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Urolithiasis: the role of imaging

DHRUV PATEL AND UDAY PATEL

The incidence of urinary

calculi is increasing, as is the
diagnostic ability of medical
imaging. The authors review
imaging modalities for the
diagnosis and treatment of
urinary stone disease, and
explain how imaging has a
key role in management of
patients with nephrolithiasis.

rinary tract calculus exerts a significant

U impact upon healthcare, with an
incidence of eight in 1000 in the general
population.1 There is a 10 per cent lifetime
risk of developing a renal stone, and urinary
stone disease has been estimated to be
responsible for 1.82 per 10 000 hospital
admissions.2 The extent of the problem is
increasing, with 720 per 1000 hospital
admissions in the USA attributed to urinary
stone disease.3 The recurrence rate is
reported at 15 per cent at one year, 35 per
cent at five years, 50 per cent at ten years
and 75 per cent at 20 years.3
Increasing use of medical imaging is
undoubtedly linked to a rise in the reported
incidence of urinary calculi. More patients are
undergoing abdominal ultrasound, computed
tomography (CT) and magnetic resonance
imaging scans than ever before, and often the
diagnosis is an incidental finding.
TYPES OF STONE
Calcium-containing stones are the most
common type encountered in UK practice.
The stones may be pure calcium oxalate or
contain a mixture of calcium oxalate and
calcium phosphate. Matrix or struvite stones
Figure 1. Intravenous urography film 15 minutes post-contrast
injection, showing an obstructing calculus at the right vesicoureteric
junction (arrow) with normal left-sided appearances
are the next most common presenting stone
type. These are composed of magnesium
ammonium phosphate. These stones may
branch and cause large staghorn calculi. Pure
matrix stones are non-opaque as a result of
lack of calcium.
Patients with hyperuricaemia may develop
uric acid stones, and cysteine stones can be
found in patients with homocystinuria.
Increasingly, calculi are being diagnosed in
patients treated for HIV with protease Dhruv Patel, MB ChB, BSc, MRCS, FRCR,
inhibitors such as indinavir. These calculi Specialist Registrar in Radiology; Uday
pose a particular challenge for clinicians Patel, MB ChB, MRCP, FRCR, Consultant
because of their relative lucency on Radiologist, St Georges Hospital, London
radiographs and CT.

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CLINICAL PRESENTATION
The classic acute presentation of urinary
tract stones is with typical severe renal
colic loin to groin pain, accompanied by
microscopic haematuria in most cases.
Nausea and vomiting may also be presenting
features. More insidious presentation may
occur with mild aching in the flanks, and
micro- or macroscopic haematuria. Patients
may also present with the symptoms and
signs of renal failure caused by bilateral
obstructing calculi or in those patients with
an obstructed single kidney. Perhaps the
most dramatic and emergent presentation
is in patients who have developed acute
sepsis as a result of an obstructing calculus.
Prompt drainage and appropriate antibiotic
therapy is of vital importance in such cases.

IMAGING MODALITIES
Imaging enables not only the diagnosis
of urinary tract calculi, but also the
characterisation of stones, planning and
stratification of further treatment and
prediction of response to such treatment.
The choice of imaging modality and
subsequent management is influenced
by patient parameters such as patient
preference, clinical status and symptom load,
as well as stone volume and location.
Plain radiograph/intravenous urography
The kidneys/ureters/bladder (KUB) radiograph
can visualise calcium-containing calculi
because of their radio-opaque nature.
However, it may be rendered relatively
insensitive by overlying bowel gas, adjacent
bony structures and patient body habitus,
with sensitivity in the order of 50 per cent.4,5
The KUB radiograph is considered most
useful in the follow-up of previously
detected radio-opaque calculi and in
planning and assessing the effects of
therapeutic interventions such as
extracorporeal shockwave lithotripsy
(ESWL) or percutaneous nephrolithotomy
(PCNL). It also serves to screen those
patients whose symptom load is relatively
light, or in whom the presentation has
been non-acute.
Figure 2. Ultrasound of bladder showing a 1.6cm calculus at the left vesicoureteric junction
casting an acoustic shadow
Intravenous urography (IVU) has largely been
superseded by CT-KUB in recent years, as the
latter has a higher sensitivity. However, it is
of use in situations where CT is not readily
available and is most useful in excluding
obstruction in the acute setting. Tomography
can be used to further increase the sensitivity
and definition obtained from an IVU series.
Such definition can be useful in planning
intervention such as PCNL, where intrarenal
anatomy and precise calyceal localisation is
often better on IVU compared to CT-KUB
(see Figure 1).
Ultrasound
Ultrasound plays an important role in
diagnosing urinary tract calculi. It is a safe and
readily available imaging technique, but its
sensitivity is modest and hugely dependent on
the operator and the body habitus of the
patient. Sensitivities range from 40 to 65 per
cent for detection of stones and from 74 to 85
per cent for detection of acute obstruction.6,7
Detection relies upon visualisation of
hyperechoic calculi and any possible
shadowing that they may cause (Figure 2).
The visualisation of such foci can be
challenging against background renal tissue;
in practice, only larger stones (>5mm) tend
to cast acoustic shadows. Ureteric calculi are
poorly demonstrated in most cases unless
situated within the proximal ureter or close
to the vesicoureteric junction.
The advantage of ultrasound relates to its
relative portability and lack of non-ionising
radiation. It can be used in the community
or in a urological outpatient clinic and it is
suitable for investigating children or pregnant
women. It is also of use in the surveillance of
those patients who are managed conservatively,
although difficulties in reproducibility arise.
Its ease and portability also allow for its
utilisation in an intraoperative setting, such
as during a PCNL procedure.
Computed tomography
CT-KUB is now the accepted gold standard
imaging modality for urinary tract calculi as
a result of its high diagnostic accuracy. Most
stones will be visible on unenhanced CT with
a sensitivity of 95 per cent in the diagnosis
of acute ureteric colic.8,9 A landmark study
in 1995 established the superiority of CT
over IVU in the diagnosis of calculi, with a
sensitivity of 91.6 per cent for CT compared
with 41.6 per cent for IVU.10

