Ct Evaluation

Application of Unenhanced Helical CT to the Evaluation of Flank Pain

Since Smith et al. first reported the use of unenhanced CT in the evaluation of patients with flank pain in 1995, CT has become the study of choice for the evaluation of suspected ureterolithiasis (5). The sensitivity of noncontrast helical CT detection of urinary calculi has been reported to range from 97% to 100%, with specificities between 92% and 100% (13-16). Stone size and location can be accurately defined.

In addition to the superior accuracy of noncontrast helical CT compared to other imaging modalities for stone detection and localization, both the rapid speed of the CT examination and the detection of nonstone disease have positioned CT as the primary diagnostic examination in acutely symptomatic patients. A modern multidetector row helical CT (MDCT) scan can be obtained in less than 20 seconds or a single breath-hold compared with at least 40 to 60 minutes for an EU examination (3). Unenhanced CT examination is currently well accepted by patients because iodinated contrast injection or bowel preparation is not needed.

Because CT exams are not limited to visualizing only the urinary tracts (in contrast to EU), the detection of nonurinary tract disease is an important advantage of CT in the evaluation of acute abdominal pain. Alternative diagnoses were made in

14% of cases in a series by Smith et al. (13). Fielding et al. reported noncalculus urinary pathology in 14% and nonurinary diagnoses in 11% of cases (14). Commonly encountered extraurinary causes for abdominal or pelvic pain—including diverticu-litis, appendicitis, inflammatory bowel disease, ruptured abdominal aneurysm, and ovarian masses thought to have undergone torsion—can all be detected with CT, as well as nonstone related urinary tract disorders such as pyelonephritis and renal masses (17).

An additional advantage of using CT for stone detection is in the evaluation of patients with complex body physiques that prevent detection on using traditional radiographic techniques. Those patients with severe scoliosis or obesity are readily studied with CT, while EU and US are often indeterminate because of physical limitations. In patients with renal transplants, CT not only defines the status of stone disease in the transplanted kidney but also permits evaluation of the native, minimally functioning kidneys for stones or collecting system obstruction.

The utilization of CT for stone disease evaluation has several disadvantages. An inexpensive and accurate way of following small stones identified on an emergency room (ER) CT scan is yet to be defined. As already stated, often, follow-up KUB radiographs are indeterminate. Nonvisualization of a calculus previously identified on a CT on a subsequent KUB film could indicate that the stone has been passed in the urine or that it is still in place but merely is not detectable on conventional radiographs to begin with. Repeated CT scans in this setting may not be cost efficient. Additionally, the detection of innumerable tiny calculi within the kidneys in asymptomatic patients has created a new class of patients who have radiographically definable stone disease, but no clinical sequelae. Patients with medullary sponge kidney and associated stone disease (Fig. 2) and those with chronic stone disease who undergo regular metabolic reevaluations may be difficult to evaluate with serial CT scanning compared to a KUB because their multiple tiny stones may change in position from study to study. In patients with chronic stone disease, major clinical decisions about stone therapy options are based on stone growth, movement, and composition. In many patients, the traditional KUB may address these specific issues equally well as the more expensive CT examination.

Comparison with Urinalysis, KUB, EU, US, and MR Urography

Recent comparison of CT with other clinical and imaging diagnostic methods, including urinalysis and other radiographic studies, has confirmed unenhanced CT's unrivaled position as the most accurate method for urinary stone detection. For example, one study has shown that reliance on the presence or absence of hematuria in deciding whether urolithiasis may be present is frequently not helpful. Luchs et al. reported an 84% sensitivity of hematuria on microscopic urinalysis in 587 patients with ureteral stones revealed by unenhanced CT (18). However, the specificity and negative predictive value were much lower, at 48% and 65%, respectively (18).

The more traditional imaging techniques of conventional radiography and EU have also proven much less sensitive. In a retrospective study by Levine et al. in 1997 comparing the sensitivity of KUB with unenhanced CT, a sensitivity of 59% was found for detecting ureteral calculi on the KUB (8). In a study by Jackman et al., only 22 of 46 (48%) ureteral stones shown on CT were visible on KUB (19). Out of 20 patients with renal colic, Smith et al. reported that both unenhanced CT and EU demonstrated ureteral obstruction in 12 patients (5). Of these 12 patients, a ureteral stone was demonstrated in five on both CT and EU, a stone was depicted

Computed Tomography Uti
Figure 2 Unenhanced CT of the right kidney demonstrates medullary nephrocalcinosis and nephrolithiasis in a patient with medullary sponge kidney. Abbreviation: CT, computed tomography.

in six on CT only, and a stone could not be delineated definitively in one patient on CT or EU. In a report by Sourtzis et al., CT was also shown to be more accurate in identifying ureteral stones than EU (20).

