Developing a Scoring System for Preoperative Factors that Affect Stone-free Rate in X-ray free Ultrasound-guided Percutaneous Nephrolithotomy: P.O.N.C.O. Prognostic Score

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Methods This study developed a scoring system to identify patients with a higher risk of residual stones after XFUS PCNL. A prospective cohort study of patients with XFUS PCNL in an Indonesian tertiary referral hospital was conducted between November 2019 and November 2023. Potential factors were analyzed using (chi-square test), and significant variables were further analyzed using multivariate logistic regression. Risk scores were calculated for each patient in the cohort, model discrimination was evaluated using the area under the receiver operating characteristic curve (AUC), and model calibration was performed using the Hosmer–Lemeshow test. Multiple logistic regression analyses with bootstrapped standard errors were used to compare the odds of residual stones. Results This study included a consecutive cohort of 162 patients. The P.O.N.C.O. prognostic score, consisting of five independent risk factors (p-value<0.05), namely, proportion/size, obstruction status, number of stones, contour, and obesity, was then established and calculated for each patient scoring 3.51 ± 2.2 with an average. The scoring model showed excellent discrimination with an AUCs of 0.924 (95%CI 0.87-0.97; P-value<0.001). The model also had good calibration with a non-significant Hosmer–Lemeshow chi-square of P = 0.95. Conclusion This study presents the first prognostic scoring tool for residual stones in XFUS PCNL with good discrimination, calibration, and clinical utility using five easily accessible predictive factors in daily practice " } { "@context": "http://schema.org", "@type": "BreadcrumbList", "itemListElement": [ { "@type": "ListItem", "position": "1", "item": { "@id": "https://f1000research.com/", "name": "Home" } }, { "@type": "ListItem", "position": "2", "item": { "@id": "https://f1000research.com/browse/articles", "name": "Browse" } }, { "@type": "ListItem", "position": "3", "item": { "@id": "https://f1000research.com/articles/14-617/v1", "name": "Developing a Scoring System for Preoperative Factors that Affect Stone-free..." } } ] } Home Browse Developing a Scoring System for Preoperative Factors that Affect Stone-free... ALL Metrics - Views Downloads Get PDF Get XML Cite How to cite this article Wijanarko Kusuma Putra H, Angga Risky Rahardja P, Rustandi R et al. Developing a Scoring System for Preoperative Factors that Affect Stone-free Rate in X-ray free Ultrasound-guided Percutaneous Nephrolithotomy: P.O.N.C.O. Prognostic Score [version 1; peer review: 1 approved, 1 approved with reservations] . F1000Research 2025, 14 :617 ( https://doi.org/10.12688/f1000research.163216.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Research Article Developing a Scoring System for Preoperative Factors that Affect Stone-free Rate in X-ray free Ultrasound-guided Percutaneous Nephrolithotomy: P.O.N.C.O. Prognostic Score [version 1; peer review: 1 approved, 1 approved with reservations] Harun Wijanarko Kusuma Putra 1 , Putu Angga Risky Rahardja https://orcid.org/0000-0003-4951-2827 1 , Reginald Rustandi 1 , [...] Widi Atmoko 1 , Nur Rasyid https://orcid.org/0000-0003-4473-755X 1 , Ponco Birowo https://orcid.org/0000-0003-2934-6753 1 , Gerhard Reinaldi Situmorang 1 , Sung Yong Cho 2 Harun Wijanarko Kusuma Putra 1 , Putu Angga Risky Rahardja https://orcid.org/0000-0003-4951-2827 1 , [...] Reginald Rustandi 1 , Widi Atmoko 1 , Nur Rasyid https://orcid.org/0000-0003-4473-755X 1 , Ponco Birowo https://orcid.org/0000-0003-2934-6753 1 , Gerhard Reinaldi Situmorang 1 , Sung Yong Cho 2 PUBLISHED 23 Jun 2025 Author details Author details 1 Department of Urology, Rumah Sakit Dr Cipto Mangunkusumo, Central Jakarta, Jakarta, 10430, Indonesia 2 Department of Urology, Seoul National University Hospital, Seoul, 03080, South Korea Harun Wijanarko Kusuma Putra Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Project Administration, Resources, Software, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Putu Angga Risky Rahardja Roles: Data Curation, Formal Analysis, Project Administration, Resources, Software, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Reginald Rustandi Roles: Data Curation, Formal Analysis, Project Administration, Resources, Software, Validation, Writing – Original Draft Preparation, Writing – Review & Editing Widi Atmoko Roles: Conceptualization, Data Curation, Investigation, Methodology, Supervision, Writing – Review & Editing Nur Rasyid Roles: Conceptualization, Data Curation, Methodology, Supervision, Validation, Writing – Review & Editing Ponco Birowo Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Gerhard Reinaldi Situmorang Roles: Conceptualization, Data Curation, Methodology, Project Administration, Supervision, Visualization, Writing – Review & Editing Sung Yong Cho Roles: Conceptualization, Formal Analysis, Methodology, Resources, Software, Supervision, Writing – Review & Editing OPEN PEER REVIEW DETAILS REVIEWER STATUS Abstract Purpose This study aimed to determine the preoperative factors that may contribute to the occurrence of residual stones after X-ray-free ultrasound-guided percutaneous nephrolithotomy (XFUS PCNL) and to develop a user-friendly prognostic tool for daily practice. Methods This study developed a scoring system to identify patients with a higher risk of residual stones after XFUS PCNL. A prospective cohort study of patients with XFUS PCNL in an Indonesian tertiary referral hospital was conducted between November 2019 and November 2023. Potential factors were analyzed using (chi-square test), and significant variables were further analyzed using multivariate logistic regression. Risk scores were calculated for each patient in the