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Purpose There is a lack of data on the natural history of asymptomatic intra-renal calculi. In this study we investigate stone related events (SREs) in patients with untreated intra-renal calculi. We also investigate predictive factors for SREs. Materials and Methods All patients diagnosed with an asymptomatic intra-renal calculus on CT KUB managed conservatively with interval imaging for ≥6 months were included. Patients were evaluated for any stone related event. The rate of event according to calculus size, location and number of calculi was also analysed. Multivariate logistic regression analysis was performed to determine significant predictors for SREs. Results In total, 266 renal units from 177 patients met inclusion criteria. The mean stone size was 4.44mm (range of 1-25mm). Duration of follow-up was 43.78 ± 26.86 months (range 6-106 months). The overall rate of SRE's including intervention (n=80) and spontaneous stone passage following ureteric colic (n= 40) was 45.1% (n=120/266). Stones >5mm were more likely to lead to an event compared to stones ≤5mm (OR: 2.94; p=0.01). Inter-polar stones and stones located in multiple calyces were more likely to cause a SRE than lower pole stones (OR: 2.05; p=0.05 and OR:2.29; p=0.03 respectively). Conclusion In this large series of patients with asymptomatic intra-renal calculi, the incidence of a spontaneous SRE was 45.1% after 41 months. Stone size and stone location were significant predictors for stone related event. Information from this study will enable urologists to accurately risk stratify patients with asymptomatic renal stones.

Objective To assess the effectiveness of a telemedicine service for ureteric colic patients in reducing the number of unnecessary face-to-face consultations and shortening waiting time for appointments. Methods A telemedicine workflow was implemented as a quality improvement study using the Plan-Do-Study-Act method. All patients presenting with ureteric colic without high-risk features of fever, severe pain, and hydronephrosis, were recruited, and face-to-face appointments to review scan results were replaced with phone consultations. Data were prospectively collected over 3 years (January 2017 to December 2019). Patient outcomes including the reduction in face-to-face review visits, time to review, reattendance and intervention rates, were tracked in an interrupted time-series analysis, and qualitative feedback was obtained from patients and clinicians. Results Around 53.2% of patients presenting with ureteric colic were recruited into the telemedicine workflow. A total of 465 patients (46.2%) had normal scan results and 250 patients (24.9%) did not attend their scan appointments, hence reducing the number of face-to-face consultations by 71.1%. A total of 230 patients (22.9%) required subsequent follow-up with urology, while 61 patients (6.1%) were referred to other specialties. Mean (SD) time to review was 30.0 (6.2) days, 6-month intervention rate was 3.4% (n = 34) and unplanned reattendance rate was 3.2% (n = 32). Around 93.1% of patients reported satisfaction with the service. Conclusion The ureteric colic telemedicine service successfully and sustainably reduced the number of face-to-face consultations and time to review without compromising on patient safety. The availability of this telemedicine service has become even more important in helping us provide care to patients with ureteric colic in the current COVID-19 pandemic.

The purpose of this study was to assess the efficacy of model-based iterative reconstruction (MBIR), statistical iterative reconstruction (SIR), and filtered back projection (FBP) image reconstruction algorithms in the delineation of ureters and overall image quality on non-enhanced computed tomography of the renal tracts (NECT-KUB). This was a prospective study of 40 adult patients who underwent NECT-KUB for investigation of ureteric colic. Images were reconstructed using FBP, SIR, and MBIR techniques and individually and randomly assessed by two blinded radiologists. Parameters measured were overall image quality, presence of ureteric calculus, presence of hydronephrosis or hydroureters, image quality of each ureteric segment, total length of ureters unable to be visualized, attenuation values of image noise, and retroperitoneal fat content for each patient. There were no diagnostic discrepancies between image reconstruction modalities for urolithiasis. Overall image qualities and for each ureteric segment were superior using MBIR (67.5 % rated as 'Good to Excellent' vs. 25 % in SIR and 2.5 % in FBP). The lengths of non-visualized ureteric segments were shortest using MBIR (55.0 % measured 'less than 5 cm' vs. ASIR 33.8 % and FBP 10 %). MBIR was able to reduce overall image noise by up to 49.36 % over SIR and 71.02 % over FBP. MBIR technique improves overall image quality and visualization of ureters over FBP and SIR.

