Urolithiasis and Nephrolithiasis

Hematuria
Renal Masses
Scheduling
Further Information
References

The advantages of multidetector CT urography over

conventional plain film excretory urography (also
known as IV pyelography and IV urography) and
ultrasound for the evaluation of the urinary tract are
numerous. Dedicated CT protocols have been
developed for these new high speed machines for
different clinical indications including "stone
protocol" for the evaluation of urinary tract calculi,
CT urography for the evaluation of patients with
hematuria and "renal mass protocol" for the Three dimensional coronal reconstruction of CT urography image,
characterization of known renal masses. showing contrast-enhanced renal collecting system, ureters, and
bladder. Note duplicated system on left side.
Multidetector CT scanning is fast, taking around 15
seconds for image acquisition from the kidneys to
urography are associated with a substantial radiation
the bladder during a single breath-hold. The images
dose. Ultrasound is good for imaging the kidney
have good spatial resolution, little mis-registration
parenchyma and for detecting hydronephrosis, does
due to respiratory movement, and the acquisition of
not require the administration of iodinated contrast,
multiple thin slices allows excellent two- and three-
and avoids radiation exposure. However, ultrasound
dimensional reconstructions of the abdominal
is not good for detecting urinary tract calculi, and
anatomy, making it possible to detect pathologies
does not adequately image the renal collecting
outside the urinary tract as well those within.
system or ureters. For these reasons, multidetector
Iodinated contrast agents are not usually required for
CT imaging has become the gold standard for the
the detection of renal stones, thus avoiding the risk
diagnosis of urinary tract calculi, the investigation of
of adverse reactions to these agents, but are
hematuria, and the characterization of renal masses
routinely used in CT urography and the renal mass
and has largely replaced both plain film excretory
protocol.
urography and ultrasound examinations for these
purposes.
In comparison to CT, plain film excretory urography
offers excellent delineation of calyceal and papillary
anatomy, the ureters and bladder, but it is inferior to
multi detector CT for imaging of the kidney
parenchyma. Both CT and plain film excretory

Urinary Tract Imaging Protocols

Stone Protocol Non-contrast CT imaging from kidney to bladder.
For detection of renal, ureteral, or bladder stones (May be necessary infrequently to use iodinated
contrast agent to distinguish between ureteral

CT Urography (Hematuria Protocol)
For evaluation for common causes of persistent
hematuria, i.e. stones, urothelial tumors, renal
tumors
Renal Mass Protocol
For characterization of renal masses detected by
other imaging studies, e.g. ultrasound, MRI
Axial image from "stone protocol" CT showing left ureteral stone.
Urolithiasis and Nephrolithiasis
Almost all ureteral and renal stones, including those
containing uric acid, can be detected by non-contrast
CT imaging. The accuracy of the technique in
diagnosing urolithiasis in patients presenting with
acute flank pain has been determined to be as high
as 97%, with a sensitivity of 95% and specificity of
98%. This compares to sensitivities in the range of
45-58% for non-contrast plain film radiography and
64-87% for plain film excretory urography.
However, it is occasionally difficult to distinguish
between non-obstructing distal ureteral calculi and
pelvic phleboliths on non-contrast CT images. In
stones and phleboliths)
Follow-up imaging with non-contrast plain film
radiography
Non-contrast followed by contrast CT imaging
from kidney to bladder
Non-contrast followed by contrast CT imaging of
kidneys only
Hematuria
The main causes of hematuria are urinary tract calculi,
renal tumors, urothelial tumors, and infection. CT
urography is the best single diagnostic examination for
diagnosing all of these pathologies, with the exception
of infection, which is effectively diagnosed in most cases
by microbiological analysis of the urine.
CT urography requires the use of contrast agent to
opacify the collecting system, the ureters, and the
bladder. In addition to optimal opacification, distension
appears to be an important requirement for thorough
evaluation of the renal collecting system and ureter. For
this reason, intravenous saline is given at the same time
as the contrast material to aid in the detection of subtle
filling defects and the discrimination between urothelial
neoplasms and other filling defects. Image
reconstruction techniques are used to create images of
the entire length of the urinary system from the kidneys
to the bladder. Multi planar 3-D reconstruction can
provide the anatomic detail required to correlate the
finding with retrograde ureterography or to perform an
endoscopic evaluation. CT has been shown to detect
parenchymal masses in the kidney with a sensitivity of
94%, compared to 67% for plain film excretory
urography and 79% for ultrasound.
Another potential advantage of CT is that reconstructed
images can show tumors in a filled bladder opacified
with contrast agent ("virtual cytoscopy"). However,
conventional cytoscopy remains the gold standard for
the detection of tumors of the bladder, as it will detect
early color-changing mucosal lesions that do not deform
these cases, it may be necessary to use intravenous the contour of the bladder wall. In addition, cytoscopy
contrast agent, so that the relationship of the has the added capability of biopsy of suspicious lesions.
calculus to the opacified ureter can be determined.
Another situation in which intravenous contrast can
be helpful is in the detection of stones in HIV
positive patients on protease inhibitors such as
Indinovir. These calculi are typically non-radio
opaque and may go undetected on stone protocol CT
scans. The use of 3-D reconstruction techniques of
contrast-enhanced pyelographic phase images can be
helpful in all of these situations.

