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Urinary Calculi Imaging

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Urinary Calculi Imaging


Author: J Kevin Smith, MD, PhD; Chief Editor: Eugene C Lin, MD more...

Overview
Preferred examination
The goals of imaging of urinary calculi are to determine the presence of stones within the urinary tract, evaluate for complications, estimate the likelihood of stone passage, confirm stone passage, assess the stone burden, and evaluate disease activity.[1, 2, 3, 4, 5, 6, 7] Images of stone disease are provided below:

Magnified scout intravenous urogram shows a large, relatively lucent calculus in the lower pole of the right kidney.

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Scout intravenous urogram shows a smooth, dense, round calculus in the left kidney.

Renal sonogram demonstrates an echogenic shadowing calculus in the renal collecting system with hydronephrosis.

Contrast-enhanced CT scan demonstrates an opaque staghorn calculus filling the left renal collecting system

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Intravenous urogram (10-min delay) Magnified view of the left ureterocele with a large stone in it.

Prone nonenhanced CT image shows that the stone in the left ureterovesical junction does not move to the dependent portion of the bladder. This finding indicates that it is still in the distal ureter at the ureterovesical junction and that it has not passed into the bladder.

Contrast-enhanced CT image of the right kidney shows a cluster of calyceal calculi without hydronephrosis.

When acute flank pain suggests the passage of a urinary stone, many methods of examination can be used.[8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19] Often, conventional radiography is initially used to screen for stones, bowel abnormalities, or free intra-abdominal air. Radiographs can also be used to monitor the passage of visible stones.

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Intravenous urography (IVU) (excretory urography) provides important physiologic information regarding the degree of obstruction. Ultrasonography (US) is useful in young or pregnant patients[20, 21] and in patients allergic to iodinated contrast material. US is also helpful in problem solving. All of these methods have become less useful with the advent of more sensitive and specific nonenhanced computed tomography (CT) scanning. When CT is available, it is now considered the examination of choice for the detection and localization of urinary stones. Almost all studies conducted to date show that IVU provides no additional clinically important information after nonenhanced CT is performed. As a result of the higher radiation dose of CT, conventional or digital radiography should be used to monitor the passage of stones if radiographic follow-up studies are indicated and if the stone is visible on conventional radiographs.[22] Passage of a urinary stone is the single most common cause of acute ureteral obstruction and affects as many as 12% of the population. The pain may be some of the most severe pain that humans experience, and complications of stone disease may result in severe infection; renal failure; or, in rare cases, death.[23]

Limitations of techniques
Because of the higher radiation dose with CT, conventional or digital radiography should be used to monitor the passage of stones if radiographic follow-up is believed to be indicated and if the stone is visible on conventional radiographs. Pregnant or pediatric patients may be imaged with US first to avoid radiation exposure. The rare false-negative finding is usually due to reader error or a protease-inhibitor CT-lucent stone. Falsepositive results are usually due to phleboliths adjacent to the ureter. In some cases, intravenous contrast material may be needed to opacify the ureter. Ultrasonography (US) has limited sensitivity for smaller stones, and does not depict the ureters well. It should be used mainly in patients who are young, those who are pregnant, or those undergoing multiple examinations (eg, patients with spine injury). IVU is the traditional examination for the assessment of urinary stone disease, and it does provide physiologic information related to the degree of obstruction. The radiation dose is generally smaller than that of CT, but it is of the same order of magnitude. Intravenous contrast is required, with

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resultant risks of an allergic reaction or nephrotoxicity. IVU is less sensitive than CT, especially for small or nonobstructing stones.

Radiography
Conventional radiography
Conventional radiography, as shown in the image below, is often performed as a preliminary examination in patients with abdominal pain possibly resulting from urinary calculi. These images should be obtained before contrast material is administered to prevent obscuring calcifications within the collecting system or calyceal diverticula. Conventional radiographs should include the entire urinary tract, and, often, 2 images are required.[24,
25, 26, 27, 28, 29, 30]

Abdominal radiograph shows calcification filling the left collecting system. This finding is consistent with a staghorn calculus. For its size, the stone is relatively lucent.

