Urolithiasis

DOI 10.1007/s00240-016-0918-1

ORIGINAL PAPER

Differentiation of ureteral stones and phleboliths using

Hounsfield units on computerized tomography: a new method
without observer bias
Yiloren Tanidir1,2 · Ahmet Sahan1 · Mehmet Kazim Asutay1 · Tarik Emre Sener1 ·
Farhad Talibzade1 · Asgar Garayev1 · Ilker Tinay1 · Cagri Akin Sekerci1 ·
Ferruh Simsek1 

Received: 26 April 2016 / Accepted: 3 September 2016

© Springer-Verlag Berlin Heidelberg 2016

Abstract To differentiate ureteral stones and phleboliths of the opacity. Using the cut-off values of 171 mm³ for vol-
by measuring density [as Hounsfield unit (HU)] and vol- ume (sensitivity 75 %, specificity 100 %) and 643 HU for
ume (as mm3) of the opacities in the bony pelvis on unen- density (sensitivity 75 %, specificity 93 %), differentiation
hanced computerized tomography (U-CT). A total of 52 between stone and phlebolith was achieved. Differentiation
patients, who underwent semirigid ureteroscopy and laser of pelvic opacities needs meticulous observation with cer-
lithotripsy for distal ureteral stone and had isochoronous tain signs on U-CT. On the other hand, our study offers a
phleboliths in U-CT, were included. Images were reviewed new method, with certain cut-off values, such as 643 HU
for density and volume of the opacities. Data were com- and 171 mm3, which can be used to precisely predict the
pared, and a cut-off value was defined with receiver operat- actual nature of opacities of interest.
ing characteristics curve analysis to differentiate the nature
Keywords  Diagnosis · Imaging · Hounsfield unit ·
Ureteral stones · Ureteroscopy
* Yiloren Tanidir
yiloren@yahoo.com
Ahmet Sahan Introduction
dr.sahan@hotmail.com
Mehmet Kazim Asutay Urinary tract stone disease constitutes a majority of urolo-
kazimasutay@hotmail.com gist’s daily practice. Stone disease has a high prevalence
Tarik Emre Sener that exceeds 10 % in developed countries and ranges up
dr.emresener@gmail.com to 37 % in certain parts of the world, while the incidence
Farhad Talibzade depends on geographical, ethnic, dietary, and genetic fac-
talibzade@gmail.com tors [1, 2]. Of all urinary tract stones, ureteral stones are
Asgar Garayev the most commonly encountered and represent an impor-
asgar.garayev@gmail.com tant pathology with high numbers of emergency admis-
Ilker Tinay sions. However, they can also be identified coincidentally.
ilker_tinay@yahoo.com Although the majority of the urinary stones can be seen
Cagri Akin Sekerci in plain kidneys–ureters–bladder (KUB) X-ray images
cagri_sekerci@hotmail.com due their calcium composition, the gold standard imaging
Ferruh Simsek technique for ureteral stone diagnosis is unenhanced com-
ferruh.simsek@gmail.com puterized tomography (U-CT). Unfortunately, endourolo-
1 gists encounter a major pitfall in diagnosing distal ureteral
Department of Urology, School of Medicine, Marmara
University, Istanbul, Turkey stones (DUS), because there may be several opacities in the
2 bony pelvis that need to be identified by further radiologi-
Marmara Universitesi Pendik Egitim ve Arastırma Hastanesi,
Fevzi Cakmak Mah., Mimar Sinan Cad. 41, Ust Kaynarca, cal evaluations to distinguish DUS from pelvic opacities.
Pendik, 34899 Istanbul, Turkey

