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EMERGENCY<br />
UROGENITAL RADIOLOGY<br />
Ljubljana, Slovenia, September 8-11, 2005<br />
Edited by:<br />
Darja Babnik Peskar<br />
Published by:<br />
Designed by: A.Wabra
CIP - Katalozni zapis o publikaciji<br />
Narodna in univerzitetna knjiznica, Ljubljana<br />
616.6:618(063)(082)<br />
616.6-073(063)(082)<br />
EUROPEAN Symposium on Urogenital Radiology (12 ; 2005 ; Ljubljana)<br />
Emergency urogenital radiology / 12th European Symposium on<br />
Urogenital Radiology - ESUR 05, Ljubljana, Slovenia, September<br />
8-11, 2005 ; edited by Darja Babnik Peskar. - Ljubljana: Slovenian<br />
Association of Radiology: Slovenian Association of Urologists ;<br />
Wien: European Society of Urogenital Radiology, 2005<br />
ISBN 961-90412-3-2 (Slovenian Association of Radiology)<br />
1. Gl. stv. nasl. 2. Babnik Peskar, Darja<br />
221056512<br />
This Syllabus has been kindly sponsored by<br />
GUERBET<br />
© all rights reserved by the<br />
EUROPEAN SOCIETY OF UROGENITAL RADIOLOGY<br />
2
Contents<br />
Acknowledgements 4<br />
ESUR 2005 Organisation 5<br />
ESUR 2005 Faculty 6<br />
Accreditation 7<br />
General information 8<br />
Map of Ljubljana 10<br />
Map of the conference area 11<br />
Programme overview 13<br />
Social programme and guided tours 14<br />
Programme 15<br />
Thursday, 8.9.2005 15<br />
Friday, 9.9.2005 17<br />
Saturday, 10.9.2005 20<br />
Sunday, 11.9.2005 22<br />
POSTER SESSION 23<br />
COURSE LECTURES 26<br />
Urogenital trauma: the traumatologist’s perspective; Matej Cimerman, Matej Jezernik 26<br />
Genitourinary trauma: the urologist's perspective; Miro Mihelic 28<br />
Upper urinary tract trauma; Anders Magnusson 34<br />
Trauma to the urethra and scrotum; Stanford M. Goldman 36<br />
Ureteral and bladder injuries; Carl M. Sandler 38<br />
Urinary obstruction: the urologist's perspective. Imaging and intervention of obstruction; Andrej Kmetec 41<br />
Imaging of stones: plain film, IVU, and ultrasound; Gertraud Heinz-Peer 44<br />
Urinary obstruction: MRU and CTU; Joern Kemper, Claus Nolte-Ernsting 46<br />
Urinary obstruction: radiation and economic aspects; Fulvio Stacul 47<br />
Investigation of microscopic hematuria: the nephrologist’s perspective; Jürgen Floege 48<br />
Urinary bleeding: imaging for suspected benign and malignant diseases; Elaine M. Caoili, Richard H. Cohan 49<br />
Imaging the patient with hemospermia; Parvati Ramchandani 52<br />
Arterial embolization in emergency uroradiology; Tarek A. El-Diasty 55<br />
Urogenital emergencies in the female patient: the obstetrician’s perspective; Tanja Premru-Srsen 56<br />
Urogenital emergencies in the female patient: a gynaecologic aspect; Adolf Lukanovic 58<br />
Preoperative assessment of benign diseases of the female pelvis: endometriosis; Karen Kinkel 62<br />
Preoperative assessment of benign diseases of the female pelvis: adnexal diseases; Izumi Imaoka 64<br />
Clinical aspects of urinary tract infections; Andrej Bren 66<br />
Diagnostic imaging of pyogenic infections in the urinary tract; Takehiko Gokan 67<br />
Tuberculosis and uncommon infections of the urogenital tract; Tarek A. El-Diasty 69<br />
Clinical evaluation of acute renal failure; Rafael Ponikvar 71<br />
Emergencies in kidney transplantation: clinical evaluation and the nephrologist’s perspective; Marko Malovrh 73<br />
Acute renal failure: imaging evaluation of native kidneys; O Hélénon, JM Correas 75<br />
The transplanted kidney: renal emergencies; Jarl Å. Jakobsen 78<br />
The transplanted kidney: extrarenal emergencies; Nicolas Grenier 80<br />
WORKSHOPS 83<br />
RF ablation of renal tumors; Peter L. Choyke 83<br />
Diagnosis of prostate carcinoma: (is there a) role for the radiologist (?); R.H. Oyen 85<br />
Assessment of local extension of prostate cancer by TRUS and TRUS-guided biopsy; François Cornud 87<br />
What to do with a suspicious adnexal mass at US?; Kaori Togashi 89<br />
Imaging of endometrial cancer: The Yorkshire Cancer Network guidelines; S.E.Swift, M.J.W. and J.A. Spencer 91<br />
Pediatric urologic emergencies: imaging in acute urogenital trauma, testicular and ovarian torsion; R. Michael 94<br />
Imaging in acute pediatric urinary tract infections; prof. Kassa Darge 96<br />
Malignant adrenal masses; Gabriel P. Krestin 96<br />
TECHNICAL PROTOCOLS FOR MALE AND FEMALE MRI OF THE PELVIS 99<br />
Magnetic resonance examinations of the male pelvis; Ullrich G. Mueller-Lisse 99<br />
Technical protocols for female MRI of the pelvis; Karen Kinkel 102<br />
CONTRAST MEDIA GUIDELINES 104<br />
Effects of iodinated contrast media on blood and endothelium; P. Aspelin, F. Stacul, A.J. van der Molen,<br />
T. Almén, M.F. Bellini, J.Å. Jakobsen, R. Oyen, J.A.W. Webb, H.S. Thomsen, S.K. Morcos 104<br />
Use of contrast in the emergency department; James H. Ellis 112<br />
ESUR guidelines on contrast medium induced nephropathy; Henrik S. Thomsen 116<br />
ABSTRACTS 121<br />
MEMBERS’ SESSION 121<br />
SCIENTIFIC SESSION 126<br />
POSTER SESSION 137<br />
3
Acknowledgements<br />
ESUR 2005 GRATEFULLY ACKNOWLEDGES<br />
THE SUPPORT OF THE FOLLOWING SPONSORS:<br />
Honorary Sponsors<br />
Minister of Health Slovenia<br />
Mayor of the City of Ljubljana<br />
Main sponsors<br />
Sponsors<br />
4
ESUR 2005 Organisation<br />
ESUR Board<br />
ESUR 2005 Honorary Committee<br />
Lorenzo Derchi President Minister of Health Slovenia<br />
Sameh K. Morcos President-Elect<br />
Mayor of the City of Ljubljana<br />
Gertraud Heinz-Peer Secretary/Treasurer<br />
Jelle O. Barentsz Past-President<br />
Anders Magnusson Member-at-Large<br />
ESUR 2005<br />
Programme Committee<br />
ESUR 2005<br />
Local Committee<br />
Darja Babnik Peskar (SI) Darja Babnik Peskar (SI)<br />
Jelle O. Barentsz (NL) Vladimir Jevtic (SI)<br />
Boris Brkljacic (HR) Ciril Oblak (SI)<br />
Richard Cohan (USA) Eveline Smrtnik (SI)<br />
Nigel Cowan (UK) Bojan Trsinar (SI)<br />
Lorenzo Derchi (I) Nado Vodopija (SI)<br />
Tarek El-Diasty (EG) Ziva Zupancic (SI)<br />
Roberto G. Figueiras<br />
(E)<br />
Nicolas Grenier<br />
(F)<br />
Gertraud Heinz-Peer<br />
(A)<br />
Karen Kinkel<br />
(CH)<br />
Anders Magnusson<br />
(S)<br />
ESUR 2005<br />
Organizing Secretariat<br />
ALPE ADRIA TURIZEM<br />
Smartinska 152 G, 1000 Ljubljana,<br />
Slovenia<br />
Tel.: +386 1 523 33 57<br />
Fax: +386 1 523 33 58<br />
e-mail: dusan@aaturizem.com<br />
ESUR 2005<br />
Scientific Secretariat<br />
Darja Babnik Peskar,<br />
KIR KC Ljubljana, Zaloska 7,<br />
1000 Ljubljana, Slovenia<br />
Tel.: +386 1 522 35 12<br />
Fax: +386 1 522 24 97<br />
e-mail: darja.babnik@kclj.si<br />
5
ESUR 2005 Faculty<br />
P. Aspellin (S) M. Glusic (SI) R. Ponikvar (SI)<br />
D. Babnik Peskar (SI) T. Gokan (J) R. Pozzi-Mucelli (I)<br />
C. Balleyguier (F) S. Goldman (USA) T. Premru-Srsen (SI)<br />
J. Barentsz (NL) N. Grenier (F) M. Prokop (NL)<br />
P. Bosnjakovic (SCG) S. Hanna (EG) S. Rainer (SI)<br />
M. F.Bellin (F) O. Helenon (F) P. Ramchandani (USA)<br />
A. Bergman (S) M. Hellstrom (S) I. Requejo Isidro (E)<br />
R. Berkenblit (USA) Jo Mc Hugo (UK) M. Riccabona (A)<br />
J. G. Blickman (NL) G. Heinz-Peer (A) C. Roy (F)<br />
A. Bren (SI) J. Hubert (F) C. Sandler (USA)<br />
B. Brkljacic (HR) I. Imaoka (J) G. Serafini (I)<br />
M. Budau (RO) J. A. Jakobsen (N) E. Smrtnik (SI)<br />
V. M. Builov (RUS) V. Jevtic (SI) J. Spencer (UK)<br />
E. Caoili (USA) R. Katz (IL) F. Stacul (I)<br />
P. Choyke (USA) J. Kemper (D) R. Stern Padovan (HR)<br />
M. Cimerman (SI) K. Kinkel (CH) K. Sugimura (J)<br />
R. Cohan (USA) A. Kmetec (SI) H. S. Thomsen (DK)<br />
M. Collins (UK) G. Krestin (NL) B. Trsinar (SI)<br />
F. Cornud (F) S. Kupesic (HR) K. Togashi (J)<br />
M. Cova (I) A. Lukanovic (SI) A. Vargha (HU)<br />
N. Cowan (UK) A. Magnusson (S) D. Vidmar (SI)<br />
T. M. Cunha (P) A. Maubon (F) N. Vodopija (SI)<br />
I. Cvitkovic Kuzmic (HR) M. Malovrh (SI) Z. Zupancic (SI)<br />
F. Danza (I) M. Marotti (HR) N. J. Wasserman (USA)<br />
K. Darge (D) M. Mihelic (SI) J. A. W. Webb (UK)<br />
S. Dorf (DK) S. K. Morcos (UK)<br />
T. A. El Diasty (EG) S. Moussa (UK)<br />
L. Derchi (I) U. Muller-Lisse (D)<br />
J. Ellis (USA) U. G. Muller-Lisse (D)<br />
R. G. Figueiras (E) Y. Narumi (J)<br />
J. Floege (DK) C. Oblak (SI)<br />
F. Frauscher (A) R. Oyen (B)<br />
G. Gayer (IL) P. Pavlica (I)<br />
6
Accreditation<br />
The 12th European Symposium on Urogenital Radiology is accredited by the European Accreditation Council<br />
for Continuing medical Education (EACCME) to provide the following CME activity for medical specialists. The<br />
EACCME is an institution of the European Union of Medical Specialists (UEMS). www.uems.be.<br />
The 12th European Symposium on Urogenital Radiology is designed for a maximum of 21 hours of European<br />
external CME credits. Each medical specialist should claim only those hours of credit that he/she actually<br />
spent in the educational activity.<br />
EACCME credits are recognised by the American Medical Association towards the Physician's Recognition<br />
Award (PRA). To convert EACCME credit to AMA PRA category I credit contact the AMA.<br />
The Post Graduate Course has been approved by the European Accreditation Council for Continuing medical<br />
Education (EACCME) for 15 CME credits.<br />
The 12th European Symposium on Urogenital Radiology has been awarded 20 CME credits by the Medical<br />
Chamber of Slovenia.<br />
The CME credit request should be filled in and returned to the Registration desk at the end of the meeting or<br />
before departure.<br />
7
General Information<br />
ABBREVIATIONS<br />
LECTURE HALLS<br />
MS Members' Session The lectures halls are named as follows:<br />
L Lectures Lecture room 1 First floor<br />
WS Workshop Lecture room 2 First floor<br />
SS Scientific Session Lecture room 3 First floor<br />
P Poster Session Lecture room 4 Ground floor<br />
Y Young Urogenital Radiologists' Forum Lecture room 5 Ground floor<br />
Please see the map of the conference area.<br />
BADGES<br />
It is obligatory for all participants to wear their<br />
badge visibly throughout the meeting as it is the<br />
entrance ticket to all sessions. In case of badge<br />
loss please contact at the Registration Desk.<br />
LIABILITY<br />
The local organisers and ESUR are not liable for<br />
personal injury and loss or damage of private property.<br />
Participants should have their own personal insurance.<br />
BANKS<br />
Banks are usually open from 9.00 –16.00<br />
LUNCHES<br />
Lunches on Friday, Sept 9 and Saturday, Sept 10 are<br />
included in the registration fee. Lunches are served at<br />
the place of the meeting. Please follow the signs and<br />
announcements.<br />
CASH BAR<br />
Outside the official coffee break times<br />
beverages, snacks and food can be purchased<br />
in the restaurant in the ground floor. Please see<br />
the map of the conference area.<br />
POSTER EXHIBITION<br />
Scientific posters are located in the ground floor.<br />
Please refer to the floor plan.<br />
The poster exhibition is open from Thursday 12.00 till<br />
Sunday 12.30.<br />
CERTIFICATE OF ATTENDANCE<br />
The CME credit request should be filled in and<br />
returned at the Registration desk.<br />
A certificate of attendance will be handed out at<br />
the end of the meeting at the Registration desk.<br />
POSTER PRIZES<br />
The three best scientific exhibits will be awarded a<br />
diploma. Evaluation of the posters will be based on<br />
novelty, accuracy, educational value and design.<br />
COFFEE BREAKS<br />
Coffee, beverages, and food will be available for<br />
registered participants during the designed<br />
coffee break times in the exhibition area.<br />
CONFERENCE LANGUAGE<br />
The Symposium is held in English.<br />
CURRENCY<br />
Slovenian tolar (SIT). 1EUR is approximately<br />
240 SIT. Major credit cards are widely accepted.<br />
8
PREVIEW CENTRE<br />
Please follow the signs from the Registration<br />
area.<br />
Opening hours:<br />
Thursday<br />
Friday<br />
Saturday<br />
Sunday<br />
September 8<br />
September 9<br />
September 10<br />
September 11<br />
11.00-17.00<br />
07.30-17.00<br />
07.30-15.00<br />
08.00-12.30<br />
Speakers must deliver their presentations in the<br />
following format: PowerPoint format for PC,<br />
version XP or older, on a CD-ROM or USB to<br />
the Preview Centre at least 90 minutes prior to<br />
the beginning of each session. Technicians will<br />
pre-load the presentation. If you are using<br />
Macintosh please make sure that your<br />
presentation is saved in PC format. If there are<br />
video sequences included in the presentation<br />
please make sure to save the video clip files<br />
onto your CD-ROM.<br />
Please note that your laptop cannot be used for<br />
the presentation in the lecture halls.<br />
REGISTRATION<br />
Registration is possible at the Registration Desk.<br />
Please follow the floor plan.<br />
Opening hours:<br />
Thursday<br />
Friday<br />
Saturday<br />
Sunday<br />
September 8<br />
September 9<br />
September 10<br />
September 11<br />
11.00-17.00<br />
07.30-17.00<br />
07.30-15.00<br />
08.00-12.30<br />
TECHNICAL EXHIBITION<br />
The technical exhibition is located in the loby<br />
outside the main auditorium. Please refer to the<br />
floor plan. The technical exhibition is open from<br />
Friday 8.00 to Sunday 12.00.<br />
YOUNG UROGENITAL RADIOLOGISTS'<br />
FORUM<br />
Young urogenital radiologists are defined as<br />
radiologists in training, or recently accredited<br />
radiologists not older than 35 years. To encourage and<br />
promote research, three best <strong>abstract</strong>s submitted by a<br />
young urogenital radiologist as the main author will be<br />
honoured and awarded.<br />
9
Map of Ljubljana<br />
1. Grand Hotel Union Executive, Miklosiceva 1, 2. Grand Hotel Union Business, Miklosiceva 3, 3. Grand<br />
Hotel Union Garni, Miklosiceva 9, 4. Hotel Slon-Best Western Premier, Slovenska 34, 5. City Hotel,<br />
Dalmatinova 15, 6. Pension pri Mraku, Rimska cesta 4, 7. Hotel Park, Tabor 9, 8. Faculty of Law,<br />
Poljanski nasip 2<br />
10
Map of the Conference Area<br />
11
Programme Overview<br />
THURSDAY<br />
September 8, 2005<br />
FRIDAY<br />
September 9, 2005<br />
SATURDAY<br />
September 10, 2005<br />
SUNDAY<br />
September 11, 2005<br />
11.00 - 17.00<br />
REGISTRATION<br />
Poster Exhibition<br />
7.30 - 17.00<br />
REGISTRATION<br />
Poster Exhibition<br />
8.00 - 10.00<br />
Lecture I<br />
7.30 - 15.00<br />
REGISTRATION<br />
Poster Exhibition<br />
8.00 - 10.00<br />
Lecture IV<br />
8.30 - 9.30<br />
Lecture VI<br />
9.30 - 11.00<br />
Lecture VII<br />
10.00 - 10.10<br />
Coffee Break<br />
10.00 - 10.15<br />
Coffee Break<br />
11.00 - 11.30<br />
Coffee Break<br />
10.10 - 11.40<br />
Lecture II<br />
MEMBERS' DAY<br />
12.30 - 12.40<br />
Introduction<br />
11.40-11.55<br />
Award Wining Paper from<br />
the Members’ Day<br />
11.55 - 12.25<br />
(Satellite symposium)<br />
10.15 - 11.45<br />
Lecture V<br />
11.45 - 12.45<br />
WS IV, WS V, WS VI<br />
11.30 - 12.30<br />
Contrast Media<br />
Guidelines<br />
12.25-12.40<br />
Opening ceremony<br />
12.40 - 13.20 Lunch<br />
12.40 - 13.50<br />
Scientific presentation 13.20 - 15.20<br />
Lecture III<br />
12.45 - 13.45<br />
Film Reading Session<br />
13.50 - 14.20<br />
Coffee break<br />
15.20 - 15.30<br />
Coffee break<br />
13.45 - 14.15<br />
Lunch<br />
14.20 - 15.20<br />
Scientific presentation<br />
15.20 - 16.30<br />
Scientific presentation<br />
15.30 - 16.30<br />
WS I, WS II, WS III<br />
16.30 - 17.30<br />
SS-1, SS-2, SS-3,<br />
WS VII<br />
14.15 - 15.05<br />
SS-4, SS-5, SS-6<br />
12.30<br />
ESUR Closing<br />
17.00<br />
Bus tour to Radovljica<br />
and Bled<br />
18.00<br />
RadiologARTists’<br />
Exhibition<br />
15.30<br />
Excursion<br />
to Postojna<br />
20.00<br />
MEMBERS' DINNER<br />
(Bled)<br />
19.00/19.30<br />
Walking tour<br />
20.00<br />
WELCOME RECEPTION<br />
(Slovenian Philharmony)<br />
20.30<br />
COURSE DINNER<br />
(Ljubljana Castle)<br />
13
Social Programme and Guided Tours<br />
Thursday, September 8, 2005<br />
Members' Dinner<br />
For ESUR members with accompanying persons only. The Members' Dinner will take place at Bled. Before<br />
dinner a visit to the Museum of Apiculture in Radovljica and a visit to Bled are organised. Price per person:<br />
50/60 EUR<br />
Friday, September 9, 2005<br />
RadiologArtists’ Exhibition Opening<br />
Opening of the RadiologArtists’ Exhibition at the Kodeljevo Castle and lunch are included in the registration<br />
fee and the fee for accompanying persons.<br />
RadiologArtists’ Exhibition<br />
Benedetta Bonichi, Ludvik Tabor, Tomaz Kunst, Maja Parac Kosem, Kajsa Haglund, Bogomir Celcer, Petra<br />
Polajner, Sasa Steparski Dobravec, Lee Talner, Margherita Levo Rosenberg and Mira Pusenjak.<br />
Most authors are radiologists who follow their artistic dream. Those who are not professionally involved with<br />
radiology are artists dealing with the concept of radiology. Artworks range from paintings to photography,<br />
video and even radiography.<br />
Friday, September 9, 2005<br />
Guided city walk<br />
Included in the registration fee is a short sightseeing tour through the old city to the place of the Welcome<br />
Reception.<br />
Friday, September 9, 2005<br />
Opening Ceremony and Welcome Reception<br />
