Download CT Urography and applications in uroephithelial tumors

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:
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Renal masses (21% for 2 cm mass)
Urinary tract stones
Renal inflammation
Renal trauma
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)
CTU at Sheba
 Since 6/2004
 ~ 500 studies
 GE MDCT 16/64 slice, Philips MDCT BR
40/64 slice
CTU Protocol
 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
Axial images – Normal CTU
MPR
MIP
3D volume rendering
CTU – Rec. bladder TCC
80 Y.O. man
Macrohematuria
S/P 17 operations for
bladder TCC
Staging - Lymphadenopathy
CTU – virtual cystoscopy
56 Y.O. man
macrohematuria
Rec. bladder TCC
seen at cystoscopy
Posterior view
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)
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
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
Nawfel et al Radiology 2004
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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
POST.
RCC. VIEW
New hydronephrosis
on CT, suspect rec.
obstructing tumor.