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 flank pain were evaluated with unenhanced CT. Confirmation of the CT diagnosis was obtained retrospectively for 172 patients with ureteral stones: 115 stones passed spontaneously and 57 required intervention. Stone size was defined as the maximum diameter within the plane of the axial CT section. Stone location was classified 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 2–4 mm, 76%; for stones 5–7 mm, 60%; for stones 7–9 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;178:101–103
0361–803X/02/1781–101 © 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 5–10% of all urinary calculi [6]. The

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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 magnification 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 flank pain were evaluated with unenhanced helical CT. We were able to independently confirm a CT diagnosis in 440 of these 850 patients on the basis of

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because many factors. mid ureter = overlying sacroiliac joints. 115 stones passed spontaneously. and documented clinical follow-up. The frequency of spontaneous passage was 56% for 8-mm stones. Stone location was defined as proximal (above the sacroiliac joints). these differences were not statistically significant ( p = 0. Frequency of spontaneous passage was calculated independently for stone size and stone location. Discussion for such information has become important. and 27% for stones that were 10 mm or larger in diameter. their mean age was 46 years. for each location except the ureterovesical junction.002). these differences were not statistically significant ( p = 0.001) and for stones located at the ureterovesical junction ( p < 0. For each stone location.02).—Proximal ureter = above sacroiliac joints.58). and 79% for stones located at the ureterovesical junction. 5–7 mm. 72% for 6-mm stones. or 8 mm and larger). we defined spontaneous passage as occurring if no intervention was performed.Coll et al. In our study population of 172 patients. Of these 440 patients. 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. stones measuring 5–7 mm frequently pass spontaneously (frequency of spontaneous passage = 60%). For stones at the ureterovesical junction. These differences in overall frequency are statistically significant for stones in the proximal ureter versus stones in the distal ureter (p < 0. All patients were 18 years old or older. interventional procedures. 75% for distal stones. As a group. 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. For the purposes of this study. Two of the seven stones at the ureterovesical junction that failed to pass spontaneously measured 2 mm in diameter. Axial images were obtained from the top of the kidneys to the base of the bladder using a 5-mm slice thickness. In most portions of the ureter. and extracorporeal shock wave lithotripsy (n = 13). 83% for 3-mm stones.32). January 2002 . mid (overlying the sacroiliac joints). each with a solitary stone. 33% for 9-mm stones. determine the need for intervention independent of stone size and location. Milwaukee. distal ureter = below sacroiliac joints. no statistically significant differences were noted in frequency of spontaneous passage based on size. In addition. As a group. We found that stones measuring 4 mm or smaller will usually pass spontaneously (frequency of spontaneous passage = 78%). no stones larger than 10 mm passed spontaneously. including ureteroscopy (n = 26). with pure indinavir stones being the only known exception [7]. The CT images were interpreted together by one senior genitourinary radiologist and one senior radiology resident. 172 had findings on CT of acute ureteral obstruction caused by a solitary stone in the ureter. to our knowledge. TABLE 2 Spontaneous Passage Rate of Ureteral Calculi as a Function of Stone Location Stones in Proximal Ureter Size (mm) 1–4 5–7 >7 All stones No. the differences in frequency of spontaneous passage based on size were statistically significant ( p < 0. such as pain tolerance and the presence of infection. The need Spontaneous Passage Rate of Ureteral Calculi as a Function of Stone Size No. 60% for mid ureteral stones. percutaneous nephrostomy (n = 18). The frequency of spontaneous passage was 60% for 5-mm stones. these differences were not statistically significant ( p = 0. All frequency comparisons were made using a chi-square test. Our results are very similar to those of studies reported in the literature that used radiography to measure stone size. and 47% for 7-mm stones. This means that spontaneous passage was patient-dependent. 