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Urology
Key Words
Kidney Ureter Colic Stone Obstruction
Introduction
Pathophysiology
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Number of
patients
Sensitivity
%
Specificity
%
85
1,333
73
84
46
99
101
85
151
45
58
59
90
69
71
101
61
85
91
66
85
90
100
100
101
180
94
95
90
67
117
191
32
88
70
44
98
93
82
61
85
106
112
85
90
87
52
100
94
94
94
417
106
100
112
105
95
87
98
94
98
98
94
100
97
98
Clinical diagnosis
Mutagi et al. [9]
Eskelinen et al. [10]
KUB
Haddad et al. [8]
Mutagi et al. [9]
Levine et al. [11]
Conventional US
Haddad et al. [8]
Hill et al. [15]
Sinclair et al. [16]
KUB + Conventional US
Haddad et al. [8]
Palma et al. [17]
DUS
Shokeir et al. [23]
de Toledo et al. [24]
Tublin et al. [21]
IVP
Hill et al. [15]
Sinclair et al. [16]
Miller et al. [30]
Yilmaz et al. [32]
NCCT
Dalrymple et al. [2]
Miller et al. [30]
Fielding et al. [31]
Yilmaz et al. [32]
Vieweg et al. [33]
Clinical Examination
Typical renal colic is felt as a colicky and constant ache
in the costovertebral angle just lateral to the sacrospinalis
and just below the last rib. This pain often spreads along the
subcostal area toward the umbilicus or lower abdominal
quadrant along the course of the ureter. In men, it may also
be felt in the bladder, scrotum, or testicle. In women, it may
radiate into the vulva. The physician may be able to judge
the position of a ureteric stone by the site of referral. If the
stone is lodged in the upper ureter, the pain radiates to the
testicle, since the nerve supply of this organ is similar to that
of the kidney and upper ureter (T1112). With stones in the
mid ureter on the right side, the pain is referred to McBurneys point and may therefore simulate appendicitis; on the
left side, it may resemble diverticulitis or other diseases of
the descending or sigmoid colon. As the stone approaches
the bladder, inflammation and edema of the ureteral orifice
ensue, and symptoms of vesical irritability may occur.
Pain caused by a urinary concrement usually results in
microscopic hematuria and may be associated with gastro-
Diagnosis
242
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hormone [5]. Reys and Klahr [7] recently provided evidence that endothelin also has a role in preglomerular vasoconstiction.
Within 1 h of acute UUO, there is an increase in UP followed 45 h later by a decrease. This decrease is considered
as a defence mechanism against parenchymal atrophy and
may explain, in part, the clinical observation of spontaneous
improvement in the severity of renal colic a few hours after
its onset in most of the patients. The decline in UP is due to
a decrease in glomerular filtration rate (GFR) and an increase in the venous and lymphatic reabsorption of urine
(pyelovenous and pyelolymphatic backflow). The reduction
in GFR is due to a decrease in the net hydraulic pressure
gradient across the glomerular capillaries due to an increase
in the tubular pressure caused by the increase in UP.
KUB and US
The simplest imaging examination for patients with renal colic remains the KUB. The sensitivity of KUB in detecting ureteral calculi ranges from 45 to 59%, thus providing limited value in the diagnosis of ureteral stones [8, 9,
11]. Superimposed bowel and bone obscure some calculi,
and vascular calcifications, especially pelvic phleboliths,
may be confused with stones. Moreover, faintly opaque and
nonopaque calculi could not be identified by KUB. Evidence of an abdominal calculus on KUB is not a sure sign
that the calcification is in the urinary tract. Therefore, the
diagnosis of acute stone disease could not be confidently
made on the basis of KUB alone.
US has many attributes which make it ideal as a method
for initial evaluation and further follow-up of patients with
renal colic. It is noninvasive, quick, portable, repeatable and
relatively inexpensive. Moreover, the avoidance of ionizing
radiation and contrast material makes it an attractive screening modality in pregnancy and renal impairment. Conventional gray-scale US helps in the diagnosis of acute renal
colic directly through visualization of calculi and/or indirectly through demonstration of pyelocaliectasis. Moreover,
the recent introduction of DUS enhanced the value of US in
the diagnosis of acute renal obstruction through study of renal resistive index (RI) and assessment of ureteric jets.
Gray-scale US allows direct demonstration of urinary
stones located at the PUJ, vesicoureteric junction (VUJ) and
in the renal pelvis or calyces. Transrectal or transvaginal US
may aid in the identification of distal ureteric stones [12,
13]. However, stones located between PUJ and VUJ are extremely difficult to visualize with US. Pyelocaliectasis or
separation by c5 mm of the renal sinus echoes is considered as an indirect sign of renal obstruction. Nevertheless,
dilatation of the collecting system depends on the size and
location of the stone, the duration and the degree of obstruction. It takes many hours for frank pyelocaliectasis to
develop after sudden, even complete obstruction. Consequently, it is not surprising that US misses 2030% of acute
obstructions caused by a ureteric stone [1416]. Moreover,
a false-positive diagnosis of obstruction could occur in patients with pyelonephritis, vesicoureteric reflux, residual
dilatation after relief of obstruction or overdistension of
the bladder. The combination of KUB and gray-scale US
through demonstration of calculi and/or pyelocaliectasis is
very helpful [8, 17]. In a study by Haddad et al. [8], this
combination yielded a sensitivity of 94% and specificity of
90% in the diagnosis of acute renal colic.