Acute flank pain is a common presentation to the emergency department (ED), and imaging studies play an important role in establishing an accurate diagnosis. Computed Tomography of Kidneys, Ureters, Bladder (CT KUB) has surpassed all other imaging modalities to become the gold standard in detection of ureteric calculi. The purpose of this study is to identify the range and management of alternative diagnoses established by CT KUB in patients with suspected ureteric colic. Two hundred and fifteen consecutive CT KUB examinations ordered in the ED of a tertiary-care centre for suspected ureteric colic were retrospectively reviewed. This comprised of 134 male (62.3%) and 81 female (37.7%) patients with a mean age of 53 years old. The positive detection rate for ureteric calculi in males was 43.3% compared to a lower rate for females of 29.6% (p < 0.05). Almost two-thirds of patients were discharged following CT KUB imaging, and admission rates were significantly higher in those with alternative radiological findings (p < 0.04) Alternative radiological findings occurred in 72 patients (33.5%), including 15 patients (7.0%) who had clinically important alternative pathology. The rate of clinically important alternative findings was significantly higher in males than females, 9.7% versus 2.5% respectively (p = 0.04). Surgical intervention was more common in patients with alternative radiological findings classified as gastrointestinal (18.2%) compared to non-gastrointestinal (3.6%), however this did not reach statistical significance (p = 0.07). In conclusion, significant alternative pathology was identified using CT KUB in 7% of patients with suspected ureteric colic. The low rates of detection of ureteric calculi and significant alternative pathology in female patients suggests a more thorough clinical assessment is warranted to improve their management, prior to ordering investigations with exposure to radiation.

Elderly patients with upper tract urothelial cancer (UTUC) may present with colic and microscopic haematuria, mimicking urolithiasis. Patients presenting to emergency departments with acute ureteric colic are investigated with a CT KUB. CT urography (CTU) identifies UTUC better than a CT KUB. Thus, there is a possibility that a CT KUB may miss UTUC. We studied patients aged 65 years or over presenting to the emergency department with ureteric colic and microscopic haematuria who had a CT KUB between January 2014 and October 2016. Patients who had both CT KUB and CTU were then compared to determine if CT KUB had missed a UTUC and if the diagnoses were concordant by the two tests. A radiologist independent from the reporting radiologists reviewed images as well as their reports. According to the Health Research Authority, England regulations, we did not obtain an ethical review on a voluntary basis for this retrospective study. Four hundred eighty-five patients [228 (47.01%) male and 257 (52.99%) female] had a CT KUB scan over the 34-month period. Their mean age was 74 (SD 6.97) [males 73 (SD 6.42), females 75 (SD 7.42)] years. One hundred eighty-seven scans were normal. Ureteric calculi (167), renal calculi (58) and renal cysts (28) were most frequent diagnoses. The diagnosis was uncertain in 33 patients (6.8%) [16 (48.49%) males and 17 (51.51%) females]. The mean age of this group of patients was 74 (SD 6.64) [males 73 (SD4.43), females 74 (SD7.64)] years. These patients had a CTU for clarity. CTU identified one UTUC not identified by CT KUB (0.2%), corroborated the diagnosis of a ureteric tumour in one patient and excluded UTUC in two others. CTU diagnosed two new bladder tumours and an endometrial tumour. Diagnoses were concordant between CT KUB and CTU in 17 of 33 patients (51.5%). CT KUB scans for patients 65 years and over presenting with ureteric colic is justified. Only a small proportion of patients will subsequently require the higher radiation dose CTU as the probability of missing UTUC is low.

Background Computed tomography is considered as an imaging modality of choice in acute ureteric colic. However due to concerns regarding radiation exposure, sonograms are re-emerging as imaging methods in such situations.Objectives To evaluate the role of sonography in detection of calculus in acute ureteric colic.Methods Total 384 patients were enrolled. Hydronephrosis was graded as mild, moderate or severe. Calculus was detected as an intraluminal echogenic focus with distal shadowing with twinkling artifact. Number, size and position of the calculi were assessed. Patients were categorized into four groups:I. ureteric colic only II. ureteric colic with hematuria III. ureteric colic with hydronephrosis and IV. ureteric colic with hematuria and hydronephrosis and then the possibility of detection of calculi has been compared among these groups.Results Out of 384 patients, 254 were found to have calculi ranging between 2.7-27mm. Nineteen had in the pelvis/ pelviureteric junction, 64 in proximal ureter, 125 in distal ureter, 6 at iliac crossing and 40 at vesicoureteric junction. Two hundred forty one had single and 14 had multiple calculi. Calculus detection is easier in category III and IV patients. The sensitivity and specificity of ultrasonography were 87.98% and 93.07%. Degree of hydronephrosis is strongly correlated with the number of calculi but weakly correlated with the size of the calculus.Conclusion Sonogram can be used in all cases of acute ureteric colic. Hydronephrosis is the most important finding because it paves the way out for the detection of calculus.Kathmandu University Medical Journal Vol.12(1) 2014: 9-15