All participants and accompanying persons are invited to the Opening Ceremony in the Slovenian<br />
Philharmony (RadiologARTists’ concert). After the Opening Ceremony there will be a welcome reception.<br />
The reception is included in the registration fee and the fee for accompanying persons.<br />
RadiologARTists’ concert<br />
Lee Talner - viola da gamba<br />
Sven Dorf - violin<br />
Domen Marincic - harpsichord<br />
Saturday, September 10, 2005<br />
Pavel Berden and Vox Medicorum<br />
Aleš Koren and Footprints - blue grass<br />
Lorenzo Derchi - guitar (and Footprints)<br />
Sasa Steparski - coreograpy & ballet - Dance Macabre<br />
Lee Talner - music & photographies<br />
Course Afternoon<br />
All participants and accompanying persons are invited to the Course Afternoon that includes a visit to the<br />
Postojna Caves and a Course Dinner. Price per person: 65/75 EUR.<br />
Saturday, September 10, 2005<br />
Course Dinner<br />
We welcome you to the Course Dinner that will take place at the Ljubljana Castle.<br />
For participants and accompanying persons that will not participate in the Course Afternoon the price per<br />
person is 50/60 EUR.<br />
14
Programme<br />
Thursday, September 8, 2005<br />
MEMBERS' DAY - SCIENTIFIC SESSIONS<br />
(Lecture room 1)<br />
11.00 – 17.00<br />
Registration<br />
Poster Exhibition<br />
12.30 – 16.00<br />
Introduction 12.30 – 12.40<br />
Members’ Session I<br />
Upper Urinary Tract<br />
Moderator: J. O. Barentzs (NL)<br />
12.40 – 13.40<br />
12.40 – 12.50 MS1 In-vivo magnetic resonance imaging of magnetically labelled stem cells in kidneys<br />
after selective intraarterial injection: initial results<br />
Harald Ittrich, Friedrich Thaiss, Claudia Lange, Hannes Dahnke, Gerhard Adam, Claus<br />
Nolte-Ernsting<br />
12.50 – 13.00 MS2 Enhancement of central scar in renal oncocytomas: a new feature<br />
Tourdias T, Grenier N, Cimpéan A, Deminière A, Pérot V.<br />
13.00 – 13.10 MS3 Coronal vs Standard Axial Image Review for CT Urography<br />
Feng FY, Caoili EM, Cohan RH, Al Hawari M, Adusumilli S, Francis IR, Nan B, Zheng, and<br />
Ellis JH<br />
13.10 – 13.20 MS4 Detection of renal perfusion defects in rabbits using non-linear contrast specific mode<br />
with low transmit power imaging and SonoVue<br />
Emilio Quaia, Manuel Belgrano, Salvatore Siracusano, Stefano Ciciliato, Stefano Cernic,<br />
Maria Cova<br />
13.20 – 13.30 MS5 Doppler Ultrasonography of Arterial Stenosis in Renal Transplanted Patients<br />
Gaute Hagen, Jonas Wadström, Anders Magnusson<br />
13.30 – 13.40 MS6 Catheter-based optical coherence tomography of the porcine ureter ex vivo:<br />
morphometric comparison with histology<br />
U.L. Mueller-Lisse, O. A. Meissner, M. Bauer, M. Jaeger, F. Roggel, G. Babaryka, M. Reiser,<br />
U.G. Mueller-Lisse<br />
13.40 – 13.50 MS7 Assessment of diagnostic confidence in renal malignancies diagnosed at contrastenhanced<br />
US<br />
Emilio Quaia, Alessandro Palumbo, Stefania Rossi, Maria Cova<br />
Members’ Session II<br />
Upper Urinary Tract<br />
Moderator: S. Morcos (UK)<br />
13.50-14.20<br />
Coffee break<br />
14.20 – 15.20<br />
14.20 – 14.30 MS8 Diagnostic criteria for acute upper urinary tract obstruction at dynamic MRI<br />
Mohamed Abo El-Ghar, Tarek El-Diasty, Ahmed Shoma, Huda Refaie, Ahmed Shokier<br />
14.30 – 14.40 MS9 Delineation of upper urinary tract segments at low-dose multidetector CT urography:<br />
retrospective comparison with a standard protocol<br />
Mueller-Lisse UG, Meindl T, Coppenrath E, Mueller-Lisse UL, Degenhardt C, Khalil R,<br />
Reiser MF<br />
14.40 – 14.50 MS10 Image-guided peritoneal core biopsy (IGB) in peritoneal carcinomatosis (PC) for<br />
tumour type and patient care: experience in 149 patients.<br />
Kirsty E Anderson, Matthew J Hewitt, Nafisa Wilkinson, Sarah E Swift, Michael Weston,<br />
John A Spencer<br />
15
14.50 – 15.00 MS11 Analysis of errors in ultrasonographic detection and characterisation of renal<br />
tumors<br />
Boris Brkljacic, Igor Cikara, Josip Curic<br />
15.00 – 15.10 MS12 Diagnosis of upper tract transitional cell carcinoma (TCC) with a single phase<br />
multidetector CT urography.<br />
F.Cornud, M.Bienvenu, H.Guerini, X. Poittevin, A.ChevrotT<br />
15.10 – 15.20 MS13 Does a limited CT Urography( CTU) offer important additional information in patients<br />
with haematuria who had normal IVU, Ultrasound and Flexible Cystoscopy?<br />
H S Ganesh, F Salim, S K Moecos<br />
Members’ Session III<br />
Lower Urinary Tract<br />
Moderator: L. Derchi (I)<br />
15.20 – 16.30<br />
15.20 – 15.30 MS14 Ferumoxtran-10 enhanced MR imaging in detection of metastases out of the surgical<br />
view in prostate cancer<br />
R.A.M. Heesakkers, J.A. Witjes, C.A. Hulsbergen- van de Kaa, J.O. Barentsz<br />
15.30 – 15.40 MS15 IMRT boost planning on dominant intraprostatic lesion by means of gold markerbased<br />
3D fusion of CT, 1H spectroscopic and dynamic contrast-enhanced MR<br />
imaging.<br />
Jurgen J Futterer, Emile N.J.Th van Lin, Stijn W.T.P.J., Heijmink, Lisette P. van der Vight,<br />
Aswin L. Hoffmann, Peter van Kollenburg, Henkjan J. Huisman, J. Alfred Witjes, Jan<br />
Willem Leer, Andries G. Visser, Jelle O. Barentsz<br />
15.40 – 15.50 MS16 The additive effect of contrast agent administration in transrectal ultrasound staging<br />
of prostate cancer<br />
Stijn W.T.P.J. Heijmink, Hilco van Moerkerk, Jurgen J. Fütterer; Christina A. Hulsbergenvan<br />
de Kaa, Ben C. Knipscheer, J. Alfred Witjes, Johan G. Blickman, Jelle O. Barentsz<br />
15.50 – 16.00 MS17 Fast-Track Diagnosis for Macroscopic Hematuria using Same -Day CT Urography &<br />
Flexible Cystoscopy<br />
NC Cowan, JMG Willatt, MH Hawkins, PJS Charlesworth, JP Crew<br />
16.00 – 16.10 MS18 Effect of tadalafil on prostate hemodynamics: preliminary evaluation with contrast<br />
enhanced US<br />
Michele Bertolotto, Gianfranco Savoca, Elena Trincia, Giulio Garaffa, Loretta Calderan,<br />
Maria Assunta Cova<br />
16.10 – 16.20 MS19 Depiction of prostatic zonal anatomy at portovenous multidetector CT<br />
Scherr MK, Nippert A, Reiser MF, Müller-Lisse UG<br />
16.20 – 16.30 MS20 The Urethral Support System as Defined By Phased-Array MRI with Cadaveric<br />
Dissection and Histological Correlation in Nulliparous Female<br />
Rania F. El Sayed, Medhat Morsi Sahar El Mashed, Mohamed S. Abd El Azim<br />
Members’ Dinner – Tour to Bled 17.00<br />
16
Friday, September 9, 2005<br />
07.30 – 17.00<br />
Registration<br />
POSTGRADUATE COURSE:<br />
EMERGENCY UROGENITAL RADIOLOGY<br />
Lecture I Urogenital trauma<br />
Moderators: Y.Narumi (J), G.Gayer (IL)<br />
(Lecture room 1)<br />
08.00 – 10.00 Traumatologist's perspective: M.Cimerman (SI)<br />
Urologist's perspective: M.Mihelic (SI)<br />
Imaging of urogenital trauma<br />
Upper urinary trauma: A.Magnusson (S)<br />
Lower urinary trauma: S.Goldman (USA)<br />
Trauma of male external genitalia: C.Sandler (USA)<br />
10.00 – 10.10<br />
Coffee break<br />
Lecture II<br />
Urinary bleeding<br />
Moderators: M. Collins (UK), J.Hubert (F)<br />
(Lecture room 1)<br />
10.10 – 11.40 Investigation of microscopic hematuria-Nephrologist's<br />
perspective: J.Floege (DK)<br />
Imaging for suspected malignant diseases:<br />
E.Caoili (USA)<br />
Imaging for benign conditions: R.Cohan (USA)<br />
Haemospermia: P.Ramchandani (USA)<br />
Arterial embolisation in emergency uroradiology:<br />
T.El-Diasty (EG)<br />
Award Winning Paper from the Members’ Day (Lecture room 1)<br />
11.40 – 11.55<br />
Satellite symposium<br />
(Lecture room 1)<br />
11.55 – 12.25<br />
Opening ceremony (Lecture room 1)<br />
12.25 – 12.40<br />
Lunch<br />
Lecture III Urinary obstruction<br />
Moderators: F.Frauscher (A), C.Oblak (SI)<br />
12.40 – 13.20 Lunch<br />
(Lecture room 1)<br />
13.20 – 15.20 Urologist's perspective: A.Kmetec (SI)<br />
Imaging and intervention of obstruction<br />
Plain films, i.v.u, and US: G.Heinz-Peer (A)<br />
CT (U) and MRU: J.Kemper (D)<br />
Radiation and economic aspects: F.Stacul (I)<br />
Intervention in obstruction: S.Moussa (UK)<br />
15.20-15.30<br />
Coffee break<br />
17
WORKSHOP I<br />
Ultrasound of kidneys and urinary bladder Hands-on WS<br />
15.30 – 16.30 B.Brkljacic (HR)<br />
P.Pavlica (I)<br />
D.Vidmar (SI)<br />
S.Rainer (SI)<br />
(Lecture room 1)<br />
WORKSHOP II<br />
Interventional radiology<br />
Moderators: P.Bosnjakovic (SCG)<br />
15.30 – 16.30 Embolisation of uterine fibroids: N. Cowan (UK)<br />
Renal tumor ablation: P.Choyke (USA)<br />
WORKSHOP III<br />
Prostatic cancer<br />
Moderators: N.F.Wasserman (USA), N.Grenier (F)<br />
(Lecture room 2)<br />
(Lecture room 3)<br />
15.30 – 16.30 Detection and the role for the radiologist?: R.Oyen (B)<br />
Staging-US or MR?: F.Cornud (F)<br />
New developments: J.Barentsz (NL)<br />
SCIENTIFIC SESSIONS – I, II, III, WS VII 16.30 – 17.30<br />
Scientific Session I<br />
TUMORS/KIDNEY AND COLLECTING SYSTEM<br />
Moderators: M. Marroti (HR), M. Budau (RO)<br />
(Lecture room 1)<br />
16.30 – 16.38 SS1 Multi-detector row CT urography in the investigation of painless hematuria; A. Ch.<br />
Tsili1, C. Tsampoulas, O. Katsios1, D. Giannakis, P. Tzoumis, D. Dristiliaris, N. Sofikitis, S.<br />
C. Efremidis<br />
16.38 – 16.46 SS2 Multiphase Multidetector-Row CT (MDCT) of Transitional Cell Carcinoma of the Renal<br />
Pelvis and the Ureter: Improved Detection, Diagnosis and Staging; Gerald A. Fritz,<br />
Helmut Schoellnast, Hannes A. Deutschmann, Martin Wehrschuetz, Manfred Tillich<br />
16.46 – 16.54 SS3 Patients at high risk of upper tract urothelial cancer: evaluation of hydronephrosis<br />
using high-resolution magnetic resonance urography; Rohit Chahal, Kathryn Taylor,<br />
Ian Eardley, Stuart N Lloyd, John A Spencer<br />
16.54 – 17.02 SS4 Pheochromocytoma: a retrospective review of 27 cases with their histopathologic<br />
correlation; Dogra VS, Bhatt S, Novak R, Martin C, MacLennan G<br />
17.02 – 17.10 SS5 Evaluation of focal renal lesions with contrast enhanced ultrasonography (CEUS)<br />
using a new microbubble contrast agent (SonoVue®); Pallwein L., Frauscher F.,<br />
Neururer R., Georg B., Klauser A, Gradl H., Schurich M.<br />
17.10 – 17.18 SS6 Multi-detector row CT cystoscopy in the assessment of urinary bladder tumors; A.<br />
Ch. Tsili, C. Tsampoulas, O. Katsios, P. Champilomatis, P. Tzoumis, N. Chatziparaskevas,<br />
N. Sofikitis, S. C. Efremidis<br />
17.18 – 17.26 SS7 Preoperative MSCT imaging of venous spread of renal cell carcinoma (RCC);<br />
Stern-Padovan R, Perkov D, Smiljanic R, Oberman B, Lusic M, Marinic J.<br />
Scientific Session II<br />
LOWER UROGENITAL TRACT<br />
Moderators: I.Requejo Isidro (E), B.Brkljacic (HR)<br />
(Lecture room 2)<br />
16.30 – 16.38 SS 8 Evaluation of Varicocele Incidence of Paraplegic Patients by Colour Doppler<br />
Ultrasonography; A. Unsal, B. Yilmaz, A. T. Turgut, C. Z. Karaman,<br />
R. Alaca<br />
18
16.38 – 16.46 SS 9 Resistivity and Pulsatility Index Alteration in Subcapsular Branches of Testicular<br />
Artery: Indicator of Impaired Testicular Microcirculation in Clinical Varicocele? ; A.<br />
Unsal, A. T. Turgut, F. Taskin, C. Z. Karaman<br />
16.46 – 16.54 SS 10 The reliability of ultrasonography in the evaluation of acute scrotal pain;<br />
Lyssiotis Ph., Constantinidis F., Alivisatos G, Anastopoulos I, Liakouras Ch., Tsines G.,<br />
Tavernaraki K., Malahias G.<br />
16.54 – 17.02 SS11 Chronic constipation is a significant factor for the etiopathogenesis of varicocele; A.<br />
T. Turgut, E. Ozden, P. Kosar, U. Kosar, B. Cakal, A. Karabulut<br />
17.02 – 17.10 SS12 Voiding Urosonography in the era of second generation ultrasound contrast agents;<br />
A.Anthopoulou, J.Tzovara, E.Siomou, A.Fotopoulos, E.Arkoumani, F.Katzioti,<br />
F.Papadopoulou<br />
17.10 – 17.18 SS13 Voiding Urosonography combined with Fluoroscopic Voiding Cystourethrography in<br />
the diagnosis of reflux: Does the order matter?; A.Anthopoulou, F.Papadopoulou,<br />
J.Tzovara, E.Siomou, E.Arkoumani, F.Katzioti, S.Efremidis<br />
17.18 – 17.26 SS14 Effect of premicturitional bladder volume on accuracy of postvoid residual urine<br />
volume measurements; Bladder fullness rate is of great importance for preventing<br />
false positive residue diagnosis; Eriz Özden, Ahmet Tuncay Turgut, Çađatay Göđüţ,<br />
Uđur Koţar, Sümer Baltacý<br />
Scientific Session III<br />
BENIGN UROGENITAL EMERGENCIES<br />
Moderators: J.A.W. Webb (UK), V.M. Builov (RUS)<br />
(Lecture room 3)<br />
16.30 – 16.38 SS15 From IVU to Unenhanced CT: Modernising the Imaging of Acute Renal Colic; Arvind<br />
Pallan, J. Graham Young, Paul Crowe, Rajesh Patel, Linda Freeman, Sean Morris<br />
16.38 – 16.46 SS16 Emergency non traumatic urogenital imaging. What happens when CT is not<br />
available?; Demosthenes D Cokkinos, Elissavet Protopapa, Nikolaos Sakaridis, Ioanna<br />
Papaconstantinou, Styliani Giannou<br />
16.46 – 16.54 SS17 Renal Injuries - Diagnostic Evaluation by Sonography; Dubravka Vidmar<br />
16.54 – 17.02 SS18 CT imaging of iatrogenic urinary lesions after urologic, gynecologic, and obstetric<br />
procedures; Hrabak M, Stern-Padovan R, Smiljanic R, Perkov D, Lusic M.<br />
17.02 – 17.10 SS19 Retrospective analysis of ureteral distension as function of delay time after i.v.<br />
contrast-media injection followed by i.v. saline infusion in CT-Urography; T Meindl, E<br />
Coppenrath, C Degenhardt, UL Müller-Lisse, M Reiser, UG Müller-Lisse<br />
17.10 – 17.18 SS20 Contrast enhanced magnetic resonance urography(MRU) versus excretory<br />
urography(EU) in non dilated upper urinary tract; M.Abd EL-Baky, T.EL-Diasty,<br />
A.Farouk, O.Mansour<br />
16.18 – 17.26 SS21 Computed tomography angiography of haemodialysis arteriovenous fistulae: Impact<br />
of 3D image reconstructions in complicated clinical cases; Dimopoulou A., Claesson<br />
K., Raland H., Wikström B and Magnusson A<br />
WORKSHOP VII<br />
Technical protocols for male and female MRI of the pelvis<br />
Moderators: R.Berkenblit (USA), M.Glusic (SI)<br />
(Lecture room 4)<br />
16.30 – 17.30 MRI of the pelvis in males: U.G.Müller-Lisse (D)<br />
MRI of the pelvis in females: K.Kinkel (CH)<br />
RadiologARTists’ Exhibition - Castle Kodeljevo 18.00<br />
19
Sightseeing / Walking tour Ljubljana 19.00 /19.30<br />
Welcome Reception / Concert - Slovenian Philharmony 20.00<br />
Saturday, September 10, 2005<br />
07.30 – 15.00<br />
Registration<br />
Lecture IV<br />
Urogenital emergencies in the female patient<br />
Moderators: K.Togashi (J),<br />
08.00 – 10.00 Obstetric aspect: T.Premru Srsen (SI)<br />
Gynaecologic aspect: A.Lukanovic (SI)<br />
Imaging of obstetrical and puerperal emergencies:<br />
Jo Mc Hugo (UK)<br />
Embolisation of post-partum bleeding: A.Maubon (F)<br />
Imaging assessment of gynaecological emergencies: G.Serafini (I)<br />
(Lecture room 1)<br />
10.00 – 10.15<br />
Coffee break<br />
Lecture V<br />
Preoperative assessment of benign diseases of the female pelvis<br />
Moderators: K.Sugimura (J), S. Kupesic (HR)<br />
10.15 – 11.45 Endometriosis: K.Kinkel (CH)<br />
Uterine diseases: N.Cowan (UK)<br />
Adnexal diseases: I.Imaoka (J)<br />
Pelvic floor dysfunction: C.Roy (F)<br />
WORKSHOP IV<br />
Female oncologic imaging<br />
Moderators: T.M.Cunha (P), A.Bergman (S)<br />
(Lecture room 1)<br />
(Lecture room 1)<br />
11.45 – 12.45 Cervical cancer staging-MRI, CT, PET?: C.Balleyguier (F)<br />
What to do with suspicious adnexal mass at US?: K.Togashi (J)<br />
Endometrial cancer: J.Spencer (UK)<br />
WORKSHOP V<br />
Pediatric urologic emergencies<br />
Moderator: Z.Zupancic (SI), I.Cvitkovic Kuzmic (HR)<br />
(Lecture room 2)<br />
11.45 – 12.45 Imaging in acute uro-genital trauma, testicular and ovarian torsion:<br />
M.Riccabona (A)<br />
Imaging in acute pediatric urinary tract infections:<br />
K.Darge (D)<br />
Neonatal urinary tract emergencies: J.G.Blickman (NL)<br />
WORKSHOP VI<br />
Upper urinary cancer<br />
Moderators: U.L.Müller-Lisse (D), R.G.Figueiras (E)<br />
(Lecture room 3)<br />
11.45 – 12.45 Kidneys: R.Pozzi-Mucelli (I)<br />
Adrenals: G.Krestin (NL)<br />
Lymphnodes: J.Barentsz (NL)<br />
20
FILM READING SESSION<br />
Moderator: L.Derchi (I)<br />
Lunch<br />
Session IV<br />
TUMORS/PROSTATE<br />
Moderators: R.Stern Padovan (HR), M.Cova (I)<br />
12.45 – 13.45<br />
(Lecture room 1)<br />
13.45 - 14.15 Lunch<br />
(Lecture room 1)<br />
14.15 – 14.23 SS22 3T endorectal MR imaging in localizing and staging prostate cancer using<br />
gadolinium-enhanced FLASH3D subtraction technique; Jurgen J. Futterer, Stijn<br />
W.T.P.J. Heijmink, Tom W.J. Scheenen, Christina A. Hulsbergen-van der Kaa, J. Alfred<br />
Witjes, Jelle O. Barentsz<br />
14.23 – 14.31 SS23 Contrast-enhanced transrectal color doppler ultrasound for assessment of<br />
tumorangiogenesis in prostate cancer; Schurich M., Frauscher F., Klauser A., Pallwein<br />
L., Strohmeyer D., Bartsch G.<br />
14.31 – 14.39 SS24 A prospective randomized trial comparing contrast-enhanced targeted versus<br />
systematic ultrasound guided biopsies: impact on prostate cancer detection;<br />
Frauscher F. Pelzer A., Berger A., Halpern E., Pallwein L., Klauser A., Gradl H., Bartsch G.<br />
14.39 – 14.47 SS25 Comparison of Contrast-enhanced Color Doppler Targeted Biopsy with Systematic<br />
Biopsy: Impact on Prostate Cancer Detection in Men with PSA between 4 to 10; Leo<br />
Pallwein, Andrea Klauser, Ethan Halpern, Alexander Pelzer, Dieter Zur Nedden<br />
