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An overview of kidney stone imaging techniques

Nature Reviews Urology volume 13, pages 654–662 (2016)Cite this article

Subjects

Key Points

  • Noncontrast CT is the most accurate imaging modality for kidney stones owing to high sensitivity, specificity, accurate stone sizing, and the ability to evaluate non-stone-related pathologies

  • Ultrasonography has a lower sensitivity and specificity than CT, but does not expose patients to ionizing radiation and is less expensive than CT

  • Ultrasonography has several limitations, but a randomized controlled trial demonstrated similar performance in the emergency department to that of CT for patients with suspected kidney stones

  • Ultrasonography is the first-line imaging modality for pregnant women and patients <14 years old

  • Low-dose CT has many of the same advantages of standard CT and reduces radiation exposure; however, its diagnostic accuracy is reduced in obese patients and dose modulation should be considered

  • In the future, improvements in CT, ultrasonography, kidney ureter bladder radiography, and MRI might improve the accuracy of imaging kidney stones

Abstract

Kidney stone imaging is an important diagnostic tool and initial step in deciding which therapeutic options to use for the management of kidney stones. Guidelines provided by the American College of Radiology, American Urological Association, and European Association of Urology differ regarding the optimal initial imaging modality to use to evaluate patients with suspected obstructive nephrolithiasis. Noncontrast CT of the abdomen and pelvis consistently provides the most accurate diagnosis but also exposes patients to ionizing radiation. Traditionally, ultrasonography has a lower sensitivity and specificity than CT, but does not require use of radiation. However, when these imaging modalities were compared in a randomized controlled trial they were found to have equivalent diagnostic accuracy within the emergency department. Both modalities have advantages and disadvantages. Kidney, ureter, bladder (KUB) plain film radiography is most helpful in evaluating for interval stone growth in patients with known stone disease, and is less useful in the setting of acute stones. MRI provides the possibility of 3D imaging without exposure to radiation, but it is costly and currently stones are difficult to visualize. Further developments are expected to enhance each imaging modality for the evaluation and treatment of kidney stones in the near future. A proposed algorithm for imaging patients with acute stones in light of the current guidelines and a randomized controlled trial could aid clinicians.

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Figure 1: A proposed algorithm for imaging patients with acute stone disease in the emergency department.
Figure 2: A coronal demonstration of bilateral 8 mm nephrolithiasis on noncontrast CT.
Figure 3: Comparison of stone size estimates by B-mode ultrasonography and CT.
Figure 4: Comparison of ultrasonography in B-mode or the novel 'S-mode' in humans.
Figure 5: Two plain films of the abdomen before and after treatment for an obstructing left-ureteral stone.
Figure 6: Image sequence demonstrating coronal cuts on MRI.

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References

  1. Scales, C. D. et al. Prevalence of kidney stones in the United States. Eur. Urol. 62, 160–165 (2012).

    Article  Google Scholar 

  2. Stamatelou, K. K., Francis, M. E., Jones, C. A., Nyberg, L. M. & Curhan, G. C. Time trends in reported prevalence of kidney stones in the United States: 1976–1994. Kidney Int. 63, 1817–1823 (2003).

    Article  Google Scholar 

  3. Fwu, C. W., Eggers, P. W., Kimmel, P. L., Kusek, J. W. & Kirkali, Z. Emergency department visits, use of imaging, and drugs for urolithiasis have increased in the United States. Kidney Int. 83, 479–486 (2013).

    Article  Google Scholar 

  4. Preminger, G. M. et al. 2007 guideline for the management of ureteral calculi. J. Urol. 178, 2418–2434 (2007).

    Article  Google Scholar 

  5. Scales, C. D. Jr et al. Urinary stone disease: advancing knowledge, patient care, and population health. Clin. J. Am. Soc. Nephrol. 11, 1305–1312 (2016).