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. In our study. the overall frequency of spontaneous passage for stones 1–4 mm in diameter was 78%.43). the measurement was taken perpendicular to the course of the ureter.001). frequencies were also calculated as a function of stone size. When we compare the overall frequency of spontaneous passage among the three groups of stones (measuring 1–4 mm. The overall frequency of spontaneous passage was 48% for proximal stones. The number of stones of each size is also indicated. 57 patients required interventional therapy. All CT examinations were performed with a HiSpeed Advantage CT scanner (General Electric Medical Systems. stones 5–7 mm in diameter was 60%. a pitch of 1. As a group. No oral or IV contrast material was administered. This group of 172 patients comprised our study population and included 110 men and 62 women. In addition. other imaging studies. the overall frequency of spontaneous passage for stones that were 8 mm or larger was 39%. and at the ureterovesical junction. WI). and a reconstruction interval of 5 mm. and 72% for both 2-mm and 4-mm stones. because CT is replacing radiography and IV urography as the initial imaging evaluation for patients with suspected renal colic. For those patients in whom the course of the ureter was readily apparent in the plane of the CT section. and stones measuring 8 mm or larger usually will not pass spontaneously (frequency of spontaneous passage = 39%). The frequency of spontaneous passage was 87% for 1-mm stones. the differences are statistically significant ( p < 0. distal (below the sacroiliac joints). unenhanced CT will reveal virtually all stones regardless of composition. have examined the relationships between stone size and location on unenhanced CT to the frequency of spontaneous passage. the overall frequency of spontaneous passage for 102 TABLE 1 Stone Size (mm) 1 2 3 4 5 6 7 8 9 10 Stones in Ureterovesical Junction 1–4 5–7 >7 All stones 25 6 3 34 92 50 33 79 Note. Stone size was measured at the maximal diameter within the plane of the axial CT image using standard soft-tissue window and level settings. AJR:178. This confirmation was done retrospectively. 19 27 16 62 Stones in Mid Ureter 1–4 5–7 >7 All stones 5 3 2 10 Stones in Distal Ureter 1–4 5–7 >7 All stones 39 14 3 56 77 71 67 75 80 0 100 60 Passage Rate (%) 47 63 25 48 No prior studies. Our study showed that CT measurements of ureteral stone size have a nearly linear relationship with the frequency of spontaneous passage.

. Management of ureteric stone: a review of 292 cases. 28% for 7-mm stones. Osborn DE. Thus even tiny stones at the ureterovesical junction may require follow-up imaging. These studies could not take into account radiolucent stones such as those composed of uric acid. xanthine. they reported frequencies of spontaneous passage of 12% for proximal ureteral stones. Verga M. 35% for 6-mm stones. Raper FP. The results of expectant treatment of ureterolithiasis: follow-up study of kidney function and recurrence. No stones exceeding 8 mm in width passed spontaneously. Otnes and Sandnes [9] compared stone size measured on radiographs to the size of the recovered stone. middle third. Resnick MI. using a standard anode-to-film distance of 40 inches and assuming a distance of 5 inches from the stone to the cassette. Diagnosis of acute flank pain: value of unenhanced helical CT. In 1977. 2]. parallel (length).24:172–176 12. It would seem most important to determine the greatest dimension of the stone perpendicular to the true long axis of the ureter. Morse and Resnick [10] determined the frequency of spontaneous passage for ureteral stones in a series of 378 patients.12:155–156 10.[suppl 219] 2. Flynn JT.704 cases derived from six studies. They reported a frequency of spontaneous passage of 94% for ureterovesical junction stones that were less than or equal to 5 mm. radiography is unable to detect many calciumcontaining stones for a variety of technical reasons. 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. Natural history and current concepts for the treatment of small ureteral calculi. Hubner WA.37:660–670 4. lower third. and 71% for distal ureteral stones. They reported an overall frequency of spontaneous passage of 60%. Comparison of radiological measurement and actual size of ureteral calculi. or mucoprotein matrix. and ureterovesical junction. Blake SP. faint radiopacity. or even oblique (e. In real practice. They reported passage rates of 100%. Our review of the literature revealed no accepted standard technique to measure stone size on radiographs.145:263–265 11. our data indicate that if a stone is present in the proximal ureter at the time of diagnosis. J Urol 1991. J Urol 1997. Sandegard found