Background It has been reported that three criteria (size of calculus ≥6 mm, visual analogue scale pain score at discharge ≥2 cm and location above mid-ureter; the Papa criteria) were sensitive for predicting patients who require intervention (surgery or lithotripsy) within 28 days of index emergency department (ED) visit for ureteric colic. It was suggested that absence of these criteria identified a group for whom early follow-up may not be needed. No validation has been reported. We aimed to validate these criteria. Methods Retrospective cohort study of patients with clinical presentation of ureteric colic and radiologically proven renal tract stones. Data collected included demographics, clinical features, features of the stone, imaging results and 28-day outcome. Outcome of interest was performance of the Papa criteria for prediction of urological intervention by clinical performance analysis. We also undertook a post hoc analysis to identify predictors of urological intervention for the group overall and for the subgroup discharged from ED. Results Two hundred and twenty-four patients were studied (median age 49, 79% male) with 75 (33%) requiring urological intervention within 28 days. The presence of any of the Papa criteria had sensitivity for urological intervention of 83.9% (95% confidence interval (CI) 71.2–91.9%) with specificity of 47.7% (95% CI 38.9–56.6%), positive predictive value of 40.9% (95% CI 31.9–50.4%) and negative predictive value of 87.3% (95% CI 76.8–93.7%). Nine patients with no Papa criteria had intervention: 12.7% (95% CI 6.8–22.4%). Conclusion The Papa criteria are not sufficiently accurate to determine which patients require intervention or a subgroup who do not need specialist urological follow-up.

Ureteric colic is a common presentation to acute emergency services. The gold standard test for the diagnosis of acute ureteric colic is a non-contrast computer tomography of the kidneys ureters and bladder (CT KUB). Non-steroidal anti-inflammatory drugs (NSAIDs) should be used as first-line analgesia, with studies showing that there is no role for steroid or phosphodiesterase-5 inhibitors. There is emerging evidence that a high body mass index (BMI) is a risk factor. The drugs used to facilitate stone passage are known as medical expulsive therapy (MET). The most evaluated being alpha-blockers. The Spontaneous Urinary Stone Passage Enabled by Drugs (SUSPEND) trial was designed to evaluate the use of MET (tamsulosin and nifedipine). This trial showed that there was no difference with MET and placebo for the spontaneous passage of ureteric stones. There is an emerging role for the use of primary ureteroscopy in the management of non-infective ureteric stones.

PURPOSE OF REVIEW Shock wave lithotripsy is the treatment of choice for small renal and upper ureteric stones. This review examines the factors that improve fragmentation and clearance of stones, and recent advances in this area. RECENT FINDINGS Several randomized trials published recently have demonstrated the role of tamsulosin in helping the clearance of ureteric fragments after shock wave lithotripsy. The role of slow shock wave delivery rate has been well established. Percussion, diuresis and inversion have been used to improve results in lower calyceal stones. Few clinical studies have explored the role of position during treatment. The effects of progressive increase of lithotripter output have been demonstrated only in experimental studies. SUMMARY Tamsulosin can be used to increase clearance, and reduce episodes of ureteric colic and the need for analgesics after shock wave lithotripsy. Shock waves at slow rate improve both the safety and efficacy of shock wave lithotripsy. Percussion, diuresis and inversion augments clearance of lower calyceal fragments.

Clinical questionDo calcium channel blockers or alpha blockers improve renal stone passage when compared with placebo?Article chosenPickard R, Starr K, MacLennan G, et al. Medical expulsive therapy in adults with ureteric colic: a multicentre, randomised, placebo-controlled trial. Lancet 2015;386(9991):25-31, doi: 10.1016/S0140-6736(15)60933-3.

Renal (ureteric) colic is a common surgical emergency. It is usually caused by calculi obstructing the ureter, but about 15% of patients have other causes, e.g. extrinsic compression, intramural neoplasia or an anatomical abnormality. This review will focus on calculus-related renal or ureteric colic, its assessment and subsequent management.

