REVIEW

CURRENT
OPINION Impact of imaging in urolithiasis treatment
planning
Dan Magrill a, Uday Patel b, and Ken Anson a

Purpose of review
Over the past 10 years, we have seen major advances in urological imaging including developments in
digital imaging, ultrasound and computerized tomography (CT) scanning. All of these have had an impact
on the management of urinary tract stone disease. In parallel with these, we have witnessed a greater
appreciation of the potential harm of irradiation exposure. In this article, we aim to provide an overview of
the impact of imaging in urolithiasis treatment planning in 2013.
Recent findings
A variety of imaging modalities are reviewed with a focus on the latest research and developments.
Advances do not always improve quality, and the deterioration in digital KUB sensitivity is discussed.
The role of ultrasonography in the diagnosis and follow-up of stone disease is explored as a clinically
valuable alternative to ionizing radiation. The explosion of interest in cross-sectional imaging for urolithiasis
(extending from the evaluation of loin pain, characterization of stone composition through to complex three-
dimensional reconstructions of the pelvicalyceal system for surgical planning) is reviewed.
Summary
A detailed understanding of the performance of all the imaging modalities available to the stone surgeon in
2013 is vital in order to offer well tolerated and effective imaging strategies for all stages of the patient
journey. CT has developed a pre-eminent role in the diagnosis of urinary stone disease, it has also found
favour as a valuable surgical planning tool and is being advocated in the surveillance protocols. However,
we must keep in mind the risks of radiation exposure in a patient population characterized by youth and a
susceptibility to repeated acute disease episodes.
Keywords
imaging, stone disease, urolithiasis

INTRODUCTION therefore other very important imaging modalities

Imaging has a critical role to play in establishing
diagnoses, planning and performing interventions,
assessing therapeutic efficacy and for the surveil-
lance of established disease for patients with urinary
tract stones. For diagnosis, noncontrast computer-
ized tomography (NCCT) plays a pre-eminent role
in assessing acute loin pain, and computerized
tomography (CT) is valuable for preoperative surgi-
cal planning and assessing outcomes. In addition,
the potential of CT to help identify the possible
metabolic make-up of a calculus at presentation
offers a more informed debate in discussions with
patients when considering different treatment
strategies. However, many of our patients are young
with recurrent disease and are increasingly shying
away from CT because of their concerns about radia-
tion exposure. Ultrasound and digitally acquired
KUB (kidneys, ureters and bladder radiograph) are
which can be employed in all stages of the patient
journey with an acceptable clinically relevant
efficacy.
In this article, we will address how these differ-
ent radiological modalities are performing in 2013.
In addition, we aim to provide some practical advice
to help inform the provision of tailored, low-risk
imaging strategies for our patients.
a
Urology Department, St George’s Hospital, Blackshaw Road, London,
SW17 0QT, UK and bRadiology Department, St George’s Hospital,
Blackshaw Road, London, SW17 0QT, UK
Correspondence to Ken Anson, Urology Department, St George’s
Hospital, Blackshaw Road, London, SW17 0QT, UK. Tel: +44 208
725 3305; e-mail: ken.anson@stgeorges.nhs.uk
Curr Opin Urol 2013, 23:158–163
DOI:10.1097/MOU.0b013e32835d8e40

