Presentation on theme: "CT Urography and applications in uroephithelial tumors"— Presentation transcript:
1CT Urography and applications in uroephithelial tumors Orith PortnoyDept. of Diagnostic RadiologySheba Medical Center, Sakler School of Med. Tel-Aviv University, Israel
2IVP (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 stonesRenal inflammationRenal traumaCT has gradually taken the place of IVP in evaluating renal masses….
3CT Urography (CTU)Single detector MDCT volumetric acquisition high resolution reconstructionsBoth renal parenchyma and urothelium shown in a single examinationShortening 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.
4CTU at Sheba Since 6/2004 ~ 500 studies GE MDCT 16/64 slice, Philips MDCT BR /64 slice
5Protocol CTU Monitored by a radiologist Non contrast phase (low dose) Nephrographic phase (100s delay) saline IVExcretory phase ( slices) tailoredReconstructions on a 4.1 or 4.2 GE workstationWe are scanning the patients in 3 phases
141 event of macrohematuria CTU and US46 Y.O. women1 event of macrohematuria
15CTU and IVP68 Y.O. manLeft flank pain US (stone) lithothripsy hematuria post 3w IVPcystoscopy (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
1961 Y.O. manRecurrent macrohematuria6 mo. before – US, IVP, cystoscopy
20CTU and PET CT Bladder TCC and CLL Retrograde pyelography – narrowed ureter
21SensitivityDetection 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
22Types of Urinary Diversion after Cystectomy Incontinent diversion (ileal, colonic)Continent cutaneous catheterizable reservoirOrthotopic neobladderThe 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.
23Imaging after bladder reconstruction ComplicationsRecurrenceUnderstanding the reconstruction anatomy helps diagnose complicationsUS, IVP, cystography/lupography antegrade/retrograde pyelography, CT, nuclear medicineCT-UROGRAPHY
30CTU - Disadvantages Radiation dose Mean effective dose: 23-35 mSv CTU 1.5 more than standard IVPThe 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 2004Time consuming processing, reviewingLack large scale research on cost-effectiveness
31CTU - summaryUseful diagnostic examination that allows comprehensive evaluation of urinary tractsProblem solving tool with other modalitiesBecoming the primary imaging study for the work-up of patients with hematuria and other genitourinary conditionsShorter diagnostic evaluation, decrease need for ureteroscopiesTailored examination can save radiationReferrals should be limited (urologists)