Beruflich Dokumente
Kultur Dokumente
Review
h i g h l i g h t s
Recent advances in Computed Tomography (CT) have improved the radiological evaluation of renal stones disease.
With DECT, it is possible to determine the in vivo composition of renal stones, assisting with diagnosis and treatment.
There are ongoing efforts to decrease radiation dose related to CT examinations, including those for renal stone disease.
a r t i c l e i n f o a b s t r a c t
Article history: Nephrolithiasis is a common cause of abdominal pain and will affect approximately 1 in 10 people in
Received 24 October 2016 their lifetime. In the past two decades, there have been several technological advances that have changed
Accepted 30 October 2016 the imaging approach to stone diagnosis and follow-up. We present a review of the current imaging
Available online 2 November 2016
evaluation for renal stone disease, and outline how new technology has helped with diagnosis and
management.
Keywords:
© 2016 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.
Nephrolithiasis
Radiology
Computed Tomography
Low dose
Ultrasound
http://dx.doi.org/10.1016/j.ijsu.2016.10.045
1743-9191/© 2016 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.
C.J. McCarthy et al. / International Journal of Surgery 36 (2016) 638e646 639
patients with urolithiasis has superseded the role of IVP in diag- can be anticipated that stones 1 mm in size will pass almost nine
nosis of this condition [10]. Although it offers additional informa- times out of ten, dropping to a 25% spontaneous passage rate in
tion over plain radiography, such as identification of anatomic those patients with a stone that is 9 mm or greater. Similarly, stones
abnormalities and assessment of renal function non-contrast CT are more likely to pass if they are located closer to the vesicoure-
with or without CT urography provides superior evaluation in teric junction [16].
comparison to IVP [11,12]. There is an increased mean effective A commonly used measurement, the Hounsfield Unit (HU), has
radiation dose to patients [13] undergoing CT urography when been used since the beginning of CT technology [17] to determine
compared to IVP. Despite the limitations of plain radiography in the attenuation of material, and thereby estimating the composi-
assessment of stone disease, it continues to play a role in the day- tion of various materials. Although this is relatively straightforward
to-day evaluation of patients with nephrolithiasis particularly in for certain materials such air, water and cortical bone, where the
the follow up of patients undergoing urologic intervention to difference between materials is large, the use of such measure-
monitor changes in stone burden. ments for renal stones is fraught with difficulties, as discussed
above.
Despite its immense advantages, MDCT has challenges with
5. Multidetector CT
accurate determination of stone composition. Reliance on estima-
tion of mean attenuation values of the calculi by placement of re-
Non-contrast CT of the abdomen and pelvis is the typically the
gion of interest (ROI) has traditionally allowed physicians to
first radiological examination ordered in those patients who are
determine the composition of stone, which in the case of uric acid
suspected to have nephrolithiasis. Over the past two decades, there
stones permits medical management through urine alkalinization.
has been a tremendous rise in the availability of CT [14], which in
Uric acid stone have CT density values ranging from 200 to 450 HU
the case of suspected nephrolithiasis, can be performed without
at 120 kV, whereas calcium phosphate stones have mean HU values
any patient preparation including need for intravenous or oral
between 1200 and 1600. Although attenuation based methods have
contrast. Typically, non-contrast axial images (5 mm) are ob-
shown success using in-vitro models [18], they have limited success
tained from the top of the kidneys to the pelvis, and reviewed in
in in-vivo studies due to [19], mixed nature of many stones [20],
conjunction with sagittal and coronal reformats (2e3 mm). Unen-
and challenges with precise positioning of the ROI particularly for
hanced CT imaging not only allows detection of calcium based
small calculi [21].