A significant proportion of emergency urological admissions are comprised of ureteric colic presenting as loin pain. A variety of alternative pathologies present in this manner and should be considered during systematic assessment. We report the case of a patient admitted with severe unilateral back and flank pain after strenuous deadlift exercise. Clinical examination and subsequent investigation following a significant delay demonstrated acute paraspinal compartment syndrome (PCS) after an initial misdiagnosis of ureteric colic. The patient was managed conservatively. We review the current literature surrounding the rare diagnosis of PCS and discuss the management options.

Background: Ureteric colic is a common presentation in the emergency department and accounts for approximately 1% of all hospital admissions. Diagnosis depends on a typical history, clinical examination and the presence of haematuria. Intravenous urography has traditionally been used as the means of investigation, but over recent years this has been superseded by CT urography. This latter investigation gives potentially more information and may detect alternative or additional pathology which would otherwise be missed on intravenous urography. Methods: 100 consecutive patients attending the emergency department with a provisional diagnosis of ureteric colic undergoing CT urography were studied to detect the incidence of alternative or incidental pathology. Results: Stone disease was found in 58% of patients, with obstruction present in 43%. The most common site of obstruction was the vesicoureteric junction. Significant incidental or alternative pathology was found in 16% of patients. It was estimated that, in 12%, these findings would not have been detected by intravenous urography. Conclusion: The use of non-contrast CT urography is recommended in the initial investigation of patients with ureteric colic.

Aim To establish whether non-contrast enhanced computed tomography (NCCT) renders the kidneys–ureters–bladder (KUB) radiograph redundant as the initial imaging investigation for suspected acute ureteric colic. Materials and methods The imaging investigations for 120 patients consecutively admitted to an emergency department-led clinical decisions unit (CDU) with suspected acute ureteric colic were retrospectively reviewed. A multidisciplinary meeting reviewed the findings and recommended that KUB radiographs should not be routinely performed prior to NCCT. Prospective assessment of 116 consecutive patients admitted over a comparable period was then undertaken. Results In the retrospective group, 61 (50.8%) patients had calculi to account for symptoms (positive NCCT) and 59 (49.2%) patients did not have stone disease (negative NCCT). Ninety (75%) patients had a KUB radiograph prior to NCCT. However, in 46 (38% of total) of these patients the NCCT was negative for stones, and therefore, they had been subjected to an unnecessary radiographic examination. These results prompted a change in practice. In the subsequent and prospectively studied group, preliminary KUB radiographs were performed in only 6% of the patients, with no significant change in the positive NCCT rate (50.8 versus 51.7%) or the total number of examinations performed (120 versus 116). Conclusion NCCT should be the initial imaging examination for acute ureteric colic. Up to 50% of patients with clinical suspicion do not have stone disease, and therefore, preliminary KUB radiographs with attendant radiation and cost implications are unjustified. Preliminary KUB radiographs can be omitted from the imaging pathway with no resultant indication creep or increase in demand for NCCT examinations.

The diagnostic approach to ureteric colic has changed due to the introduction of new radiological imaging such as non-contrast CT. The role of intravenous urography, which is regarded as the gold standard for the diagnosis of ureteric colic, is being challenged by CT, which has become the first-line investigation in a number of centres. The management of ureteric colic has also changed. The role of medical treatment has expanded beyond symptomatic control to attempt to target some of the factors in stone retention and thereby improve the likelihood of spontaneous stone expulsion.

Objective: Patients presenting to the ED with obstructive nephropathies benefit from early detection of hydronephrosis. Out of hours radiological imaging is expensive and disruptive to arrange. Emergency physician ultrasound (EPU) could allow rapid diagnosis and disposition. If accurate it might avert the need for formal radiological imaging, exclude an obstruction and improve patient flow through the ED. Methods: This was a prospective study of a convenience sample of all adult non-pregnant patients with presumed ureteric colic attending the ED with prior ethics committee approval. An emergency physician or registrar performed a focused ultrasound scan and were blinded to the patient’s other management. A computerized tomography scan was also performed for all patients while in the ED or within 24 h of the EPU. The accuracy of EPU detection of hydronephrosis was determined; using computerized tomography scans reported by a senior radiologist as the ‘gold-standard’. Results: Sixty-three patients with suspected ureteric colic were enrolled of whom 57 completed both EPU and computerized tomography imaging. Forty-nine had confirmed nephrolithiasis by computerized tomography with 39 having evidence of hydronephrosis. Overall prevalence of hydronephrosis was 68% (95% confidence interval [CI] 56–79%); compared with computerized tomography, EPU had a sensitivity of 80% (95% CI 65–89%); specificity of 83% (95% CI 61–94%); positive predictive value of 91% (95% CI 75–98%) and negative predictive value of 65% (95% CI 43–83%). The overall accuracy was 81% (95% CI 69–89%). Conclusion: Although the accuracy of detection of hydronephrosis after focused training in EPU is encouraging, further experience and training might improve the accuracy of EPU and allow its use as a screening tool.

