Relationship of Spontaneous Passage of Ureteral Calculi to Stone Size and Location as Revealed by Unenhanced Helical CT

Deirdre M. Coll 1 Michael J. Varanelli 2 Robert C. Smith 1

OBJECTIVE. Prior studies using radiography have examined the relationship of ureteral stone size and location to the probability of spontaneous passage. Given the improved accuracy and new role of unenhanced CT in the diagnosis of acute ureterolithiasis, we studied the relationship of stone size and location as determined by unenhanced CT to the rate of spontaneous passage. MATERIALS AND METHODS. Over a 29-month period, 850 patients with acute ank pain were evaluated with unenhanced CT. Conrmation of the CT diagnosis was obtained retrospectively for 172 patients with ureteral stones: 115 stones passed spontaneously and 57 required intervention. Stone size was dened as the maximum diameter within the plane of the axial CT section. Stone location was classied as proximal ureter (above the sacroiliac joints), mid ureter (overlying the sacroiliac joints), distal ureter (below the sacroiliac joints), and ureterovesical junction. RESULTS. The spontaneous passage rate for stones 1 mm in diameter was 87%; for stones 24 mm, 76%; for stones 57 mm, 60%; for stones 79 mm, 48%; and for stones larger than 9 mm, 25%. Spontaneous passage rate as a function of stone location was 48% for stones in the proximal ureter, 60% for mid ureteral stones, 75% for distal stones, and 79% for ureterovesical junction stones. CONCLUSION. The rate of spontaneous passage of ureteral stones does vary with stone size and location as determined by CT. These rates are similar to those previously published based on radiography.

Received February 5, 2001; accepted after revision July 25, 2001.

1

Department of Radiology, Weill Medical College of Cornell University, Box 141, New York Presbyterian Hospital, 525 E. 68th St., New York, NY 10021. Address correspondence to R. C. Smith.

2 Department of Diagnostic Radiology, Yale University School of Medicine, 333 Cedar St., New Haven, CT 06510.

AJR 2002;178:101103
0361803X/02/1781101 American Roentgen Ray Society

tone size and location are the most important factors used to predict the likelihood of spontaneous passage in patients diagnosed with acute ureterolithiasis [1]. Prior studies using radiography have examined the relationships between the width, length, and location of ureteral stones and their rate of spontaneous passage. In general, these studies have indicated a high likelihood of spontaneous passage for stones that are 4 mm or smaller in width and 6 mm or smaller in length, as well as for stones located in the distal ureter [2, 3]. These studies did not analyze the interdependence of these variables. The most recent guidelines published by the American Urological Association, which are based on a metaanalysis of the literature, indicate that up to 98% of ureteral stones 4 mm or smaller on radiography will pass spontaneously [4]. Unenhanced helical CT is now used almost exclusively for the diagnosis and treatment of patients with acute ureterolithiasis [5]. CT will reveal virtually all stones regardless of composition, including uric acid stones that are typically radiolucent on radiography. Uric acid stones account for 510% of all urinary calculi [6]. The

only stones known to be radiolucent on CT are those composed of pure protease inhibitors such as indinavir [7]. Several factors might result in a difference between CT and urography in determining stone size, including magnication on radiography, error and variability in CT measurements, the ability of CT to reveal tiny stones that would never be visible on radiography, and the ability of CT to visualize stones that are radiolucent on radiography (e.g., uric acid stones). No prior study has examined the relationships between the size and location of ureteral stones as determined by unenhanced CT and their rate of spontaneous passage. Given the new role of unenhanced CT in the diagnosis and treatment of patients with acute ureterolithiasis, it is important to determine this relationship.
Materials and Methods
During a 29-month period from January 1994 to June 1996, 850 patients with acute ank pain were evaluated with unenhanced helical CT. We were able to independently conrm a CT diagnosis in 440 of these 850 patients on the basis of