The disadvantage of "stone protocol" CT is that the

radiation dose is high (about 500 mrem) compared
to that needed for plain film excretory urography
(about 150-350 mrem) and non-contrast plain film
radiography (about 13 mrem). This exposure is a
significant concern, especially as urinary stones
frequently affect young people. For this reason, it is
better to avoid CT for follow up studies wherever
possible and to use non-contrast plain film
radiography instead. The initial CT scan and
reconstruction images can be used to aid subsequent
detection of stones on follow-up plain film
radiographic images since the detection rate of
stones increases from 45% identified on non-
contrast radiographic films alone to 78% on films
viewed together with 3-D reconstructions of the
initial diagnostic CT images.
Pregnant patients should be evaluated initially with
ultrasound imaging, to avoid exposure to any
unnecessary radiation, and MR urography is an
alternative imaging technique for evaluating the
renal system in pregnant women, children, and
patients with contraindications to contrast agents.
Axial CT urography image showing a filling defect in the right
renal pelvis consistent with a large urothelial tumor.
Renal masses
Many renal lesions are incidentally detected on a
variety of imaging tests, but cannot usually be
characterized at the time of detection. Currently, at
this institution "renal-mass protocol" CT is the gold
standard for the characterization of renal masses.
This protocol acquires thin section images of the
kidneys before and after intravenous contrast
administration to evaluate the important
characteristic of solid lesions, the unequivocal
demonstration of lesion enhancement post contrast.
Lesions that demonstrate unequivocal enhancement
require histologic diagnosis either by image-guided
biopsy or by surgical resection.

Scheduling Further Information

CT imaging of the urinary system has essentially For further questions on CT urography, contact
replaced conventional plain film excretory Dr. Michael Maher, MGH Department of Radiology,
urography at MGH. CT scanning for stones, 617-726-8396
hematuria, or for evaluating renal masses are
performed at Mass General West Imaging in
Waltham, Mass General Imaging in Chelsea, or the
main MGH campus. The appropriate CT protocol
will be selected by the radiologist based on the
clinical history of the patient. CT imaging studies
can be ordered by calling 4-XRAY (617-724-9729).
Results are made available to physicians online
within 24-48 hours.
Urinary Calculi
(Nephrolithiasis; Stones; Urolithiasis)
by Glenn M. Preminger, MD

NOTE: This is the Professional Version. CONSUMERS: Click here for the Consumer Version

Urinary calculi are solid particles in the urinary system. They may cause pain, nausea, vomiting,
hematuria, and, possibly, chills and fever due to secondary infection. Diagnosis is based on
urinalysis and radiologic imaging, usually noncontrast helical CT. Treatment is with analgesics,
antibiotics for infection, medical expulsive therapy, and, sometimes, shock wave lithotripsy or
endoscopic procedures.

