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OBJECTIVE To determine the diagnostic accuracy of ultra-low-dose computed tomography (ULDCT) compared with standard-dose CT (SDCT) in the evaluation of patients with clinically suspected renal colic, in addition to secondary features (hydroureteronephrosis, perinephric stranding) and additional pathological entities (renal masses). PATIENTS AND METHODS A prospective, comparative cohort study was conducted amongst patients presenting to the emergency department with signs and symptoms suggestive of renal or ureteric colic. Patients underwent both SDCT and ULDCT. Single-blinded review of the image sets was performed independently by three board-certified radiologists. RESULTS Among 21 patients, the effective radiation dose was lower for ULDCT [mean (SD) 1.02 (0.16) mSv] than SDCT [mean (SD) 4.97 (2.02) mSv]. Renal and/or ureteric calculi were detected in 57.1% (12/21) of patients. There were no significant differences in calculus detection and size estimation between ULDCT and SDCT. A higher concordance was observed for ureteric calculi (75%) than renal calculi (38%), mostly due to greater detection of calculi of

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.

OBJECTIVES To evaluate the clinical, fiscal and environmental impact of a specialist-led acute ureteric colic virtual clinic (VC) pathway. PATIENTS AND METHODS All patients with uncomplicated acute ureteric colic, referred to a single tertiary centre, were prospectively entered into the study over a 4-year period (January 2015-December 2018). Inclusion criteria were: low-dose non-contrast computed tomography of kidneys, ureters and bladder; white blood cell count

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.

INTRODUCTION AND OBJECTIVE:Renal colic is a common urological problem with a lifetime incidence of approximately 8-19% in males and 3-5% in females. The MIMIC Study was a 4171 patient cohort study ...

These guidelines have been developed by the British Association of Urological Surgeons to give a framework to clinicians, based primarily in the UK, for the management of patients presenting acutely with ureteric colic. They have been developed by consensus with reference to the American Urological Association/Endourological Society guidelines on the surgical management of stones and the European Association of Urology guidelines on urolithiasis, and adapted to the logistics of those practicing within the National Health Service. Grades of recommendation and levels of evidence are based upon the system adopted by the European Association of Urology.

Patients with ureteric calculi usually present with ipsilateral “loin to groin” pain. Rarely ureteric colic may present with contralateral pain, which is referred to as “mirror pain”. We report the case notes of a rare presentation of contralateral ureteric colic or “mirror pain” secondary to a ureteric calculus. A comprehensive literature review was also conducted. “Mirror pain” or contralateral ureteric colic is rare. Urologists should be aware of this unusual clinical presentation and appreciate that upper urinary tract calculi can cause pain on the contralateral side.

INTRODUCTION AND OBJECTIVES:Ureteric colic is a common condition that causes severe pain and generates substantial health system utilization. Traditional management includes analgesia and a trial o...

Introduction and objectives: Admissions for ureteric colic are relatively common, with up to 80% of stones passing spontaneously. In patients with refractory pain, drainage with stenting, percutaneous nephrostomy or stone removal can be performed. Due to the financial restrictions of the NHS, it is paramount to ensure patients are receiving optimal cost-effective care. We present a cost effectiveness analysis between primary ureteric stenting and emergency ureteroscopic stone removal in patients with refractory pain secondary to acute ureteric calculi. Methods: Fifty patients were analysed who underwent either primary ureteric stenting or emergency ureteroscopic stone removal in our institution. Each group contained 25 consecutive patients. The primary outcomes compared were: time to stone-free status, number of hospital re-admissions, and overall cost of treatment until stone free. Results: Both stenting ( n=25) and ureteroscopic stone removal ( n=25) groups were comparable with respect to age, sex, stone size and location. The hospital re-admission rate secondary to stone-specific issues was significantly lower in the ureteroscopy group, two versus 20. Patients became stone free significantly quicker in the ureteroscopy group (2.5 days vs. 61.9 days). The total overall cost until being declared stone free was significantly lower in the ureteroscopy group (£3104 vs. £4041, P⩽0.001). Conclusions: This study highlights that those patients undergoing ureteric stenting take significantly longer to become stone free, leading to increased hospital re-admissions, potentially increased morbidity and inevitably greater cost implications. We advocate that primary ureteroscopic stone removal should be consider instead of ureteric stenting in patients with ongoing, painful ureteric colic.

