HARVARD

MEDICAL SCHOOL

Kidney Stone Diagnosis and

Managment
Dushyant Sahani MD
Disclosures

• MGH has research agreement

– GE Health Care
– Siemens Medical Systems
 Clinical Perspective

Prevalence 5.2%
of
Urolithiasis Rising Prevalence
3.2%

1970s 1980s 1990s

• Urolithiasis has a life time risk of 10-15%

• It has a high relapse rate (50% in 5-10 yrs and 75% in 20 yrs)
• Affects Men more than women
• Common clinical presentation – Acute flank pain and hematuria
Curhan, G.C., Epidemiology of stone disease. Urol Clin North Am, 2007. 34(3): p. 287-93.
 MDCT in Urolithiasis
• Unenhanced CT - Initial investigation of choice in suspected urolithiasis

– 22% of all CT performed in the ER for acute abdomen pain

• Highly accurate test (Sensitivity = 95-98% & Specificity =96-100%)

– Detects other causes of acute flank pain

• Identification of ureterolithiasis at imaging altered management in nearly

55%–60% of patients suspected of having acute renal colic.

• Reveals associated abnormalities like congenital abnormalities,

infections and neoplasms

• Rosen MP et al. Eur Radiol 2003;13(2):418–424.
• Dalrymple NC et al. J Urol 1998;159(3):735–740.
• Wrenn K. Ann Emerg Med 1995;26(3):304–307.
Stone Types Radioopacity

Composition Occurrence On KUB On CT

Calcium oxalate monohydrate 40-60% Radio-opaque Radio-opaque

(COM) & dehydrate (COD)

Hydroxyapatite 20-60% Radio-opaque Radio-opaque

(Calcium phosphate)

Brushite 2- 4% Radio-opaque Radio-opaque

Uric Acid 5-10% Radio- lucent Radio-opaque

Struvite 5-15% Radio-opaque Radio-opaque

Cystine 1- 2.5% Mildly Opaque Radio-opaque

MDCT Technique

• Scan Coverage - Upper

pole of kidneys to the Slice thickness – 3-5 mm
base of the bladder Pitch - 1 - 1.6
• Patient preparation -
Bladder distension to
visualize stones within
the distal ureter
Coronal Reformations
(2.5 - 3mm)
 Urolithiasis –CT Diagnostic Signs

Virtually all stones are Primary sign of Ureterolithiasis

radio-opaque on CT (>200HU) Stone in the ureter (target sign) with proximal
hydroureter

Stones radiolucent on CT - Pure matrix stones and stones made of pure Indinavir
(Indinavir - Protease inhibitor used in the treatment of HIV)
 Value of Coronal Reformations
1 2

• Improved detection of stones unrecognized on axial images

• Improved detection of small ureteral and renal calculi at poles

• Phleboliths and calcified vascular plaques from urinary stones

• Enhances radiologist confidence

• Benefits the urologists in treatment decision

Lin WC et al. J Urol 2007.

Factors Influencing Treatment Decision
Urologic intervention is influenced by 3 crucial factors

Stone size/
location

Patient Stone
Symptoms Composition

Presence of obstruction is not the primary factor

considered for urologic intervention
• Bierkens AF et al. Br J Urol. 1998.
• Eisner BH et al. Urology 2008.
• Phipps S et al. Ann R Coll Surg Eng 2010.
 Stone Burden Assessment
• Stone burden (stone size and volume) determines the type of procedure
• ESWL or Ureteroscopy is performed for stones <1cm

•PCNL for stones >1.5cm

Stone Size
• Accurate stone size measurement is paramount to plan treatment options
• The ideal method for accurate measurement on CT is to measure using
bone window settings (1250 X 250) and magnification

6 mm
8mm

Soft tissue window Bone window with Eisner BH et al. J Urol 2009
Magnification
Stone Size & Treatment Decisions

Stone < 5mm Stones > 6mm & <15mm Stone >15mm or Staghorn Calculi
(98% for stones < or = 4mm (6-9 mm uereteral stone 60-25% pass)
pass spontaneously)
Stone location predicts outcome
Upper=48%, mid=60%, lower 75-79%
likely to pass spontaneously