Background: Electrohydraulic lithotripsy (EHL) has been available for endoscopic treatment of urinary calculi since 1960, but the large probe size and concerns regarding safety had previously restricted its use to the treatment of bladder calculi. However, recent refinements have made it particularly suitable for the treatment of ureteric calculi. Methods: The authors report their initial experience using EHL in conjunction with mini-ureteroscopy in the treatment of 94 ureteric calculi in 89 patients. The size of the calculi ranged from 3 to 19 mm in diameter, with a mean of 8.2 mm. The mean operating time was 29 min, ranging from 10 to 120 min. Results: A complete fragmentation rate of 91.5% of the calculi was achieved. There were no major complications and a low incidence of minor complications: haematuria (2.2%), urinary tract infection (3.4%) and postoperative ureteric colic (2.2%). There were four cases of minor ureteric perforations (4.5%); all were successfully treated using conservative measures. Conclusions: It is concluded that EHL is a safe and effective method of treating ureteric calculi.

Background Patients presenting in the emergency room with flank pain suggestive of acute ureteric colic may have alternative underlying conditions mimicking ureteric stones. An early diagnosis and appropriate treatment for other causes of flank pain is important. The majority of centers around the world are increasingly using un-enhanced helical CT (UHCT) for evaluation of ureteric colic. This study was conducted to determine the incidence and spectrum of significant incidental diagnoses established or suggested on UHCT performed for suspected renal/ureteric colic. Methods Urologist and radiologist reviewed 233 consecutive UHCT, performed for suspected renal/ureteral colic along with assessment of the medical records. Radiological diagnoses of clinical entities not suspected otherwise were analyzed. All other relevant radiological, biochemical and serological investigations and per-operative findings were also noted. Results Ureteral calculi were identified in 148 examinations (64%), findings of recent passage of calculi in 10 (4%) and no calculus in 75 examinations (32%). Overall the incidental findings (additional or alternative diagnosis) were found in 28 (12%) CT scans. Twenty (71%) of these diagnoses were confirmed by per-operative findings, biopsy, and other radiological and biochemical investigations or on clinical follow up. Conclusion A wide spectrum of significant incidental diagnoses can be identified on UHCT performed for suspected renal/ureteral colic. In the present series of 233 consecutive CT examinations, the incidence of incidental diagnosis was 12%.

Objective: To determine whether patients with proven ureteric calculi on IVU require repeat IVU after resolution of symptoms and passage of calculus on plain X–ray. Methodology: IVU reports for a 12–month period were obtained and notes and X–rays of those patients with ureteric calculi were reviewed. Presentation, management and subsequent imaging after resolution of symptoms were determined for each patient. All X–rays were reviewed by a uroradiologist. Results: Fifty–eight patients were investigated for the study. All initial IVUs showed upper tract dilation or obstruction. Forty–three eventually passed their calculi spontaneously and of these, 18 had KUB, all of which showed passage of the calculus and 25 had repeat IVU, 22 of which were normal. The 3 abnormal IVUs showed persisting calculi which were visible on the plain film. Fifteen patients required surgical intervention and all had repeat IVU, of which 5 were abnormal. Conclusion: This study suggests that following resolution of symptoms due to ureteric colic, patients who pass their calculi spontaneously can be followed up by KUB. Only those with persistent calculi on KUB or those who have had surgical intervention require repeat IVU.