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CT-KUB allows for rapid diagnosis of the a b

presence of calculi and has been adopted in
many acute centres as a first-line imaging
strategy for renal stones because of its
unparalleled ability in diagnosis of ureteric
calculi.11 It is a rapid investigation to perform,
does not involve intravenous contrast
administration and can aid in the diagnosis
of pathologies other than urinary tract
calculi that may share similar presenting
characteristics, such as appendicitis.12

The presence of hydronephrosis and other

signs of urinary tract obstruction can
also be elucidated from CT-KUB, and
accurate measurements of stone size
can be undertaken (Figure 3). In addition,
measurements of the internal composition of
the stone can be obtained in terms of stone
density, measured in Hounsfield units (HU).
This measure of density assists in treatment
stratification. For example, stones are less
likely to respond to ESWL if they are >1000
HU in density.13
CT-KUB allows for three-dimensional
reconstructions of data and is especially
useful in planning PCNL procedures. In our
institution, unenhanced CT is combined with
a post-contrast CT pyelogram to facilitate
accurate representation of the calyceal
anatomy and planning of percutaneous
tracks (Figure 4).14
Figure 3. (a) Computed tomography-kidneys/ureters/bladder (CT-KUB) axial image showing a
calculus at the right vesicoureteric junction. (b) CT-KUB coronal reformat of the same patient
showing right-sided hydronephrosis (red arrows) as a consequence of the calculus
scanning protocol utilised. However it is determining the secondary effects of calculi,
estimated at approximately 29mSv, namely obstruction and subsequent relative
compared to 0.5mSv for an abdominal loss of function between the two kidneys.
radiograph.15 To put these figures into It is especially useful in the determination
context, the dose from a standard of ongoing obstruction in those patients
anteroposterior chest X-ray is 0.1mSv.16 with long-standing ureteric/pelvicalyceal
Dose-saving techniques are in place on most dilation. However, it is not helpful as an
new CT scanners and these can reduce the acute imaging modality because of its
effective dose. It can be reduced to as low as limited availability and its insensitivity at
1mSv, but at some cost to image quality.17 diagnosing calculi.
Nuclear medicine Magnetic resonance imaging
Mercaptuacetyltriglycine (MAG-III) scanning Magnetic resonance urography can be
involves the use of the radioactive tracer utilised in those patients in whom other
technetium-99m MAG3 and can be of use in investigations are contraindicated, such as

Further CT advances include the use of dual a b

source imaging, a relatively new technique
that utilises two X-ray tubes and two
detector units, which can be used to extract
virtual non-contrast images from post-
contrast enhanced data and allows for
determination of the chemical content of
stones. In particular, this method is useful for
distinguishing uric acid stones from calcium
stones, as the former can be treated non-
invasively with urine alkalinisation (Figure 5).

The disadvantage of CT stems from the

use of ionising radiation. The effective
dose from a multidetector CT-KUB is
dependent upon many factors such as
patient habitus, the type of CT scanner and
Figure 4. (a) Coronal maximum intensity reformat of CT pyelography showing a large
left-sided staghorn calculus (white arrow) with an adjacent smaller satellite calculus in the
lower pole calyx (red arrow). (b) Volume rendered reformat of the same patient showing the
position of the staghorn calculus and its relationship to the calyceal anatomy