DUS
DUS has recently been introduced in the diagnosis of obstructive uropathy through measurement of renal RI [18].
The RI is defined as: (peak systolic velocity lowest diastolic velocity)/peak systolic velocity. It has been observed
that obstructive hydronephrosis produces changes in
Doppler waveforms whereby an increase in downstream resistance results in a more marked reduction in diastolic
blood flow than in the systolic component. This difference
causes an increase in RI. In chronic obstruction, an RI of
0.70 is accepted by most investigators as the discriminatory
value to differentiate obstructive from unobstructive dilatation. This threshold value achieved a good diagnostic accuracy in diagnosing the presence or absence of chronic obstruction in the adult [18] as well as in children [19, 20].
Nevertheless, several studies confirmed that an RI of a0.70
is of limited value in the diagnosis of acute obstruction because the time is too short to allow RI to reach this threshold value [21, 22]. More recent studies used the difference
between RI of obstructed and nonobstructed kidneys (RI)
and obtained satisfactory results [2326]. With a RI of
a 0.04 we have recently obtained a sensitivity of 95%, a
specificity of 100% and an overall accuracy of 99% in the
diagnosis of acute unilateral ureteric obstruction [26].
The advantage is that DUS involves no contrast medium
or radiation, but there are some disadvantages. The test is
operator-dependent, needs special experience and provides
very limited information about the level of obstruction. In
the presence of obstruction of a solitary kidney or bilateral
obstruction, albeit uncommon clinically, RI is of no value.
Moreover, there is no universal agreement on the discriminatory thresholds for obstruction for either RI or RI. Differences in the results could be attributed to differences in
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NCCT
Smith et al. [29] were the first to advocate the use of
NCCT in the diagnosis of acute renal colic. Several recent
studies confirmed that NCCT is an accurate radiographic
modality for the evaluation of renal colic giving a sensitivity of up to 98% and a specificity of up to 100% [2, 3033].
When compared with IVP, advantages include safety because no contrast medium is required, therefore, NCCT is
attractive particularly in patients with contrast allergies and
those with pre-existing renal failure. In addition, NCCT
provides visualization of small radiolucent stones that may
not be seen on IVP while decreasing the time for completion of the diagnostic study. The procedure takes only 5 min
and in some health systems it has been estimated to cost no
more than IVP. When stone disease is absent, NCCT accurately identifies other urinary and nonurinary abnormalities
to direct further imaging and management.
Regardless of composition, all stones are visible on
NCCT. In addition, several secondary NCCT signs of
ureteric obstruction are often present and they are useful
when a stone is not readily identified. These secondary
signs include ureteric and renal dilatation, stranding of the
perinephric fat, the soft tissue ring sign and perinephric
fluid.
There are a number of potential pitfalls in the interpretation of NCCT. Phleboliths within the pelvis can often be
seen along the normal anatomical course of the ureter and
they can mimic ureteric stones. The ring sign denotes visualization of a rim of soft tissue surrounding a stone. This
sign likely represents the edematous wall of the ureter and it
is helpful in distinguishing stones from phleboliths. In addition, a gonadal vein can sometimes be confused with a dilated ureter and can be distinguished by following the superior course of the structure in question.
The main disadvantage of NCCT in comparison to IVP
is the absence of evaluation of renal function. Moreover, the
radiation exposure of NCCT is generally higher limiting its
use in pregnancy. In addition, CT services are not univer-
244
MRI
MRI can provide anatomical information about a possibly obstructed kidney without nephrotoxic contrast media
or ionizing radiation. Nevertheless, unlike CT, MRI cannot
provide direct image of the stone. In a recent study, MR
urography was prospectively compared with IVP in the assessment of ureteric obstruction [34]. Among 41 obstructed
kidneys, MR urography correctly diagnosed obstruction in
100% and showed the site of obstruction in 80% [34]. MRI
has the potential to become a significant imaging modality
in obstructive uropathy, but there are too few studies to provide solid conclusions and more work is needed in this area.
Radionuclide Renal Study
Radionuclide renal study has been proposed by some authors as an initial investigation in the evaluation of patients
with suspected renal colic. It has the advantages of providing functional and urodynamic assessment of each kidney
separately and giving prognostic information in cases of impaired function resulting from prolonged obstruction. How-
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the degree and duration of obstruction and the use of nonsteroidal anti-inflammatory drugs (NSAIDs). To achieve
the highest diagnostic accuracy, we advise performing DUS
before giving NSAIDs [27].