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 Urolithiasis
Fig. 1  Radiological evaluations of a patient for inclusion in this
study. a The preoperative KUB X-ray shows two opacities on the left
side of the bony pelvis. b The topogram of the U-CT scan shows two
opacities on the left side of the bony pelvis. c The coronal section of
Among these opacities, phleboliths are some of the most
common pathologies that need recognition.
There are no specific signs or clues during the U-CT exami-
nation for the differential diagnosis of DUS. Several diagnos-
tic methods are used by radiologists for differential analysis in
U-CT, namely, rim sign and central opacification, among oth-
ers. These signs are investigator dependent and cannot always
help distinguish a DUS from a phlebolith. In addition, none of
these diagnostic techniques have been compared to the findings
of in vivo ureteroscopy (URS), which is considered the gold
standard diagnostic and therapeutic method for ureteral stones.
In this study, we aimed to describe a practical method
to differentiate DUS and phleboliths for patients who were
candidates for a potential semi-rigid URS. This method
was based on the stone density in terms of Hounsfield units
(HU) and stone volume in mm3 using the U-CT.
Methods
This study aimed to evaluate the efficiency of using opac-
ity density and volume in differentiating DUS from phlebo-
liths. Between 2011 and 2013, a total of 243 patients with
a DUS diagnosis underwent semi-rigid URS in our clinic.
We reevaluated the preoperative KUB X-ray along with the
preoperative U-CT and postoperative KUB X-ray images
of the 243 patients. A total of 52 patients meeting the inclu-
sion and exclusion criteria were selected as the study group.
Inclusion criteria consisted of:
• patients who underwent a semi-rigid URS;
• patients who had all three imaging procedures: a pre-
operative KUB X-ray with a preoperative U-CT and a
postoperative KUB X-ray image;
• patients who had a radiopaque DUS and an accompany-
ing ipsilateral phlebolith in the bony pelvis; and
13
the preoperative U-CT scan shows a ureteral stone and a phlebolith. d
The postoperative KUB X-ray shows the disappearance of the opacity
that belonged to the ureteral stone and the persistence of the opacity
belonging to the phlebolith
• patients in whom both opacities were visible in the
KUB image.
Exclusion criteria consisted of:
• patients who had more than two opacities on the ipsilat-
eral side of the bony pelvis;
• patients who had any opacity >15 mm; and
• patients in whom the URS did not reveal any stones.
Exclusion criteria were set to ensure a more homogene-
ous study group and to decrease the bias. For each patient,
postoperative KUB examinations on postoperative days 1
and 30 with an additional ultrasonography on postoperative
day 30 were performed to check for complete stone clear-
ance. To minimize both the risk of radiation exposure as
well as the overall costs, a postoperative U-CT scan was
not performed.
The differentiation of ureteral stones from phleboliths
was done with the aid of postoperative KUB X-ray imag-
ing. Hypothetically, the radiopaque ureteral stone should
disappear in the postoperative KUB X-ray image following
the intervention. The topogram and coronal sections of the
U-CT were matched and compared with the postoperative
KUB X-ray. Eliminated opacities were then diagnosed as
DUS, while residual opacities were diagnosed as phlebo-
liths in the U-CT (Fig. 1). Finally, transverse (T), longitudi-
nal (L), and anteroposterior (P) diameters and HU measure-
ments of each opacity were determined.
While assessing the U-CT images, non-contrast axial,
sagittal, and coronal images from a Siemens Somatom 16
Slice CT® with 5-mm section thicknesses were used.
The density of each calcification was measured in HUs
by a circle tool integrated in the Novo-PACS system (Ver-
sion 7.3.11.10). Opacity volume was calculated by the for-
mula for the ellipsoid: T  × L  × P  × π/6, as described in
earlier studies by El-Nahas et al. and Sorokin et al. [3, 4].
Urolithiasis

Statistical analyses were performed using SPSS software

version 20.0 (IBM Corp, NY, USA) along with regression
analysis and receiver operating characteristics (ROC) meth-
ods. Statistical significance was set at p < 0.05. Baseline
variables were described using means and standard devia-
tions or percentages, as appropriate. Student’s t tests were
used to evaluate the differences between quantitative meas-
urements that had normal distributions. Diagnostic values
for the maximum density and volume of the opacity for the
prediction of DUS were analyzed with ROC inclines. Sen-
sitivities, specificities, and predictive values with 95 % con-
fidence intervals were calculated.