Objective: To develop a cost-effective plan for the accurate diagnosis of urinary stone patients presenting with ureteric colic based on an assortment of investigations which are less invasive and more economical than intravenous urography (IVU). Patients and Methods: 143 consecutive emergency patients presenting with ureteric colic were admitted to hospital and prospectively studied by history recording, physical examination, laboratory tests and imaging procedures according to a preset format. Significant association of the final diagnosis of urinary stones (which was made by actual stone retrieval) with various diagnostic variables obtained from the results of investigation (including IVU) was statistically studied using bivariate correlation and multivariate logistic regression analysis. Algorithms for reaching an accurate diagnosis of urinary tract stones were formulated using the most significant diagnostic variables and the accuracy of each of those plans was compared with that of emergency IVU. Results: 18 patients were excluded for various reasons. Of the remaining 125 patients 82 (66%) were confirmed as having urinary stones. A positive IVU had the strongest correlation with the final diagnosis of urinary tract stones. Other findings associated with eventual stone retrieval in a descending order of significance were: calcular sonographic features; radio-opacities on a plain abdominal film of the kidney, ureter and bladder (KUB), and microhaematuria. Based on these findings two algorithms could be formulated to reach as accurate a diagnosis as possible. Algorithm A in which an initial ultrasound is mandatory had a sensitivity of 89%, a specificity of 88% and an overall accuracy of 88% for urinary stone detection compared with 91, 77, and 86%, respectively, for algorithm B in which ultrasonography was employed selectively after initial KUB and urinalysis for microhaematuria. This compares with 94, 79, and 89%, respectively, for IVU. Conclusion: Both plans are viable alternatives which could replace routine emergency IVU.

Imaging is required in only a minority of patients with urinary tract infection. Some patients who present with severe loin pain are imaged because ureteric colic is suspected. If urinary tract infection does not respond normally to antibiotics, imaging is undertaken to check for evidence of renal obstruction or sepsis. Finally, after the acute infection has been treated, imaging is required in some patients to check for factors pre-disposing to renal damage or to relapsing or recurrent infection. This review discusses the appropriate choice of imaging technique to use in each clinical situation and summarises the expected findings.

A 34 year old man visits his general practitioner with a short history of intermittent severe pain radiating from his right loin to right groin. He is unable to get comfortable and is also complaining of urinary frequency and occasional urgency. His temperature is normal. A urine dipstick test shows only non-visible haematuria. The initial diagnosis is suspected renal/ureteric colic secondary to a stone. Important features to explore in the history include

Summary— This study reviews 6 patients who were referred with severe loin pain radiating to the groin and in whom a presumptive diagnosis of ureteric colic was made. Of these, 3 patients were found to have carcinoma of the pancreas and the remaining 3 had retroperitoneal lymph node metastases. Retroperitoneal malignancies rarely present with loin pain, but this diagnosis should be considered in patients with long-standing loin pain in whom an obvious diagnosis is not apparent.

We report our experience with pulsed dye laser lithotripsy in the treatment of 100 ureteric stones in 95 patients over a 14-month period from July 1989 to September 1990. The overall rate of successful stone fragmentation was 97%. There was a low incidence of minor complications--mild haematuria, ureteric colic and urinary tract infection; ureteric perforation occurred in only 3 patients, all of whom were successfully treated conservatively. Pulsed dye laser lithotripsy is a safe and effective mode of treatment for ureteric stones. Current indications for laser fragmentation of stones are ureteric stones, impacted pelviureteric junction stones and Steinstrasse.

Summary— A randomised multicentre clinical trial was undertaken to compare the effect on pain of indomethacin administered either intravenously or rectally to 116 patients with ureteric colic. Adverse reactions were also assessed. Of the patients receiving the intravenous injection, 48/53 (91%) achieved good pain relief (i.e. no supplementary analgesia was required) 30 min after administration, compared with 46/63 (73%) receiving the enema. Significantly more side effects occurred in the group treated intravenously. It was concluded that indomethacin administered as an enema was less effective than the intravenous form, but it should be regarded as a good alternative in the treatment of ureteric colic.

A 69-year-old man with a history of medullary sponge kidney presented with left sided ureteric colic. An intravenous urogram (IVU) failed to adequately demonstrate the left lower pole calyces and therefore a retrograde examination was performed (Fig. 1). A filling defect within the pelvi-calyceal system was present throughout the fluoroscopic examination. Urine cytolog2r was reported as suspicious for malignancy. A CT confirmed the presence of a filling defect which was not a stone. A left nephroureterectomy was therefore performed.