www.co-urology.com Volume 23  Number 2  March 2013

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KEY POINTS
 There has never been such a wide range of accurate
imaging modalities available to clinicians to help
diagnose and plan treatment for urolithiasis.
 The dangers from ionizing radiation are particularly
important in our young patients, who suffer chronic
conditions with a high risk of recurrence, and might be
subject to repeated cross-sectional imaging.
 An understanding of which modality to employ, and
when, for individual patients is critical for the safe and
successful management of urinary stone disease
in 2013.
DIGITALLY ACQUIRED KUB RADIOGRAPH
The digital imaging revolution of the past decade
has resulted in the disappearance of conventional
plain KUB radiograph from many departments
across the world with the widespread emergence
of the digitally acquired plain KUB (dKUB).
Although these images are convenient, urologists
have noticed deterioration in the value of the ‘plain
film’ in urological practice. For complex reasons
related to the default kV and Ka on many digital
systems, the dKUB is less sensitive for renal and
ureteric stones than conventional imaging. Many
clinicians are using relatively poor-quality monitors
to view these images and this, combined with
dKUB’s reduced sensitivity, has resulted in an
increased inability to detect calculi that are
traditionally considered ‘radio-opaque’. This has
also occurred in parallel with the well documented
increased incidence of metabolic syndrome associ-
ated calculi which are also poorly radio-opaque.
Various attempts at manipulating the image on
the viewing monitor can improve urinary stone
visualization (use of bone windows and inverting
the image contrast), but these changes are not ‘hot
wired’ into the image and therefore difficult to
repeat for subsequent stone surveillance. These
limitations of dKUB are becoming well recognized
by the urological community, but this is not, as yet,
reflected in the urology literature.
ULTRASOUND
Many urologists are increasingly turning to ultra-
sound scanning (USS) as an important and valuable
imaging tool for urinary stone disease. Although
the sensitivity of conventional ultrasound may be
relatively low, this can be improved significantly by
the use of colour Doppler, and the emergence of
twinkle artefact is an important diagnostic sign for
&
urinary stone disease [1 ].
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Impact of imaging in urolithiasis treatment Magrill et al.
Many of us have also noted the very real inter-
observer variability of ultrasound and have bene-
fitted hugely from having regular sonographers
performing our scans – there is no question that a
competent individual with ‘their eye in’ can really
improve the performance of ultrasound and make it
the mainstay of many imaging strategies.
Ultrasound plays a very valuable role in
paediatric urology and the recent work has demon-
strated its particular value in paediatric stone
disease. Passerotti et al. [2] demonstrated that USS
was 100% specific and 76% sensitive for diagnosing
stones in patients with suspected urolithiasis
compared to CT. The missed stones were all small
(average diameter 2.3 mm) and it was concluded
that the difference in usefulness between the two
radiological tests may not be clinically significant.
The relatively low-lying kidneys and simple body
habitus in the paediatric population confer sig-
nificant advantages in favour of ultrasound in com-
parison to adult practice; however, the challenge
now exists to try to establish similar levels of ultra-
sound performance in the adult population.
The value of USS in offering functional infor-
mation was recently addressed by Sayani et al. [3]
who studied the value of resistive index on Doppler
USS to identify ureteric obstruction in patients with
acute renal colic. It was found that the difference in
resistive index between the kidneys was significantly
higher in obstructed kidneys, though it should be
noted that IVU was used as the comparator to identify
ureteric obstruction, rather than CT which is now
accepted as the gold standard to identify stones.
The value of USS for the surveillance of ureteric
stones remains controversial; however, recently
&
Moesbergen et al. [4 ] assessed the value in ultrasound
in the surveillance of distal ureteric calculi in 152
patients. At the same follow-up visit, they compared
USS with either NCCT or plain radiography, and
found that USS had a sensitivity of 94.3% and speci-
ficity of 99.1%. The authors concluded that ‘ureteral
calculi within 35 mm of the uretero-vesical junc-
tion can be accurately followed up by using trans-
abdominal US, which substantially reduces patient
radiation burden’. An apparent weakness in this
study was that ultrasound was not compared to CT
in all follow-up visits (nearly half had a KUB instead).
LOW-DOSE AND ULTRA LOW-DOSE
COMPUTERIZED TOMOGRAPHY
CTKUB has become the investigation of choice for
the assessment of acute loin pain and has relegated
the humble IVU to an investigation of historical
interest in centres around the world [5]. The
explosion in use of CT scanning for the investigation
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 Urolithiasis
of abdominal pain has resulted in a huge increase in
