The accuracy of noncontrast helical computed tomography versus intravenous pyelography in the diagnosis of suspected acute urolithiasis: A meta-analysis

doi:10.1067/mem.2002.126170

Annals of Emergency Medicine

Volume 40, Issue 3, September 2002, Pages 280-286

Presented at the Canadian Association of Emergency Physicians 2001 Scientific Assembly, Calgary, Alberta, Canada, March 2001.

https://doi.org/10.1067/mem.2002.126170 Get rights and content

Abstract

Study objectives: We determine the accuracy of noncontrast helical computed tomography (NHCT) compared with that of intravenous pyelography (IVP) in diagnosing acute urolithiasis. Methods: Computerized searches of MEDLINE and EMBASE were combined with hand reviews of major journals and of articles from reference lists. Articles were assessed according to a priori criteria for inclusion. Study eligibility was independently assessed by 2 reviewers in a blinded fashion. Test results were combined and analysis of log-transformed data was conducted by using general linear models. Results: No disagreement was found between the 2 investigators in terms of articles that met the inclusion criteria or between the results of the studies. Four studies involving a total of 296 patients met all of the a priori criteria. The pooled positive likelihood ratios (LR+) for NHCT and IVP are 23.15 (95% confidence interval [CI] 11.53 to 47.23) and 9.32 (95% CI 5.23 to 16.61), respectively. The pooled negative likelihood ratios (LR−) for NHCT and IVP are 0.05 (95% CI 0.02 to 0.15) and 0.33 (95% CI 0.23 to 0.48), respectively. The differences between NHCT and IVP were statistically significant for both LR+ (P =.046) and LR− (P =.013). Differences among trials were not statistically significant in either analysis (P =.125 for LR+; P =.114 for LR−). Conclusion: The studies analyzed consistently demonstrated NHCT to be superior to IVP in accurately diagnosing acute urolithiasis, and differences between the 2 tests for both LR+ and LR− were statistically significant. [Ann Emerg Med. 2002;40:280-286.]

Introduction

Flank pain is a common complaint of patients presenting to emergency departments. The most common cause of persistent flank pain of sudden onset is acute urolithiasis. Acute urolithiasis or nephrolithiasis, commonly referred to as renal colic, is the presence of a stone in the ureter, resulting in partial or complete ureteral obstruction. The true incidence of this condition cannot be known because patients might remain asymptomatic during an episode.¹ It is estimated, however, that acute urolithiasis affects between 2% and 15% of the Western population during their lifetime, 70% of whom are between 20 and 50 years of age, and has a 4 times greater predilection for men than women.1, 2, 3

Intravenous pyelography (IVP), also known as intravenous urography or excretory urography, was introduced in 1923 and has served as the diagnostic test of choice for the investigation of patients with suspected acute urolithiasis.⁴ Noncontrast helical computed tomography (NHCT) was introduced in 1994 as a possible replacement for IVP in the investigation of patients with suspected acute urolithiasis.⁵ The advantages of NHCT over IVP are multiple and include elimination of patient exposure to intravenous contrast material, visualization of radiolucent calculi, visualization of pathology outside of the urinary tract, and shorter examination time.5, 6, 7, 8, 9, 10

A number of studies report to varying degrees that NHCT is more accurate than other investigations in identifying patients with acute urolithiasis.1, 5, 7, 11, 12, 13, 14 The results of these studies are consistently in favor of NHCT; however, no formal review of the literature to confirm that NHCT is more accurate than IVP in this setting has been reported. The objective of this study, therefore, was to identify studies that directly compared NHCT and IVP in patients with suspected acute urolithiasis and to analyze the combined results of those studies selected by using explicit a priori inclusion criteria.

Section snippets

Materials and methods

Literature searches were undertaken specifically for studies in which patients with suspected acute urolithiasis were investigated with both IVP and NHCT and followed up for clinical outcome. Separate computerized MEDLINE and EMBASE searches with “urinary calculi,” “tomography,” and “urography” used as medical subject heading (MeSH) terms and key words were conducted. The limits of English language and publication between 1994 and 2000 were applied to the MEDLINE searches, and publication

Results

MEDLINE searches with “urinary calculi” revealed 19,228 articles, with “tomography” revealed 218,829 articles, and with “urography” revealed 16,376 articles. The combination of these 3 terms identified 159 articles that, when the limits of English language and publication between 1994 and 2000 were applied, was reduced to 56 articles. Of the 56 articles found in the MEDLINE search, 8 compared NHCT and IVP for the diagnosis of acute urolithiasis,1, 5, 11, 12, 13, 16, 17, 18 of which 3 were

