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CT Urography and applications in uroephithelial tumors Orith Portnoy Dept. of Diagnostic Radiology Sheba 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) v. Initial modality for upper tract imaging in hematuria, flank pain IVP (intravenous pyelography) v. Initial modality for upper tract imaging in hematuria, flank pain & others for 7 decades. v. Less sensitive than CT for: v v Renal masses (21% for 2 cm mass) Urinary tract stones Renal inflammation Renal trauma

CT Urography (CTU) v. Single detector MDCT volumetric acquisition high resolution reconstructions v. Both CT Urography (CTU) v. Single detector MDCT volumetric acquisition high resolution reconstructions v. Both renal parenchyma and urothelium shown in a single examination v. Shortening schedule for diagnostic evaluation (hematuria)

CTU at Sheba v Since 6/2004 v ~ 500 studies v GE MDCT 16/64 CTU at Sheba v Since 6/2004 v ~ 500 studies v GE MDCT 16/64 slice, Philips MDCT BR 40/64 slice

CTU Protocol v Monitored by a radiologist v Non contrast phase (low dose) v CTU Protocol v Monitored by a radiologist v Non contrast phase (low dose) v Nephrographic phase (100 s delay) saline IV v Excretory phase (400 -800 slices) tailored v Reconstructions on a 4. 1 or 4. 2 GE workstation

Axial images – Normal CTU Axial images – Normal CTU

MPR MIP MPR MIP

3 D volume rendering 3 D volume rendering

CTU – Rec. bladder TCC 80 Y. O. man Macrohematuria S/P 17 operations for CTU – Rec. bladder TCC 80 Y. O. man Macrohematuria S/P 17 operations for bladder TCC

Staging - Lymphadenopathy Staging - Lymphadenopathy

CTU – virtual cystoscopy CTU – virtual cystoscopy

56 Y. O. man macrohematuria Rec. bladder TCC seen at cystoscopy Posterior view 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 US 46 Y. O. women 1 event of macrohematuria

CTU and IVP v 68 Y. O. man v Left flank pain US (stone) CTU and IVP v 68 Y. O. man v Left flank pain US (stone) lithothripsy hematuria post 3 w IVP cystoscopy (susp. tumor)

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

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

Sensitivity v Detection of upper tract urothelial tumors by CTU – 91 -94% in Sensitivity v Detection of upper tract urothelial tumors by CTU – 91 -94% in relation to biopsy (Dillman Abd Imaging 2008) v Detection of bladder tumors: microhematuria – 40% vs. cystoscopy, macrohematuria high risk – 93% sens. , 99% spec. (Albani J Urol 2007, Turney BJU 2006) v High risk: >40 y, macrohematuria, smoking, GU tumor P/H, occupational exposure

Types of Urinary Diversion after Cystectomy v Incontinent diversion (ileal, colonic) v Continent cutaneous Types of Urinary Diversion after Cystectomy v Incontinent diversion (ileal, colonic) v Continent cutaneous catheterizable reservoir v Orthotopic neobladder

Imaging after bladder reconstruction v Complications v Recurrence v. Understanding the reconstruction anatomy helps Imaging after bladder reconstruction v Complications v Recurrence v. Understanding the reconstruction anatomy helps diagnose complications v US , IVP , cystography/lupography antegrade/retrograde pyelography, CT, nuclear medicine v CT-UROGRAPHY

Bladder reconstructin FU Bladder reconstructin FU

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

Posterior view Posterior view

CT 18 mo. before CT 18 mo. before

CTU - Disadvantages v Radiation dose Mean effective dose: 23 -35 m. Sv ØCTU CTU - Disadvantages v Radiation dose Mean effective dose: 23 -35 m. Sv ØCTU 1. 5 more than standard IVP Ø Nawfel et al Radiology 2004 v v Time consuming processing, reviewing Lack large scale research on cost-effectiveness

CTU - summary v Useful diagnostic examination that allows comprehensive evaluation of urinary tracts CTU - summary v Useful diagnostic examination that allows comprehensive evaluation of urinary tracts v. Problem solving tool with other modalities v Becoming the primary imaging study for the work -up of patients with hematuria and other genitourinary conditions v Shorter diagnostic evaluation, decrease need for ureteroscopies v Tailored examination can save radiation v Referrals should be limited (urologists)

THANK YOU! THANK YOU!

CTU and “regular” CT 66 Y. O. man 1 year post partial nephrectomy for 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.