    Article  Google Scholar 

  6. Smith-Bindman, R. et al. Ultrasonography versus computed tomography for suspected nephrolithiasis. N. Engl. J. Med. 371, 1100–1110 (2014).

    Article  CAS  Google Scholar 

  7. Miller, N. L., Evan, A. P. & Lingeman, J. E. Pathogenesis of renal calculi. Urol. Clin. North Am. 34, 295–313 (2007).

    Article  Google Scholar 

  8. Hammad, F. T., Lammers, W. J., Stephen, B. & Lubbad, L. Propagation of the electrical impulse in reversible unilateral ureteral obstruction as determined at high electrophysiological resolution. J. Urol. 185, 744–750 (2011).

    Article  Google Scholar 

  9. Ordon, M., Schuler, T. D., Ghiculete, D., Pace, K. T. & Honey, R. J. Stones lodge at three sites of anatomic narrowing in the ureter: clinical fact or fiction? J. Endourol. 27, 270–276 (2013).

    Article  Google Scholar 

  10. Fielding, J. R., Silverman, S. G., Samuel, S., Zou, K. H. & Loughlin, K. R. Unenhanced helical CT of ureteral stones: a replacement for excretory urography in planning treatment. AJR Am. J. Roentgenol. 171, 1051–1053 (1998).

    Article  CAS  Google Scholar 

  11. Coll, D. M., Varanelli, M. J. & Smith, R. C. Relationship of spontaneous passage of ureteral calculi to stone size and location as revealed by unenhanced helical CT. AJR Am. J. Roentgenol. 178, 101–103 (2002).

    Article  Google Scholar 

  12. Coursey, C. A. et al. ACR Appropriateness Criteria(R) acute onset flank pain—suspicion of stone disease. Ultrasound Q. 28, 227–233 (2012).

    Article  Google Scholar 

  13. Memarsadeghi, M. et al. Unenhanced multi-detector row CT in patients suspected of having urinary stone disease: effect of section width on diagnosis. Radiology 235, 530–536 (2005).

    Article  Google Scholar 

  14. Schwartz, B. F., Schenkman, N., Armenakas, N. A. & Stoller, M. L. Imaging characteristics of indinavir calculi. J. Urol. 161, 1085–1087 (1999).

    Article  CAS  Google Scholar 

  15. Nakada, S. Y. et al. Determination of stone composition by noncontrast spiral computed tomography in the clinical setting. Urology 55, 816–819 (2000).

    Article  CAS  Google Scholar 

  16. Shah, K. et al. Predicting effectiveness of extracorporeal shockwave lithotripsy by stone attenuation value. J. Endourol. 24, 1169–1173 (2010).

    Article  Google Scholar 

  17. Kim, S. C. et al. Cystine calculi: correlation of CT-visible structure, CT number, and stone morphology with fragmentation by shock wave lithotripsy. Urol. Res. 35, 319–324 (2007).

    Article  Google Scholar 

  18. Duan, X. et al. Differentiation of calcium oxalate monohydrate and calcium oxalate dihydrate stones using quantitative morphological information from micro-computerized and clinical computerized tomography. J. Urol. 189, 2350–2356 (2013).

    Article  CAS  Google Scholar 

  19. Primak, A. N. et al. Noninvasive differentiation of uric acid versus non-uric acid kidney stones using dual-energy CT. Acad. Radiol. 14, 1441–1447 (2007).

    Article  Google Scholar 

  20. Qu, M. et al. Dual-energy dual-source CT with additional spectral filtration can improve the differentiation of non-uric acid renal stones: an ex vivo phantom study. AJR Am. J. Roentgenol. 196, 1279–1287 (2011).

    Article  Google Scholar 

  21. Wang, J. et al. Characterisation of urinary stones in the presence of iodinated contrast medium using dual-energy CT: a phantom study. Eur. Radiol. 22, 2589–2596 (2012).

