title: Stones lodge at three sites of anatomic narrowing in the ureter: clinical fact or fiction?
abstract: Abstract Background and Purpose: Throughout the literature, the ureter is described as having three anatomic sites of narrowing at which kidney stones typically become lodged: The ureteropelvic junction (UPJ), the ureteral crossing of the iliac vessels, and the ureterovesical junction (UVJ). There is little evidence to support this notion, however. The purpose of our study is to evaluate whether three peaks in stone distribution corresponding to these anatomic landmarks exist.
  
  
  METHODS
  We retrospectively reviewed the kidneys-ureters-bladder (KUB) films of 622 patients with solitary ureteral calculi referred for shockwave lithotripsy (SWL). Pretreatment KUB films were used to categorize the location of their ureteral stone relative to 1 of 19 levels referenced to the axial skeleton. CT scans of 74 patients were used to determine the location of the UPJ, ureteral crossing of the iliac vessels, and UVJ relative to the 19 levels on KUB radiography. Histograms were then constructed to plot the distribution of stones within the ureter relative to these 19 levels. The effect of sex, stone size and side, and presence of a stent on stone distribution were analyzed.
  
  
  RESULTS
  There are two peaks in the distribution of stones within the ureter in patients referred for SWL that correspond to the UPJ/proximal ureter and intramural ureter/UVJ. In patients with larger stones (≥100 mm(2)) or a ureteral stent in place, stones were distributed more proximally (P<0.0001). When comparing sexes, there was a difference in stone distribution that approached significance (P=0.0523), with a greater peak more distally in males compared with females.
  
  
  CONCLUSIONS
  Our review demonstrates a peak in the distribution of stones corresponding to the UPJ/proximal ureter and the intramural ureter/UVJ. We failed to demonstrate a peak in stone distribution corresponding with the ureteral crossing of the iliac vessels.
authors.affiliation: Division of Urology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada. ordonm@smh.ca
authors.forename: Michael
authors.initials: M
authors.lastname: Ordon
authors.forename: Trevor D
authors.initials: TD
authors.lastname: Schuler
authors.forename: Daniela
authors.initials: D
authors.lastname: Ghiculete
authors.forename: Kenneth T
authors.initials: KT
authors.lastname: Pace
authors.forename: R John D'A
authors.initials: RJ
authors.lastname: Honey
mesh_terms: D003251:Constriction, Pathologic; D005260:Female; D006801:Humans; D007669:Kidney Calculi / Q000000981:diagnostic imaging / Q000473:pathology*; D008297:Male; D010388:Pelvis / Q000473:pathology; D011859:Radiography; D015607:Stents; D014513:Ureter / Q000000981:diagnostic imaging / Q000473:pathology*