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A Prospective, Matched Comparison of Ultra-Low and Standard-Dose Computed Tomography for Assessment of Renal Colic.

Contexto del tema: Es frecuente a nivel mundial la consulta en el servicio de urgencias por dolor tipo colico renoureteral, el cual, es sugerido por su presentación clínica, sin embargo requiere confirmación con imagen diagnóstica, siendo la más comun y hoy en día considerada como el gold estándar: la tomografia computarizada sin contraste (CT).  Gracias a esta imagen, conseguimos determinar la localización, el volúmen y la densidad de la piedra entre otros; más sin embargo, no podemos dejar de lado que no es un procedimiento inocuo para nuetsros pacientes y que al realizar cada CT estan acumulando exposición a la radiación, con una dosis estandar (SDCT) estimada en 4.5–5 mSV.  Es por esto que basados en esta preocupación, ya existen en la literatura varias publicaciones incluidos metanálisis y revisiones sistematicas sobre el uso de CT de dosis baja (LDCT<3–3,5 mSv) o CT de dosis ultra-baja (ULDCT <1–1.9 mSv).  Incluso en las guias de la sociedad europea de urologia (EAU Guidelines on Urolithiasis 2019) se plantea, que en pacientes con índice de masa corporal (IMC) < 30 la CT con baja dosis puede tener una especificidad y sensibilidad adecuada para ser la primera línea de elección.

Resumen: Este artículo es prospectivo y comparativo, realizado en Australia durante un período de 3 meses y tiene como objetivo determinar la precisión diagnóstica de ULDCT vs. SDCT en la evaluación de pacientes con sospecha clínica de cólico renal, además de características secundarias y procesos patológicos adicionales. Se incluyeron pacientes del servicio de urgencias con signos y síntomas sugestivos de cólico renoueretral, se excluyeron pacientes menores de 18 años y con prueba de embarazo positiva.  Todos los pacientes se sometieron tanto a SDCT como a ULDCT y todas las imágenes fueron revisadas con sistema de simple-ciego por 3 radiologos de forma independiente.

Se incluyeron en total 21 pacientes de los cuales 12 (57,1%) tenian urolitiasis, 3 hidronefrosis sin litiasis, uno con engrosamiento de pared vesical y 5 sin ninguna alteración.  No hubo diferencias significativas en general entre ULDCT y SDCT para la tasa de detección de cálculo o la estimación de tamaño.  Para cálculo renal, ULDCT tuvo fallas para detectar los cálculos <3 mm y detectó tres incorrectamente (calcificación vascular).  Se observó una alta tasa de concordancia para hidroureteronefrosis, mientras que SDCT identificó más lesiones parenquimatosas debido a una mejor detección de lesiones <2 cm.  En general, encontramos que ULDCT resultó en una precisión diagnóstica equivalente a SDCT para cálculos clínicamente significativos, siendo> 3 mm, con 100% de sensibilidad y 100% de especificidad y con una diferencia considerable en la exposición a la radiación entre ULDCT (1.02 mSv) y SDCT (4.97 mSv).

Valoración personal:

Puntos fuertes:

  • El más importante es ser un estudio tipo prospectivo.
  • Es un artículo relativamente fácil de leer, explica de manera concisa metodología y resultados.
  • Recoge los distintos grupos de estudio en tablas que facilita una visualización rápida del  contenido del mismo y resultado.
  • Muestra imágenes comparativas con las diferentes dosis de radiación en TC.
  • El riesgo de radiación puede reducirse con una tomografía de dosis baja mientras se mantiene la sensibilidad y especificidad adecuadas del estudio en el diagnóstico de urolitiasis. Principalmente en el seguimiento de pacientes con colico renoureteral a repeticción, donde este procedimento es impresindible para diminuir la exposición a la radiación.

Puntos débiles:

  • El tamaño de la muestra es demasiado pequeño.
  • No realizaron cálculo del IMC de manera prospeciva acorde al tipo de estudio realizado, siendo que ya se conoce que este puede ser un factor determinante.
  • Existe alteración en la evaluación de la densidad del cálculo (UH) que como sabemos puede llegar a ser determinante para el urologo.
  • Ser difícil de introducir en la práctica clínica estándar.

Ana Maria Diaz B.   MD
Urologist
Endourology Fellow – UNESP-Endourological Society

170 replies on “A Prospective, Matched Comparison of Ultra-Low and Standard-Dose Computed Tomography for Assessment of Renal Colic.”

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