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InfectionsInfections of the of the urinaryurinary tracttract

HematuriaHematuria

Mikael HellstrMikael Hellströöm, MD, PhDm, MD, PhDDepDep of of RadiologyRadiology

Sahlgrenska University Hospital Sahlgrenska University Hospital GothenburgGothenburg

UrinaryUrinary tracttract infectioninfection (UTI)(UTI)

Asymptomatic bacteriuria

Fulminant pyelonephritisAbscess formation

Life-threatening uro-sepsis

UrinaryUrinary tracttract infectioninfection

►► LowerLower//UpperUpper UTI UTI LowerLower UTI (UTI (urethritisurethritis//cystitiscystitis) ) rarelyrarely needsneeds imagingimagingUpperUpper UTI (UTI (ureterureter, , collectingcollecting system, system, parenchymaparenchyma -- pyelonephritispyelonephritis))

►► AsymptomaticAsymptomatic UTI / UTI / SymptomaticSymptomatic UTIUTI►► UncomplictedUncomplicted / / ComplicatedComplicated UTIUTI

ComplicatedComplicated►► UnresponsiveUnresponsive to to treatmenttreatment►► AtypicalAtypical bacteriabacteria►► UnderlyingUnderlying

malformationmalformationtumortumorstonestoneobstructionobstruction

AcuteAcute pyelonephritispyelonephritis-- childrenchildren --

►►At At ageage 77Girls: 8% Girls: 8% Boys: 2% Boys: 2%

►►PeakPeak incidenceincidence <1 <1 yearyear of of ageage

AcuteAcute pyelonephritispyelonephritis-- childrenchildren --

►► NewbornsNewborns//neonatesneonatesElevatedElevated, normal or subnormal , normal or subnormal temperaturetemperatureLethargyLethargy, anorexia, , anorexia, palenesspaleness, , tendernesstenderness

►► Infants and Infants and youngyoung childrenchildrenUnexplainedUnexplained feverfever ((maymay be be onlyonly symptom)symptom)IrritabilityIrritabilityVomitingVomitingFailureFailure to to thrivethrive

►► OlderOlder childrenchildrenHigh High feverfever >38.5>38.5ººC or chillsC or chillsFlank pain and local tendernessFlank pain and local tenderness

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AcuteAcute pyelonephritispyelonephritis-- childrenchildren --

►►WhatWhat are the risks?are the risks?AcuteAcute: : spreadspread of of infectioninfection leading to abscess, leading to abscess, septicemiasepticemiaLongLong--termterm: : renalrenal damagedamage ((scarringscarring))►►risk for hypertensionrisk for hypertension►►risk for risk for complicationscomplications duringduring pregnancypregnancy►►risk for risk for reducedreduced renalrenal functionfunction ifif extensive and extensive and

bilateral bilateral damagedamage Calyceal clubbing

Focal parenchymalthinning

Post-pyelonephritic scarring

PyelonephritisPyelonephritis-- childrenchildren --

►►GoalGoal of of imagingimagingIdentifyIdentify complicationscomplications ((obstructionobstruction, abscess) , abscess) that that maymay needneed acuteacute intervention (intervention (drainagedrainage, , pyelostomypyelostomy))IdentifyIdentify underlyingunderlying factorsfactors►►malformationsmalformations, , parenchymalparenchymal damagedamage, , refluxreflux, stone, , stone,

obstructionobstruction

IdentifyIdentify individualsindividuals with, or at risk of, with, or at risk of, renalrenaldamagedamage

AcuteAcute pyelonephritispyelonephritis-- childrenchildren --

►► AcuteAcute imagingimagingUltrasonographyUltrasonography►►To To detectdetect dilatationdilatation

obstructionobstructionvesicoureteralvesicoureteral refluxreflux

►► IfIf dilatationdilatationVCUGVCUG to to detectdetect gross gross refluxreflux and and posteriorposteriorurethralurethral valvevalve (boys)(boys)MAG3 MAG3 scintigraphyscintigraphy to to evaluateevaluate obstructionobstructionand split and split renalrenal functionfunction

AcuteAcute pyelonephritispyelonephritis-- childrenchildren --

►►AcuteAcute imagingimagingUltrasonographyUltrasonography►►renalrenal parenchymaparenchyma oftenoften

appearsappears normal normal ►►renalrenal swellingswelling►►heterogeneousheterogeneous parenchymalparenchymal echogenicityechogenicity

