Radiology of

Renal Stone
Disease
Pembimbing : dr. Imelda Tobing
Sp.Rad

Penyusun: Gracita Geminica

112017151
Introduction
 Kidney stones remain a very common problem, affecting
approximately 1 in 10 people at some point in their life.
 Imaging plays an important role in the management of
patients with renal stone disease including initial diagnosis,
treatment planning and follow-up after medical therapy or
urologic interventions.
 In this paper, we discuss the various imaging techniques
available for renal stone detection, together with the
recent advances that have improved our ability to not only
detect stones, but also to use these novel techniques such
as material decomposition, to characterize stone
composition.
Imaging
 Unenhanced Computed Tomography
(CT) of the abdomen and pelvis has
become the first-line test for evaluation of
renal calculi in patients with acute flank
pain and suspicion of urolithiasis.
 CT has sensitivity and specificity of over
95% for the diagnosis of nephrolithiasis.
 Fig. 1. 66 year old female
presenting with hypogastric
pain with bilateral costo-
vertebral angle tenderness.
 Axial NCCT image (a) shows a
calculus in left upper ureter.
 Axial image (b) at the level of
pelvis and coronal (c) show
colonic diverticulosis with
diffuse bowel wall thickening,
extensive pericolonic fat
stranding and fluid in distal
sigmoid colon, suggesting
acute diverticulitis
Ultrasound
 The use of ultrasound for the evaluation of renal pathology iswell established.
In particular, and with regard to nephrolithiasis, ultrasound is very effective in
the detection of hydronephrosis, which may be related to an obstructing
renal or ureteric stone. Indeed, ultrasound can reliably detect larger renal
stones exhibiting posterior acoustic shadowing (Fig. 2) with relative ease.
 Although the use of ultrasound is attractive given the relative easy of access,
low cost and absence of ionizing radiation, the authors found that in those
patients who had undergone point of care ultrasound and diagnostic
ultrasound required additional workup in the form of CT scan in 40.7% and 27%
of cases, respectively. On the other hand, this meant that more than half of
the patients enrolled in an ultrasound arm of the study did not require a
subsequent CT scan [8].
 As a result, ultrasound remains an important tool in the armamentarium of the
urologist, not only for follow-up of patients with known nephrolithiasis, but also
in those patients for whom exposure to ionizing radiation is to be avoided,
including pregnant and pediatric patients.
 Fig. 2. 79-year-old man with
history of nephrolithiasis,
undergoing follow-up
ultrasound. Sagittal image of
the left kidney reveals a large
stone in the lower pole
(arrow), with posterior acoustic
shadowing (arrowheads).
Conventional radiography
and intravenous pyelogram
(IVP)
 There is an increased mean effective radiation
dose to patients [13] undergoing CT urography
when compared to IVP.
 Despite the limitations of plain radiography in
assessment of stone disease, it continues to play a
role in the day- to-day evaluation of patients with
nephrolithiasis particularly in the follow up of
patients undergoing urologic intervention to
monitor changes in stone burden.
Multidetector CT
 MDCT has challenges with accurate determination of stone
composition.
 Reliance on estimation of mean attenuation values of the calculi by
placement of region of interest (ROI) has traditionally allowed physicians
to determine the composition of stone, which in the case of uric acid
stones permits medical management through urine alkalinization.
 Uric acid stone have CT density values ranging from 200 to 450 HU at 120
kV, whereas calcium phosphate stones have mean HU values between
1200 and 1600.
 Although attenuation based methods have shown success using in-vitro
models [18], they have limited success in in-vivo studies due to [19],
mixed nature of many stones [20], and challenges with precise
positioning of the ROI particularly for small calculi [21].
 Fig. 3. Axial (a) and coronal (b) non-contrast CT images from a
patient presenting with left flank pain and gross hematuria.
 A large staghorn calculus (arrow) occupying the majority of
the left renal collecting system was identified, with focal
cortical scarring in the lower pole (arrowhead).
 Volumetric analysis allows to more accurately estimate stone
burden in complex calculi than morphological measurements.
Dual energy CT (DECT)
 DECT can take the form of a scanner whereby a single tube alternatives between high
and low voltage (single source, ssDECT), or a scanner where there are two tubes,
typically mounted orthogonally, which operate at different voltages (140 kVp and 80
kVp), and allow for acquisition of dual energy images without the need for rapid
switching of the tube current (dual source, dsDECT).
 Dual energy CT allows for enhanced determination of material composition by
comparing the attenuation of materials at different x-ray energies. The technology is not
limited to differentiating between stone types, but can also use mathematical algorithms
to identify iodine in the acquired images, and remove it to create a virtual unenhanced
image [24].
 When imaged using DECT, renal stones exhibit different attenuation values at different x-
ray energies, depending on their composition. The values can then be applied to a look-
up table to estimate the stone composition [26], a technique that has been validated
with laboratory evaluation of stone composition [27].
 The dual energy index (DEI) is calculated using a mathematical formula that incorporates
the attenuation values from both portions of the examination, and is used by software to
generate a color-coded map (Figs. 4 and 5).