Objective To analyse the outcomes of emergency ureteroscopy (URS) cases performed in Auckland City Hospital. Methods We conducted a retrospective review of all emergency URS procedures performed at Auckland City Hospital between 1 January 2010 and 31 December 2011. Data on patients, stones and procedures were collected and analysed. Emergency URS failure was defined as fragments >3 mm or the need for a repeat procedure. Results A total of 499 URS procedures were identified. Of these 394 (79%) were emergency procedures. The mean (sd; range) patient age was 48 (16; 13–88) years. In all, 83% of emergency URS cases had an American Society of Anesthesiologists (ASA) score of 1 or 2, 25% of stones were >9 mm, with a mean (sd) size of 8 (4) mm, and 285 procedures (72%) were successful. These patients were younger (47 vs 51 years), were more likely to have an ASA score of 1 (103 patients in the successful treatment group vs 26 in the failed treatment group), had smaller stones (7 vs 9 mm) and were more likely to have distal stones (P < 0.05). A total of 20 complications (5%) were recorded including six false passages and three mucosal injuries, one of which required radiological intervention, and 50 patients (13%) re-presented, for pain (76%), bleeding (10%) or infection (14%). Conclusion We showed that emergency URS is a feasible approach for the routine management of acute ureteric colic with a low complications rate. A subgroup of younger, healthier patients may benefit the most from the procedure.

Medical expulsive therapy (MET) is one of the most common conservative modality of treatment offered by general practitioners for ureteric colic and calculi. In many occasions, such treatment may have beneficial effect, but might be counter-productive, if offered inappropriately. We report a case of unilateral pelvi-ureteric junction obstruction with a large, redundant, extra renal pelvis that was misinterpreted in ultrasonography as hydroureteronephrosis. The dilatation was assumed to be due to ureteric calculus and hence treated with MET, that resulted in forniceal rupture and urinoma. The aim of this article is to highlight the possible catastrophe that can result as a result of inappropriate administration of MET, especially in those patients treated based on empirical diagnosis of ureteric colic.

Objective To determine if the measurement of ureteric stone in coronal reconstruction plane is different from the measurement in axial plane and whether the difference can impact the management decision in patients with ureteric colic. Methods All patients who underwent unenhanced multidetector computed tomographic (MDCT) scan for the evaluation of reno-ureteral colic in outpatient clinics and emergency room were evaluated. The scans were evaluated on Picture Archiving Computer System with a 3-mm axial and reformatted 3-mm coronal sections. Maximal stone diameter was measured in 2 dimensions in the axial and reformatted coronal sections by 2 reviewers. Only scans with isolated, unilateral, solitary ureteric calculi were included in the final analysis. All patients were monitored up to 4 weeks after MDCT to determine the clinical outcome. Results A total of 331 patients (272 male and 59 female; mean age ± standard deviation, 39.8 ± 13.8 years) were included. One hundred seventy-one (51.7%) stones passed spontaneously during the follow-up period. There was a 20% underestimation of maximal stone diameter in axial plane for all stones and a 17% for the stones that passed spontaneously or with medical expulsive therapy, as compared with measurement on coronal reconstruction. Conclusion Measuring the transverse stone diameter on axial images of MDCT scan underestimates size of ureteric stone. This can have an impact on counseling of patients and their clinical outcome, coronal reformatted images be used for size estimation.

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.