Pfister et al. have shown unenhanced CT to be more effective in evaluating patients with acute renal colic than EU (21). In a study of 115 patients with asymptomatic microscopic hematuria, urinary calculi were revealed by CT in 24 patients (22). Stones were identified on EU in only 13 of these 24 patients. Calculi missed on EU tended to be relatively small. They ranged in size from 1 to 5 mm. In this series, one false positive CT for ureteral stone could have been avoided if the protocol had included unenhanced imaging of the entire ureters (22).

In a recent study of combined imaging utilizing both KUB and US compared with unenhanced CT for diagnosing ureteral stones by Catalano et al. in 2002, combining KUB and US had a stone detection sensitivity of 77% as against 92% with unenhanced CT (23). Acute ureteral obstruction detection with US is compromised because it may take many hours following onset of symptoms before identifiable distension of the upper urinary tract develops. The use of intrarenal Doppler US can improve the detection of early obstruction based on measurement of an elevated resistive index (RI). In a 2001 study by Shokeir and Abdulmaaboud, detection of a change in RI facilitated diagnosis of ureteral obstruction in 47 (90%) of 52 patients with obstructing ureteral stones shown on EU. Unenhanced CT demonstrated ureteral stones in 50 (96%) of these patients (24). US has the advantage of avoiding patient radiation exposure, but the US examination is much more time consuming and its quality is very dependent both on the operator's skills and on the patient's body habitus.

There are only a few studies that have compared the ability of MRI to diagnose urolithiasis with that of unenhanced CT. In a study of 49 patients with acute flank pain who were imaged with unenhanced CT, magnetic resonance (MR) urography with and without gadolinium, and EU, ureteral stones were found in 32 patients. The sensitivities of MR urography in detecting ureteral stones and obstruction were 94% to 100% and 100%, respectively, whereas those of CT were 87% to 91% and 94%, respectively (25). In the same study, stone size was more accurately assessed on CT than MR urography, and all small caliceal renal stones shown on CT were not defined on MR urography. MR urography does not involve radiation exposure but is more expensive, less readily available in the ER setting, and is a much longer examination than unenhanced CT.

CT Techniques

No patient preparation is required for unenhanced renal stone CT. The usual method of scanning uses 120 to 140 peak kilovolt (kVp) with 5 mm collimation and pitch of 1.0 to 1.5. At many institutions, renal stone CT is performed using reduced mA (< 100 mA rather than the more standard exposure of >200 mA). Issues related to the choice of mA will be discussed further in section 3.5. After the patient's basic abdominal anatomy is defined on the initial CT scanned projection radiograph, referred to as CT scout (GE Healthcare, Milwaukee, Wisconsin, U.S.A.) or topogram (Siemens Medical Systems, Iselin, New Jersey, U.S.A.), axial scanning proceeds from just cephalad to the kidneys (usually at the level of T12) to just below the bladder base (at the level of pubic symphysis) in one or two breath-holds in most patients. With the increased speed and tube heat capacity of the more recently introduced MDCT scanners, the entire scan can be obtained comfortably during one suspension of respiratory motion. Some authors have advocated scanning the patient in the prone position, but this often is not possible in the ER setting because patients with severe abdominal pain are too uncomfortable to lie prone. Occasionally, selective additional lateral or prone images may be helpful in determining if a stone is impacted in the ureter at the ureterovesical junction or if it has passed into the bladder (Fig. 3). An indeterminate opacity in the region of the ureter can be further assessed with retrospective scan reconstructions in 2 to 3 mm slice increments and thinner slice thicknesses through the limited region containing the opacity.

Soft copy interpretation at a workstation is more efficient and accurate than hardcopy interpretation. Curved 2-D reformation paralleling the course of the ureter has been suggested as a helpful diagnostic tool (26), but creation of these images can be time-intensive for the physician. Any reformatted images of the ureters can be generated from the axially acquired dataset on a dedicated CT workstation.