Medical Expulsive therapy • Extracorporeal Shockwave Percutaneous

(Alpha blockers)
Intervene for unremitting
pain, nausea, fever, failure
to passage on medical
therapy
lithotripsy (ESWL) Nephrolithotomy
• Ureteroscopic lithotripsy (PCNL)
(upper ureter or larger stone)
• Bierkens AF et al. Br J Urol. 1998.
• Coll DM et al. AJR 2002.
• Eisner BH et al. Urology 2008.
• Phipps S et al. Ann R Coll Surg Eng 2010.
Stone Volumetry
Threshold based
CAD Algorithms
or manual semi-
automated
22 cc methods
• Linear measurement not suitable in irregularly contoured stones like
stag horn calculi
• Measuring the stone volume eliminates this problem
• Total stone volume is an appropriate measure of stone burden

• Demehri S et al. AJR 2012.

• Singh Ak et al. RSNA 2010.
ESWL Failure: Multivariate CT
characteristics
Independent Area-Under Cut-off value Sensitivity; 95% P=value
Variables Curve Specificity (%) Confidence
(Dependent (AUC) Interval
Variable= failure (CI)
rate)
Stone Volume CAD 0.895 >712.54 mm3 80;80 0.745-0.964 P<0.0001

Stone Volume- 0.872 >564.75 mm3 88;73 0.728-0.956 P<0.0001

Products
Maximum Stone 0.839 >8.89mm 96;60 0.688-0.936 P<0.0001
Size
Number of Stones 0.755 >2 52;86 0.593-0.877 P=0.0002

Mean Stone Size 0.735 >6.25mm 92;46.7 0.571-0.861 P=0.0002

Age 0.524 <50y 96;33 0.360-0.684 P=8267

Overall model fit (Chi square)=21.818; p=0.0006

Singh Ak et al. RSNA 2010.
Stone Composition & Treatment Decisions

<400 HU > 500 HU

Uric Acid Stone

<1000 HU >1000HU
Medical Management (Struvite) (Brushite, Cystine, COM)
Allopurinol
Treatment of Hyperuricemia
ESWL Ureteroscopy
PCNL

Hamm M et al. J Urol 2002.

Parker BD et al. Urology 2004
MDCT and Stone Composition
Stone composition can be determined using HU

CT Attenuation values – 64-77% accuracy in determination of stone

composition, is not robust and reliable

Stone Composition Attenuation value at

120kVp
Uric Acid 200-450 HU
Struvite 600-900 HU
Cystine 600-1100 HU
Calcium Phosphate 1200-1600 HU
COM and Brushite 1700-2800 HU

• Stone composition also effects the efficacy of ESWL (Brushite, cystine and
COM stones are hard and resistant, while struvite stones usually fragment easily)
Dretler SP. J Endourol 2001
Motley G et al. Urol 2001
Eisner BH et al. J Urol 2009
KulkarniN et al. JCAT (in-press)
 DECT: Stone composition

Uric Acid Stone Non uric acid stone

Element composition Light Elements Heavy Elements
(H, C, N, O) (P, Ca, S)

Attenuation at 80 kVp Lower HU Higher HU

Attenuation at 140 kVp Higher HU Lower HU

Calcium Calcium
710 HU 480 HU Uric Acid
Uric Acid
290 HU 315 HU

80kV 140kV
Renal Stone Composition: 11 studies 
(dsDECT=8 & ssDECT=3)
• Uric Acid vs. Non UA stone differentiation possible
– Phantom and humans 100%
– Reliable for stones 3 mm and above

• Non-UA subtype of pure composition possible in phantom

and in humans
– mixed composition stones difficult to characterize

Stolzman P. Urol Res 2008, Graser A. Invest Radiol 2008, Matlaga B. Urology 2008, Graser A . Eur Radiol 2009, Thomas C. Eur Radiol
2009, Ball D. Radiology 2009,, Hidas G. Radiology 2010, Manglaviti G. AJR 2011, Kulkarni N. JCAT (in-press)
Stone Fragility in Guiding Treatment