Doppler/Doppler/iviv contrastcontrast maymay improveimprove detectiondetection of inflammationof inflammation

►►dilatation (dilatation (endotoxinsendotoxins and/or and/or obstructionobstruction))uretericureteric jet jet maymay helphelp in in assessingassessing obstructionobstruction

►►thickeningthickening of the of the urotheliumurothelium►►pyonephrosispyonephrosis ((echogenicechogenic puspus in in collectingcollecting system)system)

AcuteAcute pyelonephritispyelonephritis-- childrenchildren --

►► UltrasonographyUltrasonographyPatient Patient friendlyfriendly and and availableavailableAdequateAdequate for for identificationidentification of dilatationof dilatationInsufficient for Insufficient for assessmentassessment of of acuteacute inflammationinflammationInsufficient for Insufficient for assessmentassessment of of renalrenal scarringscarring

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AcuteAcute pyelonephritispyelonephritis-- childrenchildren --

►►UrographyUrographyDoes not show Does not show acuteacute inflammationinflammationUnderestimatesUnderestimates renalrenal scarringscarring, as, ascomparedcompared to DMSA to DMSA scintigraphyscintigraphy

-- HigherHigher radiationradiation dosedose

►► UrographyUrography nowadaysnowadaysnot not recommendedrecommended, , ifif DMSA DMSA scintigraphyscintigraphy is is availableavailable

TcTc9999--DMSA DMSA scintigraphyscintigraphy

►► i.vi.v. . injectioninjection►► AccumulatesAccumulates in proximal in proximal tubulartubular cells cells ►► ImagingImaging 22--3 3 hourshours after after i.vi.v. . injectioninjection►► FocallyFocally reducedreduced or absent or absent uptakeuptake in in affectedaffected parts parts

of the of the parenchymaparenchyma►► MethodMethod of of choicechoice for for assessmentassessment of of acuteacute

inflammation and for inflammation and for followfollow--upup ((scarringscarring))►► DifferentiationDifferentiation betweenbetween acuteacute and permanent and permanent

damagedamage maymay be be difficultdifficult►► RadiationRadiation dosedose ~1 ~1 mSvmSv

Voiding cystourethrography (VCUG)

Key findings: • Vesico-ureteral reflux• Posterior urethral valve

Reflux grading: I: reaching only ureterII: reaching kidney,

no dilatationIII: slight dilatationIV: moderate dilatationV: gross dilatation

UrographyUrography as as adjunctadjunct imagingimaging

Duplex

Long-term effects of acute pyelonephritis”Reflux nephropathy”

We want to prevent this

Current trend:• Acute imaging with ultrasonography• Early imaging + f/u imaging with DMSA scintigraphy

• VCUG in all children or only if reflux is suspected(dilatation at US or abnormal DMSA)

• MAG3 if suspected obstruction (dilatation at US)

• Urography/CT/MRI if unclear

Acute pyelonephritis in children

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UTI in adultsUTI in adults

►►The The majoritymajority::SporadicSporadic, , uncomplicateduncomplicated, , lowerlower UTI in UTI in womenwomen►►1/3 of 1/3 of womenwomen agedaged 2020--40 40 havehave hadhad oneone or or severalseveral

UTI:sUTI:s►►AdolescenceAdolescence and after menopausand after menopaus►►SelfSelf--limitinglimiting or or easilyeasily treatedtreated with with antibioticsantibiotics

►►In men:In men:UncommonUncommon beforebefore ageage 5050IncreasingIncreasing frequencyfrequency with with prostaticprostatic hyperplasiahyperplasia

AcuteAcute pyelonephritispyelonephritis in in adultsadults-- doesdoes it it mattermatter? ? --

►►UncontrolledUncontrolled infectioninfectionrenalrenal//perirenalperirenal abscessabscesssepticemiasepticemiasepticseptic chockchockdeathdeath

Febrile UTI + obstruction = emergency

AcuteAcute pyelonephritispyelonephritis

►► FeverFever >38>38ººCC►► Flank painFlank pain►► Tenderness over kidney areaTenderness over kidney area►► Nausea, vomiting, malaiseNausea, vomiting, malaise►► Urinary frequency, Urinary frequency, dysuriadysuria►► Symptoms may be vague, especially in elderlySymptoms may be vague, especially in elderly►► Hypotension, Hypotension, tachypneatachypnea and clinical deterioration and clinical deterioration

may indicate septicemiamay indicate septicemia

AcuteAcute pyelonephritispyelonephritis in adultsin adults

►►Who Who needsneeds imagingimaging??WomenWomen with single with single uncomplicateduncomplicatedpyelonephritispyelonephritis, that , that respondsresponds to to antibioticsantibiotics, , dodonot not needneed imagingimagingWomenWomen with >2with >2--3 3 episodesepisodes//yearyear needneed imagingimagingRecommendationsRecommendations for men for men varyvary::►►Alternative 1: as for Alternative 1: as for womenwomen►►Alternative 2: Alternative 2: imagingimaging in all in all casescases

