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Centennial Dissertation
Honoring Henry K. Pancoast, MD
and Sidney Lange, MD

Diagnosis and Management of

Acute Ureterolithiasis: CT Is Truth
Robert C. Smith 1 and Michael Varanelli 2

he Declaration of Independence be- the X-ray beam, the first radiograph of a renal

T gins with the following paragraph

[1]:
When in the course of human events,
it becomes necessary for one people to
dissolve the political bands which have
connected them with another, and to
assume among the powers of the earth,
the separate and equal station to which
the Laws of Nature and of Nature’s God
entitle them, a decent respect to the opin-
Henry K. Pancoast ions of mankind requires that they
14th President of ARRS should declare the causes which impel
1913–1914 them to the separation.
In the spirit of the preceding paragraph and in
the name of all modern practitioners of geni-
tourinary imaging, I propose to set forth below
the events and reasons that now force a separa-
tion of the modern era of imaging urinary lithia-
sis from all that has gone before. A wonderful
(and complete) review of the history of imaging
Photograph of the urinary tract is given by Howard Pollack
not available in the latest edition of the textbook he edited en-
titled “Clinical urography: an atlas and textbook
of urological imaging [2].” In what follows, I
have used this review as a guide and a source of
historical references in the literature.
Evolution
For more than 100 years, radiography has
Sidney Lange played a pivotal role in the diagnosis and treat-
15th President of ARRS ment of patients with acute ureterolithiasis. In
1914–1915 fact, within months of Roentgen’s discovery of
calculus was obtained by John Macintyre [3].
Even the (ever-present) diagnostic dilemma of
confusing a pelvic phlebolith with a ureteral
stone was quickly described [4].
It was also clear from the outset that radiog-
raphy alone was inadequate to definitively di-
agnose a ureteral stone in a patient with acute
flank pain and suspected renal colic. Even if an
opacity was present along the anatomic course
of the ureter, the ureter itself could not be di-
rectly seen on radiography. What was needed
was some other means to force the ureter to re-
veal itself so that a specific opacity thought to
be a stone could be located in (or outside of)
the lumen of the ureter. In fact, this idea was
tried within a year and the first “opacification”
of the ureter was performed by inserting a
metal wire into a ureteral catheter [5]. This
technique was subsequently replaced by mak-
ing the ureteral catheters themselves radio-
paque.
Next, air was tried as a contrast agent to re-
veal the ureter on radiographs. Air was soon re-
placed by a liquid contrast agent containing a
colloidal suspension of silver, and the first ret-
rograde pyelogram was born [6]. The useful-
ness of this technique was quickly recognized
but, unfortunately, so were the dangers associ-
ated with the silver-containing contrast agent.
The search for safer materials began and so-
dium iodide solutions, first described by Cam-
eron [7] in 1918, became the contrast agents of
choice for retrograde pyelography.

Received January 18, 2000; accepted after revision February 16, 2000.
This is the seventh in a series of Centennial Dissertations that the AJR is publishing this year in honor of the former presidents of the American Roentgen Ray Society, one of whom is
pictured above.
1
Department of Radiology, New York Presbyterian Hospital, Cornell University Medical College, Box 141, 525 E. 68th St., New York, NY 10021. Address correspondence to R. C. Smith.
2
Department of Diagnostic Imaging, Yale University School of Medicine, 333 Cedar St., New Haven, CT 06510.
AJR 2000;175:3–6 0361–803X/00/1751–3 © American Roentgen Ray Society