Stones are often found at key points of narrowing such as the ureteropelvic junction (UPJ), the ureterovesical junction (UVJ), and the point at which the ureter crossing the iliac vessels. An addition site is on the right side where the ureter passes through the root of the mesentery. Calcium stones as small as 1-2 mm can be seen. Cystine stones as small as 3-4 mm may be depicted, but uric acid stones are usually not seen unless they have become calcified. Typically, phleboliths are round or oval, and they may demonstrate a central lucency. However, they are often difficult to distinguish from ureteral calculi. Phleboliths in the pelvis are usually located lower than and lateral to the ureter, but they overlap with the ureter. Because gonadal veins parallel

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the upper ureters, contrast enhancement may be needed to opacify the ureter and demonstrate the extraurinary location of phleboliths in the gonadal veins. An erect or posterior oblique radiograph obtained on the side of the calcification may help in distinguishing urinary stones from extraurinary calcifications. This view can also depict calcifications that are projected over the sacrum or transverse processes on the frontal view. Preinjection renal tomography may depict additional stones, and it can be used to confirm the relationship of stones to the kidneys. Because stones are more visible with a lower peak kilovoltage (kVp), maintaining a maximum of 60-80 kVp is best, if possible. Larger patients may require a higher peak kilovoltage for acceptable exposure and scatter. In this situation, compression of the abdomen and collimation is critical. Mild bowel preparation may be helpful for increasing the sensitivity of conventional radiography for small stones in patients undergoing screening or follow-up observation for stones.

Intravenous urography
Intravenous urography, as shown in the images below, is useful for confirming the exact location of a stone within the urinary tract. IVU depicts anatomic abnormalities such as dilated calyces, calyceal diverticula, duplication, UPJ obstruction, retrocaval ureter, and others that may predispose patients to stone formation or alter therapy. Because contrast agents can obscure stones in the collecting system, scouting the entire urinary tract prior to their administration is critical.

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Magnified scout intravenous urogram shows a large, relatively lucent calculus in the lower pole of the right kidney.

Intravenous urogram. After the intravenous injection, contrast material in the collecting system obscures the calculus.

Scout intravenous urogram shows a smooth stone in the right kidney.

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Intravenous urogram obtained 5 minutes after the intravenous injection. Contrast material in the collecting system obscures the stone.

When an acute urinary stone is the primary consideration, compression may not be used to increase sensitivity for detection of low-grade obstruction. A caveat is that the contralateral kidney may have an abnormality that requires ureteric compression for adequate examination. In rare cases, the use of compression has been associated with forniceal rupture. When a stone causes acute obstruction, an obstructive nephrogram may be present. This may be prolonged and hyperopaque, with increasing opacity over time. The nephrogram of acute obstruction is usually homogeneous, but may also be striated or occasionally not visible on radiographs.[31] Other signs include delayed excretion, dilatation to the point of obstruction, or blunting of the calyceal fornices. Immediately after the passage of a stone, residual mild obstruction or edema can be detected at the UVJ. Delayed images may be needed to opacify to the point of the obstruction, but using gravity to position the more opaque and more distal contrast materialladen-urine is also possible by placing the patient in a prone or erect position. Extravasation of urine at the fornices may result in pyelosinus or pyelolymphatic extravasation, which is often first indicated by blurring of the calyceal fornices. Greater extravasation may outline the collecting system, and the contrast may dissect into the perinephric space; however, if the urine is not infected, this is usually clinically insignificant.

Degree of confidence
Although 90% of urinary calculi are opaque on abdominal radiographs, the sensitivity for the prospective identification of individual stones is only 5060%, and the specificity is only approximately 70%. Approximately 10% of stones are radiolucent on conventional radiographs.

False positives/negatives
Occasionally, false-positive findings result from extrarenal calcification, but these are usually correctly identified with IVU. Lucent stones appear as filling defects on IVU, but they are not distinguished from nonstone-filling defects such as transitional cell carcinomas or blood clots. US and CT are

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effective tools in making this distinction; however, much of the ureter cannot be visualized with US.

Computed Tomography
With a sensitivity of 94-97% and a specificity of 96-100%, helical CT is the most sensitive radiologic examination for the detection, localization, and characterization of urinary calcifications; therefore, helical CT is considerably more effective than IVU.[32, 33, 34, 35, 36, 37, 38, 39] Helical CT scans frequently depict non-obstructing stones that are missed on intravenous urography (IVU). CT is faster and no contrast agent is needed in most patients. CT easily differentiates between non-opaque stones and blood clots or tumors (compared with IVU, which may depict only a filling defect). In addition, helical CT is better than US or IVU in detecting other causes of abdominal pain. In fact, in most studies, IVU added little or no information.[40, 41] Rarely, pure matrix stones may demonstrate soft-tissue opacity on CT scans, and indinavir stones appear lucent.[42] However, all other stones appear opaque on CT scans.[43]

Technique
Because stones in the collecting system may be obscured by contrast material, nonenhanced CT, as shown in the images below, is usually performed.[44, 45, 46, 41, 47, 48, 49, 50, 51, 52] Helical CT is important to avoid missing stones because of section misregistration. A 5-mm helical technique with a pitch of 1.5:1 or less is preferred, although some radiologists choose to use a pitch of as much as 2:1.[53, 54, 55] The kidneys and, if possible, the entire abdomen should be scanned during a single breath hold to prevent section misregistration.[56, 57, 58]

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Axial nonenhanced CT section at the level of the kidney demonstrates an attenuating proximal ureteral calculus (arrow). No significant hydronephrosis is identified. CT can be performed much more rapidly than urography and without the use of intravenous contrast material.

