1. EDUARDO D CAMPUZANO BS,RT(R,MR,CT)
MR UROGRAPHY
EDUARDO D CAMPUZANO
BS,RT(R,MR,CT)

2. MR UROGRAPHY
MR Urography (MRU)- Have the potential to provide a comprehensive assessment of the urinary system, renal parenchyma, vascular structures, and surrounding tissues

3. OBJECTIVES
INDICATIONS
PREPARATIONS
PROTOCOL
FINDINGS
PITFALLS
SUMMARY

4. URINARY SYSTEM Diagnostic modalities: IV Urogram Renal Ultrasound
CT Urography
MR Urography
CT is the imaging of choice for acute symptoms

5. INDICATIONS Clinical Indications: Hematuria Urolithiasis
Stricture/Obstructions
Anomalies
Neoplasm
Renal Insufficiency/Allergy
Pregnancy/Pediatrics

6. MR UROGRAPHY Advantages over CT Urography:
Elimination of ionizing radiation
Non Ionic Contrast
Contrast Resolution
Non Contrast imaging (T2 Imaging)
Disadvantages vs. CT Urography:
Claustro/Implants
CT: 15 min vs. MR: 45 min
Spatial resolution ( 3-6 mm)
Calcifications not seen
Cost
Uncooperative patient
CT is the modality of choice for acute symptoms

7. PATIENT PREPARATION 250 ml IV normal saline solution Furosemiode/Lasik
PO Water (30 minutes prior to MRI)
Furosemiode/Lasik
Non Dilated Systems
Glucagon
Minimized Peristalsis
Intravenous Contrast (Multihance)
Single Dose
Lasik and Saline/Water improves urine production, dilutes urine.Furosemiode improves distention and opacification in non dilated system(better for static-fluid Urogram)

8. MR UROGRAPHY PROTOCOL Pre Contrast T2* SSFP Axial FS T2 SSTSE Axial FS
T2 SSTSE Cor
Diffusion Axial
T2 Axial TSE FS
T1 Cor 3D GRE FS
T1 Axial 3D GRE (Dixon)
T2 3D Cor Nav
SSH T2 Cor & Sag Cine
T1 3D COR GRE (Pre)
Post Contrast
T1 3D COR GRE (Arterial)
T1 3D COR GRE (60 sec)
T1 3D COR GRE (120 sec)
T1 3D COR GRE (Delays)
T1 3D GRE FS Axial
T1 3D GRE FS Cor
T2 SSTSE Cor (Post Void)

9. Comprehensive MR Urogram
Static-Fluid 2D/3D Urogram (T2)
Independent of renal excretory, uses urine as contrast
2D Cine SSH sequence allows visualization of moving urine
3D sequences best with dilated/obstructed system.
Excretory 3D Urogram (T1)
Dependent of renal excretory
Good for non dilated system.
Provides function and morphology
MRU/MRI/MRA provides a complete assessment of the Urinary System
T2 3D Static Fluid
2D Cine Static Fluid
T1 3D Excretory

10. MR UROGRAPHY Positioning
Abd/Pelvis Scout
Coronal Positioning
Ureters
Cover from Above Kidneys to below Bladder for all Axials
Cover entire Anatomy (Kidneys,Ureters ,and Bladder)

11. MR UROGRAPHY Positioning
Axial T2 TSE Fat Sat
Coronal Positioning
Ureters
Cover entire Anatomy (Kidneys,Ureters ,and Bladder)

12. 3D UROGRAM Coverage Increase coverage on the 3D volume (cost time)
Angle 3D volume to cover entire anatomy (Kidneys,Ureters and Bladder)

13. Maximum Intensity Projection (MIP)
3D T2 Static-Fluid
Maximum Intensity Projection (MIP)
Volume Rendering (VR)
Place Navigator Box, on your Coronal images.
Check box placement in the Axial images.