cohort, model discrimination was evaluated using the area under the receiver operating characteristic curve (AUC), and model calibration was performed using the Hosmer–Lemeshow test. Multiple logistic regression analyses with bootstrapped standard errors were used to compare the odds of residual stones. Results This study included a consecutive cohort of 162 patients. The P.O.N.C.O. prognostic score, consisting of five independent risk factors (p-value<0.05), namely, proportion/size, obstruction status, number of stones, contour, and obesity, was then established and calculated for each patient scoring 3.51 ± 2.2 with an average. The scoring model showed excellent discrimination with an AUCs of 0.924 (95%CI 0.87-0.97; P-value<0.001). The model also had good calibration with a non-significant Hosmer–Lemeshow chi-square of P = 0.95. Conclusion This study presents the first prognostic scoring tool for residual stones in XFUS PCNL with good discrimination, calibration, and clinical utility using five easily accessible predictive factors in daily practice READ ALL READ LESS Keywords X-ray free, Percutaneous Nephrolithotomy, Ultrasound-guided, Scoring system, Prognosis, Stone-free Rate Corresponding Author(s) Ponco Birowo ( [email protected] ) Close Corresponding author: Ponco Birowo Competing interests: No competing interests were disclosed. Grant information: This work was supported by the Hibah PUTI Q1 2024 Universitas Indonesia (NKB-287/UN2.RST/HKP.05.00/2024). The funders had no role in the study design, data collection and analysis, decision to publish, or manuscript preparation. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Copyright: © 2025 Wijanarko Kusuma Putra H et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Wijanarko Kusuma Putra H, Angga Risky Rahardja P, Rustandi R et al. Developing a Scoring System for Preoperative Factors that Affect Stone-free Rate in X-ray free Ultrasound-guided Percutaneous Nephrolithotomy: P.O.N.C.O. Prognostic Score [version 1; peer review: 1 approved, 1 approved with reservations] . F1000Research 2025, 14 :617 ( https://doi.org/10.12688/f1000research.163216.1 ) First published: 23 Jun 2025, 14 :617 ( https://doi.org/10.12688/f1000research.163216.1 ) Latest published: 23 Jun 2025, 14 :617 ( https://doi.org/10.12688/f1000research.163216.1 ) Background Current guidelines have recognized Percutaneous Nephrolithotomy (PCNL) as the gold standard of treatment for large and complex renal calculi. 1 , 2 The surgical technique has evolved thoroughly, improving the effectiveness and safety of surgery. As opposed to conventional fluoroscopy-guided PCNL, X-ray-free ultrasound-guided (XFUS) PCNL has been endorsed as a safe and feasible alternative that reduces radiation exposure to both patients and operators. 1 However, the approach is novel, and limited literature is available on elaborating and evaluating the possible factors that may affect surgical outcomes. 1 , 2 An assessment to predict the outcome and evaluate the characteristics affecting the stone-free rate is needed. Notable scoring systems such as the S.T.O.N.E. (stone size, tract length, obstruction, number of involved calices, and essence) score, Guy’s stone score, and The Clinical Research Office of the Endourological Society (CROES) nomogram have been introduced to assess and predict the stone-free rate after PCNL in the fluoroscopy-guided approach. 3 – 5 This scoring system was developed and validated specifically for X-ray-guided PCNL; thus, its compatibility with XFUS PCNL is uncertain. However, several preoperative factors have been shown to be clinically and statically significant in affecting the stone-free rate, such as stone size, obstruction, number of stones, contour, obesity, and number of involved calyces. 3 – 5 However, the weight of each factor influencing the stone-free rate in XFUS PCNL has yet to be determined. Having a standardized scoring method specifically for XFUS PCNL in SFR prediction will be beneficial for clinical practice, as patients could be counseled accurately about the possibility of a stone-free status early on. It may also help the operator advocate technical modification or consider a more conventional approach for the specific condition. 6 Therefore, this study aimed to determine the possible factors and characteristics that specifically influence the XFUS PCNL SFR and develop the data into a simple and user-friendly tool that is accessible for daily practice. Methods This study developed a scoring system to predict residual stones, specifically post XFUS PCNL. A consecutive prospective cohort study was conducted in a tertiary referral hospital in Indonesia between November 2019 and November 2023 in patients who had undergone XFUS PCNL. This study was approved by the Ethics Committee of the Faculty of Medicine, Universitas Indonesia (Institutional Review Board), under ethical approval number KET-79/UN2.F1/ETIK/PPM.00.02/2024, on January 12, 2024. All procedures were performed in accordance with institutional guidelines and adhered to the ethical principles outlined in the Declaration of Helsinki. Written informed consent was obtained from all participants prior to enrollment in the study. As part of the hospital’s standard patient registration form, participants consented to the anonymous use of their medical data for academic and research purposes. No identifiable personal information (such as full name, email address, or phone number) was collected or stored, ensuring patient confidentiality. The ethics committee approved the data collection and consent procedure. All patients with caliceal, pelvic, and upper ureteral stones with a stone burden ≥20 mm were included. Patients with uncorrected coagulopathy, congenital kidney anomalies, or intraoperative conversion to fluoroscopy were excluded from the study. Demographic data, preoperative