Imaging studies such as plain abdominal radiograph, renal ultrasound, and non-enhanced computed tomography (CT) of the abdomen and pelvis provide critical diagnostic information and should be reviewed at the time of initial patient assessment. Imaging studies performed in close proximity to the initial evaluation should be sufficient for evaluation. However, clinical judgment should determine if updated or follow-up imaging is needed. If no recent imaging is available, then clinicians should obtain a new study to assess the current stone burden and establish a baseline for future evaluation.  Initial imaging studies provide an assessment of the size, location, and number of stones which will help guide clinical decision-making. A plain abdominal radiograph (kidney, ureter, bladder radiography [KUB]) is a reasonable first-line imaging option to assess stone burden but lacks sensitivity for smaller stones and cannot detect radiolucent stones such as uric acid.102 Furthermore, KUB does not identify urinary obstruction, or hydronephrosis, nor does it assess the integrity of the renal parenchyma. Low dose, non-enhanced CT constitutes the “gold standard” for the diagnosis of kidney and ureteral stones and is commonly used as first-line imaging in symptomatic patients because of its high sensitivity (90-98%) and specificity (88-100%) for kidney stones.103, 104 Hounsfield units (HU) can be measured on CT and may be used to identify uric acid stones (typically 200-500 HU), thereby impacting counseling regarding optimal treatment selection.105 Renal ultrasound is usually the first-line imaging study used during pregnancy and for pediatric patients due to the lack of ionizing radiation. Although it has lower sensitivity and specificity compared to non-enhanced CT, especially for ureteral stones, ultrasound can identify hydronephrosis and provide information regarding renal parenchymal integrity.106, 107 Ultrasound can overestimate stone size and caution should be used when making treatment decisions based solely on ultrasound imaging.108 Magnetic resonance imaging (MRI) should not routinely be utilized for evaluating stone disease, although it may play a role in diagnosis in children and pregnant patients in whom ionizing radiation should be minimized and ultrasound may be non-diagnostic.109, 110 Clinicians should review imaging studies themselves, as indicated, rather than relying on radiology reports as there may be significant discrepancies in the findings on imaging compared to those in the dictated reports. By reviewing the films directly, clinicians can be confident in the accuracy of the findings and can use this information to counsel patients in a shared decision-making process.111, 112 The “as low as reasonably achievable,” or ALARA, principle of minimizing ionizing radiation due to the inherent biologic risk should always factor into decision-making when selecting imaging studies.