Another use of DUS in the evaluation of possible obstruction is the assessment of ureteric jets. When a ureter is
patent, a jet of urine can be detected within the urinary bladder near the vesicoureteric junction. With complete obstuction, no ureteric jet is detectable; partial obstruction of one
ureter can result in a continuous low-level jet pattern that is
asymmetric to the other ureter [28].
Fig. 1. An algorithm for the diagnosis of renal colic. KUB = Plain abdominal X-ray; US
= ultrasonography; DUS = Doppler ultrasonography; positive DUS = RI difference of
a0.04; negative DUS = RI difference of
d0.04; NCCT = noncontrast computerized
tomography.
The diagnostic approach of acute flank pain is controversial and can vary from center to center, from city to city
or from country to country depending on what is considered
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246
Shokeir
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Treatment
Special Situations
Stones in Children
Urolithiasis in children are unusual in the United States
and Europe but are not infrequently seen in developing
countries. The incidence in the United States ranges between 1 in 1,000 and 1 in 7,600 hospital admissions annually [51]. Pediatric urolithiasis occurs in 3 epidemological
patterns: (i) endemic stones seen in the Middle and Far
East; (ii) infection-related stones occurring most commonly
in Great Britain, and (iii) metabolic stones encountered
most frequently in the United States and Scandinavian
countries.
ESWL is effective in children who can pass big stone
fragments more easily than adults. With continuing improvements to and advances in endourologic technology,
the endoscopic management of children with upper urinary
tract stone disease has become an increasingly viable alternative to open surgery [46]. Ureteroscopes as small as 4
french are available and are well suited for use in children.
The choice between ESWL and ureteroscopy must be tailored according to the clinical situation.
Renal Colic in Pregnancy
Urolithiasis is an infrequent but significant problem during pregnancy with a reported incidence of 1 in 1,500 pregnancies [51]. Ureteric stones in pregnancy cause flank pain
in 84100% of cases. However, abdominal pain during
pregnancy is sufficiently common to lead to errors in the diagnosis. An incorrect diagnosis of appendicitis, diverticulitis or placental abruption was made in 28% of patients with
a confirmed stone [52]. However, the almost universal finding of hematuria in either the gross or microscopic forms
helps in the diagnosis.
The use of fluoroscopy for the diagnosis of stones during
pregnancy remains controversial. Several investigators
have highlighted the problems related to the exposure of
pregnant patients to X-rays and the incidence of tumors in
children who were irradiated during fetal life. It has been reported that the first trimester is the only significant risk period for limited ionizing radiation exposure during pregnancy, after that time birth defects and spontaneous abortion
are unlikely. Therefore, some authors still recommend limited or three-shot IVP in the diagnosis of renal colic in pregnant women. US is the safest method of diagnosis; pyelocaliectasis is the main finding suggestive of renal
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obstruction. Nevertheless, the frequent finding of pregnancy-induced upper tract dilatation makes gray-scale US a
nonspecific detector of obstruction. DUS strengthens the
role of US in this regard. We have recently shown that RI
value of a0.04 is highly sensitive and specific in the diagnosis of acute unilateral renal colic in pregnant women [26].
Treatment of renal colic in pregnancy represents a significant problem because renal colic may precipitate premature labor, and invasive therapeutic procedures may be
potentially harmful to the fetus. Therefore, conservative
temporizing treatments are commonly recommended when
urolithiasis is suspected during pregnancy. The safest analgesics to use are opiate-based drugs, NSAIDs should be
avoided [46]. In 5080% of cases, the stone is passed spontaneously. However, in some patients, the onset of fever, infection and persistent pain may require treatment of the patient before spontaneous elimination of the stone. ESWL is
contraindicated and the available options are ureteroscopy,
an indwelling ureteric stent or PCN. Both ureteric stent and
PCN carry the risk of urinary tract infection, demand regular changing to avoid encrustation, and cause discomfort to
the patient, particularly if placed early in pregnancy. Therefore, ureteroscopy seems the most suitable procedure and
has been shown to be safe and effective [53]. Nevertheless,
ureteroscopy must be carried out by an experienced urologist because if complications arise the fetus may be at risk.
Indinivan Stones
Indinivan sulfate is used for the treatment of HIV patients. It is poorly soluble and 20% is excreted unchanged in
the urine causing indinivan stones in up to 36% of the patients [46]. Pure indinivan stones cannot be visualized by
KUB or CT. A high degree of clinical suspicion is necessary
for diagnosis. Microscopic hematuria is always present and
characteristic rectangular crystals may be seen by urine microscopy with cross-polarized filters. Ultrasonography, IVP
and CT are much less often diagnostic than stones of other
constituents and ureteroscopy may be both diagnosic and
therapeutic [46]. Treatment is conservative in most of the
cases. Indinivan may be stopped temporarily and adequate
hydration must be insured [46].
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248
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