Discussion

The results of this meta-analysis show NHCT to be significantly more accurate than IVP in evaluating patients with suspected acute urolithiasis. Although the 4 studies were found to be similar in design and patient populations and used similar criteria for positive and negative test results, differences might still exist because of differences in judgment of interpretation.²¹

Ratios of 2 independent probabilities, such as LRs and relative risks (RRs) have a range of variation that is awkward for

Acknowledgements

We thank Brian Hutchison, MD, MSc, Andrew Willan, PhD, Deborah Cook, MD, MSc, Gordon Guyatt, MD, MSc, and Stephen Walter, PhD, for their valuable guidance in the design and analysis of this study. Dr. Worster thanks the Physicians' Services Incorporated Foundation for their generous financial support through a fellowship grant.

References (24)

OF Miller et al.
Prospective comparison of unenhanced spiral computed tomography and intravenous urogram in the evaluation of acute flank pain
Urology
(1998)
FL Levy et al.
Ambulatory evaluation of nephrolithiasis: an update of a 1980 protocol
Am J Med
(1995)
J Vieweg et al.
Unenhanced helical computerized tomography for the evaluation of patients with acute flank pain
J Urol
(1998)
NC Dalrymple et al.
The value of unenhanced helical computerized tomography in the management of acute flank pain
J Urol
(1998)
O Niall et al.
A comparison of noncontrast computerized tomography with excretory urography in the assessment of acute flank pain
J Urol
(1999)
DL Simel et al.
Likelihood ratios with confidence: sample size estimation for diagnostic test studies
J Clin Epidemol.
(1991)
JR Fielding et al.
Spiral computerized tomography in the evaluation of acute flank pain: a replacement for excretory urography
J Urol
(1997)
MY Chen et al.
Can noncontrast helical computed tomography replace intravenous urography for evaluation of patients with acute urinary tract colic?
J Emerg Med
(1999)
A Mutgi et al.
Renal colic: utility of plain abdominal radiographs
Arch Intern Med
(1991)
ED Osborne et al.
Landmark article February 10, 1923: Roentgenography of urinary tract during excretion of sodium iodide
JAMA
(1983)

RC Smith et al.

Acute flank pain: comparison of non-contrast-enhanced CT and intravenous urography

Radiology

(1995)

JA Levine et al.

Ureteral calculi in patients with flank pain: correlation of plain radiography with unenhanced helical CT

Radiology

(1997)

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^*: Author contributions: AW and TH conceived and designed the study. AW and IP conducted the searches and abstracted the data. BW conducted all statistical analyses. AW drafted the manuscript, and all authors contributed to its editing. AW takes responsibility for the paper as a whole.

^**: The authors were funded through salaries paid by Hamilton Health Sciences Corporation and/or McMaster University. Dr. Worster received an unrestricted fellowship grant from the Physicians' Services Incorporated Foundation, Toronto, Ontario, Canada.

^★: Address for reprints: Andrew Worster, MD, MSc, Research Coordinator, Department of Emergency Medicine, Hamilton Health Sciences, 237 Barton Street E, Hamilton, Ontario, Canada L8N 3Z5; 905-521-2100, ext. 73136, fax 905-527-7051; E-mail [email protected]

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RadiologyThe accuracy of noncontrast helical computed tomography versus intravenous pyelography in the diagnosis of suspected acute urolithiasis: A meta-analysis*,**,★

Abstract

Introduction

Section snippets

Materials and methods

Results

Discussion

Acknowledgements

Urology

Am J Med

J Urol

J Urol

J Urol

J Clin Epidemol.

J Urol

J Emerg Med

Renal colic: utility of plain abdominal radiographs

Arch Intern Med

Landmark article February 10, 1923: Roentgenography of urinary tract during excretion of sodium iodide

JAMA

Acute flank pain: comparison of non-contrast-enhanced CT and intravenous urography

Radiology

Ureteral calculi in patients with flank pain: correlation of plain radiography with unenhanced helical CT

Radiology

Radiology
The accuracy of noncontrast helical computed tomography versus intravenous pyelography in the diagnosis of suspected acute urolithiasis: A meta-analysis*,**,★