Objective: The factors associated with a successful outcome for the treatment of urinary lithiasis are well described. We reviewed current methods of imaging utilised in stone treatment planning, with specific reference to their ability to identify predictors of outcome. Methods: A literature search for articles concerning the investigation and management of patients with urolithiasis was conducted through PubMed ( www.ncbi.nlm.nih.gov/PubMed/ ). In addition a hand search of the abstract books from the most recent major urological conferences was performed to identify data of interest that have so far been presented in abstract form only. Results: Non-contrast computed tomography is superior in terms of diagnostic efficacy, with sensitivity and specificity approaching 100%. The intravenous urogram and contrast CT with 3-dimensional reconstruction provide the best anatomical detail. Conclusion: Although non-contrast helical computed tomography is the most sensitive investigation for suspected ureteric colic, the anatomical and functional information afforded by intravenous urography remains important for treatment planning in some patients.

Aortic aneurysms are very rare in Middle East unlike Europe and America. Therefore, this pathology is very likely to be missed in acute presentation to the Emergency Medicine Department. We present a case of leaking abdominal aortic aneurysm mimicking right ureteric colic, which was missed in the initial assessment.

Resume Les auteurs rapportent le cas d’une patiente de 35 ans accusant depuis 7 ans des episodes ressemblant a des coliques nephretiques rebelles en rapport avec une hernie discale thoracique. Le diagnostic a ete pose tardivement en l’absence de troubles neurologiques. Les differentes explorations radiologiques ne retrouvaient pas de lesions au niveau de l’appareil urogenital expliquant cette symptomatologie. L’imagerie par resonance magnetique medullaire a ete performante dans la mise en evidence d’une hernie discale posterolaterale compressive en T10-T11. L’evolution a ete favorable apres une decompression chirurgicale radiculo-medullaire. A notre connaissance, l’association coliques nephretiques et hernie discale thoracique n’a jamais ete rapportee dans la litterature medicale.

The first of the two articles in this section examines the dynamic rates of arterial delivery and renal drainage in patients whose renogram showed a Homsy sign, using optimised computer compartmental modelling. The author found that the standard model was unlikely to be correct, and that the Homsy sign was probably an artefact seen in patients with impeded urinary drainage. In the second, the authors from Budapest studied the effect of drotaverine in patients with ureteric colic; it was of significant help in this condition. OBJECTIVE To estimate the dynamic rates of arterial delivery and renal drainage in renograms with the Homsy sign, using optimized computed compartmental modelling. METHODS Eleven F−15 renograms and one F+15 renogram (using 99mTc-mercaptoacetyltriglycine) with the Homsy sign were studied, with 26 controls. Compartmental models were constructed for each renogram using components (blood, renal, bladder) linked by variables (arterial rate, drainage rate). Each model was optimized using the Marquadt least-squares method to numerical data from the time-activity curves (TACs). The model renal component at sample points along the TAC was minimized and the corresponding drainage rates calculated. RESULTS The models were optimized, with a mean (range) r2 of 0.811 (0.68–0.88). There were continuous low drainage rates for all type 4 renograms, with no quadrupling of the flow rate, as predicted by the standard model. CONCLUSION The standard model is unlikely to be correct and the Homsy sign is probably an artefact seen in patients with impeded urinary drainage. Computer modelling of individual renograms is feasible and can provide useful insights into the pathophysiology of renal uptake and drainage.

Objective: To assess the accuracy and benefit of urgent bedside ultrasound scanning in urological emergencies by urology trainees. Methods: In this prospective study, 111 patients (86 acute flank pain, 15 renal failure, 10 haematuria) referred as urological emergencies, were scanned for urinary tract abnormalities at the bedside, by a trainee urologist, over 18 months. The ultrasound findings were compared with the results of imaging performed by a consultant radiologist and its influence on clinical management analysed. Results: Bedside ultrasound proved life saving in 5 patients (2 pyonephrosis, 2 leaking aneurysms, one bilateral ureteric injury). It significantly influenced management in 11 patients, excluded obstruction in the presence of infection in 13 patients, helped in early diagnosis in 32 patients and ruled out gross urological pathology in 28 patients. It was misleading in 22 patients, mainly with ureteric colic (where the timing of the test can affect the findings), though the outcome was not adversely affected in any. Bedside ultrasound was reasonably accurate (sensitivity 81% and specificity 92%). Conclusions: Bedside ultrasound is a useful tool to help the decision-making in urological emergencies and reasonably accurate in hands of a trainee urologist. It is especially helpful for excluding obstruction in presence of infection or renal failure. However it has inherent limitations in assessing acute ureteric colic.

