CT Urography and applications in uroephithelial tumors Orith Portnoy Dept. of Diagnostic Radiology Sheba Medical Center, Sakler School of Med. Tel-Aviv University, Israel

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 CT has gradually taken the place of IVP in evaluating renal masses….

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) The evolution from single detector CT to multi detector CT enables us to scan the urinary tract quickly with high resolution, and obtain very good reconstructions are made easily.

CTU at Sheba Since 6/2004 ~ 500 studies GE MDCT 16/64 slice, Philips MDCT BR 40/64 slice

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 We are scanning the patients in 3 phases

Normal CTU – Axial images

MPR MIP CORONAL VIEWS: MULTI-PLANAR RECONSTRUCTION , MAXIMAL INTENSITY PROJECTION

3D volume rendering

CTU – Rec. bladder TCC 80 Y.O. man Macrohematuria S/P 17 operations for bladder TCC איליאבייב WORK-UP OF HEMATURIA

Staging - Lymphadenopathy

CTU – virtual cystoscopy

56 Y.O. man macrohematuria Rec. bladder TCC seen at cystoscopy Posterior view

1 event of macrohematuria CTU and US 46 Y.O. women 1 event of macrohematuria

CTU and IVP 68 Y.O. man Left flank pain  US (stone)  lithothripsy hematuria post 3w IVPcystoscopy (susp. tumor) This patient had an IVP done due to flank pain and hematuria which was considered normal. This is the best image in the series. Since cystoscopy suspected a bladder mass he was referred tp CTU

61 Y.O. man Recurrent macrohematuria 6 mo. before – US, IVP, cystoscopy

CTU and PET CT Bladder TCC and CLL Retrograde pyelography – narrowed ureter

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: >40y, macrohematuria, smoking, GU tumor P/H, occupational exposure

Types of Urinary Diversion after Cystectomy Incontinent diversion (ileal, colonic) Continent cutaneous catheterizable reservoir Orthotopic neobladder The first type of diversion, by a small or large bowel loop which the ureters are connected to, is through a stoma to the skin into a collecting bag. In the second continent neobladder reservoir the urine is evacuated with a catheter when desired. In the orthotopic reconstruction the intestinal neobladder is connected to the native urethra. Urination is similar to the regular way.

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

Bladder reconstructin FU

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

Posterior view

CT 18 mo. before

CTU - Disadvantages Radiation dose Mean effective dose: 23-35 mSv CTU 1.5 more than standard IVP The main disadvantage of CTU mentioned is the high radiation dose. This study found that the mean effective dose of CTU is 1.5 times more than standard IVP. Although their protocol of IVP had many images, the added information in CTU justifies the radiation in many cases. Nawfel et al Radiology 2004 Time consuming processing, reviewing Lack large scale research on cost-effectiveness

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)

THANK YOU!

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 פאליי