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The visualization of paravertebral venous collateral vessels during excretory urography may be normal when a foot vein has been injected. This finding reflects the abundant intercommunications between the caval, vertebral, and azygos venous systems and should not be mistaken for vena caval occlusion unless strong clinical suspicion of deep venous thrombosis exists.
We performed suprapubic percutaneous urography in two patients to diagnose unusual duplication anomalies of the urinary tract, since preoperative diagnosis was unclear after routine noninvasive studies. In both patients standard suprapubic puncture technique was employed. The procedure was used to confirm the diagnosis of duplication of the bladder in one case and to establish the site of origin of a ureterocele in the other. The technique employed in suprapubic cystography may be extended to the diagnosis of unusual cystic abnormalities in the pelvis that may be of urinary tract origin.
Clinical experience indicates that hypertensive excretory urography is not a satisfactory screening examination to detect patients having hypertension due to renal artery stenosis. Review of the Cooperative Study data indicates the false negative rate for screening was 21.8%. In addition, the prevalence of hypertension caused by renal artery stenosis appears quite low, in the range of 1-3%. Since the objective is to identify patients who will benefit from surgery, clinical sorting strategy should focus on evaluating patients as surgical candidates, not as having the disease. Once that is done, pharmacodynamic renal arteriography is recommended as the first imaging examination to find the renal artery lesion and determine its hemodynamic significance.
A double-blind, parallel-group trial was performed in 96 children in order to evaluate and compare the safety and efficacy of iopentol (Imagopaque, Nycomed imaging AS, Oslo, Norway) with those of routinely used contrast media. Ten children below 1 year of age received iopentol and eight received iohexol (Omnipaque, Nycomed Imaging AS, Oslo, Norway) (both 300 mg I/ml) in a random manner. Seventy-eight children (39 in each group), between one and 10 years of age, received iopentol 300 or diatrizoate (Urografin, Schering AG, Berlin, Germany) 292 mg I/ml for urography. No adverse events were observed among the children below 1 year of age. In the group between one and 10 years there was a statistically and clinically significant difference (p = 0.007) in the incidence of adverse events between the iopentol (2.6%) and diatrizoate (25.6%) groups. All adverse events were of mild or moderate intensity. No serious reactions were encountered. The overall quality of visualization was judged to be diagnostic for all patients. This study supports the use of non-ionic contrast media in pediatric patients and confirms that iopentol is a safe and effective contrast medium well suited for children from 0-10 years of age.
The introduction of multislice computed tomography with its well-known advantages has made it possible to visualize the entire urinary tract with thin collimation during a breath-holding phase. CT data acquisition during urographic contrast enhancement for contiguous imaging of the entire upper urinary tract is termed "multislice CT urography" (MSCTU). Multiplanar reconstructions, maximum intensity projections, and average intensity projections can be rendered from the volume datasets to view the urogenital tract. MSCTU will play an important role in the future of modern uroradiology. This article describes the technical aspects involved in the course of the MSCTU examination and identifies additional potential indications for clinical application.
PURPOSE: To assess the value of functional magnetic resonance urology for the noninvasive postoperative evaluation of renal transplants. METHODS: A saturation inversion projection sequence allows the selective imaging of strongly T1 weighted signal from the MR contrast agent. A control slab leads to images comparable to conventional urography which can be acquired as a sequence with four images per minute. RESULTS: 15 patients with urologic questionable findings after renal transplantation were studied. FMRU revealed in 6 patients normal findings, in 6 moderate dilatation of the renal pelvis without any urodynamic relevant obstruction. 3 pathologic findings, ureteral leak, ureteropelvic-junction obstruction and ureteral stenosis were diagnosed and consequently surgically treated. The imaging quality in all studies was diagnostic and urologically relevant. CONCLUSION: FMRU can be used as a noninvasive technique for the assessment of renal transplant in cases with suspicion of complication in the excretory system.
BACKGROUND: Recent studies have demonstrated magnetic resonance (MR) capabilities in evaluating renal morphology and function in patients with urinary obstruction. The objective of this report is to support the introduction of dynamic MR renography on any MR equipment. METHODS: A custom-made device of vials filled with different concentrations of gadolinium was studied by combinations of T1-weighted gradient-echo sequences and coils. We compared the capabilities of two coils (phased array vs. standard body), the properties of dynamic sequences, and the effects of increasing concentrations of gadolinium on signal intensity. In a second section, we designed MR urography plug-ins of Image J (DICOM image software) for the analysis of dynamic studies. RESULTS: Optimized gradient-echo sequences acquired with a phased array body coil produced acceptable quality images with a linear relation between signal intensity and the lowest concentrations of gadolinium. In vitro measurements showed loss of linearity above 8 mmol/L. CONCLUSION: Theoretical calculation and data from the literature suggest that the gadolinium dose to the patient should not exceed one-fourth of the usual one (0.025 mmol/kg). Postprocessing using Image J software and the specifically designed plug-ins was validated. The collection of plug-ins is now available on the Internet.