DiabeticsDiabetics and and immunosuppressedimmunosuppressed::►►ImagingImaging usuallyusually indicatedindicated

Acute pyelonephritis? Acute pyelonephritis

Key findings: Renal swellingPerirenal stranding(Low attenuation areas)(Dilatation)

Perirenal stranding

Unenhanced CT

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AcuteAcute pyelonephritispyelonephritis

►►UnenhancedUnenhanced CTCTto to revealreveal underlyingunderlying stonesstones►►scanningscanning diaphragmdiaphragm to to symphysissymphysis

parenchymalparenchymal swellingswelling, , focalfocal or or generalisedgeneralisedperirenalperirenal strandingstrandingwideningwidening of of collectingcollecting system/system/ureterureter►►inhibitinginhibiting action of action of bacterialbacterial endotoxins on endotoxins on smoothsmooth

musclemuscle►►mechanicalmechanical obstructionobstruction

Acute pyelonephritis

DH

Key findings: uni- or multifocal wedge-shaped or rounded low-attenuating areas

Acute pyelonephritis

DH

AcuteAcute pyelonephritispyelonephritis

►►MDCT (MDCT (CTCT--urographyurography) is ) is methodmethod of of choicechoiceNonNon--enhancedenhancedNephrographicNephrographic phasephase for for parenchymalparenchymalasessmentasessmentExcretoryExcretory phasephase (6(6--10 min) for 10 min) for asessmentasessment of of obstructionobstruction

The The latterlatter twotwo phasesphases maymay be be combinedcombined, , usingusingsplit split bolusbolus techniquetechnique

PregnancyPregnancy

►►MayMay cause cause wideningwidening of of collectingcollecting system system and and uretersureters

hormonal hormonal influenceinfluencemechanicalmechanical obstructionobstruction from large uterusfrom large uterus

►►IncreasedIncreased risk of risk of pyelonephritispyelonephritisIncreasesIncreases risk for risk for pregnancypregnancy complicationscomplications

►►ImagingImaging: MRI or : MRI or US+singleUS+single plainplain film film ((urographyurography))

DiabeticsDiabetics

►► IncreasedIncreased frequencyfrequency of UTIof UTI►► HigherHigher frequencyfrequency of of complicatedcomplicated UTIUTI

PyelonephritisPyelonephritisPapillaryPapillary necrosisnecrosisRenalRenal abscessabscessFungalFungal infectionsinfectionsEmphysematousEmphysematous pyelonephritispyelonephritis►►NecrotizingNecrotizing infectioninfection ((mostlymostly E E ColiColi))►►Gas Gas withinwithin renalrenal parenchymaparenchyma, , collectingcollecting system, system, perirenalperirenal spacespace►►Risk for progression to Risk for progression to septicseptic chock chock ►►MortalityMortality up to 50%up to 50%

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EmphysematousEmphysematous pyelonephritispyelonephritis

►►CT is CT is methodmethod of of choicechoice►►US US maymay show show reflectivereflective gas, gas, butbut is less is less

sensitive sensitive thanthan CTCT►►UrographyUrography less sensitive less sensitive thanthan CTCT

RenalRenal//perirenalperirenal abscessabscess

►►BloodBlood bornborn or or locallocal spreadspread►►Pain and Pain and fullnessfullness in the flankin the flank►►FeverFever, , malaisemalaise►►ElevatedElevated CRP and leukocytosisCRP and leukocytosis

Low-echogenic lesion in right kidneyKL KL

Non-enhancing, low density lesion

KLKL

Follow up after antibiotic treatment

Healing

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Post-pyelonephritic scars do occur also in adults,but are rarely extensive and rarely of clinical significance

Cortical defect

XanthogranulomatousXanthogranulomatous pyelonephritispyelonephritis

►►Mostly femalesMostly females►►History of UTIHistory of UTI►►Flank pain and/or palpable mass Flank pain and/or palpable mass ►►1010--30% diabetics 30% diabetics ►►Anorexia, malaise, fever, weight lossAnorexia, malaise, fever, weight loss