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Coll et al.
other imaging studies, interventional procedures, and documented clinical follow-up. This conrmation was done retrospectively. Of these 440 patients, 172 had ndings on CT of acute ureteral obstruction caused by a solitary stone in the ureter. This group of 172 patients comprised our study population and included 110 men and 62 women. All patients were 18 years old or older; their mean age was 46 years. For the purposes of this study, we dened spontaneous passage as occurring if no intervention was performed. This means that spontaneous passage was patient-dependent, because many factors, such as pain tolerance and the presence of infection, determine the need for intervention independent of stone size and location. In our study population of 172 patients, each with a solitary stone, 115 stones passed spontaneously; 57 patients required interventional therapy, including ureteroscopy (n = 26), percutaneous nephrostomy (n = 18), and extracorporeal shock wave lithotripsy (n = 13). All CT examinations were performed with a HiSpeed Advantage CT scanner (General Electric Medical Systems, Milwaukee, WI). Axial images were obtained from the top of the kidneys to the base of the bladder using a 5-mm slice thickness, a pitch of 1, and a reconstruction interval of 5 mm. No oral or IV contrast material was administered. The CT images were interpreted together by one senior genitourinary radiologist and one senior radiology resident. Stone size was measured at the maximal diameter within the plane of the axial CT image using standard soft-tissue window and level settings. For those patients in whom the course of the ureter was readily apparent in the plane of the CT section, the measurement was taken perpendicular to the course of the ureter. Stone location was dened as proximal (above the sacroiliac joints), mid (overlying the sacroiliac joints), distal (below the sacroiliac joints), and at the ureterovesical junction. Frequency of spontaneous passage was calculated independently for stone size and stone location. For each stone location, frequencies were also calculated as a function of stone size. All frequency comparisons were made using a chi-square test.

stones 57 mm in diameter was 60%. The frequency of spontaneous passage was 56% for 8-mm stones, 33% for 9-mm stones, and 27% for stones that were 10 mm or larger in diameter. As a group, these differences were not statistically signicant ( p = 0.43); the overall frequency of spontaneous passage for stones that were 8 mm or larger was 39%. When we compare the overall frequency of spontaneous passage among the three groups of stones (measuring 14 mm, 57 mm, or 8 mm and larger), the differences are statistically signicant ( p < 0.001). Table 2 shows the relationship of stone location to the overall frequency of spontaneous passage as well as the frequency at each location as a function of size. The overall frequency of spontaneous passage was 48% for proximal stones, 60% for mid ureteral stones, 75% for distal stones, and 79% for stones located at the ureterovesical junction. These differences in overall frequency are statistically signicant for stones in the proximal ureter versus stones in the distal ureter (p < 0.001) and for stones located at the ureterovesical junction ( p < 0.002). In addition, for each location except the ureterovesical junction, no statistically signicant differences were noted in frequency of spontaneous passage based on size. For stones at the ureterovesical junction, the differences in frequency of spontaneous passage based on size were statistically signicant ( p < 0.02). Two of the seven stones at the ureterovesical junction that failed to pass spontaneously measured 2 mm in diameter.
Discussion

for such information has become important, because CT is replacing radiography and IV urography as the initial imaging evaluation for patients with suspected renal colic. In most portions of the ureter, the plane of the CT section will be nearly perpendicular to the long axis of the ureter and therefore will allow determination of the greatest width of the stone. In addition, unenhanced CT will reveal virtually all stones regardless of composition, with pure indinavir stones being the only known exception [7]. Our study showed that CT measurements of ureteral stone size have a nearly linear relationship with the frequency of spontaneous passage. Our results are very similar to those of studies reported in the literature that used radiography to measure stone size. We found that stones measuring 4 mm or smaller will usually pass spontaneously (frequency of spontaneous passage = 78%); stones measuring 57 mm frequently pass spontaneously (frequency of spontaneous passage = 60%); and stones measuring 8 mm or larger usually will not pass spontaneously (frequency of spontaneous passage = 39%). In our study, no stones larger than 10 mm passed spontaneously.

