Marshall L. Stoller, Maxwell V. Meng-Urinary Stone Disease

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422 Ong and Jarrett

tion, however this was higher than the positive predictive value for clinical criteria alone

(35%) or plain abdominal films (32%) (32).

A subsequent study by Bird et al. in a series of 77 patients undergoing both noncontrast

CT imaging and 99Tc-MAG3 diuretic scintirenography for flank pain, found that

noncontrast CT is unable to determine the severity of renal obstruction. However, posi-

tive CT findings were able to differentiate patients without obstruction compared to

patients with any degree of obstruction. Findings on CT imaging associated with urinary

obstruction were perinephric and periureteral fat stranding, with odds ratios of 4.21 and

4.08, respectively (33).

Noncontrast CT imaging tends to overestimate stone size in the craniocaudal dimen-

sion. In a review of 39 patients who underwent noncontrast CT imaging as well as plain

abdominal radiography, Narepalem et al. report that craniocaudal stone size measured

by conventional abdominal films was 0.8 mm smaller than the size estimated on CT

imaging. Noncontrast CT imaging was performed using 5 mm slices, and the size dif-

ference was attributed to volume averaging. The authors concluded that finer collima-

tion or thinner cuts would improve the size estimate (34). The authors suggest a

combination of plain abdominal radiography, IVU, as well as noncontrast CT imaging

to plan treatment.

A study by Olcott et al. comparing linear nephrotomography, abdominal radiography,

and noncontrast CT imaging with three-dimensional reconstruction, found that with

three-dimensional reconstruction and thin cuts (3 mm collimation and 2 mm reconstruc-

tions), the linear dimensions of stone size were estimated to within 3.6% of the actual size

measured by plain abdominal imaging. The estimated volume was correct to within

4.8%. However, three-dimensional reconstructions are not usually performed at our

institution for renal stones owing to the increased time and expense associated with

generating a three-dimensional reconstruction (35).

Once a diagnosis of nephrolithiasis as the cause of flank pain has been established,

plain abdominal films are used to follow patients after they are discharged from the

hospital. Although some groups advocate noncontrast CT imaging without plain

abdominal radiography (36), it is difficult to correlate stone location and size on plain

abdominal radiography to the scout film of a noncontrast CT scan. Jackman et al. found

that the scout view of the noncontrast CT scan has a sensitivity of only 17%, compared

with plain abdominal radiography, which has a sensitivity of 48%. They found that plain

abdominal radiographs at the initial patient presentation facilitated patient follow-up and

obviated the need for more complicated imaging studies (37).

Corroborating these results, Assi et al. found that plain abdominal films had better

sensitivity (60%) than the scout film of noncontrast CT imaging (49%). When they

Table 2

Hematuria and Ureteral Calculi

Study No. of patients Sensitivity Specificity

Luchs 2002 950 84% 48%

Bove 1999 183 81% 40%

Abramson 2000 83 64% 55%

Chapter 22 / Treatment of Acute Renal Colic 423

stratified the sensitivity of detection for stone size larger than 3 mm, the rates increased

to 86% for plain radiography and 81% for scout CT imaging. They conclude that plain

abdominal radiography is superior to CT scout radiography for the detection of renal

calculi, particularly for proximal and mid-ureteral calculi (38).

Work by Zagoria et al. suggests an influence of both stone size and density on the

visualization of stones on plain abdominal films. In their series, they found that 78%

of stones larger than 5 mm, and only 36% of stones smaller than 5 mm were detected

on plain films. When they examined stone detection vs stone density, they found that 95%

of stones with a density equal to 300 Hounsfield units (HU) or greater were visualized.

Only 0.6% of stones with a density of 200 HU or less were visualized on plain films. Only

28% of stones with densities between 200–300 HU were visualized on plain films. Based

on these findings, they propose a treatment algorithm in which patients

with stone densities >300 HU would be followed with plain radiography. If the stones are

less then 200 HU in density, noncontrast CT imaging is required to follow stone passage.