14.47 – 14.55 SS26 Dutasteride Prior Prostate Biopsy Increases Prostate Cancer Detection; Andrea<br />
Klauser, Andreas Berger, Ethan Halpern, Leo Pallwein, Ammar Mallouhi, et all<br />
14.55 – 15.03 SS27 A comparison of MR image quality and accuracies of localization and staging of<br />
prostate cancer between a body array and endorectal coil at 3T; Stijn W.T.P.J.<br />
Heijmink, Jurgen J. Fütterer, Tom W.J. Scheenen, Christina A. Hulsbergen-v.d. Kaa, Ben<br />
C. Knipscheer, J. Alfred Witjes, Johan G. Blickman, Jelle O. Barentsz<br />
Session V<br />
FEMALE MISCELANEOUS<br />
Moderators: S.Dorf (DK)<br />
(Lecture room 1)<br />
14.15 – 14.23 SS28 16-slice multidetector CT and MRI in the detection and characterization of ovarian<br />
masses; A. Ch. Tsili, C. Tsampoulas, O. Katsios, K. Vlachos, Ev. Paraskevaidis, S. C.<br />
Efremidis.<br />
14.23 – 14.31 SS29 Bone lesions as a complication of the treatment of gynecologic malignancies - A<br />
great mimicker; S. Lima, A. Félix, T.M. Cunha<br />
14.31 – 14.39 SS30 Ultrasound-guided Transurethral Injection of Adult Stem Cells for Treatment of<br />
Urinary Incontinence; Andrea Klauser, Dieter Zur Nedden, Leo Pallwein, Rainer<br />
Marksteiner, Hannes Strasser<br />
14.39 – 14.47 SS31 Hysterosalpingograhy vs laparascopy in the assessment of infertile women; Eda<br />
Vrtacnik Bokal, Sara Korošec, Helena Ban<br />
14.47 – 14.55 SS32 The role of transvaginal sonography in detection of congenital uterine<br />
malformations; Martina Ribic-Pucelj<br />
Session VI<br />
RENAL PERFUSION, TRANSPLANTATION AND INTERVENTION<br />
Moderators: M.Hellstrom (S)<br />
(Lecture room 1)<br />
14.15 – 14.23 SS33 Effective EndoUro-Radiological Conferences: a model for success; M.C.Collins<br />
F.Salim L.Hawksworth J.Hall K.J.Hastie<br />
14.23 – 14.31 SS34 Split renal function in patients with suspected renal artery stenosis – a comparison<br />
between gamma camera renography and two methods of measurement with<br />
computed tomography; Henrik Björkman, Hampus Eklöf, Jonas Wadström, Lars-Göran<br />
Andersson, Rickard Nyman, Anders Magnusson<br />
21
14.31 – 14.39 SS35 Measuring split renal function in renal donors: can computed tomography replace<br />
renography?; Henrik Björkman, Jonas Wadström, Lars-Göran Andersson, Hans Raland,<br />
Anders Magnusson<br />
14.39 – 14.47 SS36 MR imaging in diagnosis of post-renal transplant complications; T. EL-Diasty, M.<br />
Attia, A. Youssef, U. Galal, F. Tantawy<br />
14.47 – 14.55 SS37 Quantitative T1-perfusion and renal MRAngiography: a noninvasive all-in-one<br />
approach for renovascular evaluation; M. Dujardin, S. Sourbron, R. Luypaert, P. Van,<br />
Schuerbeek, S. Makkat, F. Deridder, P. Van der Niepen, D. Verbeelen, T. Stadnik<br />
14.55 – 15.03 SS38 Changes in renal blood flow related to extracorporeal shock wave lithotripsy<br />
measured by FLASHSTAR; Eva Pallwein, Leo Pallwein, Christian Kremser, Werner<br />
Judmaier, Günther Janetschek, Ferdinand Frauscher, and Michael Schocke<br />
Excursion to Postojna Caves 15.30<br />
Course Dinner – Ljubljana Castle 20.30<br />
Sunday, September 11, 2005<br />
Lecture VI<br />
Urinary infections<br />
Moderators: R.Katz (IL), F.Danza (I)<br />
08.30 – 12.30<br />
Registration<br />
(Lecture room 1)<br />
08.30 – 09.30 Nefrologist' s perspective: A. Bren (SI)<br />
Imaging<br />
Pyogenic infections: T.Gokan (J)<br />
TB and uncommon infection of urogenital tract:<br />
T.El-Diasty (EG)<br />
Lecture VII<br />
Acute renal failure and emergencies in the kidney transplant<br />
Moderators: S.Hanna (EG), M.Prokop (NL)<br />
(Lecture room 1)<br />
09.30 – 11.00 Clinical evaluation of acute renal failure: R. Ponikvar (SI)<br />
Clinical evaluation of emergencies in the kidney transplant:<br />
M.Malovrh (SI)<br />
Imaging evaluation<br />
Native kidneys: O.Helenon (F)<br />
Transplanted kidneys - renal emergencies: J.Jakobsen (N)<br />
Transplanted kidneys - extrarenal emergencies: N.Grenier (F)<br />
11.00 – 11.30<br />
Coffee break<br />
CONTRAST MEDIA GUIDELINES<br />
Moderator: M.F.Bellin (F)<br />
(Lecture room 1)<br />
11.30 – 12.30 Effects of CM on haematology (ESUR guideline):<br />
P.Aspelin (S)<br />
Use of contrast media in the emergency room: J.Ellis (USA)<br />
Contrast Medium induced nephrotopathy-current guidelines:<br />
H.S.Thomsen (DK)<br />
ESUR Closing (Lecture room 1)<br />
12.30 – 12.45<br />
22
POSTER SESSION<br />
P1<br />
P2<br />
P3<br />
P4<br />
P5<br />
P6<br />
Low field open MRI of the adrenal glands: a pictorial essay; Robert Berkenblit<br />
Multicystic dysplastic kidney - an audit of 15 years of experience in Plymouth, UK, 1990-2004; Narayanaswamy S, Jones R<br />
Fat is the key; R García Figueiras, C Villalba Martín, A García Figueiras, M Otero Echart, G Pazos, L Oleaga, I Requejo<br />
Massive pleural effusion as the first manifestation of renal cell carcinoma - a case report; Mojca Juvan-Zavbi<br />
MR urography of obstructive uropathy: diagnostic value of the method in selected clinical groups; Joanna Zielonko<br />
Multi-detector row CT in the evaluation of renal masses; AC Tsili, C Tsampoulas, O Katsios, T Vadivoulis, D Baltogiannis, N<br />
Sofikitis, SC Efremidis<br />
P7 Sonographic detection of renal and ureteral calculi - diagnostic accuracy of the twinkle sign; Pallwein L, Frauscher F,<br />
Andrea K, Gradl H, Schurich M, Struve P, Peschel R, Bartsch G<br />
P8<br />
P9<br />
P10<br />
P11<br />
P12<br />
P13<br />
Contrast enhanced ultrasound in the evaluation of renal trauma; Regine G, Atzori M, Buffa V, Galluzzo M, Miele V, Adami L<br />
Spiral CT evaluation of nontraumatic haemorrhage of adrenals` adenoma; Patelis E, Tavernaraki K, Constantinidis F, Alexiou<br />
K, Panagiotakopoulou A, Antonopoulos P<br />
Retained calculi and complications of extracorporeal shock wave lithotripsy: evaluation with helical computed<br />
tomography; Patelis E, Tavernaraki K, Kedri K, Georgoulis P, Petroulakis A, Antonopoulos P<br />
Spontaneous rupture of renal cell carcinoma; Pertia N, Khutulashvili N, Phachuashvili M<br />
Colic pain in patients with hyperechoic US appearance of renal medulla; Manavis J, Deftereos S<br />
Bilateral tuberculosis infection of adrenal glands: utility of CT-guided biopsy in diagnosis; Kalogeropoulou CP, Liatsikos EN,<br />
Papathanassiou ZG, TsotaT Petsas I<br />
P14 The role of spiral CT in the investigation and diagnosis of pyelonephritis; Patelis E, Dalamarinis K, Constantinidis F,<br />
Tavernaraki K, Constantinidou E, Antonopoulos P<br />
P15<br />
P16<br />
YP17<br />
P18<br />
P19<br />
P20<br />
P21<br />
P22<br />
P23<br />
P24<br />
P25<br />
P26<br />
Acute pyelonephritis: comparison of diagnosis with CT and contrast-enhanced US; Andrea Klauser, Leo Pallwein, Andreas<br />
Berger, Ammar Mallouhi, Dieter Zur Nedden<br />
Evaluation of cystic renal masses: comparison of CT and contrast enhanced US by using the Bosniak classification<br />
system<br />
Michele Bertolotto, Libero Barozzi, Stefania Gava, Loretta Calderan, Anna Tiberio, Maria Assunta Cova<br />
Large adrenocortical oncocytoma: case report; Nasr El-Tabey, Essam Abou-Bieh, Ahmed Farouk, Ibrahim Eraky<br />
CT-urography (CTU) added on to CT of the abdomen: retrospective comparison of standard-dose and low-dose CTU<br />
protocols; Meindl T, Coppenrath E, Mueller-Lisse UL, Degenhart C, Reiser MF, Mueller-Lisse UG<br />
Incidentally discovered urinary and nonurinary lesions by multidetector noncontrast CT for flank pain; Huda Refaie,<br />
Ahmed Shokier<br />
The benefit of contrast-enhanced ultrasound in the diagnosis of renal tumors (preliminary results); Irena Sedonja,<br />
Marija Santl Letonja<br />
Evaluation of blunt traumatic bladder rupture by CT cystography; Luana Stanescu, Joel Gross, Hunter Wessells,<br />
Emily Meshberg, Lee Talner<br />
Misleading gastrointestinal symptoms in renal carcinoma patients; Marija Frkovic, Marijan Frkovic, Ivan Kos, Marko Kralik,<br />
Dobrila Tomic<br />
Colour doppler ultrasound assessment of the inferior vena cava in patients with renal cell carcinoma Correlation with<br />
intra-operative findings; Mojca Glusic, Bojana Cernelc, Miro Mihelic<br />
Complications of renal transplantation: emergent imaging evaluation; Navalho M, Mascarenhas V, Vitor L, Tavora I<br />
Is the radiation dose increasing in uroradiology?; Pär Dahlman, Lars Jangland, Anders Magnusson<br />
Imaging findings in urethra posterior injuries; Requejo I, Fernández P, Fernández L, Méndez C, Crespo C, Ponce J<br />
23
P27<br />
P28<br />
P29<br />
P30<br />
Integrated imaging in the evaluation of renal post-transplantation complications; M Atzori, G Regine, De Paulis P, A Cortese,<br />
L Adami<br />
Testicular masses in association with congenital adrenal hyperplasia: MR features compared with sonographic findings;<br />
Suliman HM, Stikkelbroeck NMML, Jager GJ, Blickman JG, Otten BJ, Hermus ARMM<br />
Testicular torsion - diagnosis by colour duplex sonography; Dubravka Vidmar, Alenka Visnar Perovic<br />
The effect of external scrotal cooling on the viability of the torsed testis in rats; Mahmoud Haj, Haim Farhadian,<br />
Norman Loberant, Shaul Shasha<br />
P31 Imaging findings of complications of prostate cancer therapy; Requejo I, Seoane M, Gulias D, Fernandez P,<br />
Garcia Figueiras R, Crespo C<br />
P32<br />
P33<br />
P34<br />
P35<br />
Is antibiotic prophylaxis necessary before TRUS guided transrectal prostate biopsies? Results of urine and blood cultures<br />
of patients who have undergone prostate biopsy without antibiotic prophylaxis; Tansel Inal, Eriz Ozden,<br />
Ahmet Tuncay Turgut, Murat Çilođlu, Sadettin Küpeli<br />
Illustration of TRUS findings of benign peripheral zone lesions which mimic prostate cancer sonographically;<br />
Ozden E, Tuncay Turgut A, Türkölmez K, Erdođan O, Baltacý S<br />
Imaging findings of ureteroceles; Ozden E, Tuncay Turgut A, Demirel C, Soygür T, Arýkan N<br />
Intratesticuler varicocele; Özden E, Tuncay Turgut A, Süer E, Yaman Ö<br />
P36 The evaluation of the efficiency of periprostatic nerve blockade in TRUS guided repeat biopsies; Özden E, Tuncay Turgut A,<br />
Göđüţ C, Özayar A, Baltacý S<br />
P37<br />
Evaluation of the cause of patient discomfort during TRUS guided prostate biopsy by the comparison of the effect of<br />
periprostatic nerve blockade on pain due to probe insertion and on pain related with the penetration by the biopsy needle;<br />
Ozden E, Tuncay Turgut A, Göđüţ C, Kutman K, Anafarta K<br />
P38 MSCT evaluation of emergency patients with palpable abdominal mass detected after delivery; Roglic A,1 Stern-Padovan R,<br />
Mokos I, Kralik M<br />
YP39<br />
Combined imaging approach in staging urinary bladder cancer; Abou-Bieh E, Barentsz J, Salah Wadee B, Eldiasty TA<br />
YP40 Post-contrast gradient T1WI: Has a role in patient with urinary bladder carcinoma or not; Abou-Bieh E, Barentsz J,<br />
El-Diasty T<br />
P41 MR imaging in the histologic characterization of testicular tumors; Tsili AC, Tsampoulas C, Katsios O, Vadivoulis T,<br />
Pappas A, Sofikitis N, Efremidis SC<br />
P42 Case report: presentation of splenogonadal fusion, a rare deformity; Lyssiotis P, Constantinidis F, Anastopoulos I,<br />
Liakouras C, Tsines G, Kalikatzaros E, Malahias G<br />
P43 Magnetic resonance imaging of normal and benign conditions of the urinary bladder; Manavis J, Kaldoudi E, Antoniou P,<br />
Deftereos S, Touloupidis S<br />
P44<br />
P45<br />
P46<br />
P47<br />
P48<br />
P49<br />
P50<br />
P51<br />
P52<br />
P53<br />
Imaging of urinary bladder hernias; Bacigalupo LE, Bertolotto, Barbiera, Pavlica P, Lagalla R, Pozzi Mucelli RS, Derchi LE<br />
Calculosis of the urethra as a consequence of congenital anomalies of the urinary tract; Zupancic Z, Babnik Peskar D<br />
Novel nurse led prostate biopsy service; Moussa SA, Innes A, Davis G<br />
MRI findings of pure adenomyosis of uterus after uterine artery embolization; Sang-Woon Yoon, Ki Whang Kim,<br />
Myeong-Jin Kim<br />
Prevalence of ovarian adrenal rest tumours and polycystic ovaries in females with congenital adrenal hyperplasia: results<br />
of ultrasonography and MRI imaging; Suliman HM, Stikkelbroeck NMML, Braat DDM, Jager GJ, Otten BJ<br />
Spectrum of findings in vaginal pathology - usual and unusual manifestations on MRI; Cunha TM, Félix A<br />
Müllerian duct anomalies: a radiologic and clinical overview: Souto M, Egas Moniz H, Felix A, Cunha TM<br />
Uterine sarcomas: a retrospective study; Costa N, Félix A, Cunha TM<br />
Spectrum of MRI findings in endometriosis; Oleaga L, Isusi M, García Figueiras R, De la Rosa J, Ibáńez T, Grande D<br />
Spectrum of MRI findings in adenomyosis; Oleaga L, Isusi M, García Figueiras R, Ibáńez T, De la Rosa J, Grande D<br />
24
P54 Multi-detector row CT in the detection and characterization of adnexal masses; Tsili AC, Tsampoulas C, Katsios O,<br />
Vlachos K, Paraskevaidis E, Efremidis SC<br />
P55<br />
P56<br />
P57<br />
Spectrum of imaging findings in the normal and pathologic endometrium; Pereira I, Félix A, Cunha TM<br />
Adnexal lesions with suspicious criteria for malignancy by MRI; Guerra A, Felix A, Cunha TM<br />
Transvaginal ultrasound versus hysterosonography in the assessment of depth in submucosal uterine fibroids and other<br />
benign lesions of the endometrium; Serafini G, Prefumo F, Dibilio D, Gandolfo N, Derchi L<br />
P58 Ultrasound and MRI imaging of palpable nodularities of the abdominal wall with postpartum onset; Serafini G, Prefumo F,<br />
Ciangherotti F, Gandolfo N, Derchi L<br />
P59 Tumors and tumor – like pelvic lesions: pitfalls and differential diagnosis on CT and MR imaging; Stern Padovan R,<br />
Kralik M, Lucic M, Corusic A<br />
P60<br />
P61<br />
P 62<br />
P63<br />
P64<br />
P65<br />
P66<br />
YP67<br />
Hematocolpos: Clinical presentation and imaging; Loberant N, Herskovits M, Goldfeld M, Salamon V<br />
Emergency ultrasonography in gynecologic field; Jongchul Kim<br />
Percutaneous drainage of kidney abscesses; Mylona S, Kokkinaki A, Thanos L, Stroumpouli E, Karahaliou E, Batakis N<br />
Re-audit of follow-up in patients with impaired renal function undergoing vascular imaging using contrast media;<br />
HJ Harris, S Agarwal, PWG Brown<br />
Renal cell carcinoma (RCC): is radiofrequency ablation (RFA) an effective means of treatment?<br />
Thanos L, Mylona S, Ntai S, Kokkinaki A, Tzavoulis D, Batakis N<br />
Percutaneous CT-guided nephrostomy: a quick and safe method which involves no radiation for the interventional<br />
radiologist; Thanos L, Stroumpouli E, Mylona S, Ntai S, Tzavoulis D, Batakis N<br />
Role of multislice CT scan in evaluation of living renal transplant donors; S Hanna, S Abd El-Rahman, M Shahin & H Badawy<br />
Post-traumatic high-flow priapism: diagnosis with MRA and treatment by selective arterial microcoil embolization (case<br />
report); Ahmed Farouk, Essam Abou-Bieh, Mohamed Abou El-Ghar, Yasser Osman, Tarek El-diasty<br />
P68 MSCT imaging of early and late complications after renal transplantation; Lusic M, Stern-Padovan R, Hrabak M, Sjekavica I,<br />
Molnar M, Oberman B<br />
P69<br />
P70<br />
P71<br />
Pelvo-calyceal biomodelling as an aid to achieving optimal access in percutaneous nephrolithotomy;<br />
Radecka E, Brehmer M, Magnusson P, Palm G Magnusson A<br />
Complications to double J-stents; Radecka E, Holmgren K, Magnusson A<br />
Percutaneous insertion of double-J endoprothesis in children with ureteral stenosis or occlusions; D Kljucevsek,<br />
T Kljucevsek, B Trsinar<br />
25
COURSE LECTURES<br />
UROGENITAL TRAUMA: A TRAUMATOLOGIST’S PERSPECTIVE<br />
Matej Cimerman, Matej Jezernik<br />
University Clinical Centre Ljubljana, Dept. for Traumatology<br />
The traumatologist (or trauma surgeon) in Slovenia is a general surgeon with special training in trauma<br />
surgery. He treats mostly musculoskeletal injuries and leads the trauma team in the management of multiple<br />
injured (polytraumatized) patients. Our trauma surgeon differs from the same profile in the USA and some<br />
European countries. The same system as in Slovenia is known in Germany, Austria, the Chech Republic and<br />
some other European countries. At our institution, isolated urogenital trauma is treated mostly by the<br />
consulting urologist. The traumatologist who sees the patient first, usually begins with the diagnostics and<br />
makes the first working diagnosis. A different problem is presented by urogenital trauma as a part of the<br />
polytraumatized patient. Pelvic injuries are very common in such patients. In these cases, urogenital trauma<br />
is usually associated with pelvic fractures and disruptions. In the study of Bruce et al. (2005), the average<br />
Injury Severity Score (ISS) of patients with extraperitoneal bladder rupture was 41.7, with intraperitoneal<br />
rupture 37.3, and with injured urethra 24.6, which in practice means, that the average patient with urogenital<br />
trauma is really polytraumatized.<br />
In modern traumatology, polytrauma means a syndrome of multiple injuries (ISS>17) with sequential<br />
systemic reactions which may lead to dysfunction of remote organs which were not directly injured (Trentz,<br />
2000). So, polytrauma does not mean just the sum of multiple injuries, but should be regarded as an acute<br />
systemic surgical illness. Polytrauma is always caused by high energy (velocity) and is the number one<br />
cause of death or disability among the active population worldwide. Modern treatment of multiple injured<br />
