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

2. 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….

3. 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.

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

5. Protocol CTU Monitored by a radiologist Non contrast phase (low dose)
Nephrographic phase (100s delay)  saline IV
Excretory phase ( slices) tailored
Reconstructions on a 4.1 or 4.2 GE workstation
We are scanning the patients in 3 phases

6. Normal CTU – Axial images

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

8. 3D volume rendering

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

10. Staging - Lymphadenopathy

11. CTU – virtual cystoscopy

12. 56 Y.O. man
macrohematuria
Rec. bladder TCC seen at cystoscopy
Posterior view

14. 1 event of macrohematuria
CTU and US
46 Y.O. women
1 event of macrohematuria

15. 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

19. 61 Y.O. man
Recurrent macrohematuria
6 mo. before – US, IVP, cystoscopy

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

21. 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

22. 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.

23. 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

24. Bladder reconstructin FU

26. 68 Y.O. man
6 years post bladder replacement d/t TCC
6 months intermittent macrohematuria

28. Posterior view

29. CT 18 mo. before

30. 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

31. 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)

32. THANK YOU!

33. 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