We investigated 7505 inpatients who underwent intravenous urography or contrast-enhanced computed tomography to assess risk factors for delayed adverse drug reactions to iohexol, a non-ionic iodinated contrast medium. Focusing on delayed adverse reactions, all adverse events were prospectively investigated for 7 days after injection of iohexol. To explore the relevant risk factors, the relationship between occurrence of adverse reactions to iohexol and 17 different variables was evaluated by logistic regression analysis. To assess the influence of seasonal factors, adverse reactions were separately evaluated during two periods: February to April (the pollinosis period in Japan) and July to September (the non-pollinosis period). The prevalence of delayed adverse events and delayed adverse reactions was 3.5 and 2.8%, respectively, whereas the prevalence of adverse events and adverse reactions was 5.7 and 5.0%, respectively. Multivariate analysis showed that six parameters had a significant influence on delayed adverse reactions to iohexol, including (a) a history of allergy, (b) season, (c) radiographic procedure, (d) age, (e) concomitant surgery or other invasive procedures, and (f) concomitant medication. The prevalence of delayed reactions was lower than in previous large-scale studies. Significant risk factors included a history of allergy and performance of radiography during the pollinosis period, suggesting that allergy was involved in delayed adverse reactions. The type of radiographic procedure also had an influence.
Non-ionic dimers induce less diuresis than non-ionic monomers, resulting in increased opacification of the urinary tract in intravenous urography. This trial compared the diagnostic efficacy of iodixanol and iopromide in patients with macroscopic haematuria. One hundred consecutive patients with normal renal function and macroscopic haematuria entered a double blind, comparative, randomised, parallel trial. Contrast media were given with bolus injection in doses of 300 mgI/kg b.w. Radiographs were blindly evaluated by three radiologists who analysed different parameters (calyceal density and filling, papillary blush detection, delineation of collecting ducts, renal pelvis opacification, visualisation of ureters, bladder density, bladder distention) and estimated the diagnostic confidence (whether abnormal findings were definitely absent, probably absent, doubtful, probably present or certainly present). Radiological diagnoses were compared with final diagnoses. Results were summarised as the ratio of the odds of having a worse performance of iopromide vs iodixanol. Iodixanol showed a significantly better calyceal density and filling [odds ratio (OR): 1.96; 95% confidence interval (CI): 1.60-2.41], a significantly better pelvis opacification (OR 2.91; CI 2.02-4.18) and a significantly more frequent papillary blush detection (OR 1.95; CI 1.29-2.95). Iopromide showed a significantly better ureteral visualisation (OR 0.67; CI 0.48-0.92) and a significantly higher bladder distention (OR 0.59; CI 0.36-0.99). Iodixanol allowed a significantly higher diagnostic confidence as to calyceal evaluation (OR 1.35; CI 1.01-1.79). No significant differences were found with regard to other parameters. The results confirmed theoretical expectations. The higher opacification provided by iodixanol allowed better results and a higher diagnostic confidence in the upper excretory pathway.
With the introduction of Council Directive 97/43/Euratom, all member states should establish relevant diagnostic reference levels for X-ray examinations. Diagnostic reference levels help to facilitate standardisation and optimisation within departments and attempt to reduce dose variations between hospitals. High variation of individual patient doses for plain-film examinations by up to a factor of 75 was demonstrated by a previous Irish study, which highlighted the necessity for further investigation into other examinations in Ireland. The current work aimed to establish reference values for intravenous urography (IVU) examinations, an important contributor to collective dose. Eleven Irish hospitals were randomly selected, representing 30% of the total number of hospitals. Dose-area product (DAP) readings for IVUs were recorded along with technical and procedural details. Resultant data demonstrated mean hospital and individual patient DAP variations of a factor of 4 and 58, respectively. Stepwise regression analysis demonstrated that number of images taken, method of image acquisition and patient weight were the main causal agents for dose variations recorded. A proposed diagnostic reference level of 12 Gy cm(2) was established at the level of the third-quartile value of the mean hospital DAP values. This article provides evidence of large variations in DAP values for IVU examinations. It is hoped that application of the proposed DRL of 12 Gy cm(2 )will reduce the size of these variations.