the detection of asymptomatic urinary tract stones.
The ever expanding indications for cross-sectional
imaging in asymptomatic individuals have resulted
in a diagnosis of urolithiasis in 14% of patients
attending for virtual colonoscopy [6] and in 5% of
live-related kidney donors [7]. This, combined with
CT’s excellent sensitivity and specificity for urinary
stones [8] has resulted in CT have a preeminent role as
the investigation of choice for the management of
urinary stone disease for many urologists. However,
CT scanning carries significant risks related to con-
trast nephropathy and radiation induced malignant
transformation [9]. Efforts are therefore being con-
centrated on CT protocols aimed at reducing the
radiation exposure whilst maintaining its clinical
value.
& &
Sung et al. [10 ] published a review examining the
use of low-dose multidetector CT (MDCT) in the
urinary tract. They highlighted some potential
strategies to reduce radiation whilst maintaining
adequate diagnostic performance. Studying a variety
of CT protocols, they demonstrated that the effective
radiation dose can approach that of dKUB (less than
1 mSv), but with sensitivity and specificity still over
95%.
The direct relationship between tube current and
radiation dose is one key target to improve CT safety
[11]. Tube current refers to the amount of energy
(measured in milli-amperes) used as part of the scan-
ning parameters, and determines the incident beam
energy and subsequently both the image quality and
absorbed radiation dose. Although a 50% reduction
in tube current will reduce the radiation dose by half,
there will be an increase in image noise and poten-
tially reduced diagnostic efficacy.
Direct comparison using different CT protocols
in the same patient would be an ideal way to test the
diagnostic accuracy of these low-dose protocols;
however, this is clearly impractical. Some groups
therefore have described the use of simulated tube
current reduction [12]. The projectional scan
data from the original CT can be processed with
increased noise to model the effect of lower tube
currents without the need to rescan. This technique
has been used in adults and children, and the stone
detection rate (at least for ‘clinically significant’
stones over 3 mm) appears to be adequate.
Manufacturer software allows processing of the
low-dose CT to reduce noise, offering equivalent
diagnostic yield at a lower radiation dose. Adaptive
statistical iterative reconstruction (ASIR) is said to
provide dose reduction without subjective noise
increase [13].
A potential pitfall of lower dose CT is that with a
fixed (low or ultra-low) tube current, high patient
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weight results in unsuitable image quality in the
rest of the abdomen (increased noise) resulting
in poorer diagnostic imaging of other organs. This
can be overcome with automatic tube current
modulation that adjusts the tube current in real
time according to a variety of patient factors to
achieve the right balance between efficacy and
safety [11].
One criticism of the immediate access to CTKUB
for suspected ureteric colic in most UK institutions is
that patients are now being referred to the radiology
department with that presumptive diagnosis in order
to gain access to whole-abdomen cross-sectional
imaging. This example of ‘indication creep’ has been
investigated in a UK radiology department, where it
was found that nearly half the patients referred for
CTKUB for suspected colic did have positive scans
[14 ]. These data were incomparable to previous
overall positive rates at the same institution (44%)
and other quoted series. It was noted, however, that
women had less than half the chance of men of
having a positive scan (26.8 vs. 61.6%, P < 0.001).
There was recognition that the choice of primary
imaging modality should take into account the sex
of the patient.
FOLLOW-UP AFTER COMPUTERIZED
TOMOGRAPHY
Finally, the question arises as to how to survey a
stone detected on CTKUB. One approach is to see
how well the stone is seen on the scout film and use
this as a benchmark of ‘radio-opacity’ for further
surveillance dKUBs. However, others would argue
that if a stone is detected on CT, then a synchronous
dKUB should be performed to identify that calculus
so that the same modality of imaging can be utilized
for subsequent surveillance.
Over a decade ago, the authors from the Yale
University retrospectively reviewed the imaging in
215 cases of proven urolithiasis and discovered that
in just under half the cases the stone was visible on
the scout of the NCCT series [15].
Smith and Coll [16] used these data to describe
how they deal with stones not visible on the scout
image. For stones under 5 mm (which are both
unlikely to show up on dKUB and likely to pass
spontaneously), they do not recommend further
imaging. For stones over 10 mm which are not
visible on the scout view, they do not recommend
dKUB either as these are likely to be radiolucent or
are likely to require treatment anyway. For the
remaining stones between 5 and 9 mm, they recom-
mend a dKUB at the time of CT so that comparison
between modalities can aid identification and allow
dKUB follow-up.
Volume 23  Number 2  March 2013
 Impact of imaging in urolithiasis treatment Magrill et al.