patients should be active, multidisciplinary and should follow algorithms. The positive impact of such<br />
treatment philosophy was clearly shown (Regel et al., 1991). On the other hand, it is difficult to introduce the<br />
universal algorithm which could be generally accepted worldwide. The protocols should be tailored to the<br />
individual institution respecting all the logistic possibilities. If multislice CT scan is available in the emergency<br />
room, the standard diagnostic protocol can be changed appropriately. In the acute period, where the only<br />
goal is survival the most essential issue is decompression of the body cavities (tension pneumothorax,<br />
cardiac tamponade) and of course effective hemorrhage control. In almost half of such cases, fractures of the<br />
pelvis contribute significantly to severe bleeding. The mortality rate of such patients is high, namely around<br />
50% (Eastridge et al. 2002). At our institution we use a standard polytrauma protocol which is expanded for<br />
»complex pelvic fractures« (Pohlemann 2000). After resuscitation, the basic diagnostics are done. Other<br />
sources of bleeding should be excluded. If the unstable hemodynamics comes from a pelvic instability<br />
emergency stabilization of the pelvis is performed immediately. C-clamp or external fixatior should be used. If<br />
the patient remains hemodynamically unstable, pelvic packing and/or emergency arteriography with<br />
embolization is performed. The definitive reduction and stabilization of the pelvic ring is performed later,<br />
usually after 5 to 10 days (the so called window of opportunity, Trentz 2000).<br />
The biomechanic role of the pelvis is transfer of body weight from the lower extremities to the axial skeleton.<br />
The majority of the forces are transferred via the posterior pelvic ring, and just about one forth via the anterior<br />
pelvic ring. The border is the line which connects both acetabuli. The important role of the pelvis is also the<br />
protection of the intrapelvic organs. The forces which interrupt the pelvic ring can harm these organs, as for<br />
example the urethra and bladder. Pelvic fractures and disruptions can be divided according to stability. This<br />
is the so called Tile’s classification which is used worldwide (Tile 1988). “A” type fractures represent stable<br />
fractures. The transfer of the load from the lower extremities to the axial skeleton is not disturbed. In practice,<br />
“A” type injuries are abruptions of bony parts of the pelvis or fractures of the upper part of the ala. In “B” type<br />
injuries, the pelvic ring is open or compressed, but the posterior part is still able to transfer forces to the axial<br />
skeleton. In »open <strong>book</strong>« injuries, for example, the SI joint is opened anteriorly, but the strong posterior<br />
sacroiliac ligaments are intact, which enables transfer of the forces to the spine. “C” type injuries are<br />
completely unstable. The pelvic ring is interrupted anteriorly and posteriorly. This classification is logic and<br />
serves as a base for operative decision making. “A” injuries have a better prognosis than “B” and “C” types<br />
26
and are treated mostly conservatively. “B” injuries are treated conservatively and operatively, while “C” type<br />
injuries are treated mostly operatively. The amount of forces which act on the pelvis are also correlated with<br />
this classification, “A” being the least and “C” the most. The only lack of this classification is that the direction<br />
of forces and dislocation cannot be predicted. Burgess combined Tile’s classification with direction of forces.<br />
Every type of Tile`s classification (A,B and C) is subdivided according to anterio-posterior compression<br />
(APC), lateral compression (LC), vertical shear (VS) or combined forces (C) (Burgess AR et al., 1990). For<br />
example, “C” type injuries caused by APC forces are most dangerous for fatal bleeding. We can assume<br />
from this classification that “B” and especially “C” type injuries are most likely associated with urogenital<br />
trauma, while “A” type injuries and isolated acetabular injuries are almost never associated with it. The<br />
probability of bladder injury is correlated with symphisiolysis (AiharaR et al., 2002). The probability of urethral<br />
injuries is correlated with fractures of the pubic rami as well.<br />
The emergency diagnosis of pelvic fractures or disruptions is made by plain x-ray (A-P view). This view is in<br />
most cases enough to understand the basic type of fracture and for emergency planning. For definitive<br />
operative treatment, a CT scan with 3D reconstruction is mandatory. Inspection and palpation of the<br />
anorectal region should be a routine procedure for this type of injuries. In the emergency room, the basic<br />
urologic diagnostics should be done. With gross hematuria, retrograde urethrography is followed by<br />
cistography. If there is blood at the maetus the folley catheteher should not be inserted. After the emergency<br />
diagnostics, we discuss with the urologist about the optimal treatment modality. In polytraumatized patients<br />
who are unstable, damage control procedures are advisable. With damage control procedures we protect the<br />
organs with minimal additional surgical trauma. Of course, damage control procedures are not definitive and<br />
should be followed by second look operations. In the case of urogenital trauma, the most common damage<br />
control procedure is suprapubic cistostomy. If revision of the ruptured bladder is mandatory, it can be<br />
combined with reconstruction of the anterior pelvic ring. The decision making is individual and depends on<br />
the general condition of the patient and local circumstances.<br />
Isolated urogenital trauma should be treated by the urologist. A specific problem is urogenital trauma as an<br />
associated injury of the polytraumatized patient. Management of the polytraumatized patient is<br />
multidisciplinary and in the case of urogenital trauma, the urologist and radiologist skilled in urologic<br />
diagnostics are the members of the trauma management team. Diagnostics should follow the polytrauma<br />
protocol. Treatment of urogenital injuries depends on the general conditions of the polytraumatized patients<br />
and should be tailored individually. The damage control concept can be very helpful with definitive<br />
management when the patient is stable, usually in the window of opportunity after 5 -10 days.<br />
References:<br />
Aihara R et al. Fracture locations influence the likelihood of rectal and lower urinary tract injuries in patients sustaining pelvic fractures. J<br />
Trauma 2002; 52: 205-9.<br />
Bruce H et al. Delays and difficulties in the diagnosis of lower urologic injuries in the context of pelvic fractures. J Trauma 2005; 58: 533-7.<br />
Burgess AR et al. Pelvic ring disruptions: effective classification system and treatment protocols. J Trauma 1990; 7: 848-56.<br />
Eastridge BJ, Starr A, Minei JP, O`Keefe GJ, Scalea TM. The importance of fracture pattern in guiding therapeutic decision-making in<br />
patients with hemorrhagic shock and pelvic ring disruptions. J Trauma 2002;3:446-50.<br />
Pohlemann T. Pelvic ring injuries: assessment and concepts of surgical management. In: Ruedi TP, Murphy WM eds. AO principles of<br />
fracture management. Stuttgart, New York: Thieme, 2000: 391-413.<br />
Regel G et al. Results of treatment of polytraumatited patients. A comparative analysisi of 3406 cases between 1972 and 1991.<br />
Unfallchirurg 1993; 7: 350-62.<br />
Tile M. Pelvic ring fractures: Should they be fixed? JBJS 1988; 70B: 1-12.<br />
Trentz OL. Polytrauma: pathophysilogy, priorities, and mamagement. In: Ruedi TP, Murphy WM eds. AO principles of fracture management.<br />
Stuttgart, New York: Thieme, 2000: 661-73.<br />
27
GENITOURINARY TRAUMA: UROLOGISTS' PERSPECTIVE<br />
Miro Mihelic<br />
Urologic Department, University Medical Center Ljubljana, Slovenia<br />
Abstract<br />
Rarely, upper and lower urinary tract trauma is presented solely or directly to the urologist. In our country,<br />
even genital trauma is often first presented to the trauma surgeon. Controversies and dilemmas about proper<br />
initial investigation and treatment on admission to the emergency unit lead to review of the current concepts<br />
of initial imaging and management, which the trauma surgeon and urologist should follow to avoid<br />
malpractice and late complications. The urologist's perspective should be to optimize imaging to save time<br />
and get as much information as possible when emergency treatment is needed. The European and American<br />
policy of treatment, the expectations of the clinician, and treatment outcome are discussed in this article.<br />
Introduction<br />
Trauma is the leading cause of death for people between age 1 and 37 years. After the initial evaluation, and<br />
resuscitation of the injured patient done by the anesthesiologist and trauma surgeon other specialists are<br />
attracted to work in a team. The genitourinary tract is involved in approximately 10% of injuries, the kidneys<br />
being the most commonly injured organ.<br />
RENAL TRAUMA<br />
Renal trauma represents 1-5% of all traumas (1). This most commonly injured urogenital and abdominal<br />
organ can produce a life threatening situation, but usually the injury is mild and managed conservatively. The<br />
male to female ratio is 3:1 (2).<br />
As a mechanism of injury, blunt renal trauma represents 80% (urban settings) to 90-95% (rural settings)<br />
(3,4). It is usually secondary to motor vehicle accidents, falls, contact sports and assaults. Traffic accidents<br />
represent almost half of blunt renal injuries. Renal lacerations and vascular injuries represent 10-15% of<br />
blunt renal injuries (5). It is supposed that bending of the supple organ with the applied force represents<br />
stress especially at the periphery of the organ. Renal artery injuries are associated with rapid deceleration.<br />
Traction on the artery with tear of the less elastic intima may lead to thrombosis (6). Renal injuries from<br />
penetrating trauma are less predictable as we are dealing with kinetic energy.<br />
The classification of renal injuries should help in patient's grouping, selecting appropriate therapy and<br />
predicting results. The American Association of the Surgery of Trauma’s (AAST) renal injury scaling system<br />
seems to be the most useful at the moment (7, Table 1)<br />
Table 1: AAST renal injury grading scale.<br />
Grade<br />
Description of injury<br />
1 Contusion or non-expanding subcapsular haematoma<br />
No laceration<br />
2 Non-expanding perirenal haematoma<br />
Cortical laceration < 1 cm deep without extravasation<br />
3 Cortical laceration > 1 cm without urinary extravasation<br />
4 Laceration: through corticomedullary junction into collecting system<br />
Or<br />
Vascular: segmental renal artery or vein injury with contained haematoma<br />
5 Laceration: shattered kidney<br />
Or<br />
Vascular: renal pedicle injury or avulsion<br />
28
To classify the injury, abdominal computed tomography (CT) or direct renal exploration is used. It allows<br />
predicting removal or kidney repair (8).<br />
Indicators of major renal trauma are a rapid deceleration event or direct blow to the flank or the upper<br />
abdomen or lower chest. One should be aware of preexisting renal anomalies which make the kidney more<br />
vulnerable. Physical examination is the basis for the initial assesment. The following signs indicate possible<br />
renal trauma:<br />
- hematuria<br />
- flank pain<br />
- flank ecchymoses and abrasions<br />
- fractured ribs<br />
- abdominal distension<br />
- abdominal mass and<br />
- abdominal tenderness<br />
Hematuria is the hallmark, but does not correlate with the degree of injury. Transection of the ureteropelvic<br />
junction, renal pedicle injuries and renal artery thrombosis usually go without hematuria. Urine dipstick is a<br />
reliable and rapid test, being false negative in 2,5-10% (9).<br />
Imaging<br />
Indications for radiographic evaluation are gross haematuria, microscopic haematuria and shock, and<br />
presence of major associated injuries (10). It should be done when fractures of the lower ribs and upper<br />
lumbar and lower thoracic vertebrae are detected. Patients with rapid deceleration injuries and penetrating<br />
trauma to the torso need immediate imaging.<br />
Ultrasonography<br />
This popular imaging is quick, non-invasive, low-cost but the results are highly dependent on the examiner. It<br />
cannot asses the depth and extent of the laceration and cannot provide information about the function. The<br />
fluid collection and distribution is well detected and doppler assesment gives some information about the<br />
tissue perfusion and renal vessels. It helps in the decision, which patients require more aggressive<br />
radiological imaging.<br />
Intravenous pyelography<br />
It is still the best imaging study with a sensitivity of more than 92% and gives information about the presence<br />
of both kidneys, clearly defines the renal parenchyma and outlines the collecting system. If there is no time to<br />
perform the whole examination one-shot IVP is done in the operating suite.<br />
Computed tomography (CT)<br />
When the patient is stable or needs CT scanning for other reasons a contrast CT of the kidneys and<br />
surrounding abdominal organs is the gold standard. It is more sensitive and specific than IVP. Spiral CT is<br />
more rapid but des not provide enough information about the excretory phase of the kidneys. Lacerations<br />
with extravasation are not shown (11).<br />
Angiography<br />
CT has largely replaced angiography as the method for staging renal injuries. It is useful when selective<br />
embolization for intrarenal bleeding from branching vessels is planned. When CT is not available and the<br />
kidneys on IVP are not seen, angiography is the test of choice.<br />
Treatment<br />
Dealing with renal trauma the urologist's expectations are: information about the presence of both kidneys,<br />
some data about the function and the extent of the injury.<br />
Today the major dilemma is whether to explore the damaged kidney or not. It is clear that the preservation of<br />
the kidney and minimal morbidity is the goal which cannot be always achieved, especially if the approach is<br />
aggressive.<br />
29
Major renal trauma (grade II to IV) represents only 5,4% of all renal trauma cases (10) and 98% of renal<br />
injuries can be managed conservatively. Grade V renal injury is an absolute indication for surgery and so is<br />
hemodynamic instability due to renal bleeding of any grade (12).<br />
Failure of conservative treatment is 5% (13) and it is mainly due to bleeding, infection, perinephric abscess,<br />
sepsis, urinary fistula, urinary extravasation and urinoma. Many of these early complications can be<br />
managed with radiologic or endoscopic interventions (e.g. selective arterial embolisation, drainage).<br />
URETERAL TRAUMA<br />
Because of its protected location, small size and mobility the ureter is less vulnerable to trauma representing<br />
1% of all urogenital traumas. Most of the injuries (75%) are iatrogenic and of these, 73% are gynaecological<br />
in origin (14). Injury to the ureter threatens the ipsilateral kidney function.<br />
The most diagnostic investigation is IVP with the detection of extravasation of radiological contrast media or<br />
additionally, when time permits retrograde ureteropyelogram, where the lesion is promptly delineated. CT<br />
scanning is time consuming as it takes at least 20 minutes for the contrast to extravasate.<br />
In open surgery at least one third of the injuries are recognized immediately (15) and repaired. For small<br />
lesions, a conservative approach with retrograde or antegrade stent placement is feasible.<br />
BLADDER TRAUMA<br />
Bladder trauma may be blunt, penetrating or iatrogenic. Bladder injury represents 2% of all abdominal<br />
injuries that require surgery (16). Off all bladder ruptures, blunt trauma is the cause in 67-86%, most common<br />
from motor vehicle accidents (17,18). Blunt bladder trauma is classified as extraperitoneal and<br />
intraperitoneal..<br />
70-97% of bladder injuries from blunt trauma come with pelvic fractures (19). Of them more than half are in<br />
the pubic ramus (20). In the group of those with pelvic fracture 30% will have bladder rupture and only 5-10%<br />
will have major injury (21). 25% of intraperitoneal bladder ruptures are without pelvic fracture (18). Combined<br />
extra and intraperitoneal ruptures come in 2-20% (22) and with rupture of the prostatomembranous urethra in<br />
10-29%.<br />
The degree of wall injury and location are the basis for the classification by Sandler and associates (Table<br />
2) (18).<br />
Table 4: Classification of bladder injury<br />
Type<br />
Description<br />
1 Bladder contusion<br />
2 Intraperitoneal rupture<br />
3 Interstitial bladder injury<br />
4 Extraperitoneal rupture:<br />
A. Simple<br />
B. Complex<br />
5 Combined injury<br />
Two main clinical signs with diagnosis are gross haematuria (82%) and abdominal tenderness (62%) (23).<br />