For stones in the indeterminate area between 200–300 HU, the patient may require

unenhanced CT scan to confirm plain abdominal films when clinically indicated (39).

The duration of obstruction is also important in the diagnostic accuracy of noncontrast

computed tomography. In patients with renal obstruction, there is an increase in fre-

quency of secondary signs on ureteral obstruction with increasing duration of obstruc-

tion. These signs include perinephric and periureteral stranding, ureteral dilation, and

collecting system dilation. Varanelli et al. found that ureteral dilation was the most

sensitive—in patients with duration of renal obstruction less than 2 h, the presence of

ureteral dilation was only 84%. This increases to 97% of patients with obstruction lasting

longer than 8 h. The presence of perinephric stranding was 75% and did not increase in

prevalence with time of obstruction. However, in patients who had stranding, the sever-

ity was worse with time (40).

PREGNANCY

Although fast and accurate, CT imaging is associated with a relatively high dose (6.6

mSv) of ionizing radiation as compared to IVU, which has a dose of 2.4 mSv. This is

of concern for patients who are pregnant or those who require a large number of serial

imaging studies. Because of this, alternative low-dose noncontrast CT protocols have

been developed, and CT imaging is avoided in pregnant patients whenever possible. In

patients with a relatively low body to mass index, low radiation noncontrast CT protocols

have comparable sensitivity and specificity relative to standard radiation dose noncon-

trast CT imaging (41).

Renal colic complicating pregnancy offers a unique diagnostic and therapeutic chal-

lenge. Renal colic caused by nephrolithiasis occurs in as many as 1 in 715 pregnancies,

and is the most common cause of nonobstetric abdominal pain (42,43). Some authors

have found that the incidence of stones increases with the number of pregnancies (44).

Because the anatomic relationships of retroperitoneal organs are not distorted by preg-

nancy, the symptoms of renal colic are similar in gravid and nongravid patients. How-

ever, the relationship of abdominal organs is distorted by the gravid uterus, and an

erroneous diagnosis of appendicitis, diverticulitis, placental abruption, or premature

labor may be made in 28% of patients (45). As in other cases of suspected renal colic,

it is necessary to make a rapid diagnosis to exclude many more serious conditions.

424 Ong and Jarrett

Additionally, the presence of renal colic alone in the absence of infection increases the

risk of premature labor and fetal loss.

Physiologic dilation of the collecting system is seen in 90% of all pregnancies and

is unrelated to the number of previous gestations. This dilation gradually resolves over

8 wk postpartum. Early in pregnancy, ureteral dilation may be caused by hormonal

effects on the ureter. Hydronephrosis seen later in gestation is most likely caused by

the compressive effects of the fetal head, and is more severe on the right side. The left

ureter is thought to be protected by the sigmoid colon. This makes imaging more com-

plicated, because the clinician must differentiate physiologic obstruction from patho-

logic obstruction (46).

In pregnant patients, exposure to ionizing radiation is associated with an increase

in the rate of fetal cancer induction as well as of spontaneous abortion. The amount of

damage induced by radiation depends on both the dosage as well as the stage of

pregnancy. Epidemiologic studies suggest a 40% overall excess risk of childhood

malignancies associated with 10 mSv of radiation exposure during pregnancy, which

is the radiation dose associated with obstetric X-rays (47). Exposure to diagnostic

radiation increases the risk of childhood leukemia from a background rate of 1:3000

to 1:2000.

Oxford survey data on British women receiving obstetric radiographs from 1943 to

1965 suggests that the fetus is particularly susceptible for the first 8 wk after conception

(relative risk = 4.60), followed by the first trimester (relative risk = 3.19). The relative

risk of malignancy is similar for exposure during the second and third trimesters (relative

risk 1.29 and 1.30, respectively). Based on this data, the British National Radiogical

Protection Board has concluded that there is a 6% excess risk of malignancy before the

age of 15 yr for each Sv of radiation exposure in utero. Forty percent of this increased

risk ratio is the result of an increase in childhood leukemia (47).