characteristics, and operative data were collected prospectively. Preoperative evaluation of the stones was performed using non-contrast abdominal computed tomography (CT-scan. The proportion (stone burden) was calculated using the cumulative size of the largest axis of each stone in cases of multiple stones. Staghorn stones were defined as stones occupying the renal pelvis and a minimum of one infundibulum. Hydronephrosis was graded using the SFU grading of hydronephrosis using CT-Scan. Stone-free status was evaluated based on two criteria: 1) direct visualization using the same rigid nephroscope used in PCNL and USG evaluation of the kidney immediately after stone extraction; 2) postoperative kidney-ureter-bladder (KUB) photo for patients with radio-opaque stones and Kidney USG for patients with radio-lucent stones taken 24 hours post procedure; and 3) Repeat Kidney USG 7 days post procedure. Patients with significant residual fragments (>4 mm) from KUB/USG or doubtful radiolucent stones were examined using repeat non-contrast CT-scan. Multiple residual stone fragments ≤4 mm in size were measured for cumulative stone burden and deemed significant if they were >4 mm. Operative technique for XFUS PCNL All XFUS PCNL procedures were performed by two experienced endourologists (P.B. and W.A.), either in the supine (Galdakao-modified Valdivia) or prone position, depending on the surgeon’s preference. Prophylactic antibiotics were administered prior to surgery, based on preoperative urine culture results. Anesthesia was provided either through general or spinal techniques. Retrograde ureteral catheterization using an open-ended ureteral catheter (5-Fr/70 cm) was carried out to facilitate continuous saline irrigation, which promoted artificial hydronephrosis and aided ultrasound-guided renal access. Percutaneous access was established using a 20-cm puncture needle (1.3 mm/17.5 G), with successful entry confirmed by urine flow from the needle. A 0.035-inch J-shaped stiff guidewire was then advanced into the collecting system under real-time ultrasound guidance. Tract dilatation began with fascial dilators up to 12-Fr and was followed by sequential dilation using reusable Alken metal telescoping dilators (6–30 Fr). A 28–30 Fr, 17-cm Amplatz sheath was inserted without the use of fluoroscopy. Nephroscopy was carried out using a 28-Fr rigid nephroscope. Stone fragmentation was achieved with a 3.4-Fr pneumatic lithotripter, a 3.78-Fr shock-pulse lithotripter, or a combination of both devices. Fragment extraction was performed using stone forceps. Intraoperative ultrasound and direct nephroscopic inspection were used to confirm clearance of residual stones. Placement of a nephrostomy tube, double J (DJ) stent, and/or externalized ureteral catheter was performed if indicated. Statistical analysis To develop the scoring tool, potential variables that may influence the stone-free rate were included in the analyses, consisting of preoperative patient and stone characteristics collected in the outpatient setting. To simplify the scoring system, continuous variables (stone size, BMI, etc.) were categorized into groups. All variables were then assessed by bivariate analysis (Chi-square test), and variables with P-value <0.05 were further investigated using multiple logistic regression using the backward stepwise method. Factors with statistical significance (P-value <0.1) in multiple logistic regression were identified as independent risk factors and included in the final model. Risk factors were assigned weighted points proportional to their β-regression coefficient values. The risk scores were calculated for each patient in the cohort. Discrimination of the predictive model was evaluated using the area under the receiver operating characteristic (ROC) curve (AUC). Calibration was performed using the Hosmer–Lemeshow goodness of fit test. Multiple logistic regression analyses with bootstrapped standard errors were used to compare the odds of residual stones. Operative data were available from our prospective XFUS PCNL database. Data on SFR and complications were collected from contemporaneous electronic patient records and radiological imaging findings. All analyses were performed using IBM SPSS Statistics Ver 25. Results Model development A total of 162 consecutive patients were included in this prospective cohort study with a median age of 52 (1-79). The patients were mostly male (56%) and had a stone burden of < 30 mm (60%). Approximately 20 (12%) patients had residual stones. Other patient demographics and preoperative and operative characteristics are shown in Table 1 . Age, sex, number of stones, type of stones (contour), skin-to-stone distance, stone burden (proportion), obstruction status (hydronephrosis), obesity (BMI), and history of previous flank surgery were analyzed in association with residual stones using the chi-square test, and only five variables (proportion/stone burden, obstruction status, number of stones, contour, and obesity) were qualified (p-value <0.10) to be included for further analysis ( Table 1 ). Table 1. Demographic and preoperative characteristics of the patients and their association with residual stones post X-Ray Free USG guided PCNL. Variables Total (n=162) Stone Free Status P-Value Yes n (%) No n (%) Age (years) 0.26 ≤18 14 0 (0) 14 (100) 19-59 106 13 (12) 93 (87) ≥60 42 7 (17) 35 (83) Sex 0.91 Male 91 11 (12) 80 (88) Female 71 9 (13) 62 (87) Position 0.23 Prone 62 5 (8) 57 (92) Supine 100 15 (15) 85 (85) Proportion/size 40 mm 41 10 (24) 31 (76) Obstruction status (Hydronephrosis) 0.04 None 66 2 (3) 64 (97) Grade I-II 34 4 (12) 30 (88) Grade III-IV 62 14 (23) 48 (77) Number of stones <0.001 1 81 2 (2) 79 (98) 2 54 10 (19) 44 (81) ≥3 27 8 (30) 19 (70) Contour 0.01 Non-Staghorn 102 6 (6) 96 (94) Staghorn 60 14 (23) 46 (77) Skin-to-stone distance 0.31 <70 mm 111 16 (14) 95 (86) ≥70 mm 51 4 (8) 47 (92) History of previous flank surgery 47 7 (15) 40 (85) 0.54 Obesity (BMI) 0.01 30 kg/m 2 25 9 (36) 16 (64) Residual stone 20 - - Multiple logistic regression was conducted, and all five variables included remained statistically significant as independent risk factors with the backward method, as depicted in Table 2 . β-Coefficient and odds ratios with 95% confidence intervals (CI were reported, and variables were assigned weighted points to formulate the scoring system. A prognostic score named P.O.N.C.O. (Proportion/size, Obstruction status, Number of stones, Contour, Obesity) was then established and calculated for individual patients based on score points, as depicted in Table 2 . The maximum score that could be achieved was 9. Table 2. Final model (P.O.N.C.O prognostic score) for residual stone scoring system and weighted score assignment. Variables β-Coefficient OR(95% CI) Score Proportion/size ≤30 mm (reference) 0 30-40 mm 1.0 1.35(0.54-2.74) 1 >40 mm 1.2 4.27(0.80-22.91) 1 Obstruction status None (reference) 0 Grade I-II 1.5 4.74(0.51-43.77) 1 Grade III-IV 2.4 11.86(1.71-82.59) 2 Number of stones 1 (reference) 0 2 2.1 5.50(1.07-39.01) 2 ≥3 2.9 10.30(1.35-78.77) 3 Contour Non-Staghorn (reference) 0 Staghorn 1.5 4.36(0.90-21.17) 1 Obesity 30 kg/m 2 2.2 9.07(1.63-50.32) 2 Model validation Model validation was performed by measuring the discrimination, calibration, and accuracy of the models. Discrimination was measured using a receiver operating characteristic (ROC) curve. The scoring system in the development cohort was shown to have good discrimination, with an area under the curve (AUC) of 0.924 (95% CI 0.87-0.97; P-value <0.001). The model also had good calibration with a non-significant Hosmer–Lemeshow chi-square of 1.663 (95%CI 1.92-4.39; P = 0.95). Accuracy was measured by distinguishing the cutoff point with the best sensitivity and specificity (90% and 81%, respectively), and 46 patients were estimated to have a higher risk of residual stones. The odds ratio of the high-risk group with residual stone was 36.64 (95% CI 8.03-167.24) measured by logistic regression analysis based on the scoring cut-off. Model discrimination The scoring model showed excellent discrimination in random sampling with an AUC of 0.845 (95% CI 0.71-0.98; P = 0.002), as assessed by the ROC curves depicted in Figure 1 . The model also showed good calibration, with a non-significant Hosmer–Lemenhow Chi-square of 1.025 (P = 0.96). Comparison between the poor- and good-risk groups from the P.O.N.C.O. prognostic score using the cut-off was statistically significant (P=0.006), as depicted in Figure 2 . Figure 1. Area under the receiver operating characteristic (ROC) curve in validation cohort. Figure 2. Comparison between Poor risk and good risk group from P.O.N.C.O. prognostic score for occurrence of residual stone. (P-value measured by chi-square). Discussion This study presented a novel prognostic scoring tool for residual stones in XFUS PCNL. We developed a multivariable tool with good discrimination, calibration, and clinical utility in cohorts of patients, using five demographic and preoperative characteristics that are easily accessible to the surgeon. Among the five independent factors included in the study, all have been claimed in previous studies to be potential risk factors for residual stones after PCNL. The stone-free rate has been suggested to be highly dependent on stone burden in the literature. 7 , 8 Preminger et al. showed that the higher the stone burden, the less likely it is that PCNL would be able to serve as a monotherapy. 3 The findings in our study supported the claim that a cut-off of 30 mm seemed to increase the odds of residual stone post-surgery. However, in contrast to other scoring systems, we found that stones > 40 mm were weighted significantly lower than those sized 30-40. Using multivariate analysis, it seems that stone burden is closely related to other predictors (i.e., contour and number of stones); when we remove the confounding factors, it also influences the weight of the effect. Contour is a variable that was also known as a risk factor for residual stone. Mishra et al. elaborated in their staghorn morphometry study that staghorn stone is independent of stone burden in influencing residual stone, despite being very closely related. 9 Our study also supports this claim by showing similar results in the multivariate logistic regression analysis. The obstruction or hydronephrosis status also plays an important role in predicting residual stones. Our study showed that patients with hydronephrosis had higher odds of developing residual stones after surgery. 10 BMI and the number of stones have also been suggested by other studies as predictors of residual stones after surgery. 4 , 11 , 12 Similarly, they were also independent predictors in multivariate analyses. Multiple studies have suggested the comparability of X-ray-free ultrasound-guided PCNL in terms of its efficacy and safety in fluoroscopy-guided treatment of renal stones. 13 – 15 However, a notable difference between the two is the radiation exposure. Chen et al. raised concerns about radiation exposure hazards during the treatment of nephrolithiasis. 16 Although low-dose fluoroscopy is readily available, the stochastic effects that are independent of radiation dose but dependent on the amount of exposure to radiation increase the risk of malignancy. 16 This not only affects the patient but also the surgeons who are more exposed to radiation in their daily X-ray assisted surgeries. As this problem persists, X-ray-free ultrasound-guided PCNL could be a modality of choice. However, as fluoroscopy-guided PCNL has long been the standard approach, a tool that may support familiarization and increase the learning curve for X-ray-free ultrasound-guided PCNL would benefit current practice. Stratifying the difficulty of the patient by creating a low-risk residual stone group will benefit surgeons who are trying to learn X-ray-free ultrasound-guided PCNL by patient selection during surgery. 