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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 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 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 IVPcystoscopy (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 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.