Results

We evaluated a total of 52 U-CT images. Mean ± stand-

ard deviation (SD) volumes were 32.4 ± 31.7 and
352.7  ± 333.4 mm3 for phleboliths and DUS, respec-
tively. The corresponding mean ± SD densities were
398.0 ± 290.1 and 922.7 ± 309.5 HU, respectively. A sta-
tistical power analysis was performed for these two vari- Fig. 2  ROC curve for opacity size (AUC 0.956, p = 0.001; sensitiv-
ables and revealed 100 % power, indicating sufficiency. ity 75 %, specificity 100 %, threshold value is taken as 171 mm3)
The ROC analysis revealed a threshold of 171 mm3 (AUC
0.956, 95 % CI 0.75–1.0, p = 0.001) (Fig. 2) for the opac-
ity volume value and a threshold of 643 HU (AUC 921,
95 % CI 0.75–0.93, p = 0.001) for the maximum opacity
density (Fig. 3). The calculated volumes of the calcifica-
tions were lower than 327 mm3 in all patients with a phle-
bolith. In only 7.7 % of patients with phleboliths, the calcu-
lated densities of calcifications were greater than 643 HU.
The volume of the calcification was greater than 171 mm3,
and the density was higher than 643 HU in 75 % of patients
with a final DUS diagnosis (Table 1).

Discussion

U-CT is superior to all other imaging modalities with a

97 % sensitivity and 96 % specificity in detecting urinary
tract stones [5]. Moreover, U-CT is the recommended
imaging modality in the emergency setting when a urinary
stone is suspected [6]. However, in daily practice, it can be
difficult to define a calcification in the bony pelvis as either
a ureteral stone or a phlebolith due to their similar appear-
ance and location [7–9]. To the best of our knowledge, this
is the first study to suggest a method to differentiate the Fig. 3  Maximum Hounsfield unit ROC curve (AUC 0.921,
opacities in U-CT through the eyes of a urologist. p = 0.001; sensitivity 75 %, specificity 93 %, threshold value is taken
as 643 HU)
Phleboliths are intravascular calcifications predisposed
by slowing of the blood circulation within passive venous
channels. Their chemical analysis reveals calcium and as carbonate-fluorohydroxylapatite [Ca10(PO4)5CO3(OH)
phosphate, confirmed with X-ray micro-diffraction analysis F], which provides a clear radiopaque feature [10].