17 Additionally, this practical tool should help educate the patient regarding the outcome of the surgery and provide proper consideration in planning the surgery. Higher risk patients should be notified of a high possibility for a second surgical procedure due to the residual stone and should be considered for additional fluoroscopy support. To the best of our knowledge, this is the first prognostic score for residual stones in the treatment of renal calculi with X-ray free USG-guided PCNL. Previously known residual stone scorings were made for PCNL using a fluoroscopy approach, such as the S.T.O.N.E. (stone size, tract length, obstruction, number of involved calices, and essence) score, 3 Guy’s stone score, 4 and The Clinical Research Office of the Endourological Society (CROES) nomogram. 5 Although some of the variables included in the model are similar, a direct comparison is not straightforward. There are also other limitations to our study, such as operator bias within the study (since we only included two operators, and different operators might have different preferences (i.e., position and puncture approach]). In addition, the learning curve and surgical experience of both operators were different at the start of the study. Further investigation in future studies should be conducted on a larger scale involving more operators and preferably multicenter studies to remove bias. There should also be a subsequent study to validate the scoring system to elaborate on the reproducibility and consistency of this scoring system. Conclusion This study presents the first prognostic scoring tool for residual stones in X-ray-free ultrasound-guided PCNL with good discrimination, calibration, and clinical utility in cohorts of patients, using five predictive factors that are easily accessible for the surgeon to collect in daily practice. Data availability Data protection issue The underlying dataset is safeguarded by Indonesian intellectual-property legislation, known as HAKI (Hak Atas Kekayaan Intelektual), which prevents its unrestricted distribution beyond the investigator team. Data access is limited to protect participant confidentiality and intellectual ownership. The Faculty of Medicine, Universitas Indonesia Ethics Committee has ruled that any data release must meet national intellectual property requirements. Researchers who need access may submit a formal data request by contacting the corresponding author, Ponco Birowo ( [email protected] ). Each request will be reviewed by the Ethics Committee of the Faculty of Medicine, Universitas Indonesia, to ensure compliance with national guidelines. Reporting guidelines This article complies with the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) guideline to guarantee transparent, thorough reporting of its design, methodology and results. Detailed descriptions of participant enrolment, score construction and validation are provided so that independent researchers can reproduce the work. The completed STROBE checklist is openly posted on the Open Science Framework and can be accessed at DOI 10.17605/OSF.IO/H98SZ . 18 All checklist materials are released under the Creative Commons Attribution 4.0 International (CC-BY 4.0) licence. References 1. Assimos D, Krambeck A, Miller NL, et al. : Surgical Management of Stones: American Urological Association/Endourological Society Guideline. PART I. J. Urol. 2016 Oct; 196 (4): 1153–1160. PubMed Abstract | Publisher Full Text 2. Türk C, Petřík A, Sarica K, et al. : EAU Guidelines on Interventional Treatment for Urolithiasis. Eur. Urol. 2016 Mar; 69 (3): 475–482. Publisher Full Text 3. Akhavein A, Henriksen C, Syed J, et al. : Prediction of single procedure success rate using S.T.O.N.E. nephrolithometry surgical classification system with strict criteria for surgical outcome. Urology. 2015 Jan; 85 (1): 69–73. PubMed Abstract | Publisher Full Text 4. Iqbal MW, Jamshed F, Akram A, et al. : Guy’s stone scoring in predicting postoperative residual stones. J. Aziz Fatm. Med. Dent. Coll. 2022 Feb 15; 4 (1): 37–41. Publisher Full Text 5. de la Rosette J , Assimos D, Desai M, et al. : The Clinical Research Office of the Endourological Society Percutaneous Nephrolithotomy Global Study: indications, complications, and outcomes in 5803 patients. J. Endourol. 2011 Jan; 25 (1): 11–17. PubMed Abstract | Publisher Full Text 6. Nguyen DT, Graviss EA: Development and validation of a prognostic score to predict tuberculosis mortality. J. Infect. 2018 Oct; 77 (4): 283–290. PubMed Abstract | Publisher Full Text 7. Patel U, Walkden RM, Ghani KR, et al. : Three-dimensional CT pyelography for planning of percutaneous nephrostolithotomy: accuracy of stone measurement, stone depiction and pelvicalyceal reconstruction. Eur. Radiol. 2009 May; 19 (5): 1280–1288. PubMed Abstract | Publisher Full Text 8. Preminger GM: High burden and complex renal calculi: aggressive percutaneous nephrolithotomy versus multi-modal approaches. Arch. Ital. Urol. Androl. 2010 Mar; 82 (1): 37–40. PubMed Abstract 9. Mishra S, Sabnis RB, Desai M: Staghorn morphometry: a new tool for clinical classification and prediction model for percutaneous nephrolithotomy monotherapy. J. Endourol. 2012 Jan; 26 (1): 6–14. PubMed Abstract | Publisher Full Text 10. Aboutaleb H, El-Shazly M: Ultrasound versus fluoroscopy guided percutaneous nephrolithotomy for treatment of calculi in hydronephrotic kidneys. Ann. Surg. Int. 2016; 2 (3): 015. 