stones but also permits detection of stones that are typically
radiolucent on plain radiography, such as xanthine and uric acid
stones [15]. 6. Dual energy CT (DECT)
In addition to detecting stones invisible on plain radiography
due to their size and/or composition, CT offers the additional Perhaps the biggest technological advance in renal stone im-
benefit of more precise anatomic localization of the urinary calculi aging in the last few years has been the widespread availability of
over conventional radiography. For example, stones in the ureter dual-energy CT (DECT). Although research on the potential benefits
that may be obscured by overlying bowel on plain radiographs are of dual-energy CT has been ongoing since the late 1970's [22], it is
readily demonstrated on CT. The secondary signs of ureteric stones, only in the last decade that the technology has become available to
such as hydronephrosis, hydroureter and perinephric stranding are the mainstream medical community. DECT can take the form of a
also immediately apparent on CT. Important complications, such as scanner whereby a single tube alternatives between high and low
forniceal rupture may also be detected, therefore allowing a far voltage (single source, ssDECT), or a scanner where there are two
more comprehensive assessment of not only the stone location, but tubes, typically mounted orthogonally, which operate at different
the associated effects and complications, which assists in triaging voltages (140 kVp and 80 kVp), and allow for acquisition of dual
those patients who may require more immediate management, energy images without the need for rapid switching of the tube
such as nephroureteral stent or nephrostomy placement. Similarly, current (dual source, dsDECT) [23].
patients who may be managed expectantly, or who may have Dual energy CT allows for enhanced determination of material
already passed the stone, can be identified. composition by comparing the attenuation of materials at different
The importance of reliably identifying simple parameters such x-ray energies. The technology is not limited to differentiating
as stone location and size cannot be underestimated, as doing so between stone types, but can also use mathematical algorithms to
has a direct impact on patient management (Fig. 3). For example, it identify iodine in the acquired images, and remove it to create a
Fig. 3. Axial (a) and coronal (b) non-contrast CT images from a patient presenting with left flank pain and gross hematuria. A large staghorn calculus (arrow) occupying the majority
of the left renal collecting system was identified,with focal cortical scarring in the lower pole (arrowhead). Volumetric analysis allows to more accurately estimate stone burden in
complex calculi than morphological measurements.
C.J. McCarthy et al. / International Journal of Surgery 36 (2016) 638e646 641
8. Treatment planning
9. Special situations
9.1. Pregnancy
11. Conclusion
Ethical approval
None.
Fig. 7. 33 year old female with early pregnancy presented with recent onset left flank
pain. Ultrasound image (a) shows pelvicalyceal system dilatation in the left kidney.
Ultrasound images in transverse (b) and longitudinal (c) planes at the level of bladder
show a small calculus at vesicoureteric junction and dilated lower ureter. A gravid
uterus with gestational sac and a well defined fetal pole can also be noted (c & d).
C.J. McCarthy et al. / International Journal of Surgery 36 (2016) 638e646 645
[55] D.L. Miller, Safety assurance in obstetrical ultrasound, Semin. Ultrasound CT Kidney J. 7 (2) (2014) 121e126.
MR 29 (2) (2008) 156e164. [61] D. Lehr, Clinical toxicity of sulfonamides, Ann. N. Y. Acad. Sci. 69 (3) (1957)
[56] E. Kanal, et al., ACR blue ribbon panel response to the AJR commentary by 417e447.
shellock and Crues on the ACR white paper on MR safety, AJR Am. J. Roent- [62] B.F. Schwartz, et al., Imaging characteristics of indinavir calculi, J. Urol. 161 (4)
genol. 180 (1) (2003) 31e35. (1999) 1085e1087.
[57] W.M. White, et al., Predictive value of current imaging modalities for the [63] J.B. Kopp, et al., Crystalluria and urinary tract abnormalities associated with
detection of urolithiasis during pregnancy: a multicenter, longitudinal study, indinavir, Ann. Intern Med. 127 (2) (1997) 119e125.
J. Urol. 189 (3) (2013) 931e934. [64] Y. Lotan, Economics and cost of care of stone disease, Adv. Chronic Kidney Dis.
[58] H.A. Gabert, J.M. Miller Jr., Renal disease in pregnancy, Obstet. Gynecol. Surv. 16 (1) (2009) 5e10.
40 (7) (1985) 449e461. [65] C.K. Cassel, J.A. Guest, Choosing wisely: helping physicians and patients make
[59] B. Kalb, et al., Acute abdominal pain: is there a potential role for MRI in the smart decisions about their care, JAMA 307 (17) (2012) 1801e1802.
setting of the emergency department in a patient with renal calculi? J. Magn. [66] J. Melnikow, et al., Cost analysis of the STONE randomized trial: can health
Reson Imaging 32 (5) (2010) 1012e1023. care costs be reduced one test at a time? Med. Care 54 (4) (2016) 337e342.
[60] H. Izzedine, F.X. Lescure, F. Bonnet, HIV medication-based urolithiasis, Clin.