Inabilitiy to void, abdominal distension and bruises over supra and pubic area could be found. Rarely do we<br />
see extravasation of urine which can be detected as swelling in the perineum, scrotal area or thighs.<br />
Imaging<br />
It should be stressed that retrograde cystography with 350 ml of contrast material gives an 85-100% positive<br />
result (23). It should be followed by a drainage film where 13% of bladder ruptures are detected (18). CT<br />
cystography may replace cystography when evaluating abdominal and pelvic trauma. The sensitivity is 95%<br />
and specificity 100% (24).<br />
30
Treatment<br />
Blunt extraperitoneal rupture can be managed by catheter drainage only for 10 days to three weeks (25). If<br />
bone fragments and entrapment are present or the bladder neck is injured, surgical intervention is mandatory<br />
(22). Intraperitoneal rupture from blunt force has to be managed surgically. Because of the high degree of<br />
force there may be associated injuries with 20-40% mortality rate. Peritonitis due to urine leakage heavily<br />
worsens the prognosis. Penetrating trauma to the bladder should be explored and repaired promptly.<br />
The follow up cystogram is obtained 7 to 10 day after surgical repair. All extraperitoneal ruptures if correctly<br />
diagnosed should be healed by 6 weeks (most by 10 days, almost all by 21 days), proven by a cystogram.<br />
URETHRAL TRAUMA<br />
The male urethra is divided by the urogenital diaphragm into anterior (bulbar, penile in men) and posterior<br />
(prostatic, bulbar in men). Women have only a posterior urethra.<br />
The posterior urethra is injured with pelvic fracture. Road traffic accidents (70%), falls from height (25%) and<br />
crushes are the cause (26). Blunt trauma is responsible in more than 90% of cases. The female urethra is<br />
rarely injured by contusion or laceration by bone fragments.<br />
Crush or deceleration impact injury produces shearing forces to fracture pelvic bones. The same forces<br />
stretch or tear the prostato-membranous junction. The prostate can be detached from its insertions to the<br />
posterior face of the pubic bone and displaced.<br />
In a stable pelvic fracture, the anterior entire or part of the pubic bone is broken. In almost all cases of four<br />
pelvic rami fracture (straddle fracture) with posterior urethral rupture the distal sphincter mechanism is<br />
destroyed, representing 41% of all prostatomembranous urethral injuries. In unstable pelvic fracture the<br />
distorsion of the bony pelvis is responsible for the urethral tear.<br />
Urethral injuries are never life-threatening. Associated injuries are much more important in initial<br />
management.<br />
Colapinto and McCallum classified posterior urethral injuries on the basis of radiographic findings (Table 3)<br />
(27).<br />
Table 3: Classification of posterior injuries according to Collapinto and McCallum<br />
Type Description Radiographic appearance<br />
1 Urethral contusion or stretch injury Passage of contrast into the bladder, without<br />
extravasation and elongation of posterior urethra<br />
2 Partial or complete rupture above the<br />
urogenital genital diaphragm (supradiaphragmatic<br />
rupture)<br />
3 Complete disruption of the membranous<br />
urethra and urogenital diaphragm (suband<br />
supra- diaphragmatic rupture)<br />
Contrast may reach the bladder, but<br />
extravasation is present into the pelvis<br />
Contrast does not reach the bladder and<br />
extravasation is seen into the perineum<br />
Further classifications were developed including anatomy and treatment strategies (Table 4) (28).<br />
Table 4: Classification of urethral injuries according to Goldman et al.<br />
Type<br />
I<br />
II<br />
III<br />
IV<br />
IVa<br />
V<br />
Description<br />
Posterior urethra stretched but intact<br />
Tear of the prostatomembranous urethra above the urogenital diaphragm<br />
Partial or complete tear of both anterior and posterior urethra, with disruption of the urogenital<br />
diaphragm<br />
Bladder injury extending into the urethra<br />
Injury of the bladder base with periurethral extravasation simulating posterior urethral injury<br />
Partial or complete pure anterior urethral injury<br />
31
Finally the newest classification by EAU Urological guidelines proposes a classification which combines<br />
previous classifications and leads to proper clinical management (Table 5).<br />
Table 5: Classification of blunt anterior and posterior urethra<br />
Classification<br />
I<br />
II<br />
III<br />
IV<br />
V<br />
VI<br />
Description<br />
Stretch injury. Elongation of the urethra without extravasation on rethrography<br />
Contusion. Blood at the urethral meatus; no extravasation on urethrography<br />
Partial disruption of anterior or posterior urethra. Extravasation of contrast at injury site<br />
with contrast visualized in the proximal urethra or bladder<br />
Complete disruption of anterior urethra. Extravasation of contrast at injury site without<br />
visualization of proximal urethra or bladder<br />
Complete disruption of posterior urethra. Extravasation of contrast at injury site without<br />
visualization of bladder<br />
Complete or partial disruption of posterior urethra with associated tear of the bladder<br />
neck or vagina<br />
Type I requires no treatment. Types II and III can be managed conservatively with cystostomy or urethral<br />
catheter. Types IV and V require open or endoscopic, primary or delayed treatment. Type VI requires open<br />
repair.<br />
Anterior urethral injuries result mostly from blunt trauma. With fall or blow the bulbar urethra is compressed<br />
against the inferior surface of the symphysis pubis. Occasionally we see corpora cavernosa rupture with<br />
urethral rupture, which occur during intercourse. Penetrating trauma is even less common. Constriction<br />
bands for urinary continence and chronic urethral catheters of larger dimensions injure the urethra because<br />
of ischaemia, as does cardiac bypass surgery.<br />
Clinical assessment<br />
Blood at the urethral meatus is highly suspicious of urethral injury. It is present in 37-93% of patients with<br />
posterior urethral injury and in 75% with anterior (29). There should be no instrumentation in this case and<br />
radiological imaging of the urethra is done. In the unstable patient a urethral catheter can be gently<br />
attempted to pass but in any difficulty a suprapubic catheter should be placed. More than 80% of women with<br />
pelvic fracture and urethral injury will have blood at the vaginal introitus (30). High riding prostate is an<br />
unreliable sign as most of the injured are young with a small prostate. There is pelvic haematoma which des<br />
not allow exact conclusion.<br />
Imaging<br />
Retrograde urethrography is the gold standard. A plain film should be first performed to se any bony<br />
fragments or foreign bodies. It is easy to insert a 12 or 14 Fr Foley catheter in the fossa navicularis and<br />
inflate the balloon with 1-2 ml of water to occlude the urethra. Usually, in heavily injured the oblique position<br />
is not possible and the appearance of the urethra is not ideal. If the posterior urethra is injured a suprapubic<br />
catheter is placed well above the pubic bone if it is broken. Double imaging (ante and retrograde<br />
urethrogram) is possible. If displacement is present a delayed suprapubic endoscopy to evaluate the bladder<br />
neck is possible and a radiological evaluation of the proximal urethra with the endoscope in it. CT and MRI<br />
are not useful in assessment of urethral injuries (31) as well as endoscopy as the initial diagnostic procedure.<br />
Treatment<br />
Primary realignment of posterior urethral disruptions gives a lower stricture rate as suprapubic catheter<br />
alone. The urethral continuity is achieved. The prostate and urethra are aligned. The restricture rate is 62%.<br />
Open urethroplasty is not indicated because of bad visibility and more complications (incontinence, erectile<br />
dysfunction, stricture).<br />
Delayed primary urethroplasty is performed when a usually polytraumatized patient is stable, within 10 to 14<br />
days. The main goal is to correct severe distraction injuries, not to prevent stricture.<br />
Delayed urethroplasty<br />
32
In all of the delayed procedures, repeated imaging is desired as the pathoanatomic situation changes, the<br />
patient is more cooperative and stable thus more information is provided.<br />
Literature<br />
1. Meng MV, Brandes SB, McAninch JW. Renal trauma: indications and techniques for surgical exploration. World J Urol 1999;17(2):71-<br />
77.<br />
2. Danuser H, Wille S, Zoscher G, Studer U. How to treat blunt kidney ruptures: primary open surgery or conservative treatment with<br />
deferred surgery when necessary? Eur Urol 2001;39(1):9-14.<br />
3. Krieger JN, Algood CB, Mason JT, Copass MK, Ansell JS. Urological trauma in the Pacific Northwest: etiology, distribution,<br />
management and outcome. J Urol 1984;132(1):70-73.<br />
4. Sagalowsky AI, McConnell JD, Peters PC. Renal trauma requiring surgery: an analysis of 185 cases. J Trauma 1983;23(2):128-131<br />
5. Bruce LM, Croce MA, Santaniello JM, Miller PR, Lyden SP, Fabian TC. Blunt renal artery injury: incidence, diagnosis, and<br />
management. Am Surg 2001;67(6):550-554<br />
6. Sullivan MJ, Stables DP. Renal artery occlusion from trauma. JAMA 1972;221(11):1282.<br />
7. Moore EE, Shackford SR, Pachter HL, McAninch JW, Browner BD, Champion HR, Flint LM, Gennarelli TA, Malangoni MA,<br />
Ramenofsky ML, et al. Organ injury scaling: spleen, liver, and kidney. J Trauma 1989;29(12):1664-1666.<br />
8. Santucci RA, McAninch JW, Safir M, Mario LA, Service S, Segal MR. Validation of the American Association for the Surgery of<br />
Trauma organ injury severity scale for the kidney. J Trauma 2001;50(2):195-200.<br />
9. Chandhoke PS, McAninch JW. Detection and significance of microscopic hematuria in patients with blunt renal trauma. J Urol<br />
1988;140(1):16-18.<br />
10. Miller KS, McAninch JW. Radiographic assessment of renal trauma: our 15-year experience. J Urol 1995;154(2 Pt 1):352-355.<br />
11. Brown SL, Hoffman DM, Spirnak JP. Limitations of routine spiral computerized tomography in the evaluation of blunt renal trauma. J<br />
Urol 1998;160(6 Pt 1):1979-1981.<br />
12. Armenakas NA, Duckett CP, McAninch JW. Indications for nonoperative management of renal stab wounds. J Urol 1999;161 (3):768-<br />
771.<br />
13. Herschorn S, Radomski SB, Shoskes DA, Mahoney J, Hirshberg E, Klotz L. Evaluation and treatment of blunt renal trauma. J Urol<br />
1991;146(2):274-276<br />
14. Dobrowolski Z, Kusionowicz J, Drewniak T, Habrat W, Lipczynski W, Jakubik P and Weglarz W.Renal and ureteric trauma: diagnosis<br />
and management in Poland. BJU Int 2002; 89(7): 748-751.<br />
15. Grainger DA, Soderstrom RM, Schiff SF, et al: Ureteral injuries at laparoscopy: Insights into diagnosis, management, and prevention.<br />
Obstet Gynecol 1990;75:839–843.<br />
16. Carlin BI, Resnick MI.Indications and techniques for urologic evaluation of the trauma patient with suspected urologic injury. Semin<br />
Urol 1995;13(1):9-24.<br />
17. McConnell JD, Wilkerson MD, Peters PC.Rupture of the bladder. Urol Clin North Am 1982;9 (2):293-296.<br />
18. Sandler CM, Goldman SM, Kawashima A.Lower urinary tract trauma. World J Urol 1998; 16 (1):69-75.<br />
19. Flancbaum L, Morgan AS, Fleisher M, Cox EF.Blunt bladder trauma: manifestation of severe injury. Urology 1988;31 (3):220-222.<br />
20. Cass AS.Diagnostic studies in bladder rupture. Indications and techniques. Urol Clin North Am 1989;16 (2):267-273.<br />
21. Coppola PT, Coppola M. Emergency department evaluation and treatment of pelvic fractures. Emerg Med Clin North Am<br />
2000;18(1):1-27,<br />
22. Dreitlein DA, Suner S, Basler J. Genitourinary trauma. Emerg Med Clin North Am 2001;19(3):569-590.<br />
23. Carroll PR, McAninch JW.Major bladder trauma: mechanisms of injury and a unified method of diagnosis. J Urol 1984; 132 (2):254-<br />
257.<br />
24. Deck AJ, Shaves S, Talner L, Porter JR.Computerized tomography cystography for the diagnosis of traumatic bladder rupture. J Urol<br />
2000;164 (1):43-46.<br />
25. Corriere JN, Sandler CM.Management of extraperitoneal bladder rupture. Urol Clin North Am 1989;16(2):275-277.<br />
26. Koraitim MM, Marzouk ME, Atta MA, Orabi SS.Risk factors and mechanism of urethral injury in pelvic fractures. Br J Urol 1996;77<br />
(6):876-880.<br />
27. Colapinto V, McCallum RW.Injury to the male posterior urethra in fractured pelvis: a new classification. J Urol 1977;118 (4):575-580.<br />
28. Goldman SM, Sandler CM, Corriere JN Jr, McGuire EJ.Blunt urethral trauma: a unified, Anatomical mechanical classification. J Urol<br />
1997;157(1):85-89.<br />
29. Lim PH, Chng HC. Initial management of acute urethral injuries. Br J Urol 1989;64(2):165-168.<br />
30. Perry MO, Husmann DA. Urethral injuries in female subjects following pelvic fractures. J Urol 1992;147(1):139-143.<br />
31. Dixon CM, Hricak H, McAninch JW.Magnetic resonance imaging of traumatic posterior urethral defects and pelvic crush injuries. J Urol<br />
1992;148(4):1162-1165.<br />
33
UPPER URINARY TRACT TRAUMA<br />
Anders Magnusson<br />
Department of Radiology, Uppsala University Hospital, Sweden<br />
RENAL TRAUMA<br />
Mechanism of renal injury<br />
Blunt abdominal trauma, frequently caused by car accidents, falls, contact sports and fights, is responsible<br />
for more than 80% of all renal injuries. Other traumatic causes are penetrating violence (stab and gunshot<br />
injuries) and iatrogenic injuries (shockwave lithotripsy, percutaneous biopsy and percutaneous<br />
nephrostomy).<br />
Predisposing factors<br />
Preexisting conditions such as renal tumor and cyst, horseshoe kidney and hydronephrosis makes the<br />
kidney more vulnerable. In children the kidneys are relatively larger and unprotected which makes them more<br />
vulnerable.<br />
Types of injury and classification<br />
The type of injury varies with the severity of the trauma.<br />
a) Renal contusion (intrarenal edema)<br />
b) Hematoma (intrarenal, subcapsular or perirenal)<br />
c) Laceration (subcapsular parenchymal tear)<br />
d) Rupture (parenchymal tear with capsular injury)<br />
e) Pedicle injuries<br />
Renal injuries can be graded using a number of different classification systems which are used to guide<br />
therapy. However urologists are turning more and more conservative in treating renal trauma and most<br />
classification systems are not up to date.<br />
Management of Renal Trauma<br />
Most renal injuries are treated conservatively. If surgery is necessary delayed exploration is recommended<br />
(>24 h). The goal is to drain the kidney and to remove nonviable tissue, not to reconstruct the kidney.<br />
However, there is one exception from delayed intervention. Pedicle injuries with renal infarction require<br />
immediate intervention as renal function is irreversibly lost in more than 90% of cases after 2 hours of<br />
ischemia.<br />
Radiological Workup and Findings<br />
Suspected renal injury should be investigated as soon as possible. The following questions should be<br />
answered:<br />
• Are both kidneys present and are they functioning?<br />
• Are there nonviable fragments?<br />
• Is there a urinary extravasation?<br />
• Is the urinary flow unobstructed?<br />
These questions are best answered by CT. Contrast material should always be injected and imaging should<br />
be performed during cortico-medullary as well as delayed excretory phase.<br />
Contusion and Hematoma. A heterogeneous reduction in parenchymal enhancement reflects a renal<br />
contusion (Fig. 1). Fresh parenchymal hemorrhage appears on noncontrast scans as a hyperattenuating<br />
area.<br />
Laceration. A laceration or fracture through renal parenchyma is often between major vascular branches.<br />
Lacerations and ruptures are accompanied by subcapsular (Fig. 2) or perirenal hematomas (Fig. 3) of<br />
variable size.<br />
34
Shattered kidney. The most severe form of renal laceration is the shattered kidney. The kidney is fractured<br />
into three or more separate fragments. It is important to identify devascularised fragments (Fig 4). The force<br />
to the retroperitoneum that is necessary to shatter a kidney usually results in injuries to other organs in<br />
addition.<br />
Pedicle injury. Renal artery injury is due to a sudden stretch. Blood flow through the artery is blocked by an<br />
intimal flap and thrombosis which results in segmental or global infarction. In complete renal infarction a<br />
nonenhancing kidney is discovered on CT. Cortical rim sign represents a 2-3 mm thick dense outer<br />
nephrogram and is pathognomonic for infarction. Retrograde filling of the renal vein is often detected in total<br />
arterial occlusion.<br />
Contrast extravasation. Contrast leakage from a ruptured collecting system often signifies major disruption of<br />
renal parenchyma. Leakage is often found only on late excretory images (> 10 min.). A large collection of<br />
contrast material located medially to the kidney is suggestive of pelvocalyceal or ureteral tear.<br />
A new classification of renal injuries<br />
This is a proposal of a new, simple classification of renal trauma:<br />
