CT Urography and applications in uroephithelial tumors

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CT Urography and applications in uroephithelial
tumors

• Orith Portnoy
• Dept. of Diagnostic Radiology
• Sheba Medical Center, Sakler School of Med.
  Tel-Aviv University, Israel

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IVP (intravenous pyelography)

• Initial modality for upper tract imaging in
  hematuria, flank pain others for 7 decades.
• Less sensitive than CT for
• Renal masses (21 for 2 cm mass)
• Urinary tract stones
• Renal inflammation
• Renal trauma

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CT Urography (CTU)

• Single detector ? MDCT volumetric acquisition ?
  high resolution reconstructions
• Both renal parenchyma and urothelium shown in a
  single examination
• Shortening schedule for diagnostic evaluation
  (hematuria)

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CTU at Sheba

• Since 6/2004
• 500 studies
• GE MDCT 16/64 slice, Philips MDCT BR 40/64
  slice

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Protocol CTU

• Monitored by a radiologist
• Non contrast phase (low dose)
• Nephrographic phase (100s delay) ? saline IV
• Excretory phase (400-800 slices) tailored
• Reconstructions on a 4.1 or 4.2 GE workstation

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Normal CTU Axial images
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MPR MIP
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3D volume rendering
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CTU Rec. bladder TCC
80 Y.O. man Macrohematuria S/P 17 operations for
bladder TCC
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Staging - Lymphadenopathy
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CTU virtual cystoscopy
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56 Y.O. man macrohematuria Rec. bladder TCC seen
at cystoscopy
Posterior view
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CTU and US
46 Y.O. women 1 event of macrohematuria
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CTU and IVP

• 68 Y.O. man
• Left flank pain ? US (stone) ? lithothripsy?
  hematuria post 3w? IVP?cystoscopy (susp. tumor)

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61 Y.O. man Recurrent macrohematuria 6 mo. before
US, IVP, cystoscopy
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CTU and PET CT
Bladder TCC and CLL Retrograde pyelography
narrowed ureter
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Sensitivity

• Detection of upper tract urothelial tumors by CTU
  91-94 in relation to biopsy (Dillman Abd
  Imaging 2008)
• Detection of bladder tumors microhematuria 40
  vs. cystoscopy, macrohematuria high risk 93
  sens., 99 spec. (Albani J Urol 2007, Turney BJU
  2006)
• High risk gt40y, macrohematuria, smoking, GU
  tumor P/H, occupational exposure

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Types of Urinary Diversion after Cystectomy

• Incontinent diversion (ileal, colonic)
• Continent cutaneous catheterizable
  reservoir
• Orthotopic neobladder

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Imaging after bladder reconstruction

• Complications
• Recurrence
• Understanding the reconstruction anatomy
  helps diagnose complications
• US, IVP, cystography/lupography
  antegrade/retrograde pyelography, CT, nuclear
  medicine
• CT-UROGRAPHY

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Bladder reconstructin FU
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• 68 Y.O. man
• 6 years post bladder replacement d/t TCC
• 6 months intermittent macrohematuria

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Posterior view
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CT 18 mo. before
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CTU - Disadvantages

• Radiation dose
• Mean effective dose 23-35 mSv
• CTU 1.5 more than standard IVP

Nawfel et al Radiology 2004

• Time consuming processing, reviewing
• Lack large scale research on cost-effectiveness

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CTU - summary

• Useful diagnostic examination that allows
  comprehensive evaluation of urinary tracts
• Problem solving tool with other modalities
• Becoming the primary imaging study for the
  work-up of patients with hematuria and other
  genitourinary conditions
• Shorter diagnostic evaluation, decrease need for
  ureteroscopies
• Tailored examination can save radiation
• Referrals should be limited (urologists)

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THANK YOU!
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CTU and regular CT
66 Y.O. man 1 year post partial nephrectomy for
RCC. New hydronephrosis on CT, suspect rec.
obstructing tumor.
POST. VIEW