11. Kumar U, Tomar V, Yadav SS, et al. : STONE score versus Guy’s Stone Score - prospective comparative evaluation for success rate and complications in percutaneous nephrolithotomy. Urol. Ann. 2018 Jan-Mar; 10 (1): 76–81. PubMed Abstract | Publisher Full Text | Free Full Text 12. Zuhri S, Soebadi DM: Impact of stone size, location and stone composition on the efficacy of extracorporeal shock wave lithotripsy for residual stone after percutaneous nephrolithotomy. Folia Med. Indones. 2020; 56 (2): 127–130. Publisher Full Text 13. Yang YH, Wen YC, Chen KC, et al. : Ultrasound-guided versus fluoroscopy-guided percutaneous nephrolithotomy: a systematic review and meta-analysis. World. J. Urol. 2019 May; 37 (5): 777–788. PubMed Abstract | Publisher Full Text 14. Ng FC, Yam WL, Lim TYB, et al. : Ultrasound-guided percutaneous nephrolithotomy: Advantages and limitations. Investig. Clin. Urol. 2017 Sep; 58 (5): 346–352. PubMed Abstract | Publisher Full Text | Free Full Text 15. Falahatkar S, Neiroomand H, Enshaei A, et al. : Totally ultrasound versus fluoroscopically guided complete supine percutaneous nephrolithotripsy: a first report. J. Endourol. 2010 Sep; 24 (9): 1421–1426. PubMed Abstract | Publisher Full Text 16. Chen TT, Wang C, Ferrandino MN, et al. : Radiation Exposure during the Evaluation and Management of Nephrolithiasis. J. Urol. 2015 Oct; 194 (4): 878–885. Publisher Full Text 17. Allen D, O’Brien T, Tiptaft R, et al. : Defining the learning curve for percutaneous nephrolithotomy. J. Endourol. 2005 Apr; 19 (3): 279–282. PubMed Abstract | Publisher Full Text 18. Kusuma Putra HW, Rahardja PAR, Rustandi R, et al. : Developing a scoring system for preoperative factors that affect stone-free rate in X-ray free ultrasound-guided percutaneous nephrolithotomy: P.O.N.C.O. prognostic score. OSF. 2024. Publisher Full Text Comments on this article Comments (0) Version 1 VERSION 1 PUBLISHED 23 Jun 2025 ADD YOUR COMMENT Comment Author details Author details 1 Department of Urology, Rumah Sakit Dr Cipto Mangunkusumo, Central Jakarta, Jakarta, 10430, Indonesia 2 Department of Urology, Seoul National University Hospital, Seoul, 03080, South Korea Harun Wijanarko Kusuma Putra Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Project Administration, Resources, Software, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Putu Angga Risky Rahardja Roles: Data Curation, Formal Analysis, Project Administration, Resources, Software, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Reginald Rustandi Roles: Data Curation, Formal Analysis, Project Administration, Resources, Software, Validation, Writing – Original Draft Preparation, Writing – Review & Editing Widi Atmoko Roles: Conceptualization, Data Curation, Investigation, Methodology, Supervision, Writing – Review & Editing Nur Rasyid Roles: Conceptualization, Data Curation, Methodology, Supervision, Validation, Writing – Review & Editing Ponco Birowo Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Gerhard Reinaldi Situmorang Roles: Conceptualization, Data Curation, Methodology, Project Administration, Supervision, Visualization, Writing – Review & Editing Sung Yong Cho Roles: Conceptualization, Formal Analysis, Methodology, Resources, Software, Supervision, Writing – Review & Editing Competing interests No competing interests were disclosed. Grant information This work was supported by the Hibah PUTI Q1 2024 Universitas Indonesia (NKB-287/UN2.RST/HKP.05.00/2024). The funders had no role in the study design, data collection and analysis, decision to publish, or manuscript preparation. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Article Versions (1) version 1 Published: 23 Jun 2025, 14:617 https://doi.org/10.12688/f1000research.163216.1 Copyright © 2025 Wijanarko Kusuma Putra H et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Download Export To Sciwheel Bibtex EndNote ProCite Ref. Manager (RIS) Sente metrics Views Downloads F1000Research - - PubMed Central info_outline Data from PMC are received and updated monthly. - - Citations open_in_new 0 open_in_new 0 open_in_new SEE MORE DETAILS CITE how to cite this article Wijanarko Kusuma Putra H, Angga Risky Rahardja P, Rustandi R et al. Developing a Scoring System for Preoperative Factors that Affect Stone-free Rate in X-ray free Ultrasound-guided Percutaneous Nephrolithotomy: P.O.N.C.O. Prognostic Score [version 1; peer review: 1 approved, 1 approved with reservations] . F1000Research 2025, 14 :617 ( https://doi.org/10.12688/f1000research.163216.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS track receive updates on this article Track an article to receive email alerts on any updates to this article. TRACK THIS ARTICLE Share Open Peer Review Current Reviewer Status: ? Key to Reviewer Statuses VIEW HIDE Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Version 1 VERSION 1 PUBLISHED 23 Jun 2025 Views 0 Cite How to cite this report: Özbilen MH. Reviewer Report For: Developing a Scoring System for Preoperative Factors that Affect Stone-free Rate in X-ray free Ultrasound-guided Percutaneous Nephrolithotomy: P.O.N.C.O. Prognostic Score [version 1; peer review: 1 approved, 1 approved with reservations] . F1000Research 2025, 14 :617 ( https://doi.org/10.5256/f1000research.179526.r414228 ) The direct URL for this report is: https://f1000research.com/articles/14-617/v1#referee-response-414228 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 14 Oct 2025 Mert Hamza Özbilen , University Adana City Training and Research Hospital, Adana, Adana, Turkey Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.179526.r414228 The most current version of the guideline suggestion mentioned in References 2 should be cited as references. The explicit form of ‘’SFR’’, ‘’SFU’’ should be used first before their abbreviations. It is written ... Continue reading READ ALL The most current version of the guideline suggestion mentioned in References 2 should be cited as references. The explicit form of ‘’SFR’’, ‘’SFU’’ should be used first before their abbreviations. It is written that stone-free status is