International Journal of Surgery xxx (2016) 1e9

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International Journal of Surgery

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Review

Radiology of renal stone disease

Colin J. McCarthy a, Vinit Baliyan a, Hamed Kordbacheh a, Zafar Sajjad b,
Dushyant Sahani a, Avinash Kambadakone a, *
a
b

Department of Radiology, Massachusetts General Hospital, 55 Fruit Street, White 270, Boston, MA 02114, USA
Department of Radiology, Aga Khan University Hospital, Stadium Road, Karachi 74800, Pakistan

h i g h l i g h t s
 Recent advances in Computed Tomography (CT) have improved the radiological evaluation of renal stones disease.
 With DECT, it is possible to determine the in vivo composition of renal stones, assisting with diagnosis and treatment.
 There are ongoing efforts to decrease radiation dose related to CT examinations, including those for renal stone disease.

a r t i c l e i n f o

a b s t r a c t

Article history:
Received 24 October 2016
Accepted 30 October 2016
Available online xxx

Nephrolithiasis is a common cause of abdominal pain and will affect approximately 1 in 10 people in
their lifetime. In the past two decades, there have been several technological advances that have changed
the imaging approach to stone diagnosis and follow-up. We present a review of the current imaging
evaluation for renal stone disease, and outline how new technology has helped with diagnosis and
management.
2016 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.

Keywords:
Nephrolithiasis
Radiology
Computed Tomography
Low dose
Ultrasound

1. Introduction
Kidney stones remain a very common problem, affecting
approximately 1 in 10 people at some point in their life [1]. The
incidence of kidney stones appears to have increased over the last
few decades, and although this may be partly explained by
improved detection, at least some is due to changes in diet and
rising levels of obesity [1].
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
* Corresponding author.
E-mail addresses: colin.mccarthy@mgh.harvard.edu (C.J. McCarthy), vbaliyan@
mgh.harvard.edu (V. Baliyan), hkordbacheh@mgh.harvard.edu (H. Kordbacheh),
zafar.sajjad@aku.edu (Z. Sajjad), DSAHANI@mgh.harvard.edu (D. Sahani),
AKAMBADAKONE@mgh.harvard.edu (A. Kambadakone).

decomposition, to characterize stone composition. The article will

also discuss the impact of these technological advances on medical
and urological management of nephrolithiasis.
2. Imaging
Unenhanced Computed Tomography (CT) of the abdomen and
pelvis has become the rst-line test for evaluation of renal calculi in
patients with acute ank pain and suspicion of urolithiasis [2]. CT
has sensitivity and specicity of over 95% for the diagnosis of
nephrolithiasis [3]. Even in those patients who turn out not to have
nephrolithiasis, CT allow diagnosis of alternative causes for the
patient's pain, such as appendicitis, diverticulitis or gynecological
emergencies (Fig. 1). In fact, an alternative diagnosis may be identied in up to 14% of patients undergoing CT for evaluation of
suspected urolithiasis [3].
3. Ultrasound
The use of ultrasound for the evaluation of renal pathology is

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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).

Fig. 1. 66 year old female presenting with hypogastric pain with bilateral costovertebral 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 uid in distal
sigmoid colon, suggesting acute diverticulitis.

well 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. However,
smaller stones, and in particularly those less than 5 mm in size, may
be difcult to detect on ultrasound [4e6]. Others have countered
that argument, and stated that although such small stones may be
missed on combination of ultrasound and plain radiograph of the
abdomen, such stones were not likely to become clinically important, and may pass spontaneously [7].
In a recent randomized control trial, over 2700 patients with
suspected nephrolithiasis were randomized to undergo point of
care ultrasound (by an Emergency physician), diagnostic ultrasound in the radiology department, or CT scan. 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].
Ultrasound at the point of care may also allow for the detection
of hydronephrosis. The STONE PLUS prediction tool, for example,
has recently addressed the signicance of detecting hydronephrosis [9]. By combining Sex, Timing, Origin, Nausea, Erythrocytes (STONE) with point-of-care limited ultrasonography (PLUS),
the authors noted that moderate or severe hydronephrosis
improved risk stratication of patients with nephrolithiasis, specically identifying those who may be more likely to require
intervention. 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.
4. Conventional radiography and intravenous pyelogram
(IVP)
The advent of MDCT and its advantages in the evaluation of