About 1/1000 adults in the US is hospitalized annually because of urinary calculi, which are also
found in about 1% of all autopsies. Up to 12% of men and 5% of women will develop a urinary
calculus by age 70. Calculi vary from microscopic crystalline foci to calculi several centimeters
in diameter. A large calculus, called a staghorn calculus, can fill an entire renal calyceal system.

Etiology
About 85% of calculi in the US are composed of Ca, mainly Ca oxalate (see Table: Composition
of Urinary Calculi); 10% are uric acid; 2% are cystine; most of the remainder are Mg ammonium
phosphate (struvite).

Ca Oxalate Crystals

Cystine Crystals
 Mg Ammonium Phosphate
(Struvite) Crystals

Sulfa Crystals

Composition of Urinary Calculi

Percentage of All
Composition Common Causes
Calculi
Hypercalciuria

Hyperparathyroidism
Calcium oxalate 70
Hypocitruria

Renal tubular acidosis

 Percentage of All
Composition Common Causes
Calculi
Hypercalciuria

Hyperparathyroidism
Calcium phosphate 15
Hypocitruria

Renal tubular acidosis

Cystine 2 Cystinuria
Magnesium ammonium phosphate UTI caused by urea-splitting
3
(struvite) bacteria
Urine pH < 5.5
Uric acid 10
Occasionally hyperuricosuria

General risk factors include disorders that increase urinary salt concentration, either by increased
excretion of Ca or uric acid salts, or by decreased excretion of urinary citrate.

For Ca calculi, risk factors vary by population. The main risk factor in the US is hypercalciuria,
a hereditary condition present in 50% of men and 75% of women with Ca calculi; thus, patients
with a family history of calculi are at increased risk of recurrent calculi. These patients have
normal serum Ca, but urinary Ca is elevated > 250 mg/day (> 6.2 mmol/day) in men and > 200
mg/day (> 5.0 mmol/day) in women.

Hypocitruria (urinary citrate < 350 mg/day [1820 mol/day]), present in about 40 to 50% of Ca
calculi-formers, promotes Ca calculi formation because citrate normally binds urinary Ca and
inhibits the crystallization of Ca salts.

About 5 to 8% of calculi are caused by renal tubular acidosis. About 1 to 2% of patients with Ca
calculi have primary hyperparathyroidism. Rare causes of hypercalciuria are sarcoidosis, vitamin
D intoxication, hyperthyroidism, multiple myeloma, metastatic cancer, and hyperoxaluria.

Hyperoxaluria (urinary oxalate > 40 mg/day [> 440 mol/day]) can be primary or caused by
excess ingestion of oxalate-containing foods (eg, rhubarb, spinach, cocoa, nuts, pepper, tea) or by
excess oxalate absorption due to various enteric diseases (eg, bacterial overgrowth syndromes,
chronic pancreatic or biliary disease) or ileojejunal (eg, bariatric) surgery.

Other risk factors include taking high doses of vitamin C (ie, > 2000 mg/day) , a Ca-restricted
diet (possibly because dietary Ca binds dietary oxalate), and mild hyperuricosuria. Mild
hyperuricosuria, defined as urinary uric acid > 800 mg/day (> 5 mmol/day) in men or > 750
mg/day (> 4 mmol/day) in women, is almost always caused by excess intake of purine (in
proteins, usually from meat, fish, and poultry); it may cause Ca oxalate calculus formation
(hyperuricosuric Ca oxalate nephrolithiasis).
Uric acid calculi most commonly develop as a result of increased urine acidity (urine pH < 5.5),
or rarely with severe hyperuricosuria (urinary uric acid > 1500 mg/day [> 9 mmol/day]), which
crystallizes undissociated uric acid. Uric acid crystals may comprise the entire calculus or, more
commonly, provide a nidus on which Ca or mixed Ca and uric acid calculi can form.

Cystine calculi occur only in the presence of cystinuria (see Cystinuria).