Axial nonenhanced CT image at the level of the kidneys shows bilateral renal calculi, right hydronephrosis, and moderate perinephric fluid.

Axial nonenhanced CT image of the urinary bladder demonstrates an attenuating calculus at the right ureteropelvic junction.

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Nonenhanced CT image of the pelvis shows dilatation of the distal left ureter and mild periureteral fluid near the left ureterovesical junction.

Nonenhanced CT image of the pelvis shows a small attenuating stone at the left ureterovesical junction.

Because patients with stones are often young and because stone disease may recur, minimizing the radiation dose is critical.[59] A fairly high level of noise as a result of the inherently high contrast levels is tolerable in most patients. Reported radiation doses for CT are 2.8-4.5 mSv compared with 1.3-1.5 mSv for a 3-image IVU. However, the uterine dose is approximately 0.006 Gy for 4-image IVU compared with 0.0046 Gy for nonenhanced CT.[60] At the authors' institution, approximately 12% (10-20%) of patients who undergo nonenhanced CT for possible urinary stones receive intravenous contrast material for further evaluation. To discern between phleboliths and

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urinary stones, 50 mL of low-osmolar contrast agent should be administered. After 3-5 minutes, a 5-mm helical scan is obtained through the area of concern. Fewer contrast-enhanced studies are needed with increasing experience. Soft tissue around the rim of a calculus can differentiate it from a phlebolith. A phlebolith may have a comet tail of soft tissue extending from it; this finding differentiates it from a calculus.[61] On CT scans, phleboliths do not have radiolucent centers, as often seen on plain radiographs.[43, 62] When contrast-enhanced scans, as shown in the images below, are required to evaluate pain not related to stones, routine abdominal and/or pelvic CT should be performed.[63] In this situation, 100-150 mL of a lowosmolar oral and rectal contrast agent is used, and a 5-mm helical CT scan is obtained with a pitch of 1.5:1. Patient selection determines the number of examinations needed.

Contrast-enhanced CT section reveals a dense calculus in the right kidney, but the hydronephrosis has resolved.

Axial contrast-enhanced CT scan. The excretory phase image through the kidneys shows extravasation of contrast material in and near the renal pelvis and surrounding the proximal ureter, which is opacified. The finding is consistent with fornix rupture.

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Axial contrast-enhanced CT image through the ureterovesical junction confirms the stone within a left ureterocele. A Foley catheter balloon is visible in the bladder.

Contrast-enhanced CT image of the lower abdomen shows a tiny, obstructing, left ureteral calculus.

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Contrast-enhanced CT image shows a patchy area of hypo-opacity consistent with pyelonephritis.

Stones at the UVJ may be difficult to distinguish from stones that have already passed into the bladder. If the distinction changes therapy, a repeat scan through the UVJ in the prone position may be helpful. Stones that have already passed into the bladder will drop into a dependent location.[64]

CT findings
CT may depict the following:

Stones in the ureter Enlarged kidneys Hydronephrosis (83% sensitive, 94% specific) Perinephric fluid (82% sensitive, 93% specific) Ureteral dilatation (90% sensitive, 93% specific) Soft-tissue rim sign (good positive predictive value with a positive odds ratio of 31:1); see the image below.[65, 66]

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Nonenhanced CT image shows an obstructing left proximal ureteral calculus with a slight soft-tissue rim around the stone (ie, rim sign).

The amount of perinephric fluid is correlated with the degree of obstruction seen on IVU, and as with the obstruction, the amount of fluid is correlated with the likelihood of stone passage. Normal hyperattenuating renal pyramids sometimes are seen. These indicate that significant obstruction is not present. However, this finding has been seen with proven ureteral calculi and is often absent in patients without stones. For this reason, the usefulness of IVU is limited. If contrast material is administered, a delayed or hyperattenuating nephrogram may also be visible on CT scans if the ureter has an obstruction. Conventional radiography may be helpful in visualizing larger stones, once they are identified on CT scans, to provide a baseline to follow passage of the stone. If kidney, ureter, and bladder radiographs fail to depict the stone, CT may be needed to follow its passage. Approximately 40-55% of stones are not visible on abdominal radiographs. Almost no stones with attenuation values of less than 200 HU are visible, and repeat CT scans are usually required if passage of the stone is to be followed. Cystine and urate stones have an attenuation of 100-500 HU; calcium stones usually demonstrate attenuation higher than 700 HU. Considerable overlap exists in the CT attenuation values of calcium stones.