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patients with urolithiasis has superseded the role of IVP in diagnosis of this condition [10]. Although it offers additional information over plain radiography, such as identication of anatomic
abnormalities and assessment of renal function non-contrast CT
with or without CT urography provides superior evaluation in
comparison to IVP [11,12]. 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 dayto-day evaluation of patients with nephrolithiasis particularly in
the follow up of patients undergoing urologic intervention to
monitor changes in stone burden.
5. Multidetector CT
Non-contrast CT of the abdomen and pelvis is the typically the
rst radiological examination ordered in those patients who are
suspected to have nephrolithiasis. Over the past two decades, there
has been a tremendous rise in the availability of CT [14], which in
the case of suspected nephrolithiasis, can be performed without
any patient preparation including need for intravenous or oral
contrast. Typically, non-contrast axial images (5 mm) are obtained from the top of the kidneys to the pelvis, and reviewed in
conjunction with sagittal and coronal reformats (2e3 mm). Unenhanced CT imaging not only allows detection of calcium based
stones but also permits detection of stones that are typically
radiolucent on plain radiography, such as xanthine and uric acid
stones [15].
In addition to detecting stones invisible on plain radiography
due to their size and/or composition, CT offers the additional
benet of more precise anatomic localization of the urinary calculi
over conventional radiography. For example, stones in the ureter
that may be obscured by overlying bowel on plain radiographs are
readily demonstrated on CT. The secondary signs of ureteric stones,
such as hydronephrosis, hydroureter and perinephric stranding are
also immediately apparent on CT. Important complications, such as
forniceal rupture may also be detected, therefore allowing a far
more comprehensive assessment of not only the stone location, but
the associated effects and complications, which assists in triaging
those patients who may require more immediate management,
such as nephroureteral stent or nephrostomy placement. Similarly,
patients who may be managed expectantly, or who may have
already passed the stone, can be identied.
The importance of reliably identifying simple parameters such
as stone location and size cannot be underestimated, as doing so
has a direct impact on patient management (Fig. 3). For example, it

can be anticipated that stones 1 mm in size will pass almost nine

times out of ten, dropping to a 25% spontaneous passage rate in
those patients with a stone that is 9 mm or greater. Similarly, stones
are more likely to pass if they are located closer to the vesicoureteric junction [16].
A commonly used measurement, the Hounseld Unit (HU), has
been used since the beginning of CT technology [17] to determine
the attenuation of material, and thereby estimating the composition of various materials. Although this is relatively straightforward
for certain materials such air, water and cortical bone, where the
difference between materials is large, the use of such measurements for renal stones is fraught with difculties, as discussed
above.
Despite its immense advantages, 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].
6. Dual energy CT (DECT)
Perhaps the biggest technological advance in renal stone imaging in the last few years has been the widespread availability of
dual-energy CT (DECT). Although research on the potential benets
of dual-energy CT has been ongoing since the late 1970's [22], it is
only in the last decade that the technology has become available to
the mainstream medical community. 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) [23].
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

Fig. 3. Axial (a) and coronal (b) non-contrast CT images from a patient presenting with left ank pain and gross hematuria. A large staghorn calculus (arrow) occupying the majority
of the left renal collecting system was identied,with focal cortical scarring in the lower pole (arrowhead). Volumetric analysis allows to more accurately estimate stone burden in
complex calculi than morphological measurements.

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virtual unenhanced image [24]. In patients who require iodinated

