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Media Gallery

Small renal calculus that would likely respond to extracorporeal shockwave lithotripsy.
Complete staghorn calculus that fills the collecting system of the kidney (no intravenous contrast material in this patient). Although many staghorn calculi are struvite (related to infection with urease-splitting bacteria), the density of this stone suggests that it may be metabolic in origin and is likely composed of calcium oxalate. Percutaneous nephrostolithotomy or perhaps even open surgical nephrolithotomy is required to remove this stone.
Distal ureteral stone observed through a small, rigid ureteroscope prior to ballistic lithotripsy and extraction. The small caliber and excellent optics of today's endoscopes greatly facilitate minimally invasive treatment of urinary stones.
Two calculi in a dependent calyx of the kidney (lower pole) visualized through a flexible fiberoptic ureteroscope. In another location, these calculi might have been treated with extracorporeal shockwave lithotripsy (ESWL), but, after being counseled regarding the lower success rate of ESWL for stones in a dependent location, the patient elected ureteroscopy. Note that the image provided by fiberoptics, although still acceptable, is inferior to that provided by the rod-lens optics of the rigid ureteroscope in the previous picture.
Nephrolithiasis: acute renal colic. Anatomy of the ureter.
Nephrolithiasis: acute renal colic. Distribution of nerves in the flank.
Nephrolithiasis: acute renal colic. Nerve supply of the kidney.
Nephrolithiasis: acute renal colic. Renal colic and flank pain.
Nephrolithiasis: acute renal colic. Nerve supply of the kidney.
Nephrolithiasis: acute renal colic. Distribution of renal and ureteral pain.
Noncontrast helical CT scan of the abdomen demonstrating a stone at the right ureterovesical junction.
Intravenous pyelogram (IVP) demonstrating dilation of the right renal collecting system and right ureter consistent with right ureterovesical stone.

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Table. Intravenous Pyelography Versus CT Scanning: Which Is Better?

Table. Intravenous Pyelography Versus CT Scanning: Which Is Better?

Imaging Study (Pro/Con)		Details
CT scan	Pro	Fast No IV contrast necessary, so no risk of nephrotoxicity or acute allergic reactions With only rare exceptions, shows all stones clearly May demonstrate other pathology Can be performed in patients with significant azotemia and severe contrast allergies who cannot tolerate IV contrast studies Clearly shows uric acid stones Shows perinephric stranding or streaking not visible on IVP and can be used as an indirect or secondary sign of ureteral obstruction No radiologist needs to be physically present Preferred imaging modality for acute renal colic in most EDs
	Con	Without hydronephrosis, cannot reliably distinguish between distal ureteral stones and pelvic calcifications or phleboliths Cannot assess kidney function No nephrogram effect study to help identify obstruction Size and shape of stone only estimated Lacks surgical orientation* Unable to identify ureteral kinks, strictures, or tortuousities May be hard to differentiate an extrarenal pelvis from true hydronephrosis Gonadal vein sometimes can be confused with the ureter Does not indicate likelihood of fluoroscopic visualization of the stone, which is essential information in planning possible surgical interventions May require addition of KUB radiograph^† Cannot be performed during pregnancy because of high dose of ionizing radiation exposure Usually more costly than an IVP in most institutions Higher radiation dose than IVP
IVP	Pro	Clear outline of complete urinary system without any gaps Clearly shows all stones either directly or indirectly as an obstruction Nephrogram effect film indicates obstruction and ureteral blockage in most cases, even if the stone itself might not be visible Shows relative kidney function Definitive diagnosis of MSK Ureteral kinks, strictures, and tortuousities often visible Can modify study with extra views (eg, posterior oblique positions, prone views) to better visualize questionable areas Stone size, shape, surgical orientation, and relative position more clearly defined Orientation similar to urologists’ surgical approach Limited IVP study can be considered in selected cases during pregnancy, although plain ultrasonography is preferred initially Lower cost than CT scan in most institutions Includes KUB film automatically
	Con	Relatively slow; may need multiple delay films, which can take hours Cannot be used in azotemia, pregnancy, or known significant allergy to intravenous contrast agents Risk of potentially dangerous reactions to IV contrast material^‡ Cannot detect perinephric stranding or streaking, which is visible only on CT scans Harder to visualize radiolucent stones (eg, uric acid), although indirect signs of obstruction are apparent Presence of a radiologist generally necessary, which can cause extra delay Cannot be used to reliably evaluate other potential pathologies
*Many urologists find CT scans inadequate to help plan surgery, predict stone passage, or monitor patients; however, recently developed software programs may improve the capacity of CT in this respect.^†This causes a delay, which may be significant in some institutions, and adds additional patient radiograph exposure and cost.^‡These include significant allergic responses and acute kidney injury.