XanthogranulomatousXanthogranulomatous pyelonephritispyelonephritis

►► erythrocyte sedimentation rate elevatederythrocyte sedimentation rate elevated►► leukocytosisleukocytosis, , pyuriapyuria, , anemiaanemia, , hematuriahematuria positive positive

urine culture (E Coli or Proteus)urine culture (E Coli or Proteus)►► stone and obstruction, poor functionstone and obstruction, poor function►► renal enlargementrenal enlargement►► replacement of renal tissue by lipidreplacement of renal tissue by lipid--rich rich xanthomaxanthoma

cells and inflammatory cellscells and inflammatory cells►► necrosis, cavities due to necrosis, cavities due to granulomatousgranulomatous

inflammationinflammation►► spreading to the spreading to the perirenalperirenal spacespace

PyelonephritisPyelonephritis in adultsin adults

►►IndicationsIndications for for imagingimagingTreatmentTreatment failurefailureRecurrentRecurrent pyelonephritispyelonephritisGrowthGrowth of of uncommonuncommon bacteriabacteriaDiabeticsDiabeticsSuspectedSuspected complicationscomplicationsFebrile UTI + Febrile UTI + obstructionobstruction is a medical is a medical emergencyemergency!!

►►MethodMethod of of choicechoice = CT = CT

TuberculosisTuberculosisof the of the urinaryurinary tracttract

►►Mostly history of TB, mainly of the lungs, Mostly history of TB, mainly of the lungs, but it may be years back, i.e. rebut it may be years back, i.e. re--activationactivation

►►Often asymptomatic, easily overlookedOften asymptomatic, easily overlooked►►Symptoms may be nonSymptoms may be non--specificspecific

Weight loss, fever, malaiseWeight loss, fever, malaise

►►Upper UTI, not responding to Upper UTI, not responding to standarsdstandarsdantibioticsantibiotics

►►CystitisCystitis

TuberculosisTuberculosis of the of the urinaryurinary tracttract

►►Key findingsKey findingsParenchymalParenchymal and urinary tract and urinary tract calcificationscalcificationsFocal Focal parenchymalparenchymal scarsscarsStricturesStrictures in in calycescalyces, , pelvispelvis, , ureterureterAbscessesAbscesses, , renalrenal//perirenalperirenalObstructiveObstructive uropathyuropathy

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TuberculosisTuberculosis

►►””The Great ImitatorThe Great Imitator””►►MayMay affectaffect anyany organorgan►►Always Always keepkeep TBC in mind as differential TBC in mind as differential

diagnosisdiagnosis

SchistosomiasisSchistosomiasis((BilharziaBilharzia))

►►S S haematobiumhaematobium affectsaffects the the urinaryurinary tracttract►►70 million 70 million peoplepeople in in subsub--SaharanSaharan Africa Africa

suffersuffer from from hematuriahematuria relatedrelated to S to S haematobiumhaematobium

►►32 million 32 million havehave dysuriadysuria►►18 million 18 million havehave bladder bladder pathologypathology at US at US ►►10 million 10 million havehave major major hydronephrosishydronephrosis

►►TBCTBC of the of the urinaryurinary tracttract starts in the starts in the kidneykidneyand and proceedsproceeds to the to the lowerlower urinaryurinary tracttract

►►SchistosomiasisSchistosomiasis starts in the bladder and starts in the bladder and proceedsproceeds craniallycranially

HematuriaHematuria ((macroscopicmacroscopic))

►► MalignancyMalignancyRenalRenal cell cancer cell cancer UrothelialUrothelial cancer in cancer in upperupper tracttractUrinaryUrinary bladder cancerbladder cancerProstateProstate

►► StoneStone►► Benign Benign prostaticprostatic hyperplasiahyperplasia►► InfectionInfection►► NephrologicalNephrological diseasesdiseases►► AntiAnti--coagulationcoagulation therapytherapy►► ExerciseExercise and and moremore……

AcuteAcute onsetonset ofofnonnon--traumatictraumatic hematuriahematuria

►►CancerCancerbladder, bladder, ureterureter, , collectingcollecting system, system, kidneykidney

►►AngiomyolipomaAngiomyolipoma►►RenalRenal arteryartery aneurysmaneurysm rupturerupture►►Stone (Stone (oftenoften typicaltypical symptoms)symptoms)►►Trauma after all..??Trauma after all..??