contrast for evaluation of the solid abdominal organs, or delayed
urographic imaging, for example, the availability of a virtual
unenhanced data set negates the requirement to obtain a dedicated
non-contrast acquisition, thereby reducing radiation dose [25].
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). It is important to note that acquisition of two
sets of images at different x-ray energies does not represent a
doubling of the radiation dose; instead, the total dose is split,
roughly in half, between the two acquisitions [28]. If viewed
separately, such images would appear noisy due to a relative
decrease in the number of photons producing each image, however,
in reality, the information from both portions of the exam is combined or blended using software to produce images that look
similar, if not identical, to those from conventional MDCT. It is
worth noting that a complete dual-energy CT of the abdomen can
be obtained in under 10 s [28], allowing for rapid diagnosis and
turnaround time. In cases where delayed or excretory phase imaging is required (CT urography), the ability to subtract the iodine
from the images, creating a virtual unenhanced image, at the same
time decreases the artifacts that can sometimes result from ureteric
peristalsis [29].
The ability to identify the composition of stones offers the potential for treating physicians to customize therapy based on the
crystalline composition [1] (see treatment planning section below).
7. Radiation dose considerations & low dose CT
Although physicians should attempt to reduce or minimize radiation exposure wherever possible, renal stone disease is one that
has benetted greatly from recent advances in CT.
As many patients may suffer recurrent episodes of renal colic,
necessitating multiple follow-up radiology studies, it is important
to note that cumulative radiation exposure needs to be considered.
Wherever possible, follow-up with renal ultrasound and/or plain
radiograph of the abdomen may be sufcient, thereby avoiding the
increased radiation dose associated with CT scan. This is especially
true for calcium-based stones, which are radio-dense on plain
radiography.
However, in those cases where CT is needed for reliable reevaluation, follow-up examinations should be adjusted to use the
least amount of radiation possible whilst still obtaining adequate
imaging. The ALARA principle, or As Low As Reasonably Achievable,
is a tenet of modern imaging [30], and requires the medical community to make every reasonable effort to ensure radiation doses
are kept to a minimum. Adhering to the principle has benets 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 radiation 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. Similarly, in studies addressing the in-vivo
dose reductions, it has been shown that reducing tube current can
produce reductions in dose of between 25% and 42%, whilst still
maintaining accuracy [35].
In addition to decreasing tube current, modern CT systems

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) conrms the composition of the stone
(arrow).

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

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algorithms including statistical-based and model-based IR reconstructions may allow for radiation dose savings in the region of
25% [37], which can be supplemented with other dose-saving
techniques. A recent prospective, single-center study by Moore
et al. addressed the accuracy of reduced dose CT for evaluation of
suspected ureteric stones. The authors reported an impressive 88%
reduction in dose using a customized protocol, whilst still identifying all patients who required urologic intervention [38]. These
ndings have been replicated in other studies, including a paper by
Kulkarni et al., where the authors obtained dose reduction in excess
of 80% by using modied scan parameters and advanced iterative
reconstruction algorithms [39]. Others have reported that the
decreased resolution of soft tissue structures may decrease sensitivity for detecting stones, however, especially in the pelvis, where
due to increased image noise, it may prove difcult to place a
calcication denitively within or outside the ureter, for example
[40].
A recent review of radiation dose from renal colic protocol CT
studies was performed in the United States, using information
obtained from the National Radiology Data Registry [41]. By way of
background, the Dose Index Registry (DIR) is sponsored by the
American College of Radiology (ACR), and gathers radiation exposure data from individual CT studies performed at those institutions
that participate in the project [42]. Dose information (with patient
identiers removed) is transmitted automatically from each CT
scanner to a local server, which in turn transmits the data to the
registry. This allows institutions to compare their average dose for a
particular examination to other facilities. The review found that the
dose index for renal stone protocol CT varied dramatically between
institutions (with a ve-fold range of dose indexes), and that in
general, there was considerable scope to implement low dose
protocols to decrease radiation exposure.
Nonetheless, alternatives such as ultrasound may be useful in
carefully selected patients who require long-term follow-up, to
assess for gross interval changes in the stone burden, or the presence of hydronephrosis. In this group of patients, ultrasound has
been shown to be reasonably accurate at detecting stones [43].
However, when it comes to treatment planning, ultrasound has its
limitations.
8. Treatment planning

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) conrms 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).

lungs for example, but more are required for those areas that are
difcult to penetrate, including the pelvis. These systems adjust
radiation not just at different parts of the body (z position), but also
as the tube moves around different projections in the angular or x-y
plane, within each 360-degree rotation of tube [36].
Advances in how CT information is reconstructed into images
have also played an important role in the drive to decrease radiation doses. For example, the use of newer iterative reconstruction

Accurate evaluation of the two-dimensional stone area or threedimensional 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.
With the advent of dual energy CT and material decomposition,
physicians are now able to reliably determine the composition of
renal stones in vivo, thereby providing the treating urologist with
valuable information to assist with treatment planning. For
example, in cases of uric acid stones, which account for approximately 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]. Using an in vitro model, one group demonstrated
the accuracy in identifying uric acid stones from non-uric acid
stones was in the range of 93e100% [46].
Even in those stones that are determined to be non-uric acid