The European Association of Urology guidelines and number of PCNL access tracks, and the loops
on urolithiasis [8] state that ‘The sensitivity and can be displayed as a backdrop in the operating
specificity of KUB is 44–77% and 80–87%, respect- room for real-time assistance during endoscopic
ively. KUB should not be performed if NCCT is navigation (Figs. 2 and 3). The internal ramifications
considered, however, it is helpful in differentiating of the collecting system and the navigational route
between radiolucent and radio-opaque stones and to a given stone can be more readily grasped from
&
for comparison during follow-up’. For planning these movie loops compared to static images [18 ].
stone surveillance clearly, the urologist will need
to be able to choose a reliable imaging modality and
try to avoid repeated CTKUB unless proven to be the STONE CHARACTERISTICS ON
optimum method. COMPUTERIZED TOMOGRAPHY
Over the past decade, there has been a lot of interest
in the value of the measurement of stone density
THREE-DIMENSIONAL PLANNING FOR using Hounsfield Units as a surrogate for stone
INTERVENTION composition. Ouzaid et al. [19] carried out a recent
Three-dimensional (3D) volume reconstruction of a
renal stone, say a staghorn, can be easily achieved
using data from a standard NCCT [17]. The full
volume of the stone will be seen, but this is limited.
The relationship of the stone to the pelvicalyceal
system is not known, yet the collecting system
anatomy has a bearing on renal stone management.
Calculi in the dependent calyces are less likely to
drain and the access for percutaneous nephrolitho-
tomy (PCNL) should be planned such that all target
stone volume can be safely and efficaciously
removed. In the past, planning was based on the
IVU or an intraoperative urogram. These are natu-
rally limited, in that a two-dimensional image is
used to extract 3D information. Recently, with the
advent of thin section MDCT reconstruction,
the rich variety of the renal collecting system and
the surrounding anatomy can be recreated in exqui-
&
site 3D detail [18 ] and presented as rotating movie
loops (Fig. 1). These can be used to plan the direction

FIGURE 2. At the preoperative planning meeting, calyx ‘2’

FIGURE 1. Still image from a movie loop of a 3D volume
reconstruction of the left kidney for PCNL planning. The
staghorn and its disposition in the collecting system are
clearly seen. PCNL, percutaneous nephrolithotomy.
was selected as best for complete stone clearance from a
single PCNL track, as this would allow direct access to the
target stone (renal pelvis) and is also favourable for
navigation into the lower pole calyx for the removal of
nontarget stones. PCNL, percutaneous nephrolithotomy.