AngiomyolipomaAngiomyolipoma

• Benign, but AML >4 cm tend to bleed

• May be previosusly unknown

• Bleeding may be life-threatening

• Treatable with embolisation

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Trauma after allTrauma after all……??27 y maleMild trauma, hit by knee in abdomen during play.6 hours later abd pain, vomiting, hematuria

Seemingly innocent traumamay cause bleeding if thereis pre-existing hydronephrosis

HematuriaHematuriaRoleRole for for urographyurography??

►►AdvantagesAdvantagesTime Time honouredhonouredVisualizationVisualization of of collectingcollecting system and system and uretersuretersShows Shows renalrenal and and urinaryurinary tracttract functionfunction

UrographyUrography -- disadvantagesdisadvantages

►►SuboptimalSuboptimal for for stonestone diseasedisease►►Insufficient for Insufficient for infectioninfection►►Insufficient Insufficient identificationidentification of of renalrenal tumorstumors

21% of 21% of tumorstumors <2 cm <2 cm identifiedidentified52% of 52% of tumorstumors 22--3 cm3 cm82% of 82% of tumorstumors >3 cm >3 cm ((WarshauerWarshauer 1988)1988)Less sensitive Less sensitive thanthan ultrasound, CT, MRultrasound, CT, MR

►► Insufficient for bladder Insufficient for bladder tumortumor►► Does not Does not differentiatedifferentiate cystcyst from from tumortumor

CT CT urographyurography

Definition by CT Definition by CT UrographyUrography WorkingWorking Group Group of ESUR of ESUR ((EurEur RadiolRadiol 2008;18:42008;18:4--17)17)

►►CT examination CT examination optimizedoptimized forforKidneysKidneys, , uretersureters, bladder, bladderMDCT with MDCT with thinthin slicesslicesIntravenousIntravenous contrastcontrast medium medium enhancementenhancementImagingImaging in in excretoryexcretory phasephase mandatorymandatory

PossibilitiesPossibilities with MDCTwith MDCT

►► IdentifiesIdentifies virtuallyvirtually all all stonesstones►► IdentifiesIdentifies infectioninfection►► IdentifiesIdentifies renalrenal ischemiaischemia►► IdentifiesIdentifies renalrenal parenchymalparenchymal tumorstumors►► AdequateAdequate for for upperupper uroepithelialuroepithelial lesions?lesions?►► Bladder Bladder tumorstumors??

►► VariousVarious scanningscanning phasesphasesNonNon--enhancedenhancedParenchymalParenchymal►► ArterialArterial ((corticalcortical, , corticomedullarycorticomedullary phasephase))►► VenousVenous ((medullarymedullary phasephase, , nephrographicnephrographic))

PyelographicPyelographic ((excretoryexcretory phasephase))

Problems with Problems with CTCT--urographyurography

►►RadiationRadiation dosedose►►UroepithelialUroepithelial abnormalitiesabnormalities

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CT for CT for HematuriaHematuria

►► RequiresRequires scanningscanning withoutwithout iviv contrastcontrastfor for detectiondetection of of stonesstonesas as baselinebaseline for lesion for lesion enhancementenhancement

►► RequiresRequires earlyearly contrastcontrast enhancedenhanced scanningscanningfor for renalrenal parenchymalparenchymal tumortumor (and bladder ca)(and bladder ca)

►► RequiresRequires late late contrastcontrast enhancedenhanced scanningscanningfor for urothelialurothelial tumortumor in the in the collectingcollecting system, system, ureterureter, , bladderbladder

►► Problem: 3 Problem: 3 scansscans = high = high radiationradiation dosedose

EffectiveEffective dosedose mSvmSv

►► ConventionalConventional urographyurography 33--8 8 mSvmSv►► StoneStone--CTCT 33--5 5 mSvmSv►► CTCT--urographyurography 1010--30 30 mSvmSv

CTCT--urographyurography

►► HowHow to to optimiseoptimise visualisationvisualisation of the of the collectingcollecting system and system and ureterureter? ?