I. Catastrophic injury<br />
- Devascularised kidney<br />
Treatment: Immediate surgery<br />
II. Injury which requires surgery<br />
- Large nonviable fragments<br />
- Major urinary extravasation and obstructed flow<br />
Treatment: Delayed surgery >24 h.<br />
III. Injuries treated conservatively<br />
- All other injuries<br />
Treatment: Expectance<br />
Fig. 1<br />
Renal contusion. The contused part of the kidney<br />
(arrowheads) shows hypofunction.<br />
Fig. 2<br />
Subcapsular hematoma with a typical compression of<br />
the right kidney (arrows).<br />
35
Fig. 3<br />
Perirenal hematoma surrounding the right kidney<br />
Fig. 4<br />
Shattered kidney with non-enhancing devascularised<br />
fragments (arrows)<br />
TRAUMA TO THE URETHRA AND SCROTUM<br />
Stanford M. Goldman, M.D.<br />
The University of Texas Health Science Center at Houston<br />
I. URETHRA<br />
In order to evaluate urethral injury, one must know the urethral anatomy and the mechanisms of injury. The<br />
significant clinical findings will be reviewed, followed by the various classifications (including the one we use)<br />
that are used. Finally, the various methods of imaging of the urethra will be described as well as current<br />
controversies in regards to treatment.<br />
ANATOMICAL CORRELATIONS<br />
The urethra is divided into two parts and each of these subdivided into two parts. The posterior urethra is<br />
made up of the longer prostatic segment and the extremely short membranous urethra. The extrinsic<br />
posterior compression by the verumontanum makes possible the recognition of the posterior urethra.<br />
Immediately below this is the membranous urethra, which is surrounded by the external sphincter, the key to<br />
male continence. This sphincter is part of the urogenital diaphragm (UGD) which acts as the main support of<br />
the internal viscera in the upright position. The anterior urethra is divided by the bulbous and penile urethra.<br />
The bulbous urethra consists of the 4-5 cm portion of the urethra below the symphysis pubis. Its posterior<br />
aspect is cone shaped as it joins the membranous urethra. The remaining penile urethra ends as an out<br />
pouching called the fossa navicularis. Surrounding the urethra is the facially encased corpus spongiosum.<br />
On both sides superiorly is the corpora cavernosum.<br />
MECHANISMS OF INJURY<br />
An anterior urethral injury is usually secondary to a straddle injury (e.g. a motorcycle hitting a wall). Posterior<br />
urethral injuries are usually due to crush injuries (e.g. an automobile accident invariably associated with a<br />
pelvic fracture). Iatrogenic injuries (e.g. secondary to gynecological, prostatic or bladder surgery) are also<br />
seen. Penetrating objects (e.g. knives, bullets, etc.) can also injure the penile urethra. Injuries secondary to<br />
foreign body insertion may also occur.<br />
36
SYMPTOMS AND PHYSICAL FINDINGS<br />
Ten percent (10%) of patients with pelvic fractures may have accompanying urethral injuries. Many believe<br />
that significant urethral injury does not occur without gross hematuria. Very rarely, microscopic hematuria<br />
may be associated with a severe injury. With significant anterior urethral injury, one notes an enlarged,<br />
discolored penis, scrotum and perineum. This swelling and discoloration may extend into the thigh. Blood at<br />
the urethral meatus may be noted. The so-called “floating bladder and prostate” require immediate surgery.<br />
CLASSIFICATION<br />
The old classification divided urethral trauma into posterior and anterior injuries. Anterior injuries occurred<br />
below the UGD and were secondary to a straddle injury. Posterior injuries resulted from blunt trauma with a<br />
complete transaction of the urethra above the UGD. In 1977, Colapinto & McCallum in a seminal paper<br />
suggested a new classification of blunt urethral injuries involving the “posterior” urethra. We believe this<br />
classification confusing because it is not a pure anatomical classification, but is based on the mechanism of<br />
injury and because many <strong>book</strong>s have misunderstood these authors as sub-classifying purely posterior<br />
urethral injuries. Our classification of urethral injuries follows and is compared to the other two widely used<br />
classifications.<br />
Type I - Posterior urethra intact but stretched (Colapinto and McCallum Type I)<br />
Type II - Pure posterior injuries with tear of membranous Urethra above the urogenital<br />
diaphragm – partial or Complete (Colapinto and McCallum Type II)<br />
Type III - Combined anterior/posterior urethral injury with disruption of the urogenital diaphragm<br />
– partial or complete (Colapinto and McCallum Type III injury)<br />
Type IV - Bladder neck injury with extension into the urethra<br />
Type IVA - Bladder neck injury<br />
Type V - Pure anterior urethral injury – partial or complete<br />
IMAGING TECHNIQUES<br />
1). Retrograde urethrogram<br />
This represents the main method of evaluating urethral injury. The Best technique is to place the Foley<br />
catheter balloon in the fossa navicularis and to perform the study under fluoroscopy. In the emergency room,<br />
the study can be performed blindly using a 50 cc beveled syringe or the Brodney clamp. The contrast should<br />
be diluted to 10-15% to prevent the development of a urethritis and to prevent obscuring pathology by overly<br />
dense contrast. In all suspected lower urinary tract trauma, the urethra should be evaluated before a<br />
catheter is placed in the bladder to prevent the conversion of a partial tear to a complete one. If a drainage<br />
catheter has already been placed into the bladder, the urethra can be studied by placing a small catheter<br />
next to the bladder catheter and injecting contrast.<br />
In complete anterior urethral tears, contrast fails to enter the bladder, but the contrast dissects into the<br />
scrotum, penis and along Colles’ fascia toward the umbilicus and even into the thigh. In type I injuries of the<br />
posterior urethra, there is only a stretching and narrowing of the urethra. This injury may require no<br />
treatment or only short-term catheter drainage. In type II injuries, the extravasation occurs just above the<br />
UGD. The bladder is elevated and pear-shaped and may mimic an extraperitoneal bladder injury. In type II<br />
injuries, contrast extravasates high below the bladder. These are indistinguishable radiologically and require<br />
follow-up or surgery. In type V tears, the contrast is seen below the symphysis pubis. In incomplete or<br />
partial tears, some contrast enters the bladder.<br />
2). Computed tomography<br />
CT is not routinely needed in evaluating urethral injuries. However, in select cases, residents and<br />
inexperienced faculty have used it to confirm the location of extravasated contrast from the urethrogram.<br />
Recently, Radiographics article with Ali, et al has suggested that CT being performed in patients with multiple<br />
trauma is valuable in predicting the presence and type of injury. This needs to be confirmed by others.<br />
37
3). Magnetic resonance imaging<br />
This technique is not used acutely because of expense and lack of ready availability on a 24-hour basis.<br />
However, Dixon et al, has shown it to be excellent in the pre-operative evaluation of the injured urethral<br />
because of its multiplanar capabilities and its ability to evaluate the surrounding soft tissues.<br />
TREATMENT<br />
In the past, immediate surgical repair was performed. Some trauma surgeons still operate on these patients<br />
acutely, claiming a lower incidence of complications. This approach can only be used by experienced<br />
trauma urologists, as will be discussed. Most urologists treat conservatively, except in the case of the<br />
floating prostate or in select type IV injuries to prevent urinary incontinence. If a catheter can be placed<br />
gingerly through the urethra in incomplete tears into the bladder, then the catheter acts as a urethral stent.<br />
Unfortunately, this catheterization is often unsuccessful, but some feel it is worthwhile trying. If not, a<br />
suprapubic tube is placed and a stricture is allowed to form. Surgery is then performed from above or below<br />
as appropriate. Impotence is less often a problem with the conservative approach over time.<br />
CORPORAL INJURIES<br />
Where injuries of the corpus cavernosum or corpus spongiosum is suspected, an ultrasound or MRI should<br />
be performed. Ultrasound is usually readily available, but often difficult to interpret because of the associated<br />
hematomas that are so often present. MRI gives more anatomical detail in multiple planes, but is not always<br />
available. Corpus cavernosonography may also be used. The surgeon is interested in the status of Buck’s<br />
fascia since severe tears of this fascia require repair.<br />
II. SCROTAL INJURIES<br />
The scrotum can be injured by either blunt or penetrating injuries. In these injuries, the urologist is most<br />
interested to know if the fascia surrounding the testes is intact in order to determine whether surgical<br />
intervention is indicated. Ultrasound is the technique most often used because of its ready availability.<br />
Unfortunately, the omnipresent edema and hemorrhage often make it difficult to answer this question. MRI, if<br />
available, may be more diagnostic in these situations. Besides tears of the fascia, intervention for significant<br />
hematomas are advocated in order to prevent loss of testicular function<br />
References<br />
1. Colapinto V, McCallum RM. Injury to the male urethra in the fractured pelvis: A new classification. J Urol 1977; 118-575-585.<br />
2. Dixon CM, Hricak H, McAninch JW. Magnetic Resonance Imaging of Traumatic Posterior Urethral Defects and Pelvic Crush Injuries.<br />
J Urol 1992;148:1162-1165.<br />
3. Kawashima A., Sandler CM, Corriere JN, Goldman SM. Type IV urethral injuries: retrograde urethrographic findings in six cases.<br />
Radiology 1998; 209(P):335.<br />
4. Kawashima A, Sandler SC, Corriere JN, Rogers BM, Goldman SM.<br />
Ureteropelvic junction injuries secondary to blunt abdominal trauma. Radiology 1997:205:4787-4792.<br />
5. Sandler CM. Urinary Tract Trauma in Text<strong>book</strong> of Uroradiology, 3 rd ed. Edited by Dunnick NR, Sandler CM, Newhouse JH, Amis ES<br />
Jr. Philadelphia: Lippincott Williams & Wilkins, pp. 473-483, 2001<br />
URETERAL AND BLADDER INJURIES<br />
Carl M. Sandler, M.D.<br />
University of Texas MD Anderson Cancer Center Houston, Texas<br />
Email: carl.sandler@di.mdacc.tmc.edu<br />
URETERAL INJURIES<br />
The ureter may be injured by blunt, penetrating or iatrogenic trauma.<br />
Almost all blunt ureteral injuries occur at the ureteral pelvic junction (UPJ) as a result of a deceleration injury.<br />
With rapid deceleration, the ureter may be avulsed or lacerated from its connection to the renal pelvis. The<br />
injury results in extravasation of urine (or contrast material) from the renal pelvis at the UPJ. On both<br />
38
urography and by CT, medial perinephric contrast material extravasation associated with a circumrenal<br />
urinoma is the characteristic finding. With complete avulsion, no filling of the ureter distal to the site of injury<br />
is present; with laceration, some filling distally is usually present. The differentiation is important as complete<br />
avulsion requires surgical repair whereas laceration may be treated conservatively or with a ureteral stent.<br />
Penetrating ureteral injury almost always occur with a wound to the back when caused by stabbings or<br />
anywhere in the path of the missle when due to gunshot wounds. The injury generally results in contrast<br />
material extravasation on imaging. On occasion, contrast extravasation will be present when the injury has<br />
been close to the ureter but not directly in its path as a result of blast effect and resultant ureteral necrosis.<br />
The majority of ureteral injuries are iatrogenic. The ureter may be tied or injured with any type of pelvic<br />
surgery but is particularly common with gynecologic procedures such as hysterectomy and laparoscopy.<br />
The injury may not be apparent for several days; in such cases fever of unknown cause may be the initial<br />
presenting symptom. Ureteral injury is also common in a wide variety of urologic procedures including<br />
ureteroscopy and stone basketing.<br />
BLADDER INJURIES<br />
Injury of the bladder may occur as a result of blunt, penetrating or iatrogenic trauma. The susceptibility of the<br />
bladder to injury varies with its degree of filling; a collapsed or nearly empty bladder is much less vulnerable<br />
to injury than is a distended organ.<br />
Radiologic Examination: The static or CT cystogram is the examination of choice for the diagnosis of a<br />
bladder injury. At least 300 ml of contrast should be used and with a conventional cystogram, a postdrainage<br />
radiograph following as complete emptying of the bladder as possible must be included. Studies have shown<br />
that the diagnosis of bladder injury may be established on this radiograph only in approximately 10% of the<br />
cases.<br />
The accuracy of cystography for the diagnosis of bladder injuries varies between 85-100% in the reported<br />
series. All authors stress, however, that careful attention to proper technique in the performance of<br />
cystography is necessary to achieve a high degree of accuracy. Falsely negative cystograms have been<br />
more commonly reported in patients suffering injury to the bladder secondary to small caliber bullets. In such<br />
cases, it is assumed that the bladder rent seals with either mesentery or blood clot and result in the falsely<br />
negative examination.<br />
Because computed tomography has gained increased acceptance for the evaluation of patients suffering<br />
blunt abdominal and pelvic trauma, there has been recent interest in the value of this modality for the initial<br />
evaluation of bladder injuries. Me and coworkers demonstrated that CT cystography performed utilizing<br />
excreted contrast material after intravenous injection was unreliable for the detection of acute bladder<br />
injuries, when compared to conventional cystography. Their findings were not surprising since it is well<br />
known that the cystographic phase of an excretory urogram is also unreliable for the detection of major<br />
bladder injuries. Subsequently, studies in which CT cystography was performed with retrograde filling of the<br />
bladder utilizing diluted contrast material report an accuracy comparable to that obtained with conventional<br />
cystography.<br />
Bladder Injury in Blunt Pelvic Trauma: Major bladder injury occurs in approximately 10% of patients suffering<br />
pelvic fracture. Such injuries are classified radiologically as:<br />
Type I<br />
Type II<br />
Type III<br />
Type IV<br />
Type V<br />
Bladder Contusion<br />
Intraperitoneal Rupture<br />
Interstitial Bladder Injury<br />
Extraperitoneal Rupture<br />
a. Simple<br />
b. Complex<br />
Combined Bladder Injury<br />
39
Bladder contusion (Type I) represents an incomplete tear of the bladder mucosa following blunt injury. The<br />
results of cystography are normal. The diagnosis of bladder contusion is usually established by exclusion in<br />
patients with hematuria following blunt pelvic trauma for which no other cause is found. While bladder<br />
contusion is generally regarded as the most common form of bladder injury following blunt trauma, it is not<br />
considered to be a major injury. Intraperitoneal rupture (Type II) occurs when there is a sudden rise in<br />
intravesicle pressure as a result of a blow to the lower abdomen in a patient with a distended bladder. The<br />
increased intravesicle pressure results in rupture of the weakest portion of the bladder, the dome, where the<br />
bladder is in contact with the peritoneal surface. Intraperitoneal rupture accounts for approximately one-third<br />
of major bladder injuries. Approximately 25% of such injuries occur in patients without pelvic fracture. On<br />
cystography, contrast material extravasation into the paracolic gutters and outlining loops of small bowel will<br />
be present. Interstitial bladder injury (Type III) represents an incomplete perforation of the bladder wall<br />
without frank rupture. On cystography a mural defect in the bladder wall will be found, but there is no<br />
contrast material extravasation. The classically described mechanism for extraperitoneal bladder rupture<br />
(Type IV) is laceration of the bladder by a bone spicule in association with an anterior pelvic arch fracture.<br />
Recent data, however, has shown that cystograms in such patients often demonstrate that the site of<br />
contrast material extravasation is often far removed from the site of fracture and thus the validity of this<br />
mechanism has been questioned. Extraperitoneal rupture represents approximately 60% of major bladder<br />
injuries. With simple extraperitoneal rupture, contrast extravasation is limited to the pelvic extraperitoneal<br />
space. With complex extraperitoneal rupture, contrast material extravasation may extend into the anterior<br />
abdominal wall, the penis, the scrotum and the perineum. The presence of a complex extraperitoneal injury<br />