It is frequently advantageous to have a radiologist review the images while the patient is still on the CT table. Sometimes, intravenous administration of iodinated contrast material can determine if the opacity of interest lies within the ureter when unenhanced CT findings are indeterminate. Such intravenous contrast enhancement may be necessary in 12% of cases (3). Opacification of the ureters usually can be displayed on CT images obtained five minutes after starting intravenous contrast administration. The concept of "indication creep'' has been defined where some physicians request CT for stone detection as a general screening test for all patients with abdominal pain (27). Close interactions between CT radiologists and ER physicians

Scan Vas Deferens Swelling

Figure 3 Tiny bladder calculus recently passed from the left ureter. (A) Unenhanced CT scan reveals a stone in the posterior aspect of the urinary bladder (small arrow). Occasionally, it is difficult to determine whether stones in this location are in a distal ureter near the ureterove-sical junction or have passed into the bladder ureterclasis present (curved arrow). (B) Repeat CT scan obtained in the prone position confirms that this stone is mobile within the bladder (small arrow). Left ureterectasis is seen on both the supine and the prone CT images (curved arrow). Abbreviation: CT, computed tomography.

Figure 3 Tiny bladder calculus recently passed from the left ureter. (A) Unenhanced CT scan reveals a stone in the posterior aspect of the urinary bladder (small arrow). Occasionally, it is difficult to determine whether stones in this location are in a distal ureter near the ureterove-sical junction or have passed into the bladder ureterclasis present (curved arrow). (B) Repeat CT scan obtained in the prone position confirms that this stone is mobile within the bladder (small arrow). Left ureterectasis is seen on both the supine and the prone CT images (curved arrow). Abbreviation: CT, computed tomography.

can help determine when intravenous contrast administration may be helpful after a nondiagnostic unenhanced scan to further evaluate for noncalculus renal pathology [e.g., acute pyelonephritis, infected hydronephrosis (pyonephrosis), renal infarct, renal vein thrombosis, tumor] and nonurinary pathology in patients with somewhat nonspecific symptoms (Fig. 4) (3,28,29).

Big Size Kidney Stone

Figure 4 Pyonephrosis (infected hydronephrosis). Enhanced CT scan demonstrates left pyelocaliectasis with irregular urine-contrast level (arrows) due to collecting system debris. Coarse hypoattenuating areas in the left renal parenchyma are characteristic of acute pyelonephritis. CT scans at a lower level displayed an obstructing stone in the left ureter (not shown). Abbreviation: CT, computed tomography.

Figure 4 Pyonephrosis (infected hydronephrosis). Enhanced CT scan demonstrates left pyelocaliectasis with irregular urine-contrast level (arrows) due to collecting system debris. Coarse hypoattenuating areas in the left renal parenchyma are characteristic of acute pyelonephritis. CT scans at a lower level displayed an obstructing stone in the left ureter (not shown). Abbreviation: CT, computed tomography.

Although the KUB has a limited value for the initial diagnosis of urinary stones, it may still be useful for following patients with stones documented by non-contrast CT. CT scanned projection radiography (SPR) images primarily are obtained as the initial anatomic reference to prescribe the subsequent axial CT scan parameters, but the performance and role of CT SPR images have been studied in evaluating CT-detected urinary stones. Chu et al. (30) and Assi et al. (31) reported 49% and 47% sensitivities, respectively, of CT SPR images obtained at 120 to 140 kVp and 80mAs for the detection of ureteral stones. In a study from our institution, 7 (30%) to 11 (48%) of 23 ureteral stones were prospectively identified on CT SPR images obtained at 80 kVp and 300 mA, without the prior knowledge of unenhanced CT findings (32). When correlated with the unenhanced CT findings, 16 (70%) of 23 ureteral stones were visible on CT SPR images, a sensitivity comparable to that of KUB, where 17 (74%) of the ureteral stones were identified. Therefore, a review of the CT SPR image in patients with diagnosed ureteral stones may be useful in determining if the affected patient can be followed with KUB rather than by serial CT exams. In some instances, axial CT image characteristics of a detected calculus can be used to predict the likelihood of stone visibility on a KUB radiograph. Zagoria et al. found that 95% of stones measuring greater than 300 Hounsfield Units (HU) on axial CT images obtained using 5 mm thickness could be seen on KUB films, whereas only 7% of calculi measuring less than 200 HU could be detected (33). Nearly 80% of calculi measuring 5 mm or larger on the axial CT images could be detected on KUB films, as opposed to only 37% measuring less than 5 mm (33).

