IMAGING IN THE DIAGNOSIS OF

PEDIATRIC UROLITHIASIS
ABSTRACT

• Pediatric urolithiasis is an important and increas-ingly prevalent cause of

pediatric morbidity and hospital admission.

• We emphasize the importance of improved communication with a greater

collaborative approach between pediatric and general radiology departments
so children undergo the appropriate imaging evaluation.
INTRODUCTION
• Urolithiasis in children is an increasingly common cause of morbidity and
hospital admission.
• Incidence also varies depend-ing on geographical location and patient
ethnicity.
• Metabolic risk factors in pediatric urolithiasis can be identified in 75-84% of
evaluated children .
• Lastly, there are several rare genetic disorders, such as primary
hyperoxaluria (types 1, 2 and 3), cystinuria, Dent disease and renal tubular
acidosis, that are associated with nephrolithiasis and nephrocalcinosis and
are important to detect early to prevent further stone formation and, in some
cases, prevent or decrease progression to end-stage renal disease.
• Radiologists play a key role in diagnosing urolithiasis by both recommending
the correct imaging modality and often making the initial diagnosis.
RADIOGRAPHS

• An abdom-inal radiograph is also useful as a baseline study after a stone is

discovered by another imaging modality, for follow-up to assess for stone
passage or for preoperative planning
• The mineral content determines stone density, which in turn affects the
conspicuity of stones on conventional radiographs
• If clinical suspicion is high enough to merit imaging, another modal-ity, ideally
US, is usually chosen.
ULTRASOUND
• The European Society of Pediatric Radiology and the American Urological
Association recommend US as the ini-tial imaging choice with CT reserved
for indeterminate cases, or in cases where exact size/location of stone is
important for surgical decisions
• Urinary tract stones are classically described as discrete echogenic foci that
produce posterior acoustic shadowing within the urinary tract
• Children are more likely than adults to have smaller stones and stones that
are poorly calcified, and thus stones in children are less likely to shadow.
• current literature indicates that although presence of a twinkle artifact
suggests urolithiasis, it is not sufficient for diagnosis and should not be
considered definitive evidence of stones.
• At diagnosis, two-thirds of pediatric urinary tract calculi are intrarenal, with
the remaining one-third located in the ure-ters and bladder
• Urinary tract dilation may be caused by stones or lead to stone formation.
• An acute obstruction also causes the kidney to enlarge and become diffusely
hypoechoic as a result of edema.
• Long-standing obstruction may not be associated with an increased renal
parenchymal resistive index.
• A stone should be visible in two perpendicular imaging planes and ideally
measured in three planes with measurements obtained from the echogenic
edge to echogenic edge, although measurement of width of the acoustic
shadow may be more accurate
US TECHNIQUE
• Patient size and body habitus, hydration status, operator skill, equipment
quality and setting modifications are important var-iables in determining the
US sensitivity for detecting urolithiasis children are generally smaller and
have a lower body mass index than adults, higher frequency transducers
may be used for image acquisition
• Mid ureteral stones are poorly visualized by US due to overlying bowel gas
and, in the absence of proximal dilatation, can be missed entirely.
• Adequate hydration is important to maximally distend the portion of the
urinary tract proximal to the obstruction and to aid visualization of calculi in
the distal ureters and bladder.
• The absence of jets in combination with hydroureteronephrosis can indicate
the presence of obstruction.
COMPUTED TOMOGRAPHY

• The potential risks of ionizing radiation from CT are common-ly discussed,

and frequently debated, but it should be noted that below levels of 100 mSv
above background, it has been suggested that the risks of exposure to
ionizing radiation are not statistically different from zero, and epidemiological
stud-ies have not demonstrated consistent estimates of radiation risk for
whole-body equivalent doses below 100 mSv. However, in the interest of
prudence, and in the spirit of the ALARA (as low as reasonably achievable)
principle, it is the authors’ belief that every effort should be made to mini-
mize the pediatric population’s exposure to ionizing radiation whenever
possible
• Radiologists must continue to play a vigilant role to steer children toward US
for the initial evalu-ation of nephroureterolithiasis and to recommend CT for
sit-uations where the US findings are not definitive.
• At CT, urinary tract calculi are identified as high attenua-tion foci measuring
between 200-1,200 Hounsfield units.
• As with US, the associated secondary signs of obstruction include renal
enlargement, hydroureteronephrosis, perinephric fat stranding or fluid
• Examination time is much shorter and studies are less operator-dependent CT is
consistently more sensitive and specific than US for detecting stones, especially
nonobstructing or ureteric stones
• Using conventional single source CT, the HU density measurement used to determine
whether a hyperattenuating focus in the urinary tract falls within the stone range,
approximately 200-1,200 HU.
• Dual-energy CT offers a major advantage over single-source CT to determine stone
composition
• The impact of this technology on the pediatric population may be limited because very few
children have uric acid or cystine stones. The increased radiation associated with dual-
energy CT will also raise concerns.
• Athough the risks of a single CT study are thought to be very small [33], many children
with urolithiasis may undergo mul-tiple CTs for each stone episode
• Preoperative CT is considered the standard of care for large stones when percutaneous
nephrolithotomy is planned.
• Radiologists have an important role in optimizing CT tech-nique to maximize diagnostic
sensitivity and minimize dose.
• Meta-analysis of low dose/optimized dose CT for urolithiasis (<3 mSv) yields a sensitivity
and specificity for renal tract calculi of 96.6% and 94.9%, respectively
• For the detection of calculi >3 mm in size, dose reductions up to 75% have not affected
diagnostic accuracy in simulated studies
• We advocate the use of an optimized renal stone CT pro-tocol similar to the
technique proposed by Karmazyn et al
• The authors believe this is a potential topic for future research
• If sub-millisievert CT scanning became routine, the dose and risk from CT
scans for urolithiaisis might decrease significantly, as this dose is slightly
less than the average annual dose from background environmental radia-tion
• dose estimates for dual energy CT performed in adults for stone composition
range from 6 to 26.2 mGy
• With advances in technology, radiation doses from CT scanners will
undoubtedly continue to decrease while maintaining diagnostic accuracy.
INTRAVENOUS PYELOGRAPHY IN UROLITHIASIS

• When CT is not available, a tai-lored protocol using three or four views and
collimation may be useful in evaluating a patient with suspected urolithiasis
and a negative US study, while sparing the patient the dose of a full,
traditional intravenous pyelography study
MAGNETIC RESONANCE UROGRAPHY IN
UROLITHIASIS
• Magnetic resonance urography can be performed instead of CT to avoid
excessive radiation exposure in patients with recurrent stone disease
WHAT THE REFERRING PHYSICIANS WANT TO
KNOW
• Once the presence of a stone has been established, the loca-tion, size and
composition will affect patient management
• CT is more accurate than US for predicting the size of stones, some patients
with stones diagnosed by US will have the stones’ size confirmed by CT
during treatment planning.
• Ureteroscopy may also be used for larger stones when percu-taneous
nephrolithotomy is not an option for any number of reasons.
CONCLUSION

• Ultrasound is the recommended primary imaging modality for suspected

urolithiasis in children, a view endorsed by all of the largest pediatric and
urological societies.
• Ongoing improvements in CT technology will likely continue to decrease
radiation dose while maintaining diag-nostic accuracy