evaluated with 2 criteria, but there are 3 items. When was non-contrast CT performed in patients suspected of having residual stones? Is this time sufficient to assess stone-free status? In Table 1, the presence of residual stones should be grouped as "yes" and stone-free status as "no." There is confusion. What were the values ​​determined for age 60, stone size 3-4 cm, skin-to-stone distance 70 mm, and BMI 25-30? These should be detailed in the material and method section. The study included 14 patients under the age of 18. Among them was a one-year-old child. What are your thoughts on performing surgery with a 28-Fr nephroscope on these patients? Each of the parameters should be discussed in detail in light of the study's findings in the discussion section. The study's discussion section is quite weak. Is the work clearly and accurately presented and does it cite the current literature? Partly Is the study design appropriate and is the work technically sound? Partly Are sufficient details of methods and analysis provided to allow replication by others? Partly If applicable, is the statistical analysis and its interpretation appropriate? I cannot comment. A qualified statistician is required. Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Yes Competing Interests: No competing interests were disclosed. Reviewer Expertise: Urology I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Özbilen MH. Reviewer Report For: Developing a Scoring System for Preoperative Factors that Affect Stone-free Rate in X-ray free Ultrasound-guided Percutaneous Nephrolithotomy: P.O.N.C.O. Prognostic Score [version 1; peer review: 1 approved, 1 approved with reservations] . F1000Research 2025, 14 :617 ( https://doi.org/10.5256/f1000research.179526.r414228 ) The direct URL for this report is: https://f1000research.com/articles/14-617/v1#referee-response-414228 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Views 0 Cite How to cite this report: Chew BH. Reviewer Report For: Developing a Scoring System for Preoperative Factors that Affect Stone-free Rate in X-ray free Ultrasound-guided Percutaneous Nephrolithotomy: P.O.N.C.O. Prognostic Score [version 1; peer review: 1 approved, 1 approved with reservations] . F1000Research 2025, 14 :617 ( https://doi.org/10.5256/f1000research.179526.r394416 ) The direct URL for this report is: https://f1000research.com/articles/14-617/v1#referee-response-394416 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 23 Aug 2025 Ben H. Chew , University of British Columbia, Vancouver, Canada Approved VIEWS 0 https://doi.org/10.5256/f1000research.179526.r394416 This article introduces the P.O.N.C.O. prognostic score, developed to predict residual stones following X-ray free ultrasound-guided percutaneous nephrolithotomy (XFUS PCNL). The study is a prospective cohort of 162 patients undergoing XFUS PCNL at a tertiary hospital in Indonesia, with ... Continue reading READ ALL This article introduces the P.O.N.C.O. prognostic score, developed to predict residual stones following X-ray free ultrasound-guided percutaneous nephrolithotomy (XFUS PCNL). The study is a prospective cohort of 162 patients undergoing XFUS PCNL at a tertiary hospital in Indonesia, with data collected between November 2019 and November 2023. Multivariate logistic regression identified five independent preoperative risk factors—proportion/size, hydronephrosis, number of stones, contour (staghorn), and obesity—which were weighted to create the score. The scoring model demonstrated strong discrimination (AUC 0.924) and calibration (non-significant Hosmer–Lemeshow test). The authors conclude that the score is practical for clinical use, allowing early identification of patients at higher risk for residual stones. I am not an expert in creating nomograms but it appears to be an appropriate way to create a prognostic tool for this surgical outcome. In my opinion, the manuscript would be improved by the following. 1. could you comment on why you assigned similar point values to 30–40 mm and >40 mm stone categories, when past literature suggest larger stones may confer higher risk and worse outcomes. 2. it may be helpful to the reader to provide a detailed, stepwise guide or worked example on how a clinician should calculate and apply the P.O.N.C.O. score for an individual patient in practice. 3. as per standard reporting, it would be helpful to specify the total number of patients undergoing XFUS PCNL during the study period, how many were excluded (and why) 4. does this need external validation? what are next steps to make it widely generalizeable? 5. would sub-analysis by stone type be of significance or helpful? Overall, i think this is very helpful data to the published literature. Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Yes If applicable, is the statistical analysis and its interpretation appropriate? Yes Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Yes Competing Interests: No competing interests were disclosed. Reviewer Expertise: kidney stone disease I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Chew BH. Reviewer Report For: Developing a Scoring System for Preoperative Factors that Affect Stone-free Rate in X-ray free Ultrasound-guided Percutaneous Nephrolithotomy: P.O.N.C.O. Prognostic Score [version 1; peer review: 1 approved, 1 approved with reservations] . F1000Research 2025, 14 :617 ( https://doi.org/10.5256/f1000research.179526.r394416 ) The direct URL for this report is: https://f1000research.com/articles/14-617/v1#referee-response-394416 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Comments on this article Comments (0) Version 1 VERSION 1 PUBLISHED 23 Jun 2025 ADD YOUR COMMENT Comment keyboard_arrow_left keyboard_arrow_right Open Peer Review Reviewer Status info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Reviewer Reports Invited Reviewers 1 2 Version 1 23 Jun 25 read read Ben H. Chew , University of British Columbia, Vancouver, Canada Mert Hamza Özbilen , University Adana City Training and Research Hospital, Adana, Turkey Comments on this article All Comments (0) Add a comment Sign up for content alerts Sign Up You are now signed up to receive this alert Browse by related subjects keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Özbilen M. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 14 Oct 2025 | for Version 1 Mert Hamza Özbilen , University Adana City Training and Research Hospital, Adana, Adana, Turkey 0 Views copyright © 2025 Özbilen M. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions The most current version of the guideline suggestion mentioned in References 2 should be cited as references. The explicit form of ‘’SFR’’, ‘’SFU’’ should be used first before their abbreviations. It is written that stone-free status is evaluated with 2 criteria, but there are 3 items. When was non-contrast CT performed in patients suspected of having residual stones? Is this time sufficient to assess stone-free status? In Table 1, the presence of residual stones should be grouped as "yes" and stone-free status as "no." There is confusion. What were the values ​​determined for age 60, stone size 3-4 cm, skin-to-stone distance 70 mm, and BMI 25-30? These should be detailed in the material and method section. The study included 14 patients under the age of 18. Among them was a one-year-old child. What are your thoughts on performing surgery with a 28-Fr nephroscope on these patients? Each of the parameters should be discussed in detail in light of the study's findings in the discussion section. The study's discussion section is quite weak. Is the work clearly and accurately presented and does it cite the current literature? Partly Is the study design appropriate and is the work technically sound? Partly Are sufficient details of methods and analysis provided to allow replication by others? Partly If applicable, is the statistical analysis and its interpretation appropriate? I cannot comment. A qualified statistician is required. Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Yes Competing Interests No competing interests were disclosed. Reviewer Expertise Urology I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (0) Özbilen MH. Peer Review Report For: Developing a Scoring System for Preoperative Factors that Affect Stone-free Rate in X-ray free Ultrasound-guided Percutaneous Nephrolithotomy: P.O.N.C.O. Prognostic Score [version 1; peer review: 1 approved, 1 approved with reservations] . F1000Research 2025, 14 :617 ( https://doi.org/10.5256/f1000research.179526.r414228) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/14-617/v1#referee-response-414228 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Chew B. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 23 Aug 2025 | for Version 1 Ben H. Chew , University of British Columbia, Vancouver, Canada 0 Views copyright © 2025 Chew B. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions This article introduces the P.O.N.C.O. prognostic score, developed to predict residual stones following X-ray free ultrasound-guided percutaneous nephrolithotomy (XFUS PCNL). The study is a prospective cohort of 162 patients undergoing XFUS PCNL at a tertiary hospital in Indonesia, with data collected between November 2019 and November 2023. Multivariate logistic regression identified five independent preoperative risk factors—proportion/size, hydronephrosis, number of stones, contour (staghorn), and obesity—which were weighted to create the score. The scoring model demonstrated strong discrimination (AUC 0.924) and calibration (non-significant Hosmer–Lemeshow test). The authors conclude that the score is practical for clinical use, allowing early identification of patients at higher risk for residual stones. I am not an expert in creating nomograms but it appears to be an appropriate way to create a prognostic tool for this surgical outcome. In my opinion, the manuscript would be improved by the following. 1. could you comment on why you assigned similar point values to 30–40 mm and >40 mm stone categories, when past literature suggest larger stones may confer higher risk and worse outcomes. 2. it may be helpful to the reader to provide a detailed, stepwise guide or worked example on how a clinician should calculate and apply the P.O.N.C.O. score for an individual patient in practice. 3. as per standard reporting, it would be helpful to specify the total number of patients undergoing XFUS PCNL during the study period, how many were excluded (and why) 4. does this need external validation? what are next steps to make it widely generalizeable? 5. would sub-analysis by stone type be of significance or helpful? Overall, i think this is very helpful data to the published literature. Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Yes If applicable, is the statistical analysis and its interpretation appropriate? Yes Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Yes Competing Interests No competing interests were disclosed. Reviewer Expertise kidney stone disease I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. reply Respond to this report Responses (0) Chew BH. Peer Review Report For: Developing a Scoring System for Preoperative Factors that Affect Stone-free Rate in X-ray free Ultrasound-guided Percutaneous Nephrolithotomy: P.O.N.C.O. Prognostic Score [version 1; peer review: 1 approved, 1 approved with reservations] . F1000Research 2025, 14 :617 ( https://doi.org/10.5256/f1000research.179526.r394416) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/14-617/v1#referee-response-394416 Alongside their report, reviewers assign a status to the article: Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. 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