Although data from the atom bomb survivors shows no association between fetal

irradiation and childhood cancers, the Oxford data is corroborated by animal experi-

ments, which demonstrate an increased risk of malignancy in beagles exposed to high-

dose ionizing radiation in utero (48).

There appears to be a threshold value of 100 mSv below which there does not appear

to be any increased risk of fetal damage. Exposure of the fetus to radiation doses in this

range or higher is a strong indication for a therapeutic abortion (49). The majority of

diagnostic procedures do not approach this level, even with repeated exposures (50). A

causal association between radiation and birth defects is difficult to establish scientifi-

cally, because 5–10% of all children with no history of radiation exposure have a detect-

able congenital anomaly (51).

In spite of this, there have been several lawsuits following the birth of a child with

multiple birth defects after exposure to low-dose radiation in utero. Because of these

concerns, it is prudent to avoid ionizing radiation whenever possible in the diagnosis and

treatment of pregnant patients with suspected renal colic. MRI has been suggested as an

alternative to CT imaging owing to its lack of ionizing radiation. The National Radio-

logical Protection Board does not recommend routine use of this imaging technique

during the first trimester owing to the unknown effects of magnetic fields on fetal

development (49). However, it has been used safely for the routine evaluation of mater-

nal pelvic masses and fetal growth restriction later during gestation, and for MR urog-

raphy (52).

Chapter 22 / Treatment of Acute Renal Colic 425

Ultrasound (US) is the imaging technique recommended by the ACOG as long as the

energy delivered by the ultrasound falls below 94 mW/cm

(49). However, this imaging

method may be of limited use, because the sensitivity of ultrasound ranges from 35–95%

(46).

A study by Fowler et al. comparing US to noncontrast CT imaging for stones in the

renal parenchyma and pelvis in a series of 123 patients found that US had a sensitivity

of only 24% and a specificity of 90% for stones in these locations. US frequently missed

renal stones less than 3 mm in size (53). Patlas et al. examined the sensitivity of US

compared to noncontrast CT imaging for ureteral stones. In their study, US had a sen-

sitivity of 93% and specificity of 95% when compared to noncontrast CT examination.

US was most effective in detecting the presence of a stone in the setting of hydoureterone-

phrosis secondary to nephrolithiasis. The sensitivity of US is better for the detection of

ureteral stones than renal parenchymal or pelvic stones (54).

A prospective study by Irving and Burgess comparing a two-film IVU and US in 15

women with flank pain presenting at 32 wk of pregnancy found that all women in the

study presented with hydronephrosis ipsilateral to the symptoms when screened with

US. Of these patients, 14 out of 15 were found to have delayed excretion, and 3 out of

15 were found to have obstructing stones. The authors suggest that IVU should be the

imaging method of choice, because it gives both anatomic and functional information

(55).

They conclude that ultrasound may not be useful to screen for hydronephrosis,

because the majority of pregnancies are associated with upper tract dilation by term, and

may be seen as early as 6 to 10 wk of gestation.

Variations on the technique of US, such as looking for evidence of ureteral jets,

imaging the full length of ureter, or examining the renal resistive index may add extra

sensitivity to US. The renal resistive index is calculated by (peak systolic velocity - peak

diastolic velocity) / peak systolic velocity. Values less than 0.7 are considered as normal

in the nonobstructed kidney. Values >0.7 are considered as suggestive of an obstructed

system (46).