that small stones in the lower half of the ureter passed spontaneously in 93% of patients. [12] of 134 patients with confirmed ureteral stones divided stone location into upper third of the ureter. [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). but passage rates were independent of stone size.10:544–546 9. distinguished between the distal ureter and the ureterovesical junction. Stoller ML. the overall frequency of spontaneous passage is less than 50%. medium (4–6 mm) and large (> 6 mm). Most radiographic measurements were within ± 25% of the actual measurement. Ogawa A. Ueno et al. including small size. 46% for mid ureteral stones. Even under ideal circumstances. et al. Observations on the analysis of ten thousand urinary calculi. the size and location of ureteral calculi are considered the most important prognostic factors for the treatment of patients with acute ureterolithiasis. In 1991. A study by Kinder et al. Pyrah LN.171:717–720 8. given the finite focal-spot size and the divergence of the X-ray beam. In fact. Measurements can be taken perpendicular (width). even for smaller stones (Table 2). Relation of spontaneous passage of ureteral calculi to size. Ureteral calculi: natural history and treatment in an era of advanced technology. Irby P. the orientation of the greatest length of a given stone will be unknown. Prognosis of stone in the ureter.116:44–53 3.Helical CT of Ureteral Calculi With regard to stone location. the maximal overestimation was 4 mm. 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 [1–3]. Ureteroscopy and ureteric calculi: how useful? Br J Urol 1987. Morse RM. Sandegard E. Uric acid stones are by far the most common radiolucent stone and account for 5–10% of all urinary calculi [6]. and stones were categorized into three groups: small (< 4 mm). These guidelines do not specify a definition of stone size. On the basis of a recent meta-analysis of the literature. Sandnes H. Eur Urol 1993. Acta Chir Scand 1956. greatest dimension) to the expected course of the ureter. the American Urological Association published guidelines for the treatment of ureteral stones [4]. however.158:1915–1921 5. In conclusion. McNicholas MM. Nonopaque crystal deposition causing ureteric obstruction in patients with HIV undergoing indinavir therapy. [11] in 1993 included 2. Kawamura T. Ureteral stones: clinical guidelines—panel summary report on the management of ureteral calculi. The latter study included 122 confirmed cases. Preminger GM. 2. and 4 mm in width. These rates are very similar to those previously published based on radiography. This analysis reported an overall spontaneous passage rate of 71–98% 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. 22% for mid ureteral stones. Kinder RB. Sandegard E. Otnes B. Ueno A . some magnification will occur on radiographs. Herring LC. Takayasu H. They found that overestimation of size was more common than underestimation. depending on the clinical circumstances. 3. Acta Chir Scand 1958. McCarthy SM. 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. Rosenfield AT. 87%. Urology 1977. Neither Morse and Resnick nor Hubner et al. 93%. January 2002 103 .166:97–101 6. and obscuration by overlapping structures. The frequency was related to stone location: 22% for proximal stones.88:545–562 7. Scand J Urol Nephrol 1978. an error of slightly less than 10% is to be expected for a stone whose greatest dimension is perpendicular to the X-ray beam. stones greater than 5 mm had a frequency of spontaneous passage of only 45%. Smith RC. Stones were also characterized as being present in the upper or lower half of the ureter.60:506–508 AJR:178. The frequency of spontaneous passage of stones in the mid and distal ureters was significantly higher than that of stones in the proximal ureter. Br J Urol 1965. respectively. The initial work on this topic was published by Sandegard in 1956 and 1958 [1. Smart JG. Assimos DG. In addition. and 14% for 8-mm stones. and 78% for stones measuring 1. Segura JW. the rate of spontaneous passage of ureteral stones does vary with stone size and location as determined by CT. whereas small stones in the upper half of the ureter passed spontaneously in 81% of patients. AJR 1996. Despite the limitations of radiography for making these determinations. Raptopoulos V.g. References 1. Fox M. J Urol 1962. and 45% for distal ureteral stones. The rate of spontaneous passage dropped to 57% for stones 5 mm in width. two stones lodged at the ureterovesical junction that measured 2 mm did not pass spontaneously. AJR 1998. 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. A review of the literature published by Hubner et al.

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