CT urography recently has evolved as the primary radiologic examination for the evaluation of patients with common and uncommon urologic conditions (34,35). Excretory phase-enhanced CT is an essential part of CT urography protocols.

When pyelonephritis is suspected in a febrile patient with a ureteral stone revealed by noncontrast CT, contrast-enhanced CT can help estimate the degree of urinary obstruction and demonstrate changes of acute renal inflammation. Excretory phase-enhanced CT scans are useful in determining whether an indeterminate calcification lies in the intrarenal collecting system or ureter and in differentiating parapelvic cysts from hydronephrosis (36). Excretory phase-enhanced CT can also establish a diagnosis of a caliceal diverticulum complicated with stones or better delineate other complex stone diseases with associated distortion of the intrarenal collecting system.

Interpretation

The primary sign of ureterolithiasis on unenhanced CT is the identification of a focus of increased attenuation located within the ureteral lumen. The ureter can be followed on axial CT slices from the renal pelvis as it courses caudally, anterior to the psoas muscle, and initially lateral to the gonadal vein. Lower in the abdomen, the gonadal vein crosses the ureter, and the ureter courses medially. In the pelvis, the ureter overrides the iliac vessels, courses through the mid-pelvis laterally, and then turns medially to the ureterovesical junction through the space anterior to the seminal vesicle and posterior to the posterolateral aspect of the bladder. Calculi commonly become lodged at several typical sites along the course of the ureter: at the ureteropelvic junction, as the ureter crosses the iliac vessels, and at the ureterovesical junction.

Secondary signs have been described for aiding the diagnosis of ureteral stones in difficult cases (5,13,37,38). These signs include pyelocaliectasis and ureterectasis proximal to a stone, perinephric edema, and nephromegaly on the symptomatic side. The contralateral kidney and ureter can be used as an intrinsic reference. Perinephric edema consists of stranding in the perinephric fat, perinephric fluid collections, and/ or thickening of the renal fascia (Fig. 5) (39). In a study by Katz et al. (38), dilatation a JSP*»——*» «IS»*

Figure 5 Unenhanced CT scan demonstrates a renal stone at the ureteropelvic junction associated with a perinephric fluid collection (straight arrow). The fluid collection extends to Gerota's fascia (curved arrow). Gerota's fascia is also thickened (open arrow). Abbreviation: CT, computed tomography.

of the ipsilateral renal collecting system was present in 69% of patients with ureteral stones, ureteral dilatation in 67%, perinephric edema in 65%, and periureteric edema in 65%. When several secondary signs are seen together, however, the positive predictive value increases dramatically. For example, the combination of perinephric edema and ureteral dilatation for the diagnosis of ureteral obstruction has been reported to occur in 99% of cases (37). Because the presence of secondary signs on the symptomatic side is highly indicative of a stone in the ureter, careful scrutiny to identify a stone is necessary. An indeterminate opacity in the region of the ureter should strongly suggest a ureteral stone if the secondary signs are present.

Perinephric edema seen on CT manifests the physiologic changes in the kidney secondary to acute obstruction. Increased pressure in the intrarenal collecting system in the acute phase of obstruction causes increased lymphatic flow in the perinephric space. In addition, there can be pyelotubular, pyelolymphatic, pyelosinus, and pye-lovenous backflow, and elevated intrarenal venous pressure. The perinephric edema seen on CT probably represents resorbed urine and lymphatic fluid infiltrating the perinephric space along the renal capsule, the bridging septa of Kunin, and the para-renal fascia. A perinephric fluid collection probably represents a later phase of the same process, with confluent fluid collections most frequent on CT along the renal capsular surface. Occasionally, excretory phase-enhanced CT scans can document urinary extravasation from caliceal rupture secondary to an obstructing ureteral stone (Fig. 6). The amount of perinephric edema has been reported to correlate with the degree of ureteral obstruction as shown on EU (39). However, other studies have not found this to be the case. When limited perinephric edema is found, low-grade obstruction is likely to be found with EU. Extensive perinephric edema on CT is highly predictive of the calculus causing high-grade obstruction on EU (39). In a report with contrary results by Bird et al., the secondary CT findings alone were not helpful in differentiating high-grade obstruction from low-grade obstruction as evidenced by furosemide diuretic scintirenography (40). In a study by Varanelli et al., the presence of secondary signs on CT increased in frequency related to the prolongation of the duration of patient symptoms (41). It also remains controversial whether the presence and severity of the secondary CT signs of obstruction can predict the likelihood of spontaneous stone passage. Takahashi et al. reported that, in addition to stone size, the degree of perinephric fat stranding and perinephric fluid collection was helpful in predicting the stone passage (42), whereas Boulay et al. (43) and Fielding et al. (44) reported that secondary CT signs of obstruction were not useful in predicting the clinical outcome.