Work in animal models demonstrates changes in renal hemodynamic parameters

accompanying renal obstruction, and suggests a role for Doppler US in the diagnosis of

complete or partial obstruction (56,57). This has not been shown to be reproducible in

clinical trials. Cronan et al. found that only 30–37% of patients with obstruction could

be diagnosed with acute obstruction using published guidelines for the change in renal

resistive index. In this series, the duration of obstruction was uncertain, and many

patients had received nonsteroidal analgesics before radiographic evaluation. They con-

clude that the use of Doppler US is highly operator-dependent, and should be reserved

to centers experienced in this technique (58). The sensitivity of this index may be depen-

dent on the duration of obstruction and is most sensitive after 3–4 h, although patients

have presented with a complete obstruction and a completely normal renal resistive

index (55).

This contrasts with the results of Shokeir et al., who published the results of a prospec-

tive study of 109 patients that compared noncontrast CT with Doppler US and IVU in

the setting of renal colic. They found that the change in renal resistive index (∆RI 0.04)

had a sensitivity of 90%, specificity of 100%, and diagnostic accuracy of 95%, for the

diagnosis of renal obstruction, which is comparable to the accuracy of noncontrast CT

imaging. In their series, patients with unilateral obstruction had an observed increase in

renal resistive index of 0.059 ± 0.01 (p <0.0001) in the obstructed side. Patients were

imaged using US before administration of nonsteroidal analgesics, and while the patient

426 Ong and Jarrett

was still experiencing pain. Shokeir suggests that the routine use of nonsteroidal anti-

inflammatory drugs before US imaging may decrease the diagnostic accuracy of Dop-

pler ultrasound (59).

If therapeutic intervention is required in pregnant patients, a number of authors have

published techniques that exploit the potential of US for real-time imaging (60). If

radiographic imaging is unavoidable, judicious use of fluoroscopy during stent place-

ment to mark the ureteral orifice and confirm stent placement is associated with a radia-

tion exposure of only 2.5 mSv. Irving and Burgess advocate nephrostomy tube placement

under US guidance late in gestation, with double-J stent placement earlier in pregnancy.

In light of the higher rate of ureteral stent encrustation during pregnancy, and the high

rate of discomfort associated with percutaneous nephrotomy, other authors suggest

definitive removal of the stones using holmium laser lithotripsy and ureteroscopy. In

experienced hands, this treatment is safe and avoids numerous procedures for stent

changes as well as the discomfort associated with percutaneous nephrostomy (61,62).

Extracorporeal shock-wave lithotripsy is absolutely contraindicated in all pregnant

patients.

Magnetic resonance urography is a relatively new technique, which is able to accu-

rately visualize fluid within closed spaces without the need for contrast. This imaging

method is particularly well suited for the pediatric population, and is more sensitive than

either US or IVU for the detection of congenital anomalies (63). There is a report of

HASTE-MR urography used for the determination of the cause of hydronephrosis in a

pregnant patient, whose fetus was also found to have hydronephrosis in utero (64).

However, MR urography may not be as sensitive for the detection of ureteral stones.

Blandino et al. suggest that some ureteral stones may be missed without careful scrutiny

of the MR study because ureteral stones appear as an area of signal void (74). It is

possible for these areas to be obscured by the surrounding high-intensity signal arising

from fluid or urine. Roy suggests an emerging role for MR urography as a second-line

relatively noninvasive diagnostic test when the US study is nondiagnostic (65).

URINARY EXTRAVASATION

The presence of urinary extravasation as demonstrated by IVU is estimated to be 0.1%

in normal individuals, but may be as high as 25% in patients with ureteral obstruction

receiving high-dose intravenous contrast (66). Urinary extravasation may occur in either

peripelvic or perirenal locations. Peripelvic extravasation is much more common and

arises from microscopic tears in the urothelium of the calyceal fornices or by transflow

of urine through mucosa in the setting of increased hydrostatic pressure. The normal

resting pressure of the renal pelvis is 5–15 cm water. Pyelosinus backflow (lymphatic

backflow) occurs at pelvic pressures of 30 cm water, and forniceal rupture at 50–100 cm

water (67). Extravasation is a natural mechanism of renal decompression and is usually

managed conservatively, although urinoma and abscess formation have been reported

following urine extravasation (68).