    Article  Google Scholar 

  22. Coursey, C. A. et al. Dual-energy multidetector CT: how does it work, what can it tell us, and when can we use it in abdominopelvic imaging? Radiographics 30, 1037–1055 (2010).

    Article  Google Scholar 

  23. Vujovic, A. & Keoghane, S. Management of renal stone disease in obese patients. Nat. Clin. Pract. Urol. 4, 671–676 (2007).

    Article  Google Scholar 

  24. Neitlich, T. & Neitlich, J. The imaging evaluation of cholelithiasis in the obese patient-ultrasound versus CT cholecystography: our experience with the bariatric surgery population. Obes. Surg. 19, 207–210 (2009).

    Article  Google Scholar 

  25. Fulgham, P. F., Assimos, D. G., Pearle, M. S. & Preminger, G. M. Clinical effectiveness protocols for imaging in the management of ureteral calculous disease: AUA technology assessment. J. Urol. 189, 1203–1213 (2013).

    Article  Google Scholar 

  26. Türk, C. et al. EAU guidelines on interventional treatment for urolithiasis. Eur. Urol. 69, 475–482 (2015).

    Article  Google Scholar 

  27. Blacklock, N. J. The pattern of urolithiasis in the Royal Navy. J. R. Nav. Med. Serv. 51, 99–111 (1965).

    CAS  PubMed  Google Scholar 

  28. National Research Council. Health Risks from Exposure to Low Levels of Ionizing Radiation: BEIR VII, Phase I, Letter Report (The National Acadamies Press, 1998).

  29. Brenner, D. J. & Hall, E. J. Computed tomography — an increasing source of radiation exposure. N. Engl. J. Med. 357, 2277–2284 (2007).

    Article  CAS  Google Scholar 

  30. Jellison, F. C. et al. Effect of low dose radiation computerized tomography protocols on distal ureteral calculus detection. J. Urol. 182, 2762–2767 (2009).

    Article  Google Scholar 

  31. Niemann, T., Kollmann, T. & Bongartz, G. Diagnostic performance of low-dose CT for the detection of urolithiasis: a meta-analysis. AJR Am. J. Roentgenol. 191, 396–401 (2008).

    Article  Google Scholar 

  32. Alsyouf, M. et al. Comparing stone attenuation in low- and conventional-dose noncontrast computed tomography. J. Endourol. 28, 704–707 (2014).

    Article  Google Scholar 

  33. Poletti, P. A. et al. Low-dose versus standard-dose CT protocol in patients with clinically suspected renal colic. AJR Am. J. Roentgenol. 188, 927–933 (2007).

    Article  Google Scholar 

  34. Gervaise, A. et al. Low-dose CT with automatic tube current modulation, adaptive statistical iterative reconstruction, and low tube voltage for the diagnosis of renal colic: impact of body mass index. AJR Am. J. Roentgenol. 202, 553–560 (2014).

    Article  Google Scholar 

  35. Erwin, B. C., Carroll, B. A. & Sommer, F. G. Renal colic: the role of ultrasound in initial evaluation. Radiology 152, 147–150 (1984).

    Article  CAS  Google Scholar 

  36. Asrat, T., Roossin, M. C. & Miller, E. I. Ultrasonographic detection of ureteral jets in normal pregnancy. Am. J. Obstet. Gynecol. 178, 1194–1198 (1998).

    Article  CAS  Google Scholar 

  37. Ray, A. A., Ghiculete, D., Pace, K. T. & Honey, R. J. Limitations to ultrasound in the detection and measurement of urinary tract calculi. Urology 76, 295–300 (2010).

    Article  Google Scholar 

  38. Melnikow, J. et al. Cost analysis of the STONE randomized trial: can health care costs be reduced one test at a time? Med. Care 54, 337–342 (2016).

    Article  Google Scholar 

  39. Patel, S. J., Reede, D. L., Katz, D. S., Subramaniam, R. & Amorosa, J. K. Imaging the pregnant patient for nonobstetric conditions: algorithms and radiation dose considerations. Radiographics 27, 1705–1722 (2007).