Stone size is the single most reliable indicator of spontaneous ureteral stone passage. In a 2002 study by Coll et al., the spontaneous passage rate for stones measured on axial CT at 1mm in diameter was 87%; for stones 2 to 4 mm, 76%; for stones 5 to 7 mm, 60%; for stones 7 to 9 mm, 48%; and for stones larger than 9 mm, 25% (45). The spontaneous passage rate as a function of stone location was 48% for proximal ureter stones, 60% for mid-ureteral stones, 75% for distal stones, and 79% for ureterovesical junction stones. In general, stones 6 mm or greater in size have usually required intervention. In an experimental phantom study by Olcott et al., three-dimensional (3-D) maximal intensity projection images have been shown to be more accurate in determining stone size than conventional radiography and nephrotomography (46). Coronally reformatted images have also been shown to more accurately predict stone size than axial CT images alone in a clinical study (47). Both 3-D and coronal reformatted images likely allow for more accurate determination of stone size along the z-axis, which is often the longest stone diameter.

Perinephric Edema Scans

Figure 6 Urinary extravasation due to an obstructing ureteral stone. (A) Unenhanced CT scans demonstrate stranding of the perinephric fat on the left and a large amount of perinephric (short straight arrow) and pararenal (curved arrow) fluid. Gerota's fascia is thickened (long straight arrow). (B) Excretory phase-enhanced CT scan reveals urinary extravasation into the left perinephric (short straight arrow) and posterior pararenal (curved arrow) spaces. Thickening of Gerota's fascia (long straight arrow). Abbreviation: CT, computed tomography.

Figure 6 Urinary extravasation due to an obstructing ureteral stone. (A) Unenhanced CT scans demonstrate stranding of the perinephric fat on the left and a large amount of perinephric (short straight arrow) and pararenal (curved arrow) fluid. Gerota's fascia is thickened (long straight arrow). (B) Excretory phase-enhanced CT scan reveals urinary extravasation into the left perinephric (short straight arrow) and posterior pararenal (curved arrow) spaces. Thickening of Gerota's fascia (long straight arrow). Abbreviation: CT, computed tomography.

Georgiades et al. have reported that differences in renal parenchymal attenuation on unenhanced CT between an acutely obstructed kidney and the nonobstructed contralateral normal kidney is a reliable secondary sign of acute renal obstruction (48). The attenuation of the "pale" kidney secondary to renal parenchymal edema from obstruction is less than that of the normal side and the difference in attenuation is usually more than 5 HU. This sign is not completely specific for an acute obstruction. The "pale" kidney sign may also be caused by interstitial edema from acute pyelonephritis and by venous congestion from renal vein thrombosis.

A major pitfall in the interpretation of unenhanced CT in the evaluation of patients with suspected ureterolithiasis is the frequent inability to identify accurately the ureter amongst periureteral vessels and to differentiate with certainty ureteral stones from extraurinary calcifications (e.g., renal artery calcification, iliac artery calcification, phleboliths, and calcified vas deferens). In some cases, intrinsic morphologic features of a pelvic calcification can be used to help determine whether it is within or merely adjacent to the urinary tract.

While it has long been known that on KUB films phleboliths are typically round and may contain a central area of lucency, this lucency is only rarely seen on CT (Fig. 7). Whereas most phleboliths are round or oval, most ureteral calculi are slightly angular in shape (49).