Radiologic findings suggestive of this etiology are “hornlike” extension of contrast

from a calyceal fornix, peripelvic opacification, parallel translucent lines around the

ureteric wall, and demarcation of the lateral psoas border (69). The presence of a dense

nephrogram in the setting of perirenal contrast extravasation helps to confirm the diag-

nosis (70).

Retrograde pyelography is contraindicated in this setting, as it is thought that

it may worsen the extravasation or enlarge the forniceal tear (67). In the rarer form of

Chapter 22 / Treatment of Acute Renal Colic 427

perirenal extravasation, of which there are two reported cases, it is thought that urine

extravasation takes place directly across the renal parenchyma (71).

This entity may also occur in patients without obstruction of the collecting system,

and is termed spontaneous obstruction. As with extravasation following renal obstruc-

tion, excellent results are obtained with conservative management (72,73). Significant

fibrosis may result from urinary extravasation and may be confused with idiopathic

retroperitoneal fibrosis (68).

Other entities that may be confused with forniceal rupture are spontaneous rupture of

the pelvis and rupture of calyceal diverticula, both of which are managed operatively

with decompression and repair (75). Decompression is also indicated in cases of forniceal

extravasation with persistent pain, fever, or leukocytosis.

TREATMENT

Patients initially present in the emergency room with acute renal colic and are given

pain medications before any urologic consult. The emergency medicine literature has

found intravenous ketorolac is more effective than intravenous opioids for the relief of

flank pain caused by renal obstruction. There is a theoretical increase in ureteral smooth

muscle tone accompanying many opioid analgesics, and this may exacerbate the degree

of ureteral spasm associated with renal stones.

Sandhu et al. compared ketorolac to meperidine in a prospective double-blinded

randomized study in patients with renal colic. In this study, a single dose of ketorolac

30 mg or meperidine 100 mg was administered to patients. They found that 56% of

patients receiving ketorolac required repeat analgesia within 24 h, as compared to 80%

of patients receiving meperidine. They also observed a faster onset of pain relief and

lower incidence of side effects in the group of patients treated with ketorolac when

compared to the group receiving meperidine (76).

This agrees with the results found by Oosterlink et al., who conducted a randomized,

double-blinded trial comparing ketorolac with meperidine. This group found that

ketorolac in the 90 mg dose was superior to both meperidine 100 mg and ketorolac 10 mg

for pain control. Fewer patients in the high-dose ketorolac group required subsequent

medication (17%) for pain control as compared to patients in the meperidine 100 mg arm

(47%), or ketorolac 10 mg (39%). This group also found a dose-dependent effect for

ketorolac and perceived pain intensity, with the results favoring the ketorolac 90 mg

dosage. There was no statistically significant difference between the ketorolac 10 mg

group and the meperidine 100 mg group in terms of efficacy of pain control or durability

of pain relief. The incidence of adverse effects, especially vomiting, was lower in the

ketorolac groups than in the meperidine group (77).

Aggressive hydration in the setting of renal colic may help to pass the renal stones.

However, this may also increase patient discomfort and require ureteral stenting. Patients

suffering from renal stones are advised to ingest 2–3 L of fluid per day (78).

However,

it is interesting to note that patients who are encouraged to drink more fluids only

increased their daily urine output by only 0.3 L/d. Accompanying this increase in urine

volume was an increase in the filtered sodium load, which in turn increases calcium

excretion and can increase the risk of recurrent stone disease (79).

Hospitalization for potential decompression is indicated for patients unable to tolerate

oral hydration, have no relief of pain with oral analgesics, or have a concomitant urinary

tract infection in the setting of urinary obstruction. More aggressive management is also

428 Ong and Jarrett

indicated in patients with a solitary kidney with renal colic or symptoms of renal obstruc-

tion. Patients with symptoms refractory to a trial of intravenous hydration and analgesics

should be strongly considered for stent placement. Stenting or urinary tract decompres-

sion is also indicated in patients with an impacted calculus >6 mm in diameter, or who

fail to pass a stone after 4 wk (79).