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Author

Chirag N Dave, MD Physician in Sexual and Male Reproductive Medicine and Urology, Advanced Urology Institute of Georgia

Chirag N Dave, MD is a member of the following medical societies: American Urological Association, Sexual Medicine Society of North America

Disclosure: Nothing to disclose.

Coauthor(s)

Seema Mehta, DO, MSc Resident Physician, Department of Family Medicine, University of Michigan Medical School

Disclosure: Nothing to disclose.

Kristen Meier, MD Resident Physician, Department of Urology, Oakland University William Beaumont School of Medicine

Kristen Meier, MD is a member of the following medical societies: Alpha Omega Alpha, American Medical Association, American Urological Association, Phi Beta Kappa, Phi Kappa Phi

Disclosure: Nothing to disclose.

Sugandh Shetty, MD, FRCS Associate Professor of Urology, Oakland University William Beaumont School of Medicine; Attending Physician, Department of Urology, William Beaumont Hospital

Sugandh Shetty, MD, FRCS is a member of the following medical societies: American Urological Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Bradley Fields Schwartz, DO, FACS Professor of Urology, Director, Center for Laparoscopy and Endourology, Department of Surgery, Southern Illinois University School of Medicine

Bradley Fields Schwartz, DO, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Association of Military Osteopathic Physicians and Surgeons, Endourological Society, Society of Laparoscopic and Robotic Surgeons, Society of University Urologists

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Endourological Society Board of Directors; President Elect North Central Section of the American Urological Association<br/>Serve(d) as a speaker or a member of a speakers bureau for: Cook Medical.

Additional Contributors

David S Howes, MD Professor of Medicine and Pediatrics, Residency Program Director Emeritus, Section of Emergency Medicine, University of Chicago, University of Chicago, The Pritzker School of Medicine

David S Howes, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Richard H Sinert, DO Professor of Emergency Medicine, Clinical Assistant Professor of Medicine, Research Director, State University of New York College of Medicine; Consulting Staff, Vice-Chair in Charge of Research, Department of Emergency Medicine, Kings County Hospital Center

Richard H Sinert, DO is a member of the following medical societies: American College of Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Robert E O'Connor, MD, MPH Professor and Chair, Department of Emergency Medicine, University of Virginia Health System

Robert E O'Connor, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Heart Association, American Medical Association, National Association of EMS Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Sandy Craig, MD Residency Program Director, Carolinas Medical Center; Associate Professor, Department of Emergency Medicine, University of North Carolina at Chapel Hill School of Medicine

Sandy Craig, MD is a member of the following medical societies: Alpha Omega Alpha, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Stephen W Leslie, MD, FACS Founder and Medical Director, Lorain Kidney Stone Research Center; Associate Professor of Surgery, Creighton University School of Medicine, Chief of Urology, Creighton University Medical Center

Stephen W Leslie, MD, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, National Kidney Foundation, Ohio State Medical Association

Disclosure: Nothing to disclose.

J Stuart Wolf, Jr, MD, FACS David A Bloom Professor of Urology, Associate Chair for Urologic Surgical Services, Director, Division of Endourology and Stone Disease, Department of Urology, University of Michigan Medical School

J Stuart Wolf, Jr, MD, FACS is a member of the following medical societies: Catholic Medical Association, Endourological Society, Engineering and Urology Society, Society of Laparoscopic and Robotic Surgeons, Society of University Urologists, Society of Urologic Oncology, American College of Surgeons, American Urological Association

Disclosure: Nothing to disclose.

Kassem Faraj Oakland University William Beaumont School of Medicine

Kassem Faraj is a member of the following medical societies: American Medical Association, American Medical Student Association/Foundation, American Urological Association, Michigan State Medical Society

Disclosure: Nothing to disclose.

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