AJR:175, July 2000 3


The next step in this evolutionary process
was to eliminate the need to directly intro-
duce the contrast agent into the urinary sys-
tem. An indirect means might be faster and
safer. In fact, in 1923, Osborne et al. [8] de-
scribed the use of a high dose of IV sodium
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iodide to reveal the ureters on radiography.
This was a novel idea whereby the IV con-
trast agent was filtered by the kidneys and
then excreted directly into the urine. Al-
though images of the urinary system ob-
tained in this manner were suboptimal, this
led to the development of more robust agents
that were IV administered and then excreted
into the urine. The first such agents to yield
higher quality urograms were iodinated pyri-
dine compounds described by Swick [9] in
1929. In fact, iodinated pyridine compounds
were routinely used to perform IV urography
for the next 20 years. Then, in 1952, pyridine
compounds were replaced by the even safer
iodinated benzoic acid derivatives. These lat-
ter agents are still sometimes used today, al-
though the newer nonionic compounds are
now the dominant force when IV contrast
material is required for imaging studies of all
types, including IV (or excretory) urography.
However, despite the improved safety of the
nonionic agents, even these carry the risk of
allergic reactions, which vary from a few
hives to respiratory distress and, in rare
cases, death.
By obtaining radiographs before and after an
IV contrast agent is administered, one can theo-
retically determine if an opacity seen on radi-
ography is actually in the ureter. In addition,
when a stone is obstructing the ureter there will
be delayed filling of the collecting system (and
ureter) as well as dilatation compared with the
normal side. Would that things were so simple.
Despite protest to the contrary [10–13], only
about 60% of all ureteral stones will actually be
visible on radiographs [14]. In addition, when
significant obstruction is present, it may take an
inordinate amount of time for contrast material
to reach the level of obstruction. Even when
contrast material does reach the level of ob-
struction, it still may not be possible to show
that a specific opacity is the obstructing stone.
Revolution
Long ago, the genitourinary “pundits” and
“keepers of the faith” concluded that contrast
material and radiography were essential to
properly diagnose patients with acute ureteral
obstruction caused by urinary lithiasis. They
would have us believe that only IV urography
4 AJR:175, July 2000
Smith and Varanelli
could provide physiologic information that was
necessary for patient treatment. This is where
things stood for nearly 65 years (1929–1994);
however, in the early 1970s, the seeds of a new
revolution were planted. By the early 1990s,
the hypotheses that lie at the foundations of
classical genitourinary imaging were chal-
lenged. Because of the relatively high attenua-
tion of virtually all kidney and ureteral stones
on CT, a new relativistic theory of imaging pa-
tients with suspected acute ureterolithiasis was
put forward.
Computerized axial tomography was first
described by Hounsfield and Ambrose in
1973 [15, 16]. Nearly since its inception, it
had been well-known that CT could reveal
almost all renal (and hence ureteral) stones.
In fact, it was even suggested that CT attenu-
ation values could be used to determine the
composition of renal stones [17]. At the same
time, CT can reveal the ureter itself so that
the relationship between a calcific density
and the ureter can be precisely determined.
This can even be done without the benefit of
IV contrast material, so why not use CT to
diagnose acute ureteral obstruction? This
could have been done even on early CT scan-
ners using relatively thick sections, but long
scan times and respiratory variation between
sections were apparently formidable obsta-
cles to the advocacy of CT for this purpose.
All of this changed, however, with the advent
of helical CT scanners.
Since its first description in 1994 (Essen-
macher KR, Smith RC, Rosenfield AT. An-
nual Meeting of the Society of Uroradiology,
January 1994) and first publication 1 year
later [18], unenhanced helical CT has quickly
become the imaging study of choice to exam-
ine patients with acute flank pain and sus-
pected urinary lithiasis. Unenhanced helical
CT takes only minutes to perform and is
highly accurate and completely safe. CT re-
veals the size and location of virtually all ure-
teral stones. These are the two most important
factors used for patient treatment. In addition,
CT can diagnose nearly all other serious con-
ditions that mimic renal colic.
To paraphrase (and give a modern inter-
pretation of) the last paragraph of the Decla-
ration of Independence:
We, therefore, the Representatives of
the new generation of Genitourinary
Radiologists, in Public, Assembled,
appealing to the Supreme Judge of the
Radiology World (i.e., the Editor of the
AJR) for the rectitude of our intentions,
do in the Name, and by Authority of the
good people of radiology, solemnly pub-
lish and declare, That the practitioners of
Genitourinary Radiology are, and of
right ought to be, free and Independent;
that they be absolved from all Allegiance
to the Excretory Urogram (formerly
known as the “IVP”) and that all con-
nection between past and present prac-
tices are and ought to be totally
dissolved; and that as Free and Indepen-
dent Thinkers, they have full Power to
Levy war on the excretory urogram,
conclude that it is unnecessary for the
diagnosis of ureteral obstruction, con-
tract new Allegiances, establish new Pro-
cedures and to do all other Acts and
Things which Independent Thinkers
may of right do. And for the support of
this Declaration, with a firm reliance on
the protection of divine Providence, we
mutually pledge to each other our Lives,
our Fortunes our new Allegiance to
Unenhanced CT and our sacred Honor.
Current Practice
Unenhanced helical CT has become the im-
aging technique of choice for the examination
of patients with acute flank pain in whom the
diagnosis is uncertain. Virtually all stones are of
sufficient attenuation to be revealed on CT. The
only known exception is a stone that consists
entirely of protease inhibitors, such as indinavir
sulfate (Crixivan; Merck, Rahway, NJ) [19]. In
addition to the direct visualization of a stone in
the lumen of the ureter (Fig. 1), secondary signs
of obstruction on CT are commonly present.
Ureteral dilatation (Fig. 2) has a sensitivity of
approximately 90% for use in making a diagno-
sis of acute ureteral obstruction. Similarly,
stranding of the perinephric fat (Fig. 3) and
stranding of the periureteral fat (Fig. 4) both
have sensitivities of approximately 85%. Per-
haps more importantly, in approximately 80%
of patients with acute flank pain ureteral dilata-
tion and perinephric stranding will be present or
absent simultaneously. In this large subgroup of
patients with acute flank pain, the presence of
both ureteral dilatation and perinephric strand-
ing has a positive predictive value of nearly
100%, and the absence of both findings has a
negative predictive value of approximately 95%
for the diagnosis of acute ureterolithiasis.
On CT, secondary signs of obstruction can
aid in the diagnosis of acute renal colic when a
stone is not readily apparent. The frequency of
CT secondary signs of obstruction on CT has
 CT of Acute Ureterolithiasis