Non contrast helical computed tomography (CT) study of the abdomen is frequently performed in evaluation of suspected ureteric colic. We present CT images of a young adult male patient who had torsion of an undescended, non-neoplastic testis and describe the “Inguinoscrotal whirlpool sign on CT”.

Objective : Sonography is unfrequently used for direct visualisation of ureteric calculi. In a sonography prospective study with 3 experienced examinators, sonographical results in primary detection of ureteric calculi were compared to plain renal radiography and intravenous urography. Methods : In a prospective study, patients with suspected renal or ureteric colic were examined using both sonography and excretory urography. The only diagnostic criterion for sonography was the evidence of a calculus, while for excretory urography direct and indirect indications of a calculus were permitted. Results: Sixty two patients were examined using ultrasound and excretory urography. In detecting ureteric calculi, sensitivity of sonography and excretory urography was 93% and 76%, and specificity was 93% and 100%, respectively. In the present study, plain renal radiography was relatively less conclusive as a diagnostic tool for the detection of ureteric calculi and does not seem to be necessary as an additional procedure to sonography. In the case of renal calculi, sonography and excretory urography achieved a sensitivity of 94% and 77%, respectively, and a specificity of 100% each. Conclusions: Ultrasonographic examination carried out by a well-experienced investigator, using the graded compression technique, should be used as the primary examination method. Additional excretory urography remains open if there is a discrepancy between clinical symptoms or findings and sonographical diagnosis.

Introduction: This retrospective study investigates the role of the emergency ureteroscopic (URS) approach in the definitive treatment of ureteric stones.Methods: We reviewed all patients admitted for ureteric stones from May 2003 to December 2010. Those who underwent URS stone treatment were selected and stratified into emergency (EMG) and elective groups (ELG). Emergency URS is defined as URS being performed within 24 hours of admission to the emergency room. The main indication for emergency treatment was refractory ureteric colic in spite of narcotic analgesia. Both groups were statistically compared in terms of their patient-, stone- and outcome-related variables. The overall success rate was defined by the clearance of the stone and/or presence of residual fragments (

Aim: To evaluate the sensitivity and specificity of noncontrast helical computerized tomography (CT) in ureteric colic with comparative evaluation of KUB and ultrasonography (USG). Setting: Tertiary care university hospital. Materials and Methods: One hundred patients aged between 20 and 75 years referred from the emergency department as acute ureteric colic were evaluated with KUB and USG followed by noncontrast helical CT. Results: Noncontrast helical CT was 91% sensitive and 98% specific in detecting urolithiasis compared to a sensitivity of 20% and 30% for KUB and USG and specificity of 94% and 98% respectively. Conclusion: Noncontrast helical CT is a very sensitive and specific investigation for evaluation of acute flank pain due to urolithiasis, besides helping in the detection of nonrenal causes of pain.

Most ureteral stones can be observed with reasonable expectation of uneventful stone passage. When an active ureteral stone treatment is warranted, the best procedure to choose is dependent on several factors, besides stone size and location, including operators' experience, patients' preference, available equipment and related costs. Placement of double-J stent or nephrostomy tube represents the classical procedures performed in a renal colic due to acute ureteral obstruction when the conservative drug therapy does not resolve the symptoms. These maneuvers are usually followed by ureteroscopy or extracorporeal shockwave lithotripsy, which currently represent the mainstay of treatment for ureteral stones. In this review paper a literature search was performed to identify reports dealing with emergency management of renal colic due to ureteral stones. The main aspects related to this debated issue are analyzed and the advantages and disadvantages of each treatment option are carefully discussed.