Heterogenous
More fragile to Homogenous
Lithotripsy More resistant
to lithotripsy

• CT helps predict stone fragility and susceptibility to lithotripsy

• Stones which are heterogeneous are more fragile than homogenous

stones which are more resistant to ESWL
 Stone Precursor-Randall’s Plaque
• Randall’s Plaque - Calcium salt deposits
30 HU
in the tip of renal papilla of patients with
Normal papillae
nephrolithiasis and are potential sites for

calculus formation

• These stone bearing papillae appear Whitish deposits

denser on non-contrast CT and represent
- Randall’s plaque

Randall’s plaque on endoscopy

• MDCT can help select patients at high-

risk for stone formation, who may

undergo appropriate medical

management to halt the formation of 58 HU

stones
Stone bearing papillae
Eisner BH et al. J Endourol 2008
 MDCT in Planning Intervention

• Simple trigonometry on CT of the patients with complex stones could help

endourologists in planning renal access.
• CT also helps in planning surgical interventions by identifying the location of the
posterior calyx thus guiding fluoroscopic procedures like percutaneous
nephrolithotomy
Stone Follow up
In patients managed medically,

CT attenuation is a good predictor of utility of radiography in routine follow up

>300 HU Follow up Radiograph <200 HU Follow up CT

Calculi with attenuation > 300 HU are Calculi with attenuation < 200 HU are
radio-opaque & are followed up by radiolucent & hence followed up by CT
Abdominal Radiograph
Stone Follow up –Post Intervention
Pre Treatment Post Treatment

Significant Stone Burden Residual Stone Burden

though significantly reduced

Significant stone burden necessitates further treatment

 Stone vs Stent
Abdominal window Bone window

Stent

Stones

• Differentiation between stent and stone is vital in post surgical follow up

• Stents and stones have the same CT appearance on abdominal window.

• Bone window allows visual distinction between the stent and the stone
which is accounted for by differences in pixel density.

Tanricut C et al. Urology 2004

 MDCT and Radiation Dose
• A key concern for repeated CT examinations in recurrent stone disease.

• The effective radiation dose during unenhanced CT

2.8 to 13.1 mSv for men / 4.5 to 18 mSv for women

• Techniques for Reduction of Radiation dose

- Limit scanning area (not typical Abd+Pelvis exam)

- Increase in axial slice thickness to 5mm from 1-3 mm

and include 2.5-3 mm coronal reconstructions

- Lower dose CT exam ( noise index, kVp, pitch)

Strategies for Dose Reduction
Limit
Scanning area
Increase slice thickness
Include coronal reformations

+ Low kVp

DLP
1000 mGy-cm
+ Low mAs

+
Total Dose Reduction
by 40-70% from DLP
200 mGy-cm
Standard dose
Ultra-low dose approaches
Renal stone

Initial scan – Standard dose CT (low mAs)

Follow up scan – ultra-low dose CT

WT kVp mA

Low dose CT <200 lbs 80 75-150

> 200 lbs 100 75-150

Ultra-low dose approaches

177 lbs 280 lbs

 IRIS/ASIR/iDOSE/ADIR/SAFIRE MBIR/Veo
FBP VS. Partial IR VS. Full IR
Simple Comprehensive Advanced
Blend
FBP+IR

Ideal Few
Advanced
System Iterations
model

CPU CPU CPU

Simple Better IQ Optimal IQ
Fast Low dose Low noise
High noise Low noise Better resolution
18 DEC 2007 22 DEC 2008

DLP 388 DLP 184

5.82 2.76
53%
 Radiation Dose-ULD Stone CT

8.8

87% 90% 85%

mSv

1.1

2 view KUB
Std dose CT ULD CT
Wt CTDI mSv CTDI mSv
Category
Over all 11.4 8.8 1.8 1.1
< 200 lbs 10.6 8.6 1.3 0.8
> 200 lbs 15.4 10.8 2.3 1.5
Kulkarni N M et al. Radiology 2012
 More aggressive dose reduction

=
2 View KUB = 0.6 – 1.2 mSv CT KUB = < 1 mSv
Kulkarni N M et al. Radiology doi:10.1148/radiol.12112470
 Author Year Abdomen CT