The ''soft tissue rim'' sign, a 1mm to 2mm halo of soft tissue attenuation around a focus of increased attenuation on unenhanced CT, has been described as a useful sign in diagnosing ureteral stones and in differentiating a ureteral stone from a pelvic phlebolith (Fig. 8). The rim is considered to represent the edematous ureteral wall surrounding an impacted stone. The sensitivity and specificity of this sign have been reported in one study to be 76% and 92%, respectively (50). In another study, the rim sign was positive in 50% of ureteral stones, indeterminate in 34% (because of the lack of a periureteral fat plane), and negative in 16% (51). Therefore, the absence of the soft tissue rim sign does not preclude the diagnosis of ureteral stone. The soft tissue rim is present around only 0% to 20% of phleboliths (50-52). Larger (greater than 5 mm) stones less commonly exhibit a "rim" sign, likely due to stretching of the ureteral wall. In a study by Guest et al., the presence of a positive ''rim'' sign only without associated secondary signs was found in only 1 of 37 patients with ureteral stones (53). The rim sign is rarely the sole indicator of the presence or absence of ipsilateral ureterolithiasis.

The "comet-tail" sign, an eccentric tapering of soft tissue extending from one surface of a calcification (analogous to the appearance of a comet), has been reported as a useful sign in diagnosing phleboliths (52,54) (Fig. 9). The presence

Phleboliths Pelvic
Figure 7 Pelvic phlebolith with central lucency. The central lucency of a phlebolith in the left side of the pelvis (arrow) on a 2.5 mm slice thickness CT scan that was retrospectively generated from the original 5 mm slice thickness CT scan. Abbreviation: CT, computed tomography.
Distal Ureteral Stone
Figure 8 Unenhanced CT scan reveals a small stone in the distal right ureter (arrow) associated with the "soft tissue rim'' sign, a halo of soft tissue attenuation surrounding the stone. Abbreviation: CT, computed tomography.

of the tail sign has been reported in 21% of phleboliths and 0% of ureteral stones (52). Identification of a positive "comet-tail" sign does not preclude the coexistence of ureterolithiasis because the sign is occasionally present adjacent to calculi or in patients with ipsilateral calculi located elsewhere in the pelvis (53).

The complications of urinary stone disease are better defined with CT than competing imaging modalities. Renal and perinephric abnormalities secondary to

Comet Tail Sign
Figure 9 Unenhanced CT scan shows the "comet-tail" sign {arrow), an eccentric tapering soft tissue extension from one surface of calcification as from a comet, characteristic of a phle-bolith. Abbreviation: CT, computed tomography.

acute stone disease are described above. Renal abscess formation secondary to infected stone material is well defined on CT (28). CT is also the radiologic examination of choice for delineating chronic urinary tract abnormalities related to underlying stone disease, such as renal parenchymal atrophy, renal sinus replacement lipomatosis (Fig. 10), and xanthogranulomatous pyelonephritis (Fig. 11) (28).

Radiation Exposure

Physician and patient concerns remain about the radiation exposure that results from widespread and often repeated use of CT. The target population with symptomatic stone disease is generally young and has a nonfatal illness (3). Although unen-hanced CT provides diagnostic advantages and does not require intravenous iodinated contrast material, the radiation exposure accompanied by CT has been reported to be two to three times higher than that of EU (21). In one study, Denton et al. reported exposure of CT as 4.7 mSv versus 1.5 mSv for a three-film EU (55). Homer et al. reported an average effective dose of 4.95 mSv for unenhanced CT performed with 5 mm thick images, a 2.0 pitch, 120 kV, and 280 mA versus 1.48 mSv for EU (56). In a study by Pfister et al., the mean radiation dose was 6.5 mSv for unenhanced CT with 5 mm collimation, 1.5 pitch, 120 kV, and 260 mAs versus 3.3 mSv for EU (21).

For patients undergoing a CT examination, the absorbed radiation dose depends on the CT technique. Scanning techniques utilizing reduced mAs (decreased from typically used values exceeding 200 mA to well under 100 mA) still allow for detection of most stones, while exposing patients to less radiation. Studies on modifying CT techniques to maintain accurate detection of stones with reduced radiation dosage are in progress (57-60). Newer CT scanners include better collimators, detectors, and processors so that the dose from a single noncontrast helical CT is

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