Mg ammonium phosphate calculi (struvite, infection calculi) indicate the presence of a UTI
caused by urea-splitting bacteria (eg, Proteus sp, Klebsiella sp). The calculi must be treated as
infected foreign bodies and removed in their entirety. Unlike other types of calculi, Mg
ammonium phosphate calculi occur 3 times more frequently in women.

Rare causes of urinary calculi include indinavir, melamine, triamterene, and xanthine.

Analgesia
Facilitate calculus passage, eg, with -receptor blockers such as tamsulosin (described as
medical expulsive therapy)

For persistent or infection-causing calculi, complete removal using primarily endoscopic

techniques

Analgesia

Renal colic may be relieved with opioids, such as morphine and, for a rapid onset, fentanyl.
Ketorolac 30 mg IV is rapidly effective and nonsedating. Vomiting usually resolves as pain
decreases, but persistent vomiting can be treated with an antiemetic (eg, ondansetron 10 mg IV).

Medical expulsive therapy

Although increasing fluids (either oral or IV) has traditionally been recommended, increased
fluid administration has not been proven to speed the passage of calculi. Patients with calculi < 1
cm in diameter who have no infection or obstruction, whose pain is controlled with analgesics,
and who can tolerate liquids can be treated at home with analgesics and -receptor blockers (eg,
tamsulosin 0.4 mg po once/day) to facilitate calculus passage. Calculi that have not passed within
6 to 8 wk typically require removal. In patients with infection and obstruction, initial treatment is
relief of obstruction with a ureteral stent and treatment of the infection followed by removal of
calculi as soon as possible.

Calculus removal

The technique used for removal depends on the location and size of the calculus. Techniques
include shock wave lithotripsy and, to ensure complete removal or for larger calculi, endoscopic
techniques. Endoscopic techniques may involve rigid or flexible ureteroscopes (endoscopes) and
may involve direct-vision removal (basketing), fragmentation with some sort of lithotripsy
device (eg, pneumatic, ultrasonic, laser), or both.
For symptomatic calculi < 1 cm in diameter in the renal pelvis or proximal ureter, shock wave
lithotripsy is a reasonable first option for therapy. For larger calculi or if shock wave lithotripsy
is unsuccessful, ureteroscopy (done in a retrograde fashion) with holmium laser lithotripsy is
usually used. Sometimes removal is possible using an endoscope inserted anterograde through
the kidney. For renal stones > 2 cm, percutaneous nephrolithotomy with insertion of a
nephroscope directly into the kidney, is the treatment of choice.

For midureteral calculi, ureteroscopy with holmium laser lithotripsy is usually the treatment of
choice. Shock wave lithotripsy is an alternative.

For distal ureteral calculi, endoscopic techniques, such as direct removal and use of
intracorporeal lithotripsy (eg, pneumatic, electrohydraulic, laser), are considered by many to be
the procedures of choice. Shock wave lithotripsy can also be used.

Calculus dissolution

Uric acid calculi in the upper or lower urinary tract occasionally may be dissolved by prolonged
alkalinization of the urine with K citrate 20 mEq po bid to tid, but chemical dissolution of
calcium calculi is not possible and of cystine calculi is difficult.

Urinary calculi may remain within the renal parenchyma or renal pelvis or be passed into the
ureter and bladder. During passage, calculi may irritate the ureter and may become lodged,
obstructing urine flow and causing hydroureter and sometimes hydronephrosis. Common areas
of lodgment include the ureteropelvic junction, the distal ureter (at the level of the iliac vessels),
and the ureterovesical junction. Larger calculi are more likely to become lodged. Typically, a
calculus must have a diameter > 5 mm to become lodged. Calculi 5 mm are likely to pass
spontaneously.

Even partial obstruction causes decreased glomerular filtration, which may persist briefly after
the calculus has passed. With hydronephrosis and elevated glomerular pressure, renal blood flow
declines, further worsening renal function. Generally, however, in the absence of infection,
permanent renal dysfunction occurs only after about 28 days of complete obstruction.

Secondary infection can occur with long-standing obstruction, but most patients with Ca-
containing calculi do not have infected urine.