Marin D Radiology. 2010

Prakash P Invest Radiol. 2010

Sagara Y AJR Am J Roentgenol. 2010

20%-
Singh S Radiology. 2010 50%

May MS Invest Radiol. 2011

Schindera ST Radiology. 2011

Martinsen AC Eur J Radiol. 2011

Vorona GA Pediatr Radiol. 2011

IQ Dos
e
Current Imaging Strategy

The scope of imaging has extended beyond the mere

detection of stone and its location

The current strategy is to determine the stone composition,

its fragility and quantification which has great implications in

treatment planning
 Summary Points
• MDCT with multiplanar reformations is accurate in stone assessment

• The qualitative assessment by CT influences management by

dictating treatment options like ESWL.

• Spectral imaging and CAD is emerging for stone

composition/Quantitation

• Various stratergies for radiation dose reduction in imaging of

urolithiasis achieving accurate diagnosis and reduced radiation dose

delivery.

• New reconstruction algorithms (ASIR) is promising in dose reduction

 Thank You

Dushyant V Sahani, MD
Division of abdominal imaging and intervention
Department of Radiology
Massachusetts General Hospital
White 270, 55 Fruit street
Boston, MA-02114

Email:dsahani@partners.org
Ph (o): 617-726-8396
 References
1. Curhan, G.C., Epidemiology of stone disease. Urol Clin North Am, 2007. 34(3): p. 287-93.
2. Sandhu, C., K.M. Anson, and U. Patel, Urinary tract stones--Part I: role of radiological imaging
in diagnosis and treatment planning. Clin Radiol, 2003. 58(6): p. 415-21.
3. Ege, G., et al., Acute ureterolithiasis: incidence of secondary signs on unenhanced helical CT
and influence on patient management. Clin Radiol, 2003. 58(12): p. 990-4.
4. Heneghan, J.P., et al., Helical CT for nephrolithiasis and ureterolithiasis: comparison of
conventional and reduced radiation-dose techniques. Radiology, 2003. 229(2): p. 575-80.
5. Boulay, I., et al., Ureteral calculi: diagnostic efficacy of helical CT and implications for treatment
of patients. AJR Am J Roentgenol, 1999. 172(6): p. 1485-90.
6. Fielding, J.R., et al., Unenhanced helical CT of ureteral stones: a replacement for excretory
urography in planning treatment. AJR Am J Roentgenol, 1998. 171(4): p. 1051-3.
7. Lin WC, Uppot RN, Li CS, Hahn PF, Sahani DV. Value of automated coronal reformations from
64-section multidetector row computerized tomography in the diagnosis of urinary stone
disease. J Urol 2007; 178:907-911; discussion 911.
8. Smith, R.C., et al., Diagnosis of acute flank pain: value of unenhanced helical CT. AJR Am J
Roentgenol, 1996. 166(1): p. 97-101.
9. Eisner BH, Iqbal A, Namasivayam S, Catalano O, Kambadakone A, Dretler SP, Sahani DV.
Differences in Computed Tomography Density of the Renal Papillae of stone formers and Non-
stone formers: A pilot study. J Endourol 2008 Oct 2.
10. Bilen CY, Kocak B, Kiticci G, Danaci M, Sarikaya S. Simple trigonometry on computed
tomography helps in planning renal access. Urology. 2007 Aug;70(2):242-5; discussion 245
Jouranal/Yea DECT # Stones
r Technique
Dual-Energy CT for Stone
Composition
1 2
• Dual Source CT: By operating the two
tubes at different energies (80 & 140 kVp)
it is effective in tissue material composition
2 1

•Gem stone spectral imaging (single

source DECT) - is a recent DE CT
operated on rapid kVp switching is also
available for tissue characterization/stone
composition

Stolzman et al Urol Res 2008, Graser et al 2008 Invest Radiol, Graser et al 2009 Eur
Radiol, Thomas et al Eur Radiol 2009
 Post Processing - DSDCT
80 kV 140 kV