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containing, work has been done on determining the fragility of

stones, and suitability for ESWL. In one study, an ex vivo model was
used to measure stone volume, roughness and internal
morphology. Specically, the authors measured the ratio of CT
numbers on both the low and high-energy components of the examination, and developed a model that predicted stone fragility
based on time to comminution using a lithotripsy system [48]. The
reliability of dual energy for predicting the major component of
renal stones has also been validated using in vivo models [49].
Additionally, the ability to measure parameters such as the stone to
skin distance (SSD) on CT allows for patients to be accurately
identied for suitability for ESWL. Stones that are greater than
10 cm from the skin surface are less likely to respond to ESWL
[50,51].
The anatomic information obtained on CT, including stone
location, obstructions of the collecting system and complications
related to nephrolithiasis allow for detailed follow-up of patients to
assess for response to treatment. In those patients who have undergone stent placement, dual energy can also assist in differentiating the stent from a small residual stone fragment (Fig. 6). The
ability to accurately detect and localize stones allows patients to be
stratied into various treatment algorithms by the treating Urologist, using additional information including stone composition and
the presence or absence of hydronephrosis [52].
Although ultrasound continues to be used for treatment planning, it has been shown to overestimate the size of small stones,
with the potential for recommending treatment when in fact the
stone is smaller, and may have passed itself [6]. In particular, ultrasound may overestimate the size of small stones (5 mm) by
almost 85% [53], something that both radiologists and treating
urologists should be cognizant of.
9. Special situations
9.1. Pregnancy

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 difculty separating a residual calculus (arrow) from the ureteric
stent (arrowhead). Color-coded dual-energy CT (b) exhibits the benets 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.

Acute abdominal pain in pregnancy can be a challenging diagnostic dilemma. Once obstetric causes have been ruled out, physicians must then set about the process of identifying the etiology of
the patient's pain. Nephrolithiasis is the commonest cause of nonobstetric abdominal pain in pregnancy. As a general rule, CT or any
form of ionizing radiation are best avoided if at all possible [54],
leaving ultrasound or MRI as two of the potential methods for
evaluating the pregnant patient. Typically, ultrasound is used as a
rst-line tool for the evaluation of nephrolithiasis in pregnant patients (Fig. 7), and its safety has been well established [55]. MRI, on
the other hand, is generally reserved as a second-line tool, with a
well-established safety prole [56], particularly in the second and
third trimesters. As a last resort, and in rare situations, low dose CT
scan has been performed in pregnant patients [57].
Formation of stones in pregnancy is multifactorial, and includes
altered glomerular ltration [58], increased excretion of uric acid
and oxalate, together with increased stasis of urine as a result of
compression the ureters from the gravid uterus, particularly in the
later stages of pregnancy. Due to physiologic hydronephrosis that
can be seen even in those patients without urolithasis, interpretation of the sonographic ndings can prove problematic. When there
is persistent concern, MRI without gadolinium can provide additional diagnostic information. It should be noted that MRI is relatively insensitive for the detection of the renal calculi themselves,
but does provide excellent soft tissue contrast that may allow for
the detection of secondary signs of nephrolithiasis, such as perinephric or periureteric stranding, or hydronephrosis, for example
[52,59]. In some cases, a renal or ureteric stone may not be found,
but instead an alternative etiology may become apparent.

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9.2. Drug induced stones

It has been estimated that approximately 1 or 2% of all renal
calculi are drug-induced [60,61]. Patients on protease inhibitors
such as indinavir may also develop calculi, however such stones are
not visible on radiography or conventional non-contrast CT [62],
due to their low attenuation. As with any renal stone, patients may
require invasive procedures such as nephroureteral stent placement or percutaneous nephrostomy, and so early diagnosis and an
understanding of the potential pitfalls is important. In these cases,
urinalysis may offer a clue, as indinavir crystals may be visible on
light microscopy [62,63]. Additionally, if drug-induced nephrolithiasis is strongly considered, CT urography may identify the
lling defect on delayed phase imaging.
10. 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. However, the authors found that the
total costs within 7 days were similar in all groups, due to a combination of factors, including the fact that the initial diagnostic
study formed only a small fraction of the total cost of care, particularly in those patients who required hospitalization [66]. 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.
11. 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 benets associated
with imaging to provide best possible care for patients with stone
disease.
Ethical approval
None.

Fig. 7. 33 year old female with early pregnancy presented with recent onset left ank
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 dened fetal pole can also be noted (c & d).

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Sources of funding
None.
Author contribution
Colin J. McCarthy.
Vinit Baliyan.
Hamed Kordbacheh.
Zafar Sajjad.
Dushyant Sahani.
Avinash Kambadakone.
All the authors have equal contribution in literature search,
manuscript writing and proof reading.
Conicts of interest
None.
Guarantor
Avinash Kambadakone.
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