implies that the fascial boundaries of the pelvis have been disrupted by the injury. Such findings should not<br />
be mistaken as evidence of a coexisting urethral injury. Combined bladder injury (Type V) results when both<br />
intraperitoneal and extraperitoneal bladder injury is present. This injury represents approximately 5% of<br />
major bladder injuries.<br />
External Penetrating Bladder Injury: Penetrating injury of the bladder occurs as a result of bullet or knife<br />
wounds of the pelvis or perineum or as the result of impalement of the bladder by a variety of objects.<br />
Penetrating injuries are classified as intraperitoneal rupture, extraperitoneal rupture or combined bladder<br />
injury.<br />
References<br />
1. Kawashima AK, Sandler CM, Corriere JN Jr, Rodgers B, Goldman SM: Ureteropelvic junction injuries secondary to blunt abdominal<br />
trauma. Radiology 205:487-492, 1997<br />
2. Vaccaro JP, Brody JM: CT cystography in the evaluation of major bladder trauma. RadioGraphics 20(5):1378-1381, 2000<br />
3. Sandler CM, Hall JT, Rodriguez MB, Corriere JN Jr: Bladder injury in blunt pelvic trauma. Radiology 158(3):633-638, 1986<br />
4. Peng MY, Parisky TY, Cornwell EE III, Radin R, Bragin S: CT cystography versus conventional cystography in evaluation of bladder<br />
injury. AJR 173(5):1269-1272, 1999<br />
5. Pao DM, Ellis JH, Cohan RH, Korobkin M: Utility of routine trauma CT in the detection of bladder rupture. Acad Radiol 7(5):317-324,<br />
2000<br />
6. Corriere JN Jr, Sandler CM: Mechanisms of injury, patterns of extravasation and management of extraperitoneal bladder rupture due<br />
to blunt trauma. J Urol 139(1):43-44, 1988<br />
7. Deck AJ, Shaves S, Talner L, Porter JR: Current experience with computed tomographic cystography and blunt trauma. World J Surg<br />
25(12):1592-1596, 2001<br />
8. Deck AJ, Shaves S, Talner L, Porter JR: Computerized tomography cystography for the diagnosis of traumatic bladder rupture. J Urol<br />
164(1):43-46, 2000<br />
9. Kane NM, Francis IR, Ellis JH: The value of CT in the detection of bladder and posterior urethral injuries. AJR 153(6):1243-1246,<br />
1989<br />
10. Morgan DE, Nallamala LK, Kenney PJ, Mayo MS, Rue LW III: CT cystography: radiographic and clinical predictors of bladder<br />
rupture. AJR 174(1):89-95, 2000<br />
11. Morey AF, Iverson AJ, Swan A, Harmon WJ, Spore SS, Bhayani S, Brandes SB: Bladder rupture after blunt trauma: guidelines for<br />
diagnosis imaging. J Trauma 51(4):683-686, 2001<br />
12. Carroll PR, McAninch JW: Major bladder trauma: mechanisms of injury and a unified method of diagnosis and repair. J Urol<br />
132(2):254-257, 1983<br />
13. Corriere JN Jr, Sandler CM: Bladder rupture from external trauma: Diagnosis and management. World J Urol 17(2):84-89, 1999<br />
40
URINARY OBSTRUCTION: A UROLOGIST′S PERSPECTIVE<br />
Imaging and intervention of obstruction<br />
Andrej Kmetec<br />
Department of Urology, University Medical Centre Ljubljana, Slovenia<br />
Urinary system obstruction is a common cause of acute and chronic renal failure. Evaluation and<br />
management of obstruction is of key importance to preserve renal function. Symptoms and signs of<br />
obstruction can be in the acute phase clearly expressed, while in the chronic phase they are mild or with long<br />
announcing history. The urinary tract is a connected system originating from the renal collecting tubules to<br />
the ureter and bladder and ending at the urethral orrifice. Any obstacle in the lower urinary parts causes<br />
higher pressure of urine above the obstruction and is later transmitted to the upper urinary tract, directly to<br />
the nephron tubules. Obstruction can be complete or partial, on one side or both sides, acute or chronic. In a<br />
human lifetime, we can observe two or even three peaks when obstruction is more often recognised. The first<br />
peak is observed in childhood, resulting from hereditary disorders involved in the urinary tract development.<br />
The second one, a lower peak, is expressed in mid lifetime between 30 and 40 years of age, resulting in<br />
obstruction from urinary stones or extrinsic processes such as compression from lymph nodes,<br />
retroperitoneal fibrosis or trauma accidents. The third peak of obstruction comes after 60 years of age mostly<br />
from obstruction in the lower urinary tract from benign prostate enlargement, cancer or urethral stenosis<br />
(1,2,3).<br />
Usually we use two conceptions: obstructive uropathy, which means disturbance in urine flow with renal<br />
function preserved, but lowered. If blockade is eliminated in time a complete recovery of renal function is<br />
expected. In such case, obstruction is acute, partial and one sided. The second conception is obstructive<br />
nephropathy in which blockade of the urinary system causes deterioration of renal function in such a degree<br />
that it cannot be reversed even when obstruction is eliminated. If the obstruction lasts 24 hours, renal<br />
function recovers in 7 to 10 days after it has been eliminated. If obstruction lasts 2 to 3 weeks, renal tubular<br />
function is permanently damaged and transition occurs from obstructive uropathy into obstructive<br />
nephropathy. In 4 to 8 weeks of obstruction, renal function ceases and we speak of an afunctional kidney.<br />
This happens when silent, gradually arising chronic obstruction in lower parts of the urinary system appear<br />
with chronic urine retention and high pressure in the bladder, which is transmitted to the upper urinary<br />
system or when retroperitoneal fibrosis compresses both ureters. Urine volume production can be normal,<br />
but the urine is not concentrated, the kidney is enabled to eliminate waste body products. Urine production<br />
depends on three factors: the pressure gradient from the glomerulus to the Bowman′s capsule, the peristalsis<br />
of the renal pelvis or ureters, and the effects of hydrostatic pressure (4.5).<br />
Causes of urinary obstruction are divided as follows:<br />
Infravesical: urethral strictures, posterior urethral valves, benign prostate enlargement, abscess<br />
in prostate, prostate cancer<br />
Supravesical: 1 Exstrinsic obstruction<br />
a/ vessels anomalies (retrocaval ureter, aortal aneurysm)<br />
b/ gynaecological diseases<br />
c/ gastrointestinal diseases (Chron′s disease, cancer, pancreatitis)<br />
d/ retroperitoneal lesions (fibrosis, tumours, lymph nodes)<br />
2 Intraluminal obstructions<br />
Pelviureteric stenosis, urolithiasis, blood clots, necrotic papilas<br />
Urotelial cancer, ureteral strictures<br />
3 Iatrogenic lesions- during gynaecological or bowel operations<br />
4 Obstruction in transplanted kidney<br />
Blood clots, stones, necrosis or stricture in transplanted ureter<br />
Stenosis or oedema in ureteral orifice, lymphocoele<br />
Pathoanatomic changes<br />
Above the place of obstruction there is urine stasis with higher pressure and dilatation of the collecting<br />
system. Higher pressure is transmitted to the kidney, causing interstitial nephritic fibrosis spread particularly<br />
round the Bowman′s capsule. This lesion can be observed even prior to 28 days of obstruction. Renal tissue<br />
41
gradually becomes thin – atrophic. Fibroblast spreading and collagen deposition in the renal tubule can be<br />
recognised after 2 weeks when the tubular basement membrane thickens (5, 7).<br />
Physiological changes<br />
Physiological changes can be seen in three phases as changes of the ureteric pressure, renal blood flow,<br />
glomerular filtration rate and tubular function during the first 18 hours after the obstruction appears. These<br />
changes are in the first phase oriented to increase the production of urine, while increasing the pressure<br />
intends to overcome obstruction. In the next phases, changes are intended to minimise damage to the kidney<br />
caused by obstruction. Variables measured during obstruction are represented in table 1 (6, 2, 4, 7).<br />
Table 1 Kidney response to acute obstruction.<br />
Phase 1<br />
1(0-90 min)<br />
Phase2<br />
(90 min-5h)<br />
Phase 3<br />
(5-18h)<br />
Increase to 50-70 mmHg Initial sharp fall<br />
plateau<br />
Gradual decrease with<br />
reduced renal blood flow<br />
After 4 hours reduced to<br />
52%<br />
Reduced to 23% at 12 h<br />
and 2% at 48h<br />
Initial increase due to<br />
preglomerular vasodilatation<br />
Reduced with post glomerular<br />
rise in resistance<br />
Progressive reduction with<br />
preglomerular vasoconstriction<br />
Leahy AL e tal. J Urol 1989.<br />
Renal tubular function: the renal concentration ability is affected early with the production of a large volume<br />
of hypotonic urine. This is a response when the kidney tends to overcome obstruction. Namely, in obstruction<br />
the prostaglandine production increases and blocks the antidiuretic hormone efect. Beside this reaction there<br />
is insufficient acidification and renal tubular acidosis appears. Potassium reabsorbtion is lowered first, later<br />
after 24 hours it increases and hyperkalemia occurs. Renal tubular permeability is increased (6) (Table 2).<br />
Table 2 Tubular function<br />
Acute obstruction<br />
Chronic obstruction<br />
Reabsorbtion Na + Raised Lowered<br />
Reabsorbtion K + Lowered Raised<br />
Concentrating ability Reduced or N Reduced<br />
Acidification N or slightly reduced Reduced<br />
Imaging and diagnosis<br />
Physical signs suggesting the use of imaging studies to confirm obstruction: renal colics with or without<br />
haematuria, miction disorders, low urine volume output or even absence of urine, incontinence, frequent<br />
infections, hypertension and renal failure (2).<br />
Dilatation of the urinary collecting system is the main sign of obstruction. The goal of the imaging study is to<br />
determine the site of obstruction and to distinguish obstructive dilatation from nonobstructive-functional<br />
dilatation. The latter is seen in an ectopic kidney, a kidney after certain surgical operations, an extrarenal<br />
pyelon, congenital megacalyces, calyceal diverticula, vesicoureteral reflux and some other causes. We must<br />
be aware, that obstruction in the first some hours can be without dilatation. The first examination is the plain<br />
X ray picture which presents stones in the urinary tract and an ultrasound examination showing dilatation, but<br />
the exact site of the obstruction lower to the pyeloureteric part cannot be identified. The ultrasound<br />
examination is subjected to individual interpretation and in 20% there are false positive or negative results<br />
(8). In the acute phase when there is no obvious dilatation, Doppler ultrasound and calculating resistent<br />
indexes can differentiate between obstructive and nonobstructive dilatation. A resistive index 0,7 and over<br />
confirms obstructive dilatation (8, 11). Some additional information in the detection of hydronephrosis gives a<br />
radionucleotide scan, having 90% sensitivity, but the exact location of obstruction also cannot be defined. In<br />
acute obstruction it shows renal function, which can be even worse then it exists on itself. Intravenous<br />
pyelography is still the procedure of choice for defining the extent and anatomy of obstruction, which is still<br />
quite useful in stone disease and helps to make an appropriate decision about therapy. It has disadvantages<br />
like nephrotoxity and a long time of dye excretion in patients with renal failure. The same is with invasive-<br />
42
etrograde pyelography which is useful in visualising tumours in the renal pelvis. In such cases, both imaging<br />
techniques cannot replace CT or MR. Contrast X ray uretrography is still the best way to determine urethral<br />
stricture or stricture at the bladder neck. Today, contrast CT or spiral CT is the best way to determine the<br />
extent and location of obstruction (9, 2).<br />
Management of urinary obstruction<br />
Treatments of obstruction are divided into those for early relief of urine blockade with intention to prevent<br />
damage and deterioration of renal function. After acute obstruction is solved and renal function normalises,<br />
we have time enough for additional imaging and getting information for final decisions. Three main areas<br />
have developed in urology: interventional urology, the development in the technology of protheses and<br />
stents, endoscopy with a new technology in surgery.<br />
Urethral obstruction due to stricture can be solved by thin catheter insertion, if it is not possible, suprapubic<br />
cystostomy catheter drainage is the best solution. Urine retention due to prostate enlargement is solved<br />
using urine catheters or suprapubic cystostomy drainage. The final solution is done by endoscopic resection<br />
of the enlarged prostate. A prothesis disposed on the urethral stricture or on the bladder neck is not the best<br />
solution, because it can slip out of position, causing incontinence or fibrous tissue can spread through the<br />
prothesis. Removing the prothesis out of the urethra or bladder can sometimes be nearly impossible.<br />
Ureteral stone obstruction causes stretching of the collecting system and produces colic pains. More than<br />
90% of the stones less than 5-7mm in size pass spontaneously. If obstruction is severe JJ stent insertion<br />
passes the stone and decompresses the kidney. The position of the stone determines the preferred method<br />
of removal – ureterorenoscopy, percutaneous nephroscopy or shock wave lithotripsy. Long standing stone<br />
obstruction is complicated by infection. In such cases percutaneous nephrostomy is safer than retrograde<br />
catheterisation, which may introduce infection into the closed blockaded urinary system. Sometimes JJ<br />
insertion is a good temporary solution in cases of enlarged lymph nodes or others extrinsic lesions<br />
compressing the ureter. Gynaecological or bowel cancer compresses and invades the ureter in such way<br />
that it is better to insert a percutaneous nephrostomy tube. Retroperitoneal fibrosis or aortal aneurysm cause<br />
mild and proximal ureter obstruction, percutaneous nehrostomy is indicated instead of a JJ stent. Stents<br />
block ureter peristaltic and make intraluminal ureter compression so it is advisable that patients have<br />
nephrostomy for some months. When ureters are decompressed after appropriate therapy seen on contrast<br />
X ray imaging through the nephrostomy tube stents can be inserted (2).<br />
Used urine catheters, splints or nephrostomies are usually temporary interventions to avoid obstruction and<br />
preserve renal function. Elective surgery or endoscopic procedures may then be performed after adequate<br />
definition of the place and cause of obstruction. In some patients having bad prognosis as in advanced<br />
cancer disease, nephrostomy or splints can be a definite solution to maintain at least adequate renal<br />
function.<br />
Every obstruction in the urinary system may cause infection and urosepsis. Obstruction treatment may<br />
introduce infection into the closed urinary system. A urinary catheter can in three days cause bacterial<br />
infection in the lower urinary tract. Ureteral catheters and splints can introduce infection into the upper urinary<br />
tract. Splints may cause complications such as movement out of the bladder to the upper tract or they can<br />
fall into the bladder, cause haematuria, or pain in the loins due to vesicoureteral reflux. Percutaneous<br />
nephrostomy insertion may also introduce bacteria into the urinary tract, producing haematuria and later<br />
calcium settings on the tube which makes tube occlusion. We suggest that preventive antibiotic therapy is<br />
advisable in all cases when artificial materials stay in the urinary system for a longer period.<br />
Transplanted kidney<br />
Patients with a transplanted kidney have immunosuppressive therapy and are susceptible for infections. In<br />
the transplanted kidney, ureter stenosis in the lower part of the ureter or stenosis at the new-formed orifice<br />
causes dilatation of the urinary system. Retrograde insertion of a ureter catheter or JJ splint is almost always<br />
impossible; also infection can be introduced into the kidney. Percutaneous nephrostomy insertion is<br />
mandatory. Later we can perform contrast imaging through the tube or CT to visualise the extent and exact<br />
place of stenosis. The cause of ureteral stenosis is insufficient blood supply or knicking of the ureter. The<br />
interventional radiologist can dilate the stenosis and insert a splint through the nephrostomy, but this is not<br />
the final solution. The splint may further compromise the ureter blood supply. To solve the problem, surgical<br />
resection of the ureter, using bladder flap to elongate the gap between the bladder and the ureter and<br />
neoimplantation is mandatory. Sometimes the patient’s own ureter is used instead of the transplanted one.<br />
External compression and obstruction can cause lymphocoele. Simple tube insertion into the lymphocoele<br />
43
cavity produces lymphatic drainage for a long period, loosing proteins with bacterial invasion into the cavity. It<br />
is advisable to drain the lymphocoele into the abdominal cavity where the lymph spontaneously resorbs. In<br />