80

140

High and low kVp

Two X-ray tube

• Uric acid stones - Red

(Syngo VA 11; Siemens)
• Non Uric acid stones - Blue 3 material decomposition algorithm
 Post Processing - SDCT
MD Water MD Iodine

Uric Acid stone = MD Water +, MD Iodine –

High and low kVp Non-Uric Acid stone = MD Water +, MD Iodine +

Rapid kV twitching

Effective Z Image

Effective z number – scatter plot

Dual-Energy CT for Stone
Composition
Phantom Model – Uric Acid vs Non uric Acid
DSDCT SDCT
65 stones (Size Range- 2-18mm) 35 stones (Size range 3-19mm)

MD Water MD Iodine

Uric acid Non-Uric acid Uric acid Non-Uric acid Uric acid Non-Uric acid

Accuracy Sensitivity
<3mm >3mm
DSDCT 8/8 57/57 65/65
(UA -16, Non UA =49) (100%) (100%) (100%)

SDCT 2/2 33/33 35/35

(UA -6, Non UA =29) (100%) (100%) (100%)
Dual-Energy CT for Stone
Composition
Patients – Uric Acid vs Non uric Acid
DSDCT SDCT
37 stones 49 stones
Mean size-6mm, Range 2-24mm) (Mean size-6.8mm, Range 1.2-28mm)

CT CT

UA 7 UA 15

Non UA 23 Non UA 34

Not Identified 7 Not Identified -

Final confirmation Final confirmation

- 9/18 patients - 3/17 patients
- 20 Stones (6 uric acid & 14 non uric acid) - 8 Stones (All calcium oxalate)
Dual-Energy CT for Stone
Composition
Phantom Model – Differentiation of Non uric Acid
DSDCT SDCT
Red Blue Calculated Effective Z
Effective z
1.15 Uric Acid Struvite, Brushite,
COM, Cystiene Uric Acid 6.92 7.2
1.30 Uric acid Cystine, Brushite
Struvite COM Struvite 9.72 9.99
1.45 Uric acid Brushite
Cystine 11.07 11.25
Struvite, Cystine COM
1.60 Uric acid, Struvite,
COM 14.37 13.12
Brushite, COM,
Cystiene

90% Cystine stones (9/10) / 100% Accuracy

84.2% Struvite stones (11/13)
 Strategies for Dose Reduction– Coverage Area

From top of diaphragm to lower border From Top of kidneys to base

of pubic symphysis of urinary bladder

Restrict Scanning Area

Dose Reduction by 15-20%

Targeted scans focused to area of interest can be performed for follow up CT exams
Strategies for Dose Reduction - Slice Thickness

1-3mm 5mm

Increase Slice thickness from 1-3mm to 5mm

and include 2.5-3mm Coronal Reformations

Dose Reduction by 20-40%

Strategies for Dose Reduction
Role of Low kVp - Exam based on Body Weight
140 kV (> 250 lbs)
Dose= kVp

120 kV (141-249 lbs)

100/80 kV (<140 lbs)

20% reduction

20% reduction
Total 40 %
Dose Reduction
Strategies for Dose Reduction- Increase in Noise Index/
reference mAs (100-180)
Noise Index -15

Noise Index -20

Noise Index -30

15-20% reduction

15-20% reduction

Total 30-40 %
Dose Reduction
MDCT Protocol Modifications
GE WT Slice Th mA NI

<300 5 150-450 25- I

16/64-
30 - F
MDCT >300 5 150-450 25- I

30 - F

Siemens WT Ref Sl DC Pitch

mA Thick
16-64 All wt 100- 5 24x1.2
group 160
1.2
NI- Noise index
I - Initial scan kV (100-120)
F- Follow up scan
MDCT Protocol Modifications
Review Phase (116 lbs)

Monitoring Phase (114 lbs)

61%

CTDI- 11.5

CTDI- 4.22
 Adaptive Statistical Iterative
Reconstruction (ASIR)
• Noise reduction reconstruction method to improve the
signal-to-noise
• Relies on the accurate modeling of the distribution of
noise in the acquired data

• MGH Experience (GE HD 750) 65 patients studied so far

• Radiation dose reduction achieved (25-81%)

Kole et al 2006 Phys Med Biol