14. SSH T2 Coronal Cine Except only 1 slices in multiple measurements
Same sequence as a Single Shot MRCP
Except only 1 slices in multiple measurements

15. SSH T2 Coronal Cine Positioning
1- Sagittal Scout
SSH T2 (Cine) COR
2D Slab SSFSE ( Red Box)
Sat Band (Yellow Box),angle if needed
Use 8-12 Dynamics(cine) Wait 5-10 secs between dynamics

16. SSH T2 Sagittal Cine Positioning
1- Coronal SSH
SSH T2 (Cine) Sag
Use 8-12 Dynamics(cine) Wait 10 secs between dynamics
2D Slab SSFSE ( Red Box),70-80 cm
Angle if needed ,do Both Kidneys.

17. SSH T2 Sagittal Cine Positioning
1- Coronal SSH
SSH T2 (Cine) Sag
Ureter must be seen in cine, reposition/repeat if needed

18. STRICTURE/OBSTRUCTION

19. STRICTURE/OBSTRUCTION
T2 3D Static Fluid
2D Cor Cine Static Fluid
2D Sag Cine Static Fluid

20. KIDNEY TRANSPLANT
3D Cor T2 Static Fluid
T2 Axial TSE
2D Cor Cine

21. PREGNANCY Pregnancy (Acute):
Contrast-enhanced MR urography is generally not recommended in pregnant women.
3D T2-weighted (static-fluid) urography(Navigator) is performed.
Cine MR urography(multiple acquisitions ) may be necessary to visualize the entire ureters and exclude fixed narrowing or filling defects.
Images copyright of John R. Leyendecker, MD. Department of Radiology, Wake Forest University School of Medicine, Medical Center Blvd, Winston-Salem

22. PEDIATRICS Pediatric (Congenital):
MR Urography provides imaging(Urinary System) without ionizing radiation.
Is performed without iodinated contrast (Renal Impairment).
Images copyright of John R. Leyendecker, MD. Department of Radiology, Wake Forest University School of Medicine, Medical Center Blvd, Winston-Salem

23. MR UROGRAPHY AT 3T

24. MR UROGRAPHY @ 3T Limitations: Dielectric Effect
Minimized on newer scanners, dialectric pads.
Susceptibility Artifacts
Due to local distortion(air, metal),use shortest TE available.
Motion Artifacts
Increases at 3T (Peristalsis, Flow)
Specific Absorption Rate (SAR)
HASTE, split the acquisitions in order to minimized SAR.
Chemical Shift Artifacts
Increases at 3T ,Steady State sequence are hampered by this artifact.

25. RENAL CALCULUS TRUFISP FS AXIAL T1 3D AX VIBE (Pre)
T1 3D AXIAL VIBE (Post)

26. NEOPLASM
RENAL CELL CARCINOMA
AXIAL T1 3D VIBE
CORONAL T1 3D VIBE

27. RELATED PATHOLOGIES Prostate Enlargement Gonadal Vein Varicose
Bladder Thickened
Uterine Fibroids
Renal Cyst

28. POST PROCCESSING TECHNIQUES Maximum Intensity Projection (MIP)
Volume Rendering (VR)
Thin Volume (MIP)
Multiple Planar Reconstruction (MPR)

29. PITFALLS & ARTIFACTS Non Dilated System (3D T2 Static Fluid) Pitfalls:
Can mimic stricture/obstruction
Artifacts:
High concentration of Gadolinium
T2* shortening (Single Dose)
T2 COR HASTE
T1 3D VIBE POST
T2 3D Static Fluid

30. TIPS & TRICKS Prone Position Tips: Minimizes peristalsis motion
Coverage
Include entire Urinary System
Appropriate Delays
Continue scanning until ureters are fully filled.
Full Bladder
Improves visualization of Urinary System.
Prone Position
Minimizes peristalsis motion
Better visualization of Urinary system.
Tricks:
Use Navigator of Liver or Kidney (Nav within FOV)

31. CONCLUSION MR Urography:
Is a technique that can be useful for assessing patients with a variety of urinary tract disorders.
MRU provides a morphological and functional evaluation of the urinary system.
Extremely useful on patients with no excretory function (T2).
MRU can be combined with MRA/MRV and MRI of the urinary system to provide a complete diagnostic evaluation of the urinary system.