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 Urolithiasis
Table 1  The size (when the cut-off opacity size was accepted as 171 mm3) and the density (calculated maximum Hounsfield unit was accepted
as 643 HU) of pelvic radio-opacities
Density and size of pelvic radio-opacities Phlebolith [n (%)]
<643 HU and <171 mm3 48 (92.3 %)
<643 HU and >171 mm3 0 (0 %)
>643 HU and<171 mm3 4 (7.7 %)
>643 HU and>171 mm3 0 (0 %)
Total 52 (100 %)
U-CT is commonly used in daily practices for the diag-
nosis of urinary tract stone disease. This technique has been
shown to be superior to all other imaging modalities in the
detection of urinary tract stones. However, phleboliths in
the bony pelvis represent a real challenge for the differen-
tial diagnosis of DUS as they share similar radiological fea-
tures [2, 11, 12]. In these scenarios, further imaging with
contrast agents or endoscopic imaging may be necessary to
confirm suspected stones located in the distal ureter [5].
Negative URS is not insignificant. The major predictors
of a negative URS are small stone size and a distal loca-
tion as opposed to preoperative pain and the presence of
hydronephrosis [13]. Thus, in patients undergoing URS for
small, distal stones, the diagnosis should be clear to avoid
unnecessary surgery. There are methods such as additional
imaging or specific interpretation techniques for differ-
ential diagnoses. However, it should be kept in mind that
additional imaging may have the disadvantage of additional
radiation exposure.
Several studies have reported various methods to dif-
ferentiate stones from phleboliths on U-CT scans. These
methods include measuring the density of the opacity and
looking for specific signs, such as the rim sign, tail sign,
and central lucency [6, 9, 14]. The sign has been studied
as an indicator of differentiation between DUS and phle-
boliths, but again, this differentiation depends on a subjec-
tive evaluation method [15]. Almost all of the studies were
reported from radiology departments where the findings
were compared with a different imaging technique. How-
ever, none of these compared U-CT imaging to URS, the
most reliable method to diagnose and treat ureteral stones
at this location [16].
Another way of differentiating a ureteral stone from a
phlebolith is by analyzing the composition of the opacity
with the help of U-CT imaging. However, this may result
in some interobserver variability, especially between radi-
ologists and urologists [17, 18]. Measuring the density
of a urinary tract stone is a crucial part of the diagnosis
and treatment and is recommended by the European Asso-
ciation of Urology (EAU) Guidelines before deciding on
the method of treatment [8]. Moreover, measurements of
HU and opacity volumes allow us to have an objective,
13
Distal ureteral stone [n (%)] Total [n (%)] p value
6 (11.5 %) 54 (51.9 %) 0.0001
7 (13.5 %) 7 (6.7 %) 0.0126
7 (13.5 %) 11 (10.6 %) 0.5256
32 (61.5 %) 32 (30.8 %) 0.0001
52 (100 %) 104
universally accepted, and quantitative result that can be
applied to any patient. We think the evaluation of any
opacity with these easy-to-use tools that are integrated in
most imaging software would help in the differential diag-
nosis and provide successful treatment outcomes. In this
study, we suggest a method to help differentiate a suspi-
cious stone from a phlebolith by measuring its density and
size on the U-CT image. We hypothesized that one can
identify an opacity in a U-CT scan as a urinary tract stone
or a phlebolith based on the HU value. This is based on
the fact that 61.5 % of opacities with a density of higher
than 643 HU and a size bigger than 171 mm3 were found
to be ureteral stones. In addition, our study suggests that
the density of the opacity together with its size is a better
indicator of a stone compared to the central lucency sign.
U-CT has limited sensitivity and specificity in diagnosing
a phlebolith when compared to URS. However, the diag-
nostic accuracy of U-CT could significantly be improved
with certain suggested tools [5, 19–21]. As Patatas et al.
reported, a significant percentage of negative examinations
implies that an improvement in current practice is needed
[22]. These cut-off values provide the highest sensitivity
along with the highest specificity possible as the area under
the curve (AUC) in ROC analysis for this differentiation
method provides a value of 0.921. This means that our
method has a 7.9 % false negativity, which could be con-
sidered fairly high in the absence of objective differentia-
tion methods. Thus, the importance of DUS should never
be disregarded. Small ureteral stones have a tendency to
pass spontaneously; therefore, the EAU Guidelines sug-
gest “expectant management” as an important treatment
option in these stone patients [8]. Nevertheless, any treat-
ment option should be discussed, and patients should be
followed up on a stringent schedule to avoid unwanted
harmful effects that can occur due to an untreated ureteral
stone causing an obstruction.
Limitations of the study
The major limitations of this study are the small sample
size and the case–control study design. The sample size
Urolithiasis
was sufficient to demonstrate the proposed association in
the statistical power analysis (100 %). Since we recruited
patients with both DUS and phleboliths, the data acquisi-
tion had to be retrospective. However, reassessments of
tomography sections were performed prospectively after
the final diagnosis of the patients. Another limitation con-
cerns the proficiency of the formula used in stone volume
calculations, as it might fail to reflect the absolute stone
volume. Interestingly, several other studies have also used
this formula in which the opacity was presumed to have an
ellipsoid shape [3, 4]. This measurement is not so accurate,
because pelvic opacities could have various shapes due to
surface irregularities, but the calculation of such irregular-
shaped opacities is a very complex procedure requiring
special measurement software as well as the help of radi-
ologists [23].
In conclusion, there is a need for some specific signs to
differentiate ureteral stones from phleboliths on U-CT. Our
data show that the density (cut-off value of 643 HU) and
volume (cut-off value of 171 mm3) of opacities can be used
for accurate differentiation, and they can be quickly and
easily calculated and interpreted with limited inter-observer
variability.
Parameters like density and volume in U-CT contrib-
ute in the decision making for pelvic opacities. Thus,
urologists might avoid unnecessary imaging and surgical
interventions for the sake of differential analysis, which
will improve the financial outcome for health expenses.
Improvement in diagnostic accuracy can provide a faster,
safer, and more accurate therapeutic approach.
The phrase primum non nocere (first, do no harm)
must never be forgotten. Thus, endourologists should
never underestimate an easily manageable pathology such
as a DUS by leaving it untreated and should never harm
the patient with overtreatment due to additional radiation
exposure and unnecessary interventions. We must be fully
competent to interpret all of our findings and act on them
accordingly, and this requires adequate knowledge and
practice to reach an accurate diagnosis.
Compliance with ethical standards  doi:10.1016/j.urology.2011.03.008
Conflict of interest  The authors have no conflict of interest to declare.
Ethical standard  This study was conducted after receiving approval
from the institutional review board.
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