Special Article Clinical Effectiveness Protocols for Imaging in the Management of Ureteral Calculous Disease: AUA Technology Assessment

Purpose: This technology assessment addresses the optimal use of imaging in the evaluation and treatment of patients with suspected or documented ureteral stones. Materials and Methods: A comprehensive literature search addressing 4 guiding questions was performed for full text in English articles published between January 1990 and July 2011. The search focused on major subtopics associated with the imaging of ureteral calculi, and included specific imaging modalities used in the diagnosis and management of ureteral calculous disease such as unenhanced (noncontrast) computerized tomography, conventional radiography, ultrasound, excretory urography, magnetic resonance imaging and nuclear medicine studies. Protocols (in the form of decision tree algorithms) were developed based on this literature review and in some instances on panel opinion. The 4 questions addressed were 1) What imaging study should be performed for suspected ureteral calculous disease? 2) What information should be obtained? 3) After diagnosis of a ureteral calculus, what followup imaging should be used? 4) After treatment of a ureteral calculus, what followup imaging studies should be obtained? Results: Based on these protocols, noncontrast computerized tomography is recommended to establish the diagnosis in most cases, with a low energy protocol advocated if body habitus is favorable. Conventional radiography and ultrasound are endorsed for monitoring the passage of most radiopaque stones as well as for most patients undergoing stone removal. Other studies may be indicated based on imaging findings, and patient, stone and clinical factors. Conclusions: The protocols generated assist the clinician in establishing the diagnosis of ureteral calculous disease, monitoring stone passage and following patients after treatment. The protocols take into account not only clinical effectiveness but also cost-effectiveness and risk/harm associated with the various imaging modalities. Abbreviations and Acronyms