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Special concerns
In the diagnosis and treatment of kidney stones, special concerns exist in patients who are pregnant, in those who have contraindications to the use of contrast media, and in those with renal insufficiency. Pregnancy does not predispose patients to stone formation; however, stone formation is a complication in as many as 0.05% of pregnancies, and the diagnosis may be difficult to establish with imaging because of the displacement and obscuration of organs by the enlarged uterus and fetus.[20] Consider using US first in a pregnant patient, especially in the first trimester. IVU can be used, but the views should be limited to scout and 10- to 30-minute images if possible.[67] CT can also be useful, and the radiation dose may be justified (especially if the clinical picture is confusing), because any fetal damage is unlikely at the typical radiation doses. Minimize the dose by increasing the pitch and decreasing the milliamperage. MRI may be a useful tool for problem solving. Nonenhanced CT results are usually diagnostic,[68] but if contrast material is needed, actions can be taken to decrease the risk of an adverse reaction in patients. The patient can be premedicated with steroids and histamine blockers. Use of low-osmolar contrast agent also helps. Use of iodinated contrast agents should be avoided in patients who have had previous lifethreatening reactions. Nonenhanced CT is usually sufficient with the aid of US and MRI as problem-solving tools. Nuclear scintigraphy may also be helpful in confirming obstruction.[69] Usually, in patients with renal insufficiency, nonenhanced CT is sufficient. Very poor renal function results in a failure to opacify the collecting system. As in pregnant patients, US, MRI, and scintigraphy can be useful as problem-solving tools. If contrast material is used for IVU or for problem solving with CT, nephrotoxicity and allergy-like reactions are possible. Patients may potentially sue for contrast materialrelated injuries if nonenhanced CT was available but not used. Radiation exposure should be minimized in pregnant women, and female patients should be questioned carefully. If needed, a pregnancy test should be performed prior to CT scanning or radiography. US may be used initially in pregnant or pediatric patients, but CT may be indicated to confirm or

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diagnose urinary stone disease and exclude other pelvic pathology in pregnant women.[70]

Degree of confidence
Individual CT signs are associated with varying degrees of confidence, as noted in CT findings above. False-positive results are almost exclusively the result of a phlebolith adjacent to the ureter. False-negative results are primarily due to indinavir radiolucent stones and error. CT scans often suggest an alternative or additional diagnosis when renal stone disease is clinically suspected.[71, 72]

Magnetic Resonance Imaging


Stones are not directly visible on MRIs because they produce no signal. However, they may be indirectly visualized as a filling defect in the ureter or collecting system on heavily T2-weighted images or on gadoliniumenhanced T1-weighted images.[73, 74, 75, 76] MRI can be useful as a problemsolving tool if the use of iodinated contrast material or radiation is contraindicated (eg, during pregnancy). Gadolinium-based contrast agents have been linked to the development of nephrogenic systemic fibrosis (NSF) or nephrogenic fibrosing dermopathy (NFD). The disease has occurred in patients with moderate to end-stage renal disease after being given a gadolinium-based contrast agent to enhance MRI or MRA scans. NSF/NFD is a debilitating and sometimes fatal disease. Characteristics include red or dark patches on the skin; burning, itching, swelling, hardening, and tightening of the skin; yellow spots on the whites of the eyes; joint stiffness with trouble moving or straightening the arms, hands, legs, or feet; pain deep in the hip bones or ribs; and muscle weakness.

Ultrasonography
On sonograms, stones are demonstrated as bright echogenic foci with posterior acoustic shadowing. Stones are visualized fairly well with US in the kidneys and the distal ureter at or near the UVJ, especially if dilatation is present. US is good for the visualization of complications such as hydronephrosis (or other signs of obstruction); however, some patients with acute obstruction have little or no dilation.[77, 78, 79, 80, 81] In particular, US is helpful in evaluating those with renal insufficiency or contraindications for the use of contrast media; however, US is often skipped in favor of nonenhanced CT.[82]

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In addition, US is good for characterizing lucent filling defects that are visualized as stones on IVU. However, US does not provide direct physiologic information regarding the degree of obstruction. Doppler imaging may demonstrate a high resistive index in acute obstruction, but this may not occur immediately or after forniceal rupture. Absence of the ureteral jet, as visualized with color Doppler on the symptomatic side, is presumptive evidence for a high-grade obstruction in a well-hydrated patient.[83, 84, 85, 86, 87]

Degree of confidence
US is very insensitive for stones, especially stones smaller than 2 mm, stones at the UPJ, or stones in the mid ureter. Fowler et al suggest that US has a sensitivity as low as 24%, compared with nonenhanced CT. Furthermore, estimations of stone size may not be accurate. Compared with nonenhanced CT, US is more dependent on the operator's ability and more time consuming.