TABLE 2

Spontaneous Passage Rate of Ureteral Calculi as a Function of Stone Location

Stones in Proximal Ureter Size (mm) 14 57 >7 All stones No. 19 27 16 62 Stones in Mid Ureter 14 57 >7 All stones 5 3 2 10 Stones in Distal Ureter 14 57 >7 All stones 39 14 3 56 77 71 67 75 80 0 100 60 Passage Rate (%) 47 63 25 48

No prior studies, to our knowledge, have examined the relationships between stone size and location on unenhanced CT to the frequency of spontaneous passage. The need
Spontaneous Passage Rate of Ureteral Calculi as a Function of Stone Size No. of Stones 15 43 23 18 15 18 17 9 3 11 Passage Rate (%) 87 72 83 72 60 72 47 56 33 27

Results

Table 1 shows the relationship of stone size (in 1-mm increments) to the frequency of spontaneous passage. The number of stones of each size is also indicated. The frequency of spontaneous passage was 87% for 1-mm stones, 83% for 3-mm stones, and 72% for both 2-mm and 4-mm stones. As a group, these differences were not statistically signicant ( p = 0.58); the overall frequency of spontaneous passage for stones 14 mm in diameter was 78%. The frequency of spontaneous passage was 60% for 5-mm stones, 72% for 6-mm stones, and 47% for 7-mm stones. As a group, these differences were not statistically signicant ( p = 0.32); the overall frequency of spontaneous passage for
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TABLE 1 Stone Size (mm) 1 2 3 4 5 6 7 8 9 10

Stones in Ureterovesical Junction 14 57 >7 All stones 25 6 3 34 92 50 33 79

Note.Proximal ureter = above sacroiliac joints, mid ureter = overlying sacroiliac joints, distal ureter = below sacroiliac joints.