Unenhanced helical computed tomography (UHCT) has evolved into a well-accepted alternative to intravenous urography (IVU) in patients with acute flank pain and suspected ureterolithiasis. The purpose of our randomized prospective study was to analyse the diagnostic accuracy of UHCT vs IVU in the normal clinical setting with special interest on economic impact, applied radiation dose and time savings in patient management. A total of 122 consecutive patients with acute flank pain suggestive of urolithiasis were randomized for UHCT ( n=59) or IVU ( n=63). Patient management (time, contrast media), costs and radiation dose were analysed. The films were independently interpreted by four radiologists, unaware of previous findings, clinical history and clinical outcome. Alternative diagnoses if present were assessed. Direct costs of UHCT and IVU are nearly identical (310/309 Euro). Indirect costs are much lower for UHCT because it saves examination time and when performed immediately initial abdominal plain film (KUB) and sonography are not necessary. Time delay between access to the emergency room and start of the imaging procedure was 32 h 7 min for UHCT and 36 h 55 min for IVU. The UHCT took an average in-room time of 23 min vs 1 h 21 min for IVU. Mild to moderate adverse reactions for contrast material were seen in 3 (5%) patients. The UHCT was safe, as no contrast material was needed. The mean applied radiation dose was 3.3 mSv for IVU and 6.5 mSv for UHCT. Alternative diagnoses were identified in 4 (7%) UHCT patients and 3 (5%) IVU patients. Sensitivity and specificity of UHCT and IVU was 94.1 and 94.2%, and 85.2 and 90.4%, respectively. In patients with suspected renal colic KUB and US may be the least expensive and most easily accessable modalities; however, if needed and available, UHCT can be considered a better alternative than IVU because it has a higher diagnostic accuracy and a better economic impact since it is more effective, faster, less expensive and less risky than IVU. In addition, it also has the capability of detecting various additional renal and extrarenal pathologies.
The aim of this study was to determine the prevalence of filling defect artefacts (FDA) in magnetic resonance urography (MRU). Retrospectively, we assessed MRU examinations of 45 patients with neurogenic bladder dysfunction (21 men, 24 women; mean age 35 years, age range 18-71 years). The MRU was performed 30 min after intramuscular injection of 20 mg frusemide using heavily T2-weighted fast-spin-echo techniques [axial, thick coronal slab, coronal maximum intensity projection (MIP) images] with fat saturation. The images were reviewed by two observers to determine the presence of filling defects and dilatation of pelvicalyceal system and ureters. The filling defects were classified into central, eccentric and complete. Clinical course and plain films were reviewed to determine significance of the detected filling defects. True filling defects were observed in 5 patients (11%) and all due to stones seen on the plain radiograph of the abdomen. Filling defects artefacts (FDAs) were seen in 23 patients (51%; 17 pelvicalyceal system, 17 upper third of ureters, 7 mid ureters and 1 distal ureter). No stones were seen on the plain radiograph of these patients and they had a favourable clinical course for over 24 months. The true filling defects were large in size, eccentric in position and seen in more than one sequence of the MRU examination (axial, n=5; slab, n=5; and MIP, n=4). Four (80%) of the patients with true defects and 21 (91%) of those with FDAs had dilatation of the pelvicalyceal system and ureters. The FDAs were small in size, centrally placed (74%) and always seen in axial images, rarely in slab images (2 cases) and not seen in MIP images. Artefactual filling defects can be seen in MRU examinations. The cause of the FDAs is not fully explained and could be secondary to turbulent and fast flow of the urine. Some of the FDAs seen in the calyces could be due to the tips of the papillae. Awareness of such defects obviates misinterpretation and prevents unnecessary further investigations or interventions.
The optimal delay time after intravenous (i.v.) administration of contrast medium (CM) for opacification of the upper urinary tract (UUT) for multidetector computed tomography urography (MDCTU) was investigated. UUT opacification was retrospectively evaluated in 36 four-row MDCTU examinations. Single- (n=10) or dual-phase (n=26) MDCTU was performed with at least 5-min delay after i.v. CM. UUT was divided into four sections: intrarenal collecting system (IRCS), proximal, middle and distal ureter. Two independent readers rated UUT opacification: 1, none; 2, partial; 3, complete. Numbers and percentages of scores, and the 5%, 25%, 50%, 75% and 95% percentiles of delay time were calculated for each UUT section. After removing diseased segments, 344 segments were analysed. IRCS, proximal and middle ureter were completely opacified in 94% (81/86), 93% (80/86) and 77% (66/86) of cases, respectively. Median delay time was 15 min for complete opacification. The distal ureter was completely opacified in 37% (32/86) of cases and not opacified in 26% (22/86). Median delay time for complete opacification was 11 min with 25% and 75% percentiles of 10 and 16 min, respectively. At MDCTU, opacification of the IRCS, proximal and middle ureter was hardly sensitive to delay time. Delay times between 10 and 16 min were favourable in the distal ureter.