URINARY DECOMPRESSION

Depending on the clinical setting, there is some debate over the most appropriate

method of decompression in the setting of obstructed pyelonephritis. To date, there is no

conclusive study that demonstrates superiority of one technique over the other. A ran-

domized prospective study by Pearle et al. comparing retrograde ureteral stenting with

percutaneous nephrostomy found no significant difference in efficacy or time to recov-

ery between the two groups. The only significant difference was that percutaneous

nephrostomy was more cost-effective in their center than retrograde ureteral stenting.

Interestingly, they had one failed percutaneous nephrostomy that was salvaged by ret-

rograde ureteral stenting. There was no incidence of unsuccessful retrograde stenting in

their study. The rate of positive urine cultures was also higher in the percutaneous

nephrostomy group, suggestive of better urinary drainage than retrograde ureteral

stenting (80).

This is similar to the results of Joshi et al., who found no statistically significant

difference in clinical outcome between double-J stenting and percutaneous nephrostomy

in a nonrandomized prospective trial. The authors suggest that percutaneous nephrostomy

tube placement is a less invasive procedure than ureteral stenting, and may be associated

with a lower rate of urosepsis, although this was not seen in their study (81).

This contrasts with the findings of a randomized controlled trial by Mokhmalji com-

paring ureteral stenting with percutaneous nephrostomy in a series of 40 patients. This

study approached but did not reach statistical significance. They found that percutaneous

nephrostomy was associated with less postoperative pain, less radiation exposure, and

was successful in every case. In their study, double-J stent placement had a success rate

of 80%, and was found to have a 20% conversion rate to percutaneous nephrostomy.

Unsuccessful cases were attributed to lack of adequate sedation in half of the patients and

benign prostatic hypertrophy in the remainder. There was no incidence of failed percu-

taneous nephrostomy tube placement; however, up to 40% of patients with proximal

ureteral stones and 10% of patients with distal ureteral stones required revision of the

nephrostomy tube the following day (82).

Though not statistically significant, there was a statistical trend in the same study

suggesting that the duration of diversion, amount of administered analgesic, and length

of antibiotic therapy with a percutaneous nephrostomy were consistently less than with

a ureteral stent, suggesting that percutaneous nephrostomy was more efficient at drain-

ing the obstructed kidney. The same findings also showed that males and patients less

than 40 yr of age tolerated nephrostomy tubes better than indwelling stents. The authors

conclude that a percutaneous nephrostomy should be preferred to ureteral stent place-

ment in cases of infected hydronephrosis or upper ureteral stones (82).

Both studies found a statistically significant, though not clinically significant, dif-

ference in the amount of fluoroscopy time required for placement of retrograde ure-

teral stents versus percutaneous nephrostomy tubes. It is interesting to note, however,

that the success of percutaneous nephrostomy is dependent on the number of cases

Chapter 22 / Treatment of Acute Renal Colic 429

performed by the radiologist per year. Lee et al. found that the success rate is close to

100% for radiologists performing more than 20 cases/yr. This rate drops to 83% for

those performing fewer than 10 procedures/yr, and may play a factor in the decision

between retrograde ureteral stent placement and percutaneous nephrostomy place-

ment (83).

Disadvantages of nephrostomy tube placement are patient discomfort with an ind-

welling tube, tube dislodgement, leakage, and potential to introduce infection. Advan-

tages include potentially better drainage, the ability to perform antegrade studies without

intravenous contrast, and the ability to perform the procedure under regional or local

anesthesia. When appropriately placed, the nephrostomy tube tract may also be used for

definitive stone removal. If retrograde stenting is chosen as a method of decompression,

the operative success rate may be improved with general anesthesia instead of intrave-

nous sedation.

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