Fig. 1.—60-year-old man with left-sided flank pain. Un-

enhanced CT scan reveals stone in distal left ureter
(arrow).
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Fig. 2.—43-year-old man with right-sided flank pain. Un-

enhanced CT scan reveals marked dilatation of proximal
right ureter (arrow).
1 2

Fig. 3.—38-year-old woman with left-sided flank pain. Unenhanced CT scan re- Fig. 4.—55-year-old woman with left-sided flank pain. Unenhanced CT scan reveals
veals severe perinephric stranding on left side. Note normal perinephric fat on severe periureteral stranding.
right side.

recently been shown to correlate with the dura-
tion of pain [20]. This should be kept in mind
when interpreting CT studies, particularly in
patients whose duration of pain is less than 2 hr.
In addition, secondary signs on CT can be used
to make the diagnosis of a recently passed
stone [21]. In the latter case, some stones will
actually be revealed while still present in the
bladder. All patients should be scanned in the
prone position so that a stone that has already
passed into the bladder is not confused with a
stone still lodged in the ureter at the ureteroves-
ical junction [22].
Once the diagnosis of obstruction by a ure-
teral stone has been made on CT, prognosis and
patient treatment can be guided on the basis of
the site of obstruction and the size of the stone.
In fact, the CT scout view can itself often be used
as a baseline study in patients requiring follow-
up imaging and in patients who will undergo
lithotripsy [23]. We performed an exhaustive re-
view of the literature in an attempt to find a sin-
gle study that has shown that the degree of
obstruction (as determined on excretory urogra-
phy) can be used to guide patient treatment or
determine prognosis. Our review failed to reveal
any such article. In addition, several recent stud-
ies strongly suggest that the secondary signs of
obstruction on CT can in fact be used to deter-
mine the degree of obstruction as well as help
predict the likelihood of stone passage [24, 25].
It would indeed be the ultimate irony if CT find-
ings are shown to more accurately reflect the de-
gree of obstruction and predict the likelihood of
stone passage than excretory urography.
With negative findings for acute ureterolithi-
asis on unenhanced helical CT, radiographers
can confidently exclude the diagnosis of clini-
cally significant stone disease and many other
causes of acute flank pain. In addition, despite
the lack of IV or oral contrast material, unen-
hanced CT can reveal many other causes of
acute flank pain that are unrelated to the urinary
system, such as pelvic masses, appendicitis,
and diverticulitis. Unenhanced CT may also re-
veal abnormalities of the urinary system unre-
lated to stone disease, such as pyelonephritis
[26]. In some patients, it may occasionally be
necessary to repeat the CT scan after the ad-
ministration of IV or oral contrast material to
make a diagnosis. Examples include patients
with renal vein or renal artery thrombosis and
patients with renal infarcts. We would never
hesitate to administer contrast material when
necessary and appropriate.
The one remaining pitfall in the interpreta-
tion of unenhanced helical CT is the confu-
sion of a phlebolith with a ureteral stone,
especially in the pelvis. Two prior studies
have addressed this issue [27, 28], but the

AJR:175, July 2000 5

 Smith and Varanelli

pitfall remains. However, with experience
and by using the secondary signs of obstruc-
7.
tion, this difficulty can usually be overcome.
Future Directions
8.
As the specialty of genitourinary imaging
Downloaded from www.ajronline.org by 180.254.224.33 on 05/03/18 from IP address 180.254.224.33. Copyright ARRS. For personal use only; all rights reserved
genographie des Nierenbeckens nach Kollargolful-
ling. Munch Med Wschr 1906;53:105–106
Cameron DF. Aqueous solutions of potassium and
sodium iodide as opaque mediums in Roentgenog-
raphy. JAMA 1918;70:754–755
Osborne ED, Sutherland CG, Scholl AJ, Rowntree
LG. Roentgenography of the urinary tract during ex-
tion in patients with HIV undergoing indinavir
therapy. AJR 1998;171:717–720
20. Varanelli MJ, Levine JA, Rosenfield AT, Smith
RC. Relationship between the duration of pain in
patients with acute ureterolithiasis and secondary
signs of obstruction on unenhanced helical CT.
Radiology 1999;213(P):683

continues to evolve, CT (and MR imaging) will
continue to replace classic radiographic tech-
niques. This is as it should be. For now, anyway,
unenhanced helical CT is the new “king” when
it comes to imaging patients with acute flank
pain and suspected renal colic. However, we
must always keep an open mind. In the future,
some new as yet undiscovered technique (or
technology) will replace even unenhanced CT
for this purpose. When that day comes, unen-
hanced CT will be relegated to a place of historic
interest (not unlike the excretory urogram). For
the moment however, at least in relation to stone
disease, unenhanced helical CT is truth.
References
1. Lucas, Stephen E. The stylistic artistry of the decla-
ration of independence. Q Natl Arch 1990;22:25–43
2. Pollack HM. Uroradiology. In: Pollack HM, ed.
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3. Pollack HM. Uroradiology. In: Pollack HM, ed.
Clinical urography: an atlas and textbook of urolog-
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4. Orton GH. Some fallacies in the X-ray diagnosis of
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6 AJR:175, July 2000