OBJECTIVE: (1) To determine the accuracy of accident and emergency (A&E) doctors' diagnosis of radio-opaque ureteric calculi on plain abdominal radiographs; (2) to study the predictive value of haematuria with a history suggestive of ureteric colic. DESIGN: A prospective study of all patients seen in a three month period with a provisional diagnosis of ureteric colic. Intravenous urography (IVU) was used as the gold standard for diagnosis of ureteric calculi. SETTING: The accident and emergency department and medical unit of a large teaching hospital. SUBJECTS: 60 patients who were admitted with an initial diagnosis of ureteric colic, 51 subsequently undergoing intravenous urography. RESULTS: A&E doctors achieved a calculated sensitivity of 29% (95% confidence intervals 13% to 49%) and a specificity of 73% (52% to 90%) for identification of renal calculi on plain abdominal radiograph, compared with figures of 68% (48% to 84%) and 96% (78% to 100%) respectively for consultant radiologists. The difference between these results was highly significant (P = 0.0011). No patient with a definitive diagnosis of ureteric colic had a negative result for haematuria on urinary dipstick analysis. CONCLUSIONS: A&E doctors are poor at identifying radio-opaque ureteric calculi on plain abdominal radiographs. If haematuria is absent on urinalysis then ureteric colic is an unlikely diagnosis.

1 Xie HG, Kim RB, Wood AJ, Stein CM. Molecular basis of ethnic differences in drug disposition and response. Annu Rev Pharmacol Toxicol 2001; 41: 815–50. 2 Lin JH, Chiba M, Baillie TA. Is the role of the small intestine in first-pass metabolism overemphasized? Pharmacol Rev 1999; 51: 135–58. 3 Lown KS, Mayo RR, Leichtman AB, et al. Role of intestinal P-glycoprotein (mdr1) in interpatient variation in the oral bioavailability of cyclosporine. Clin Pharmacol Ther 1997; 62: 248–60. 4 Lindholm A, Welsh M, Alton C, Kahan BD. Demographic factors influencing cyclosporine pharmacokinetic parameters in patients with uremia: racial differences in bioavailability. Clin Pharmacol Ther 1992; 62: 359–71. 5 Andrews PA, Sen M, Chang RW. Racial variation in dosage requirements of tacrolimus. Lancet 1996; 348: 1446. diagnose non-stone causes for pain, and commonly takes many hours to complete, CTU generally takes less than 5 min to do, uses no contrast (and is therefore safe in patients with renal insufficiency or at risk of contrast reactions), and can diagnose other causes of flank pain, such as leaking aortic aneurysms and other serious intra-abdominal disorders. A substantial number of patients with acute colic have stones (eg, uric acid calculi) that are radio-opaque on plain radiography. CTU shows most such stones. All these advantages are achieved at the cost of a higher radiation dose, but, when faced with a patient with suspected ureteric colic, I would always go for CTU as the diagnostic test of choice.

Summary A clinicopathologic correlation of 2 patients with crossed renal ectopia presenting with ureteric colic and 4 cases collected from the literature is presented. The correlation serves to reaffirm the theory of ureteral and not renal, migration as the primary aberration resulting in this defect.

A retrospective study of 1097 male in-patients with ureteric colic was conducted to try and define the aetiological effect of climate on the disease. The overall monthly incidence for the study period of 10 years was found, on statistical analysis to correlate with ambient temperature thus: (1) directly with the mean temperature of the preceding month, (2) directly with the difference between mean maximum and mean minimum temperatures of the same month, and (3) inversely with the mean maximum temperature of the same month. The correlation was interpreted on the basis that hot ambient temperatures promoted stone generation whereas cold ones promoted stone descent through cold-induced diuresis. This trend, among its other implications, could pinpoint the reason for the increase in nephrolithiasis with industralisation.

Ten cases of campylobacter bacteraemia, which were diagnosed over a three-year period, are described. Four patients presented with acute gastrointestinal illness, three patients had acute febrile illnesses, two patients had cellulitis and one patient presented with ureteric colic. Two patients had lifelong agammaglobulinaemia, two were undergoing corticosteroid therapy and there was one nosocomial infection. In contrast with previous reports, the most common species that was isolated was Campylobacter jejuni, which was found in eight cases, and this includes the first report of cellulitis that was most probably caused by C. jejuni. All of these isolations of campylobacter have occurred since the introduction of the radiometric technique of processing blood cultures.