Abdominal Abdominal compressioncompression??DiureticsDiuretics??IntravenousIntravenous fluid?fluid?►► McTavishMcTavish et al 2002: et al 2002: salinesaline infusion infusion effectiveeffective►► MaherMaher et al 2001: et al 2001: salinesaline infusion not infusion not effectiveeffective►► SudakoffSudakoff et al 2006: et al 2006: salinesaline infusion not infusion not effectiveeffective

Oral Oral hydrationhydration??SupineSupine vs vs proneprone position?position?MovingMoving the patient the patient aroundaround

No definite consensus as No definite consensus as yetyet

TwoTwo alternativesalternatives

►► SingleSingle bolusbolus (3 or 4 (3 or 4 scanningscanning phasesphases))UnenhancedUnenhanced phasephaseCorticomedullarCorticomedullar phasephase (25(25--35 35 secsec after start of after start of injinj) ) ––shows shows tumortumor enhancementenhancement, , includingincluding bladder bladder tumorstumorsNephrographicNephrographic phasephase (90(90--110 110 secsec))ExcretoryExcretory phasephase (~8(~8--12 min)12 min)

►► Split Split bolusbolus (2 (2 scanningscanning phasesphases))unenhancedunenhanced phasephasecombinedcombined nephrographicnephrographic--excretoryexcretory phasephase

Age of the patient is an important factor in the choice of methodology

CT CT UrographyUrography

►►Patient preparationPatient preparationNo positive oral No positive oral contrastcontrastOral Oral hydrationhydration with 1 liter of water 30 min (20with 1 liter of water 30 min (20--60 mon) 60 mon) beforebefore CT CT urographyurography►►PromotesPromotes diuresisdiuresis and and ureteralureteral visualisationvisualisation►►((IntravenousIntravenous dripdrip infusion of up to 500 ml 0.9% infusion of up to 500 ml 0.9%

salinesaline as alternative)as alternative)

Do not Do not emptyempty bladderbladder

CTCT--urographyurography, split , split bolusbolus, , exampleexample

1 liter of water to drink during 30 minutespreceding the CT

Scan 1: Non-enhanced low-dose (stone-CT) over urinary tract

Contrast inj 1: 40 ml 400 mg I/ml, 3 ml/s

+60 ml saline

Wait 8 min

Contrast inj 2: 60 ml 400 mg I/ml, 2 ml/s

+ 40 ml saline

Scan 2 (90-110 s): Urinary tract standard mAs

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Normal

MIP

MIP-imagesfor anatomicaloverview

MIP

MIP

Duplex

MIP

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Duplex

MIP

Duplex

MIP

Duplex Duplex

MIP

Duplex

MIP

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MIP reformatted images should not be used in isolation for diagnostic reading

Lesions may become hidden if surrounded by high intensity material (contrast), due to the projection of only maximum intensities

Always scrutinize the source images

UrothelialUrothelial tumortumor

►►SlightlySlightly hyperdensehyperdense massmass, as , as comparedcompared to to urineurine and and renalrenal parenchymaparenchyma, on , on nonnon--contrastcontrast scanningscanning

►►CompressionCompression of the of the renalrenal sinus fatsinus fat►►FillingFilling defectdefect►►EnhancingEnhancing massmass►►Wall Wall thickeningthickening►►Proximal dilatationProximal dilatation

UrothelialUrothelial tumortumor gradegrade II--II with infiltration in the II with infiltration in the parenchymaparenchyma

UrothelialUrothelial tumortumor gradegrade II--II with infiltration in the II with infiltration in the parenchymaparenchyma

UrothelialUrothelial tumortumorgradegrade II--II with II with infiltration in infiltration in the the parenchymaparenchyma

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UrothelialUrothelial tumortumorgradegrade II--II with II with infiltration in infiltration in the the parenchymaparenchyma

Urothelial tumor

Uroepithelial tumor

Compression of sinus fat Uroepithelial tumor

Urothelial tumor

73 HU

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High density ureteral tumor

CTCT--urographyurography for bladder cancerfor bladder cancer

PromisingPromising, , butbut still still inferiorinferior to to cystoscopycystoscopy(79% (79% sensitivitysensitivity -- SadowSadow et al, et al, RadiologyRadiology OctOct 2008)2008)

Unenhanced Arterial phase Excretory phase

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ConclusionsConclusions CTCT--urographyurography

►►CoversCovers mostmost importantimportant conditionsconditions►►LimitedLimited scientificscientific evidenceevidence availableavailable for for

small small uroepithelialuroepithelial tumorstumors►►CTCT--urographyurography worksworks in in clinicalclinical practicepractice►►ReplacingReplacing urographyurography►►RadiationRadiation dosedose has to be has to be consideredconsidered

Need for urography?

No, …but availability, cost,

radiation concerns with CT, and tradition, may still be life-saving for urography

Thank you