Abstract
We are very pleased to see that our paper on patients’ selection for cone beam computed tomography’s role in enhancing (CBCT)-assisted percutaneous nephrolithotomy (PCNL) has caught the attention of dr. Fu-Xiang Lin and colleagues. We would like to sincerely thank them for the time invested in reflecting on our paper and take this opportunity to further delve into this topic while addressing their comments.
The goal of every stone treatment should be to achieve a complete stone-free status. 1,2 As we previously described, postoperative residual fragments <4mm, usually referred to as clinically insignificant residual fragments, have a level of significance comparable to larger residual fragments. 3 The presence of residual fragments of any size is associated with increased rates of stone-related events including re-interventions. 3 Given these findings, we fail to agree with the authors that small fragments may not always necessitate removal.
The authors list limitations we agree with and have already addressed in our paper. They reflect on how the retrospective nature of the study limits its level of evidence and on how the 4-week interval between surgery and postoperative CT-scan can allow for spontaneous passage of residual fragments. Being aware of these limitations, we concluded in our paper that the benefit of CBCT-assisted PCNL appears to increase with more complex stone surgery cases. 4 In addition, we state that to further determine the clinical significance of CBCT-assisted PCNL, a prospective randomized controlled trial was taking place. 5
The authors also note two remarkable areas for improvement as cost-analysis and patients’ perspective. Both topics are highly relevant and deserve proper attention. However, the current study describes our initial experience with intraoperative CBCT during PCNL and analyzes its role in potentially improving PCNL outcomes. Including matters of cost-analysis and patients’ perspective in the same paper would have prevented us from addressing these topics both with the appropriate significance.
We hope our paper contributed to the scientific relevance of CBCT-assisted PCNL. We again thank the authors and the Editor for eliciting the discussion on this topic, pointing to new directions to explore its clinical significance.