    Article  Google Scholar 

  40. Dunmire, B. et al. Use of the acoustic shadow width to determine kidney stone size with ultrasound. J. Urol. 195, 171–177 (2016).

    Article  Google Scholar 

  41. Sorensen, M. D. et al. B-mode ultrasound versus color Doppler twinkling artifact in detecting kidney stones. J. Endourol. 27, 149–153 (2013).

    Article  Google Scholar 

  42. Cunitz, B. et al. Improved detection of kidney stones using an optimized doppler imaging sequence. IEEE Int. Ultrason. Symp. 2014, 452–455 (2014).

    PubMed  PubMed Central  Google Scholar 

  43. Sapozhnikov, O., Lu, W., Bailey, M. R., Kaczkowski, P. & Crum, L. A. 2aBA6 Bubbles trapped on the surface of kidney stones as a cause of the twinkling artifact in ultrasound imaging. Proc. Meet. Acoust. 19, 075033 (2013).

    Article  Google Scholar 

  44. Dunmire, B. et al. Tools to improve the accuracy of kidney stone sizing with ultrasound. J. Endourol. 29, 147–152 (2015).

    Article  Google Scholar 

  45. Khokhlova, T., Li, T., Sapozhnikov, O. & Hwang, J. H. The use of twinkling artifact of Doppler imaging to monitor cavitation in tissue during high intensity focused ultrasound therapy. Proc. Meet. Acoust 19, 075034 (2013).

    Article  Google Scholar 

  46. Sorensen, M. D. et al. Focused ultrasonic propulsion of kidney stones: review and update of preclinical technology. J. Endourol. 27, 1183–1186 (2013).

    Article  Google Scholar 

  47. Sanders, J. L., Noble, V. E., Raja, A. S., Sullivan, A. F. & Camargo, C. A. Jr. Access to and use of point-of- care ultrasound in the emergency department. West J. Emerg. Med. 16, 747–752 (2015).

    Article  Google Scholar 

  48. Talley, B. E. et al. Variable access to immediate bedside ultrasound in the emergency department. West J. Emerg. Med. 12, 96–99 (2011).

    PubMed  PubMed Central  Google Scholar 

  49. Worster, A., Preyra, I., Weaver, B. & Haines, T. The accuracy of noncontrast helical computed tomography versus intravenous pyelography in the diagnosis of suspected acute urolithiasis: a meta-analysis. Ann. Emerg. Med. 40, 280–286 (2002).

    Article  Google Scholar 

  50. Thomson, J. M., Glocer, J., Abbott, C., Maling, T. M. & Mark, S. Computed tomography versus intravenous urography in diagnosis of acute flank pain from urolithiasis: a randomized study comparing imaging costs and radiation dose. Australas. Radiol. 45, 291–297 (2001).

    Article  CAS  Google Scholar 

  51. Johnston, R., Lin, A., Du, J. & Mark, S. Comparison of kidney-ureter-bladder abdominal radiography and computed tomography scout films for identifying renal calculi. BJU Int. 104, 670–673 (2009).

    Article  Google Scholar 

  52. Ege, G., Akman, H., Kuzucu, K. & Yildiz, S. Can computed tomography scout radiography replace plain film in the evaluation of patients with acute urinary tract colic? Acta Radiol. 45, 469–473 (2004).

    Article  CAS  Google Scholar 

  53. Bishoff, J. T. & Rastinehad, A. R. in Campbell-Walsh Urology Vol. 1. Ch. 2 (eds Wein, A. J., Kavoussi L. R., Partin, A. W., Peters, C. A.) 26–62 (Elsevier, 2016).

    Google Scholar 

  54. Houssami, N. & Skaane, P. Overview of the evidence on digital breast tomosynthesis in breast cancer detection. Breast 22, 101–108 (2013).