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Figure 5. Volume rendered reformat of dual-energy
CT-KUB showing a right-sided staghorn calcium-
containing calculus (blue) and a left-sided uric acid
calculus (pink)
children or pregnant patients. It allows
for depiction of ureteric/pelvicalyceal
dilation as a result of obstruction, but
accurate identification of a calculus may be
challenging as many artefacts mimicking
stones may be encountered.18
Retrograde ureterorenography
Fluoroscopic techniques can be utilised to
demonstrate and assist in the removal of
stones at cytoscopy and ureteroscopy
through endoscopic cannulation of
the ureter and subsequent retrograde
injection of contrast material. This would
KEY POINTS
Urinary tract calculus is a common
urological condition that places a
significant burden on both community
and hospital resources
Accurate imaging is of vital importance
in allowing diagnosis of stones and in
planning treatment
Computed tomography-kidneys/ureters/
bladder (CT-KUB) is the accepted gold
standard for detection of urinary tract
calculi, with sensitivities of >95 per cent
KUB radiography and ultrasound still
play an important role in diagnosing
calculi in those patients with a low
pretest probability and in the surveillance
of patients with known stones
www.trendsinurology.com
be undertaken only very rarely without the
assistance of preceding imaging and it
usually requires general anaesthesia.
However, retrograde ureterorenography may
be utilised if other investigations have
proven inconclusive. Such a technique also
allows for placement of a ureteric stent
and/or extraction of stone particles.
CONCLUSION
Accurate imaging is of the utmost
importance in the diagnosis of urinary
calculi. Each modality has its differing
strengths and weaknesses, and the choice
of imaging technique should always relate
back to the strength of clinical suspicion.
In those non-emergent patients with vague
symptoms, investigation with plain film KUB
and ultrasound may be sufficient. However, it
is now well established that CT-KUB is the
gold standard investigation for the diagnosis
of urinary tract stones and its use in the
acute setting is the optimal means of
investigating urinary calculi.
Declaration of interests: none declared.
REFERENCES
1. Galvin DJ, Pearle MS. The contemporary
management of renal and ureteric calculi.
BJU Int 2006;98:12838.
2. Watts RWE. Urinary stone disease. In:
Weatherall DJ, Warrell DA, eds. Oxford
textbook of medicine. New York: Oxford
University Press, 1989.
3. Moe OW. Kidney stones: pathophysiology
and medical management. Lancet 2006;
367:33344.
4. Mutgi A, Williams JW, Nettleman M.
Renal colic. Utility of the plain abdominal
roentgenogram. Arch Intern Med 1991;
151:158992.
5. Haddad MC, Sharif HS, Shahed MS, et al.
Renal colic: diagnosis and outcome. Radiology
1992;184:838.
6. Deyoe LA, Cronan JJ, Breslaw BH, Ridlen MS.
New techniques of ultrasound and color
Doppler in the prospective evaluation of
acute renal obstruction. Do they replace
the intravenous urogram? Abdom Imaging
1995;20:5863.
7. Sinclair D, Wilson S, Toi A, Greenspan L.
The evaluation of suspected renal colic:
ultrasound scan versus excretory urography.
Ann Emerg Med 1989;18:5569.
8. Dalrymple NC, Verga M, Anderson KR, et al.
The value of unenhanced helical computerized
tomography in the management of acute flank
pain. J Urol 1998;159:73540.
9. Smith RC, Coll DM. Helical computed
tomography in the diagnosis of ureteric colic.
BJU Int 2000;86(Suppl 1):3341.
10. Smith RC, Rosenfield AT, Choe KA, et al. Acute
flank pain: comparison of non-contrast
enhanced CT and intravenous urography.
Radiology 1995;194:78994.
11. Catalano O, Nunziata A, Altei F, Siani A.
Suspected ureteral colic: primary helical CT
versus selective helical CT after unenhanced
radiography and sonography. AJR 2002;
178:37987.
12. Koroglu M, Wendel JD, Ernst RD, Oto A.
Alternative diagnoses to stone disease on
unenhanced CT to investigate acute flank
pain. Emerg Radiol 2004;10:32733.
13. Joseph P, Mandal AK, Singh SK, et al.
Computerized tomography attenuation
value of renal calculus: can it predict
successful fragmentation of the calculus
by extracorporeal shock wave lithotripsy? A
preliminary study. J Urol 2002;167:196871.
14. Patel U, Walkden RM, Ghani KR, Anson K.
Three-dimensional CT pyelography for
planning of percutaneous nephrostolithotomy:
accuracy of stone measurement, stone
depiction and pelvicalyceal reconstruction.
Eur Radiol 2009;19:12808.
15. Patel U, Walkden M. Principles of radiological
imaging. In: Mundy AR, Fitzpatrick J, Neal DE,
George NJR, eds. The scientific basis of
urology, 3rd edn. London: Informa, 2010.
16. Shu XO, Jin F, Linet MS, et al. Diagnostic
X-ray and ultrasound exposure and risk
of childhood cancer. Br J Cancer 1994;
70:5316.
17. Jin DH, Lamberton GR, Broome DR, et al.
Effect of reduced radiation CT protocols on
the detection of renal calculi. Radiology
2010;255:1007.
18. Rothpearl A, Frager D, Subramanian A, et al.
MR urography: technique and application.
Radiology 1995;194:12530.
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