Forty-six ureteroscopies were carried out over a 12-month period. A simple technique is described. The desired level was reached in 72% of cases and the pre-operative objective achieved in 60% of cases overall. Fifty per cent of all ureteric stones were safely retrieved by ureteroscopy. The instrument was used to establish a diagnosis of upper urinary tract abnormality in 16 of 23 cases. The overall complication rate was low, most problems relating to short-lived ureteric colic (23%) which was seen mainly after stone manipulation. Transurethral ureteroscopy is a safe procedure with a number of diagnostic and therapeutic possibilities.

Two cases of cystic dilatation of the intrahepatic biliary tree are described. Both patients succumbed to recurrent bile stasis, cholangitis and septicaemia. The pre-operative diagnosis is not easy but should be considered in patients who have symptoms of biliary tract disease and recurrent urinary tract infections, ureteric colic or haematuria; particularly if urography demonstrates renal cysts or medullary sponge kidney.

Summary— In this study the analgesic effect of indomethacin in ureteric colic was demonstrated in 15 patients. Of the 15 patients, 12 had prompt and effective pain relief. It is concluded that indomethacin suppositories offer a safe and effective alternative to pethidine in the treatment of ureteric colic.

High-energy shock waves were used to disintegrate kidney stones in dogs and man. In 96% of 60 dogs with surgically implanted renal pelvic stones, the fragments were discharged in the urine. The same effect was achieved in 20 out of 21 patients with renal pelvic stones. In the twenty-first patient, a staghorn calculus was broken up to facilitate surgical removal. 2 patients with upper ureteric stones also received shock waves, but their stones had to be removed surgically; in 1 of these the stone had been embedded in the ureteric wall by connective tissue. The procedure can in many cases be done under epidural instead of general anaesthesia. Side-effects consisted of slight haematuria and, occasionally, of easily treatable ureteric colic. They were probably due to passage of fragments down the ureter. Disintergration of kidney stones by shock waves seems to be a promising form of treatment that reduces the need for surgery.

Summary— Experiments have been carried out with isolated ring preparations of human ureter. The tissue displayed spontaneous activity and contracted when exposed to barium chloride (0.5-4 mM) but no responses were obtained with carbachol (0.1 micromolar-0.1 mM). This raises questions about the value of treating ureteric colic with anti-muscarinic drugs.

A randomised prospective double-blind study of the effect of 1 mg glucagon intravenously was done on 51 consecutive patients with acute uretic colic. No significant difference between glucagon and placebo could be demonstrated as to pain relief or passage of calculi.

Ureteric obstruction causes increased synthesis and release of prostaglandins. As a result renal pelvic pressure rises, causing renal colic. This double-blind study in 66 patients with acute renal colic shows that intramuscular injection of a potent prostaglandin-synthetase inhibitor (diclofenac sodium) is more effective and has fewer side-effects than a narcotic drug commonly used to treat ureteric colic.

Diagnostic accuracy in identifying calculi in patients with ureteric colic is poor. Lower ureteric calculi may be confused with other pelvic calcific opacities. A characteristic appearance of some larger lower ureteric calculi is described and likened to the root of a tooth. It is hoped that the tooth-root sign will be of assistance in the diagnosis of distal ureteric stones.

The literature concerning the investigation of ureteric colic is reviewed. I have compared previous papers with the results of a prospective study of 50 patients who underwent emergency urography and testing for haematuria. Haematuria was present in 88% of all patients and in 97% of those with proven ureteric colic. The high haematuria figure is thought to be due to patient selection. Thirty-four patients (68%) had abnormal urographic findings consistent with ureteric colic. Seven of these patients (20%) had no plain film abnormality and the contrast films therefore confirmed the diagnosis. Haematuria is a useful indication of ureteric colic. However, since ureteric obstruction occurs without haematuria, and a normal urogram may be associated with haematuria, emergency urography is essential to confirm ureteric colic. This should be performed soon after the onset of pain if maximal information is to be obtained, thereby avoiding unnecessary investigation.

Une observation chez une malade de 57 ans. Douleurs evoquant une colique nephretique mais pas d'antecedents ni de symptomatologie urologique. Le diagnostic correct de rupture d'anevrysme est fait tardivement au moyen des ultrasons

We performed a retrospective study of 134 patients presenting at an Accident and Emergency department with ureteric colic, to determine if the presence of dipstick haematuria could be used as a screening test for the presence of a calculus.