 Fig. 4. Characterization of kidney
stones using dual-energy
computed tomography (DECT).
 Axial non-contrast CT image (a)
shows a calculus at the upper-
pole region of left kidney.
 Post-processed color map (b)
shows a calcium containing
calculus in the left kidney colored
in blue.
 Dual energy plot (c) confirms the
composition of the stone (arrow).
 Fig. 5. Characterization of kidney
stones using dual-energy computed
tomography (DECT).
 Axial non-contrast CT image (a)
shows a small calculus at the mid-
pole region of the right kidney.
 Post-processed color map (b)
showing a uric acid renal calculus
in the right kidney colored in red.
 Dual energy plot (c) confirms the
composition of the stone (arrow).
 Note the mild dilatation of right
pelvicalyceal system (a), due to
another calculus in the right ureter
(not shown).
Radiation dose considerations
& low dose CT
 The ALARA principle, or As Low As Reasonably Achievable, is a tenet of
modern imaging [30], and requires the medical com- munity to make every
reasonable effort to ensure radiation doses are kept to a minimum. Adhering
to the principle has benefits not only for the patient, but also the wider
community as a whole, and is underpinned by regulatory limits and societal
guidelines [31e33].
 It has been shown that careful estimation of the radiation required to produce
diagnostic quality images can reduce the ra-diation dose by up to 65% in
those undergoing surveillance of renal stones [34], from 22 mSv to 7.8 mSv
(effective dose equivalent) on MDCT using a phantom.
 In addition to decreasing tube current, modern CT systems typically come
equipped with other methods to assist with dose reduction.
 For example, automatic tube current modulation allows for the real-time
adjustment of tube current depending on the patient's body habitus; less x-
rays are required for extremities and lungs for example, but more are required
for those areas that are difficult to penetrate, including the pelvis.
Treatment planning
 Accurate evaluation of the two-dimensional stone area or
three- dimensional stone volume on CT allows the treating
physicians to estimate the likelihood of success using
extracorporeal shockwave lithotripsy (ESWL) [44,45]. In addition,
determination of stone volume has been demonstrated to be
more accurate determinant of stone burden in morphologically
complex stones such as staghorn calculi.
 For example, in cases of uric acid stones, which account for
approxi- mately 10% of all stones, urinary alkalization can be
performed to aid with their dissolution [46]. Uric acid stone are
composed mainly of light chemical elements, such as hydrogen,
carbon, oxygen and nitrogen, in contradistinction to non-uric
stones, which contain heavy elements including calcium. On
DECT, the attenuation of uric acid stones varies considerably
between the low and high x-ray energy acquisitions, unlike other
renal stones, where the values are more similar [47].
 Fig. 6. 52 year old woman with history of
recurrent nephrolithiasis. Following a
recent lithotripsy and stent placement, a
follow-up CT was performed.
 Axial non-contrast CT (a) highlights the
difficulty separating a residual calculus
(arrow) from the ureteric stent
(arrowhead).
 Color-coded dual-energy CT (b) exhibits
the benefits of material decomposition,
allowing the stone to be clearly
delineated from the adjacent stent.
 An additional stone fragment (c, arrow)
was also detected in the distal left ureter
adjacent to the stent (arrowhead), best
seen on dual-energy images.
Special situations
 Pregnancy
 Drug induced stones
 Fig. 7. 33 year old female with
early pregnancy presented with
recent onset left flank pain.
 Ultrasound image (a) shows
pelvicalyceal system dilatation
in the left kidney.
 Ultrasound images in transverse
(b) and longitudinal (c) planes
at the level of bladder show a
small calculus at vesicoureteric
junction and dilated lower
ureter.
 A gravid uterus with gestational
sac and a well defined fetal
pole can also be noted (c & d).
Financial considerations
 Renal stone disease is estimated to cost in the region of $2 billion per annum
[64].
 As a result, there are efforts to decrease the costs associated with
management of nephrolithiasis, including the imaging studies that are
performed [65].
 In a multisite randomized control trial, the comparative cost of point of care
ultrasound (performed by an Emergency Department physician), diagnostic
ultrasound performed in radiology, and abdominal CT was analyzed.
 The Study of Tomography of Nephrolithiasis Evaluation (STONE) trial examined
over 2700 patients.
 The authors found that cost of point of care ultrasound was $113, compared
with $141 for a formal diagnostic ultrasound in the radiology department and
$248 for a CT scan of the abdomen.
 It is clear that healthcare costs associated with diagnosis and treatment of
renal stone disease is complex, and identifying and achieving cost savings is
challenging.
 Conclusion
 Radiological techniques play an integral role in the management of
patients with urolithiasis.
 Advances in technology particularly in the realm of MDCT have
enabled these techniques to not only provide accurate detection but
also provide urologists with information crucial for patient selection,
treatment planning and monitoring response to various urologic
interventions.
 Continued attention to radiation dose considerations related to CT
technology remains of paramount importance.
 Radiologists and urologists should work in tandem to optimally utilize
imaging techniques exploring alternative imaging methods or low dose
techniques to ensure an optimal balance between risks and benefits
associated with imaging to provide best possible care for patients with
stone disease.