False positives/negatives
US is fairly specific when stones are seen, with a specificity as high as 90%. With US, matrix or indinavir stones may have soft tissue echogenicity without shadowing. False-positive findings may result from renal vascular calcifications. False-positive diagnoses of hydronephrosis also result from dilated vascular structures in the renal hilum. Doppler imaging is helpful in distinguishing dilated vascular structures from hydronephrosis.

Nuclear Imaging
Nuclear medicine studies may demonstrate the retention of activity in the cortex or collecting system when the obstruction is ongoing. Nuclear medicine tests are useful in determining differential renal function for treatment planning and for assessing how much renal function might return after the obstruction is relieved.[88, 69] For example, a kidney with very little function might be removed if very little function persists after a trial of drainage. Occasionally, confirming the obstruction with nuclear medicine studies is useful if the administration of iodinated contrast material is contraindicated. Renal function evaluation is not reliable in the presence of ongoing obstruction. Conversely, imaging findings may be normal with low-grade obstruction.

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Contributor Information and Disclosures


Author J Kevin Smith, MD, PhD Professor of Abdominal Imaging, Vice Chair for Veterans Affairs, Department of Radiology, University of Alabama at Birmingham School of Medicine; Chief of Service, Department of Radiology, Birmingham Veterans Affairs Medical Center

J Kevin Smith, MD, PhD is a member of the following medical societies: Alpha Omega Alpha, American College of Radiology, American Roentgen Ray Society, International Society for Magnetic Resonance in Medicine, Radiological Society of North America, and Society of Radiologists in Ultrasound

Disclosure: Nothing to disclose. Coauthor(s) Mark E Lockhart, MD, MPH Professor of Radiology, Associate Director of Radiology Medical Student Education, Chief of Abdominal Imaging, University of Alabama at Birmingham School of Medicine Mark E Lockhart, MD, MPH is a member of the following medical societies: American Institute of Ultrasound in Medicine, American Roentgen Ray Society, Association of University Radiologists,Radiological Society of North America, Society of Radiologists in Ultrasound, and Society of Uroradiology Disclosure: Nothing to disclose. Nicole W Berland Outreach Support for Hurricane Relief, Collat Jewish Family Service Disclosure: Nothing to disclose. Philip Kenney, MD Professor of Radiology and Chairman, Department of Radiology, University of Arkansas for Medical Sciences

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Philip Kenney, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Radiology, American Roentgen Ray Society, Association of University Radiologists,Radiological Society of North America, and Society of Uroradiology Disclosure: Nothing to disclose. Specialty Editor Board Steven Perlmutter, MD, FACR Associate Professor of Clinical Radiology, The School of Medicine at Stony Brook University; Medical Director of Radiology, Peconic Bay Medical Center Steven Perlmutter, MD, FACR is a member of the following medical societies: American College of Radiology, American Institute of Ultrasound in Medicine, American Medical Association, American Roentgen Ray Society, Association of Program Directors in Radiology, Association of University Radiologists, Medical Society of the State of New York, Radiological Society of North America, Society of Breast Imaging, Society of Nuclear Medicine, and Society of Uroradiology Disclosure: Nothing to disclose. Bernard D Coombs, MB, ChB, PhD Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand Disclosure: Nothing to disclose. Robert M Krasny, MD Resolution Imaging Medical Corporation Robert M Krasny, MD is a member of the following medical societies: American Roentgen Ray Societyand Radiological Society of North America Disclosure: Nothing to disclose. Chief Editor Eugene C Lin, MD Attending Radiologist, Teaching Coordinator for Cardiac Imaging, Radiology Residency Program, Virginia Mason Medical

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Center; Clinical Assistant Professor of Radiology, University of Washington School of Medicine Eugene C Lin, MD is a member of the following medical societies: American College of Nuclear Medicine, American College of Radiology, Radiological Society of North America, and Society of Nuclear Medicine Disclosure: Nothing to disclose.

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