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ObjectiveTo evaluate the usefulness of measuring stone density in Hounsfield Unit by Low-dose Non Contrast Computed Tomography scan in predicting the outcome of extracorporeal shockwave lithotripsy for renal stone clearance. Materials & Methods A total of 96 patients with renal stone size d” 20 mm attending at the OPD of BSMMU were included in this study. The outcome measures were complete clearance of stone, number of ESWL sessions and number of shock waves required to become stone free. ResultThe mean size of the stone was 1.8 ± 0.3 cm. The mean stone density was 663.7 ± 69.8 HU. 25% of the patients underwent 2 sessions of ESWL, 52.1% three sessions and 22.9% more than 3 sessions. Of the patients 83.3 % were successfully cleared of their stone. The mean number of shock waves 6689.2±268.4 required for stone fragmentation of d” 750 HU and 9945±375.7 required > 750 HU stone density respectively. 85.5% of the patients with stone density d” 750 HU needed d” 3 sessions to become stone-free; whereas only 55.5% of the patients with stone density > 750 HU became stone-free in d” 3 sessions. 14.5% patients needed > 3 sessions of ESWL with stone density of e” 750 HU. 78.8% of the patients with stone density d” 750 HU exhibited complete clearance of stone as opposed to 37.5% of those with stone density > 750 HU. The chance of having complete stone clearance is 6-fold (95% CI = 1.9-19.4) higher in patients with low density stone (d” 750 HU) than that in patients with high density stone (d” 750 HU) (p = 0.002). Conclusion-In conclusion a stone density less than 750 HU should be treated with ESWL as first choice of treatment. Key wardsStone, Density, ESWL Bangladesh J. Urol. 2016; 19(2): 90-97 Correspondences: Dr. Mohammad Al Amin, Dept. of Urology, BSMMU, Dhaka Introduction: The incidence of nephrolithiasis is reported to be increasing across the world[1,2]. This increase is seen regardless of factors such as age, sex and race. However, obesity, diminished intake of fluid, increased consumption of calcium, sodium, oxalate, animal protein are considered the most important risk factors for renal stone formation[3,4]. Because of its high frequency, urolithiasis is of particular concern of health economics as well as increased of total annual cost. Therefore, scheduling the management of the urolithiasis is of utmost importance in decreasing the subsequent cost after diagnosis. Since 1980, extracorporeal shock wave lithotripsy is the first-line of treatment for renal stones of < 2 cm in diameter[5]. Analyzing different series, its success rates  Bangladesh J. Urol. 2016; 19(2): 90-97 90 varies from 60 – 99%[6]. However, the outcome of ESWL depends on many factors, like stone size, composition, fragility, the shock wave generator, the presence of obstruction or infection and the distance from the skin to stone[7.80]. After the introduction of the concept of fragility, stone composition has emerged as the main factor influencing the efficacy of ESWL[9]. Non Contrast CT (NCCT) has long been used to evaluate causes of radiolucent filling defects using measurements of substance density in Hounsfield units (HU) to distinguish calculi from tumours or blood clot[10,11]. As it provides greater density discrimination than a conventional plain skiagram of abdomen, it is now the preferred method to evaluate which patients with urinary calculi will have successful outcome following ESWL[12]. Its ability to detect density differences as low as 0.5% has been exploited to determine the composition and fragility of urinary stones[9,13]. The density of stone varies with composition and affects the fragility of a calculus, which ultimately governs the clinical outcome in ESWL. Therefore, knowing the fragility of a calculus before ESWL is of utmost importance to increase the efficacy and reduce the number of hospital visits and cost of treatment. The stone density and ability of a stone to resist ESWL is based in the part on the composition as well as microcrystal of the stone. Stone composed of calcium oxalate dihydrate, magnesium ammonium phosphate, uric acid tend to be softer and to fragment more easily with ESWL. Stone composed of calcium oxalate monohydrate, cystine stone are less susceptible to ESWL. The more crystalline dehydrate stones are easiest to break. The monohydrates stones are much harder to break. Therefore, Low density renal stone easily fragments by ESWL and High density renal stone difficult to fragments or not fragmented by ESWL[13]. Repeated ESWL use causes various complications like peri-renal, subscapular or intra-renal hemorrhage, post ESWL hematuria, recurrent urinary tract infection, stone fragments inducing obstructive uropathy and hypertension. For that reason to reduce the number and complication of the stone diseases, this study proposed to find out the outcome of treatment of renal stone clearance by extra corporeal shockwave lithotripsy after evaluating the stone density detected by non-contrast computed tomography (Low-dose). Materials and Method: This prospective observational type of study was carried out in the Department of Urology, BSMMU, Dhaka over a period of 18 months between January 2013 to June 2014 with patients of renal stone attending at the department. Total 96 adult patients were selected by standard statistical sampling formula and inclusion & exclusion criteria, with solitary renal stone (size>5 mm and d” 20 mm) except in lower calyx and residual single stone after surgery were included in this study in. All patients were included with informed written consent. Data were collected using a structured questionnaire (Research Instrument) containing all the variables of interest. The questionnaire were finalized following pre testing. Collected data were checked daily and edited. Data were processed and analysed using computer software SPSS (Statistical Package for Social Sciences). The test statistics used for analysis of data are Chi-square Test (for comparison of categorical data between groups) and Student’s t-Test (for comparison of continuous data between groups). The association between stone density and outcome ESWL were tested by means of univariate analyses. Level of significance was set at 0.05 and p < 0.05 were considered significant.

bangladesh journal of urology

Stone Density Detected by Non Contrast Computed Tomography (Low Dose) Is a Predictor of Successful Outcome of Renal Stone Clearance by Extra Corporeal Shock Wave Lithotripsy