.