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Helical CT of Ureteral Calculi With regard to stone location, our data indicate that if a stone is present in the proximal ureter at the time of diagnosis, the overall frequency of spontaneous passage is less than 50%, even for smaller stones (Table 2). The frequency of spontaneous passage of stones in the mid and distal ureters was signicantly higher than that of stones in the proximal ureter, but passage rates were independent of stone size. We found that the frequency of spontaneous passage of stones lodged at the ureterovesical junction at the time of initial diagnosis was strongly determined by stone size and varied from 33% to 92% (Table 2). However, two stones lodged at the ureterovesical junction that measured 2 mm did not pass spontaneously. Thus even tiny stones at the ureterovesical junction may require follow-up imaging, depending on the clinical circumstances. Prior studies using radiography have examined the relationship between the size and location of ureteral stones at the time of initial diagnosis and their subsequent frequency of spontaneous passage [13]. These studies could not take into account radiolucent stones such as those composed of uric acid, xanthine, or mucoprotein matrix. Uric acid stones are by far the most common radiolucent stone and account for 510% of all urinary calculi [6]. In addition, radiography is unable to detect many calciumcontaining stones for a variety of technical reasons, including small size, faint radiopacity, and obscuration by overlapping structures. Despite the limitations of radiography for making these determinations, the size and location of ureteral calculi are considered the most important prognostic factors for the treatment of patients with acute ureterolithiasis. The initial work on this topic was published by Sandegard in 1956 and 1958 [1, 2]. The latter study included 122 conrmed cases, and stones were categorized into three groups: small (< 4 mm), medium (46 mm) and large (> 6 mm). Stones were also characterized as being present in the upper or lower half of the ureter. Sandegard found that small stones in the lower half of the ureter passed spontaneously in 93% of patients, whereas small stones in the upper half of the ureter passed spontaneously in 81% of patients. Sandegard also reported that medium-sized stones in the lower half of the ureter passed spontaneously in 53% of cases but large or medium-sized stones in the upper half of the ureter rarely passed spontaneously. In 1977, Ueno et al. [8] evaluated 520 patients and calculated the rate of spontaneous passage of ureteral calculi as a function of stone width and length (in 1-mm increments). Their study found that the degree of obstruction was more directly related to the width rather than the length of the stone and concluded that the width was the critical measurement. They reported passage rates of 100%, 93%, 87%, and 78% for stones measuring 1, 2, 3, and 4 mm in width, respectively. The rate of spontaneous passage dropped to 57% for stones 5 mm in width, 35% for 6-mm stones, 28% for 7-mm stones, and 14% for 8-mm stones. No stones exceeding 8 mm in width passed spontaneously. On the basis of a recent meta-analysis of the literature, the American Urological Association published guidelines for the treatment of ureteral stones [4]. This analysis reported an overall spontaneous passage rate of 7198% for stones in the distal ureter that are 5 mm or smaller and a spontaneous passage rate of 29 98% for stones in the proximal ureter that are 5 mm or smaller. These guidelines do not specify a denition of stone size. Our review of the literature revealed no accepted standard technique to measure stone size on radiographs. Measurements can be taken perpendicular (width), parallel (length), or even oblique (e.g., greatest dimension) to the expected course of the ureter. It would seem most important to determine the greatest dimension of the stone perpendicular to the true long axis of the ureter. In real practice, however, the orientation of the greatest length of a given stone will be unknown. Even under ideal circumstances, given the nite focal-spot size and the divergence of the X-ray beam, some magnication will occur on radiographs. In fact, using a standard anode-to-lm distance of 40 inches and assuming a distance of 5 inches from the stone to the cassette, an error of slightly less than 10% is to be expected for a stone whose greatest dimension is perpendicular to the X-ray beam. Otnes and Sandnes [9] compared stone size measured on radiographs to the size of the recovered stone. They found that overestimation of size was more common than underestimation. Most radiographic measurements were within 25% of the actual measurement; the maximal overestimation was 4 mm. In 1991, Morse and Resnick [10] determined the frequency of spontaneous passage for ureteral stones in a series of 378 patients. They reported an overall frequency of spontaneous passage of 60%. The frequency was related to stone location: 22% for proximal stones, 46% for mid ureteral stones, and 71% for distal ureteral stones. A review of the literature published by Hubner et al. [11] in 1993 included 2,704 cases derived from six studies; they reported frequencies of spontaneous passage of 12% for proximal ureteral stones, 22% for mid ureteral stones, and 45% for distal ureteral stones. Neither Morse and Resnick nor Hubner et al. distinguished between the distal ureter and the ureterovesical junction. A study by Kinder et al. [12] of 134 patients with conrmed ureteral stones divided stone location into upper third of the ureter, middle third, lower third, and ureterovesical junction. They reported a frequency of spontaneous passage of 94% for ureterovesical junction stones that were less than or equal to 5 mm; stones greater than 5 mm had a frequency of spontaneous passage of only 45%. In conclusion, the rate of spontaneous passage of ureteral stones does vary with stone size and location as determined by CT. These rates are very similar to those previously published based on radiography.
References
1. Sandegard E. Prognosis of stone in the ureter. Acta Chir Scand 1956;[suppl 219] 2. Sandegard E. The results of expectant treatment of ureterolithiasis: follow-up study of kidney function and recurrence. Acta Chir Scand 1958;116:4453 3. Fox M, Pyrah LN, Raper FP. Management of ureteric stone: a review of 292 cases. Br J Urol 1965;37:660670 4. Segura JW, Preminger GM, Assimos DG, et al. Ureteral stones: clinical guidelinespanel summary report on the management of ureteral calculi. J Urol 1997;158:19151921 5. Smith RC, Verga M, McCarthy SM, Roseneld AT. Diagnosis of acute ank pain: value of unenhanced helical CT. AJR 1996;166:97101 6. Herring LC. Observations on the analysis of ten thousand urinary calculi. J Urol 1962;88:545562 7. Blake SP, McNicholas MM, Raptopoulos V. Nonopaque crystal deposition causing ureteric obstruction in patients with HIV undergoing indinavir therapy. AJR 1998;171:717720 8. Ueno A , Kawamura T, Ogawa A, Takayasu H. Relation of spontaneous passage of ureteral calculi to size. Urology 1977;10:544546 9. Otnes B, Sandnes H. Comparison of radiological measurement and actual size of ureteral calculi. Scand J Urol Nephrol 1978;12:155156 10. Morse RM, Resnick MI. Ureteral calculi: natural history and treatment in an era of advanced technology. J Urol 1991;145:263265 11. Hubner WA, Irby P, Stoller ML. Natural history and current concepts for the treatment of small ureteral calculi. Eur Urol 1993;24:172176 12. Kinder RB, Osborn DE, Flynn JT, Smart JG. Ureteroscopy and ureteric calculi: how useful? Br J Urol 1987;60:506508

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