The normal anatomy and many pathologies of the pediatric genitourinary system can be assessed with different imaging modalities. Most of them are based on the use of ionizing radiation and/or invasive techniques. The contribution of magnetic resonance imaging in this regard has opened new ways of approaching pathological conditions in this patient group. The addition of the newly developed rapid techniques has enhanced the superiority of MRI, and both morphological and functional evaluation of the genitourinary system can be achieved. There are different factors on which rely the optimization and the efficiency of magnetic resonance urography (MRU). Of importance is adequate patient immobilization and the use of optimal imaging sequences. The rapid technical development, including the advent of the post-processing respiratory navigator, allows acquisition of high-quality images independent of the patient's respiratory rate. In the future, it is expected that MRU, due to its non-use of ionizing radiation, will become the most important tool in the diagnostic work-up of genitourinary pathologies in infants and small children.
Contrast-enhanced magnetic resonance urography (MRU) is a promising tool in the evaluation of the renal collecting system, but it can be limited by T2* effects resulting from hyperconcentrated gadolinium chelates. The aim of this study was to evaluate a low-dose dimeglumine gadopentetate (Gd-DTPA) MRU technique consisting of a dynamic fast low-angle-shot (FLASH) 2D sequence and a static fast imaging in steady state precession (FISP) 3D sequence for depicting the kidneys and urinary tract. The Gd-DTPA dose (0.01 mmol/kg) was established experimentally in a healthy volunteer study. Ninety-one patients presenting with various renal disorders were examined with a low-dose Gd-DTPA MRU and a T2-weighted turbo spin echo (TSE) MRU technique on a 1.5-T system. Image quality and diagnostic value were considered at least satisfactory in 98.9% of the FLASH 2D studies, 83.5% of the FISP 3D studies and 78.5% of the TSE T2-weighted studies. Typical enhancement patterns were established for the renal cell carcinoma and transitional cell carcinoma. The major limitations were motion artefacts and insufficient hydration of the patients. Low-dose Gd-DTPA MRU appears to be a useful technique in the evaluation of the kidneys and urinary tract, especially in cases of renal tumours.
Urography is regarded as one of the best screening tests for evaluation of urinary tract disease and is commonly used in the search for a cause of hematuria or the presence of upper tract urothelial masses. It is also used in the evaluation of patients with trauma, known or suspected urolithiasis, or renal infection and for the documentation of obstruction or congenital abnormalities. The physician should have a basic understanding of iodinated contrast media and their benefits and effects on the patient. Patient risk factors include a history of (1) renal impairment, (2) significant allergies, (3) asthma, (4) diabetes mellitus, and (5) cardiac disease (particularly congestive heart failure, arrhythmias, unstable angina, recent myocardial infarction, and primary pulmonary hypertension). Changing options for imaging modalities, contrast media, and patient preparation require continued attention to detail and individualization to allow optimization of the urographic examination.
With the advent of multi-detector row CT scanners, evaluation of the urothelium of the entire urinary tract with high-resolution thin sections during a single breath-hold has become a reality. Multidetector CT urography (MDCTU) is a single examination that allows evaluation of potential urinary tract calculi, renal parenchymal masses, and both benign and malignant urothelial lesions. Initial results with this new technique are encouraging. Current investigations of MDCTU focus on methods to improve opacification and distension of the upper urinary tract-the collecting systems, pelvis, and ureters. The role of abdominal compression, infusion of saline and/or furosemide, and optimal time delay of excretory phase imaging is being explored. Upper tract urothelial malignancies, including small lesions less the 5 mm in diameter, can be detected with high sensitivity. Methods to reduce radiation exposure are being explored, including split-bolus contrast injection techniques that combine nephrographic and excretory phases into a single phase. It is likely that in the near future, radiological evaluation of significant unexplained hematuria or of known or prior urothelial malignancy will consist of a single examination--MDCTU.
The platelet function was investigated in 65 patients submitted to diagnostic excretion urography (injection of 60 ml contrast medium). Blood sampling was performed before (T0) 90 seconds after (T1) and 30 minutes after (T2) injection of the radiocontrast molecule (RCM). Five RCM of different osmolality ionicity and nature of the lateral chain have been tested. Platelet aggregation, platelet release of ATP, osmolality, total calcemia and ionized calcium level were determined on each plasma sample as well as RCM concentration at T1 and T2. Decrease (20 - 40%) of platelet aggregation occurred at T1, whichever platelet aggregating agent (ADP, collagen, Ristocetin or thrombin) were used (significant after Iopamidol 300 and Na Meg Ioxaglate). Platelet release of ATP induced by collagen was also decreased or delayed. These changes were rapidly reversible and a tendency to improvement was observed at T2. Among the five RCM tested, one (Na Diatrizoate) might be a proaggregating agent. No changes of osmolality occurred in the plasma and no correlation could be established between RCM concentration and platelet inhibition. A pathogenic hypothesis is suggested by the significant fall of total and ionized calcium level after RCM injection.