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 Urolithiasis
FIGURE 3. These intraoperative radiographs show the
successful stone clearance after the puncture of calyx ‘2’.
prospective study in 50 patients assessing the value
of Hounsfield Units on NCCT in predicting the
outcome of extracorporeal shockwave lithotripsy
(ESWL). ESWL was significantly more likely to result
in rendering the patient stone free with lower
Hounsfield Units densities. Specifically, a cut-off
of 970 Hounsfield Units was suggested, with stone
densities below this achieving stone-free rates of
96% and above this density a stone-free rate of only
38%. This adds to a range of previous studies inves-
tigating what promises to be a simple method to
council patients about the likelihood of successful
ESWL outcome [20,21].
However, Kijvikai and de la Rosette [22] recently
questioned the role of Hounsfield Units alone,
stating that it has ‘limited value as a predictor of
stone composition or the response to ESWL treat-
ment’, and they felt that more accurate measures
of stone morphology could give clinicians these
answers.
Dual-energy CT technology has existed for
35 years; however, its clinical introduction was
initially hampered by the lack of fast-acquisition
techniques such as helical or MDCT. These advances
in CT have led to the manufacture of many
dual-energy systems which rely on the fact that at
different photon energies (measured in kilovolts –
kV), materials will have characteristic absorption
patterns. The chemical composition can then be
inferred from measuring these differences. In the
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era of cross-sectional imaging, we have relied upon
single-energy attenuation counts (usually Houns-
field Units) to indicate the possible composition
of the stone. Coursey et al. [23] suggested that
‘the use of dual-energy CT, with pixel-by-pixel post-
processing techniques, may allow for better charac-
terization of renal stones than is possible with
single-energy techniques’.
Another application of this technology may be
in ‘subtracting’ the iodine from postcontrast images
using postprocessing techniques to create a ‘virtual
unenhanced’ image in which a stone is suspected.
This phantom study [24] looking at a variety of
stones in different iodine mediums offers the possi-
bility that patients who have undergone a postcon-
trast dual-energy CT scan only may be saved a repeat
noncontract CT to image stones.
REDUCING RADIATION EXPOSURE IN
STONE PATIENTS
Patients suffering from urinary stone disease are
a particular at-risk group. They are often young
(therefore radiosensitive) and suffer from a chronic
condition with a high risk of recurrence and each
episode can lead to high imaging requirements.
Considerable work has concentrated on the radia-
tion exposure that a single-imaging episode or single
treatment can generate; however, there has been
very limited attention on the cumulative exposure a
patient can experience for each single-stone episode
from diagnosis to being rendered stone free. We
should be particularly aware that the absolute life-
time risk of cancer induction from one abdominal
CT scan has been estimated to be approximately
1/700 [25].
In our United Kingdom Stone Unit in 2008, we
retrospectively reviewed the records of 60 consecu-
tive patients who were rendered stone-free and
calculated the estimated radiation exposure to aver-
age 5.3 mSv per stone episode [26]. Renal stones,
cross-sectional imaging and the need for interven-
tion were identified as predictors of higher radiation
&
exposure. Fahmy et al. [27 ] performed a similar
review of over 100 consecutive patients presenting
to their Canadian department with an acute stone
episode. During the first year after presentation,
the average effective radiation dose per patient
approached 30 mSv, with 17% of their patients
exceeding 50 mSv. They found, however, that
during the second year following diagnosis, this
was attributed to fewer CT scans and a greater use
of ultrasound.
Though this effective radiation dose per patient
seems high compared with our UK series, the
average exposure is similar to that reported recently
Volume 23  Number 2  March 2013

by two centres from the USA [28], where a median
exposure of 29.7 mSv per patient was noted and a
similar 20% of patients exceeded 50 mSv.
CONCLUSION
In summary, the evidence supporting the use of
CTKUB for the evaluation of acute loin pain is
compelling, but follow-up imaging strategies are
poorly described. In clinical practice, digitally
acquired plain KUB radiographs are proving some-
what disappointing for identifying small calculi and
inexperienced ultrasound performance can over-
estimate both the presence and size of calculi. On
the other hand, 3D CT PCNL protocols can provide
breathtaking images which can help improve the
surgical performance, but at the cost of higher radi-
ation exposure for our patients. An understanding
of which modality to employ, and when, for indi-
vidual patients is critical for the successful manage-
ment of urinary stone disease in 2013.
Acknowledgements
None.
Conflicts of interest
There are no conflicts of interest.
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