    Article  Google Scholar 

  55. Svahn, T. M., Houssami, N., Sechopoulos, I. & Mattsson, S. Review of radiation dose estimates in digital breast tomosynthesis relative to those in two-view full-field digital mammography. Breast 24, 93–99 (2015).

    Article  CAS  Google Scholar 

  56. Svahn, T. M., Macaskill, P. & Houssami, N. Radiologists' interpretive efficiency and variability in true- and false-positive detection when screen-reading with tomosynthesis (3D-mammography) relative to standard mammography in population screening. Breast 24, 687–693 (2015).

    Article  Google Scholar 

  57. Neisius, A. et al. Digital tomosynthesis: a new technique for imaging nephrolithiasis. Specific organ doses and effective doses compared with renal stone protocol noncontrast computed tomography. Urology 83, 282–287 (2014).

    Article  Google Scholar 

  58. Mermuys, K. et al. Digital tomosynthesis in the detection of urolithiasis: diagnostic performance and dosimetry compared with digital radiography with MDCT as the reference standard. AJR Am. J. Roentgenol. 195, 161–167 (2010).

    Article  Google Scholar 

  59. Karabacakoglu, A., Karakose, S., Ince, O., Cobankara, O. E. & Karalezli, G. Diagnostic value of diuretic-enhanced excretory MR urography in patients with obstructive uropathy. Eur. J. Radiol 52, 320–327 (2004).

    Article  Google Scholar 

  60. Robson, M. D., Gatehouse, P. D., Bydder, M. & Bydder, G. M. Magnetic resonance: an introduction to ultrashort TE (UTE) imaging. J. Comput. Assist. Tomogr. 27, 825–846 (2003).

    Article  Google Scholar 

  61. Yassin, A. et al. In vitro MR imaging of renal stones with an ultra-short echo time magnetic resonance imaging sequence. Acad. Radiol. 19, 1566–1572 (2012).

    Article  Google Scholar 

  62. Mullins, J. K., Semins, M. J., Hyams, E. S., Bohlman, M. E. & Matlaga, B. R. Half Fourier single-shot turbo spin-echo magnetic resonance urography for the evaluation of suspected renal colic in pregnancy. Urology 79, 1252–1255 (2012).

    Article  Google Scholar 

  63. White, W. M. et al. Low-dose computed tomography for the evaluation of flank pain in the pregnant population. J. Endourol. 21, 1255–1260 (2007).

    Article  Google Scholar 

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Acknowledgements

This work and Review are part of a large collaborative effort, and we appreciate the help of our many collaborators at the University of Washington Center for Industrial and Medical Ultrasound, the University of Washington Department of Urology, Washington, and the National Institute of Diabetes and Digestive and Kidney Diseases Program Project DK043881, USA. This material is the result of work supported by resources from the VA Puget Sound Health Care System, Seattle, Washington, USA. Funding was provided by National Space Biomedical Research Institute through NASA NCC 9–58, grants from the National Institute of Diabetes and Digestive and Kidney Diseases (DK043881 and DK092197), the University of Washington Applied Physics Laboratory, and the University of Washington Department of Urology.

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Authors and Affiliations

  1. Department of Urology, University of Washington School of Medicine, 1959 NE Pacific Street, Box 356510, Seattle, 98195, Washington, USA

    Wayne Brisbane & Mathew D. Sorensen

  2. Center for Industrial and Medical Ultrasound, Applied Physics Laboratory, University of Washington, 1013 NE 40th Street, Seattle, 98105, Washington, USA

    Michael R. Bailey

  3. Division of Urology, Department of Veteran Affairs Medical Center, 1660S Columbian Way, Seattle, 98108, Washington, USA

    Mathew D. Sorensen

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Correspondence to Mathew D. Sorensen.

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Brisbane, W., Bailey, M. & Sorensen, M. An overview of kidney stone imaging techniques. Nat Rev Urol 13, 654–662 (2016). https://doi.org/10.1038/nrurol.2016.154

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