the transplanted kidney, urinary stones or blood clots may produce obstruction. If dilatation stands for a<br />
longer period percutaneous nephrostomy insertion is advisable to prevent kidney deterioration and to wait for<br />
particles to eliminate spontaneously (12).<br />
Conclusion<br />
Recognition and detection of urinary obstruction using appropriate imaging methods enables to apply<br />
suitable methods to free urine flow and prevent renal damage or infection. Insertion of splints,<br />
nephrostomies, and catheters is a time limited procedure to alleviate the acute phase of obstruction and to<br />
consider about further decisions. The final solution of obstruction is surgical or endoscopic, except in patients<br />
having advanced disease with bad prognosis. Obstruction which lasts for a longer period produces infection<br />
with renal function deterioration. Artificial materials introduced into the urinary system may cause chronic<br />
infection which affects also the renal function. A combination of intraluminal stenting and urinary system<br />
reconstruction will give the best results and minimise morbidity.<br />
LITERATURE<br />
1. Kmetec A, Oblak C. Najpogostejši vzroki zapore zgornjih sečil in naši diagnostični postopki.Zbornik podiplomskega tečaja kirurgije,<br />
Ljubljana 1992; 164-169.<br />
2. Janež J. Patofiziologija zapore sečil. Zbornik podiplomskega tečaja kirurgije, Ljubljana 1992; 153-163.<br />
3. Catell R W. Renal function and obstructive nephropaty; in Webster G, Kirby R, King L, Goldwaser B: Reconstructive urology,Boston<br />
Vol1, Blackwll Scientific Publications. 1993. 5-13.<br />
4. Klahr S. Obstructive nephropathy. Kidney Int 1998; 54: 286-300.<br />
5. Gulmi FA, Felsen D, Vaughan ED Jr: Pathophysiology of urinary tract obstruction; in Walsh PC, Retik AB, Vaughan ED Jr, Wein A:<br />
Campbell′s Urology, ed 7. Philadelphia, Saunders, 1977, 342-385.<br />
6. Sharma AK, Mauer SM, Kim Y, Micharl AF. Interstitial fibrosis in obstructive nephropathy. Kidney Int 1993; 44: 774-780.<br />
7. Ryan CP, Maher KP.Murphy B,Hurley DG, Fitzpatrick MJ. Experimental partial ureteric obstruction: pathophysiological changes in<br />
upper tract pressures and renal blood flow. J Urol 1987; 138: 674-8.<br />
8. Kmetec A. Ultrazvok v klinični diagnostiki obstrukcije sečil. Thesis, Ljubljana 1999.<br />
9. Steinhausen e tal. Glomerular blood flow. Kidney International 1990; 38:769-84.<br />
10. Catalano C, Pavone P, Laghi A. MR pyelography and conventional MR imaging in urinary tract obstruction. Acta Radiol, 1999, 40:<br />
1107-13.<br />
11. Platt JF. Urinary obstruction. Radiol Clin N Amer 1996; 34: 1113-1129.<br />
12. Kahan B, Ponticelli C. Principles and practise of renal transplantation. Martin Dunitz Ltd Blackwell Scientific publication, 2000.<br />
IMAGING OF STONES: PLAIN FILM, IVU, AND ULTRASOUND<br />
Gertraud Heinz-Peer, M.D.<br />
Dept. of Radiology, Medical University of Vienna<br />
Urolithiasis is a common problem in patients presenting to emergency departments. Radiologic imaging has<br />
always had a primary role in the work-up of these patients. Traditionally, evaluation consisted of conventional<br />
radiography (KUB) followed by intravenous urography (IVU). With the advent of ultrasonography (US) those<br />
patients who could not safely undergo IVU could be evaluated for primary or secondary (ie, hydronephrosis)<br />
signs of obstruction. In the past several years, the introduction of unenhanced spiral CT has dramatically<br />
changed the role of the various imaging techniques in evaluation of urolithiasis. The number of pulications on<br />
the issue of intravenous urography (IVU) versus computed tomography (CT) is abundant. During the last<br />
years advocates of the CT make up the majority. In the recent literature some authors believe that it is time<br />
for IVU to retire after 70 years of good performance. However, daily practice shows that urologists still like<br />
those “old” techniques.<br />
This lecture will review the pros and cons of KUB, IVU, and ultrasound. In addition, aspects of radiation<br />
dosage, requirements for further imaging, impact on urological interventions and follow-up examinations as<br />
well as aspects on diagnostic utility and the measured clinical outcome will be addressed.<br />
44
Learning objectives:<br />
1. Assess the advantages and limitations of KUB, IVU, and ultrasound<br />
2. Work out remaining diagnostic fields for these techniques<br />
3. Learn about relation between imaging and clinical management of urolithiasis<br />
References<br />
1. 8 Swick M. Demonstration of the kidneys, ureters, bladder and urethra by x-rays using intravenous administration of a new contrast<br />
medium uroselectan. Klin Wschr 1929; 8:2085-2087.<br />
2. 9 Dalla Palma L, Stacul F, Bazzocchi M et al. Ultrasonography and plain film versus intravenous urography in ureteric colic. Clin<br />
Radiol 1993; 47:333-336.<br />
3. 10 Sourtzis S, Thibeau, Damry N, Raslan A, Vandendris M, Bellemans M. Radiologic Investigation of Renal Colic: Unenhanced Helical<br />
CT compared with Excretory Urography. AJR 1999; 172:1491-1494.<br />
4. 11 Liu W, Esler SJ, Kenny BJ, Goh RH, Rainbow AJ, Stevenson GW. Low-Dose Nonenhanced Helical CT of Renal Colic: Assessment<br />
of Ureteric Stone Detection and Measurement of Effective Dose Equivalent. Radiol 2000; 215:51-54.<br />
5. 12 Miller OF, Rineer SK, Reichard SR, Buckley RG, Donovan MS, Graham IR, Goff WB, Kane CJ. Prospective comparison of<br />
unenhanced spiral computed tomography and intravenous urogramin the evaluation of acute flank pain. Urol 1998; 52:982-987.<br />
6. 13 Dalla Palma L. What is left of i.v. urography? Eur Radiol 2001; 11:931-939.<br />
7. 17 Levine JA, Neitlich J, Verga M, et al. Ureteral calculi in patients with flank pain: correlation of plain radiography with unenhanced<br />
helical CT. Radiology. 1997; 204:27-<br />
8. 18 Ripolles T, Agramunt M, Errando J, Martinez MJ, Coronel B, Morales M. Suspected ureteral colic: plain film and sonography vs<br />
unenhanced helical CT. A prospective study in 66 patients. Eur Radiol 2004; 14:129-136.<br />
9. 19 Catalano O, Nunziata A, Altei F, Siani A. Suspected ureteral colic: primary helical CT versus selective helical CT after unenhanced<br />
radiography and sonography. AJR 2002; 178:379-387.<br />
10. 21 Deyoe LA, Cronan JJ, Breslaw BH, Ridlen MS. New techniques of ultrasound and color Doppler in the prospective evaluation of<br />
acute renal obstruction. Do they replace the intravenous urogram? Abdom Imaging. 1995; 20:58-63.<br />
11. 24 Fielding JR, Steele G, Fox LA, Heller H, Loughlin KR. Spiral computerized tomography in the evaluation of acute flank pain: a<br />
replacement for excretory urography. J Urol 1997; 157:2071-2073.<br />
12. 25 Radermacher J. Internist 2003; 44:1413-1431.<br />
13. 26 Sandhu C, Anson KM, Patel U. Urinary Tract Stones – Part I: Role of Radiological Imaging in Diagnosis and Treatment Planning.<br />
Clin Radiol 2003; 58:415-421.<br />
14. 28 Yilmaz S, Sindel T, Arslan G, et al. Renal colic: comparison of spiral CT, US and IVU in the detection of ureteral calculi. Eur Radiol<br />
1998; 8:212-217.<br />
15. 33 Sandhu C, Anson KM, Patel U. Urinary Tract Stones – Part II: Current Status of Treatment. Clin Radiol 2003; 58: 422-433.<br />
16. 35 Smith RC, Rosenfield AT, Choe KA, et al. Acute flank pain: comparison of unenhanced-enhanced CT and intravenous urography.<br />
Radiology 1995; 194:789-794.<br />
17. 36 Sommer FG, Jeffrey RB, Rubin GD, et al. Detection of ureteral calculi in patients with suspected renal colic: value of reformatted<br />
noncontrast helical CT. AJR 1995; 165:509-513.<br />
18. 37 Smith RC, Verga M, McCarthy Sh, Rosenfield AT. Diagnosis of acute flank pain: value of unenhanced helical CT. AJR 1996;<br />
166:97-101.<br />
19. 47 Dalla Palma L, Pozzi-Mucelli R, Stacul F. Present-day imaging of patients with renal colic. Eur. Radiol 2001; 11:4-17.<br />
20. 48 Kawashima A, Sandler CM, Boridy IC, Takahashi N, Benson GS, Goldman SM. Unenhanced Helical CT of Ureterolithiasis: Value<br />
of the Tissue Rim Sign. AJR 1997: 168:997-1000.<br />
21. 49 Heneghan JP, Dalrymple NC, Verga M, et al. Soft-Tissue “Rim” Sign in the Diagnosis of Ureteral Calculi with Use of Unenhanced<br />
Helical CT. Radiol 1997; 202:709-711.<br />
22. 50 Boridy IC, Nikolaidis P, Kawashima A, Goldman SM, Sandler CM. Ureterolithiasis: value of the tail sign in differentiating phleboliths<br />
from ureteral calculi at nonenhanced helical CT. Radiology 1999; 211:619-621.<br />
23. 51 Takahashi N, Kawashima A, Ernst RD, et al. Ureterolithiasis: Can clinical outcome be predicted with Unenhanced Helical CT?<br />
Radiology 1998; 208:97-102.<br />
24. 53 Bell TV, Fenlon HM, Davison BD, et al. Unenhanced helical CT criteria to differentiate distal ureteral calculi from pelvic phleboliths.<br />
Radiol 1998; 207:363-367.<br />
25. 57 Thomson JM, Glocer J, Abbott Ch, Maling Th. Computed tomography versus intravenous urography in diagnosis of acute flank<br />
pain from urolithiasis: A randomized study comparing imaging costs and radiation dose. Australasian Radiology 2001; 45:291-297.<br />
26. 69 Amis ES, Jr. Epitaph for the Urogram. Radiol 1999; 213:639-640.<br />
27. 70 Denton ER, Mackenzie A, Greenwell T, Popert R, Rankin SC. Unenhanced helical CT for renal colic: is the radiation dose<br />
justifiable? Clin Radiol 1999; 54: 444-447.<br />
45
URINARY OBSTRUCTION – MRU AND CTU<br />
Joern Kemper, MD; Claus Nolte-Ernsting, MD<br />
Clinic of Diagnostic and Interventional Radiology<br />
University Hospital Eppendorf – Hamburg, Germany<br />
Urinary obstruction with hydronephrosis is a common outcome of many urologic diseases. A wide variety of<br />
pathological processes, intrinsic and extrinsic to the urinary system, can cause urinary obstruction. Calculi,<br />
neoplasms, infection, coagulopathy and inflammatory and fibrotic processes are important pathologies. Most<br />
acute obstructive uropathies are associated with significant pain that alerts the clinician to the need for<br />
appropriate diagnostic work-up and treatment. However, chronic urinary obstruction often requires a high<br />
index of suspicion, which prompts an appropriate imaging modality that my confirm or rule out the presence<br />
of obstruction.<br />
Many imaging modalities have been used to evaluate patients with urinary obstruction. Historically,<br />
intravenous urography (IVU) has been the primary method of imaging in these patients. Currently, the<br />
examinations that are commonly used to evaluate patients with urinary obstruction include IVU,<br />
ultrasonography (US), computed tomography (CT), magnetic resonance (MR) imaging, retrograde<br />
ureterography and pyelography, cystoscopy, and ureteroscopy. Evaluation of patients with urinary<br />
obstruction frequently requires several imaging modalities. Each offers its specific advantages. Both CT<br />
urography (CTU) and MR urography (MRU) have evolved into important diagnostic tools in modern<br />
uroradiology.<br />
Magnetic resonance urography (MRU) has the potential to provide anatomical and functional information<br />
about a possible obstructed urinary tract without nephrotoxic contrast media or radiation exposure 1, 2 . The<br />
classic MR-urographic technique utilizes unenhanced, heavily T 2 -weighted turbo spin-echo sequences for<br />
obtaining static fluid images of the upper urinary tract independent of the excretory renal function. T 2 -<br />
weighted MR urograms have proved to be excellent in visualizing the dilated urinary tract, even in nonexcreting<br />
kidneys. In addition, T 1 -weighted MRU reflects the excretory renal function and displays the urine<br />
flow within the upper urinary tract after renal excretion of gadolineum chelate. Fast T 1 -weighted 3D gradientecho<br />
sequences provide impressive urograms of both non-dilated and obstructed collecting systems in<br />
patients with normal and moderately impaired renal function. Using these advantages, MRU has the potential<br />
to be a valuable diagnostic tool in the assessment of obstructive uropathy especially in pediatric or post renal<br />
transplant settings.<br />
The introduction of multislice-computed tomography (MSCT), with its well known advantages has provided<br />
the possibility to obtain thin axial images of the entire urinary tract in one breath-hold. This advance has had<br />
a significant impact on imaging of the urinary tract. Application of MSCT to the collecting system during<br />
urographic phase has been termed “CT-Urography” 3-8 . Consequently, CTU is also an excretory urography<br />
like T 1 -weighted MRU. It can be combined with low-dose furosemide or saline for accelerated passage of<br />
excreted contrast material making abdominal compresssion dispensable 4, 5, 9, 10 . The acquired volume<br />
dataset allows the reconstruction of high-resolution multiplanar (MPR), maximum-intensity (MIP), and<br />
average-intensity (AIP) images of the collecting system. It has the potential to provide a complete<br />
assessment of the genitourinary tract. The outlined benefits of MSCTU also pose significant challenges in<br />
terms of optimal imaging protocols and control the radiation exposure to the patient 11, 12 .<br />
The aim of this lecture is to review the current technical principles and imaging protocols of MRU and CTU.<br />
The imaging capabilities and the relative merits of these modalities in the evaluation of upper urinary<br />
obstruction are discussed by means of clinical examples.<br />
References<br />
1. Nolte-Ernsting CC, Staatz G, Tacke J, Gunther RW. MR urography today. Abdom Imaging 2003; 28:191-209.<br />
2. El-Diasty T, Mansour O, Farouk A. Diuretic contrast-enhanced magnetic resonance urography versus intravenous urography for<br />
depiction of nondilated urinary tracts. Abdom Imaging 2003; 28:135-45.<br />
3. Caoili EM, Cohan RH, Korobkin M, et al. Urinary tract abnormalities: initial experience with multi-detector row CT urography. Radiology<br />
2002; 222:353-60.<br />
4. McTavish JD, Jinzaki M, Zou KH, Nawfel RD, Silverman SG. Multi-detector row CT urography: comparison of strategies for depicting<br />
the normal urinary collecting system. Radiology 2002; 225:783-90.<br />
5. Nolte-Ernsting CC, Wildberger JE, Borchers H, Schmitz-Rode T, Gunther RW. Multi-slice CT urography after diuretic injection: initial<br />
results. Rofo 2001; 173:176-80.<br />
46
6. El-Ghar ME, Shokeir AA, El-Diasty TA, Refaie HF, Gad HM, El-Dein AB. Contrast enhanced spiral computerized tomography in<br />
patients with chronic obstructive uropathy and normal serum creatinine: a single session for anatomical and functional assessment. J<br />
Urol 2004; 172:985-8.<br />
7. Noroozian M, Cohan RH, Caoili EM, Cowan NC, Ellis JH. Multislice CT urography: state of the art. Br J Radiol 2004; 77 Spec No<br />
1:S74-86.<br />
8. Mueller-Lisse UG, Mueller-Lisse UL, Hinterberger J, Schneede P, Reiser MF. Tri-phasic MDCT in the diagnosis of urothelial cancer.<br />
Eur Radiol 2003; 13:B7.<br />
9. Kemper J, Regier M, Begemann PG, Stork A, Adam G, Nolte-Ernsting C. Multislice computed tomography-urography: intraindividual<br />
comparison of different preparation techniques for optimized depiction of the upper urinary tract in an animal model. Invest Radiol<br />
2005; 40:126-33.<br />
10. Caoili EM, Inampudi P, Cohan RH, Ellis JH. Optimization of multi-detector row CT urography: effect of compression, saline<br />
administration, and prolongation of acquisition delay. Radiology 2005; 235:116-23.<br />
11. Kemper J, Nolte-Ernsting C, Regier M, Begemann PGC, Stork A, Adam G. Multislice-CT-Urography (MSCTU): dose reduction with<br />
regard to image quality. Eur Radiol 2004; 14:T2.<br />
12. Nawfel RD, Judy PF, Schleipman AR, Silverman SG. Patient radiation dose at CT urography and conventional urography. Radiology<br />
2004; 232:126-32.<br />
URINARY OBSTRUCTION – RADIATION AND ECONOMIC ASPECTS<br />
Fulvio Stacul<br />
Istituto di Radiologia, Ospedale di Cattinara, Trieste, Italy<br />
Unenhanced spiral CT (UHCT) is the new gold standard for imaging patients with renal colic, but radiation<br />
dose and costs are a significant problem.<br />
These two issues will be separately analysed.<br />
UHCT- Radiation dose<br />
The radiation issue is very significant in this clinical setting because we are often dealing with young patients<br />
at significant life time risk for recurrent renal colics, that is for additional CT procedures.<br />
It should be underscored that stone detection is the main goal of CT in these patients and this is a good<br />
opportunity for dose reduction because of the high contrast between stones and adjacent soft tissues.<br />
When using single-detector scanners (SDCT) the radiation dose delivered with CT was usually reduced<br />
increasing the pitch. The higher is the pitch, the lower is the corresponding dose (i.e. increasing the pitch<br />
from 1 to 1.5 corresponds to a dose reduction of 33%). The dose reduction is due to increased spacing,<br />
which provides on the other side a lower image quality on the reconstructed images (however slice thickness<br />
has a higher influence on the image quality).<br />
Using imaging parameters on multi-detector-scanners (MDCT) that are similar to those used with SDCT can<br />
result to greater dose exposures. It was reported (1) that studies using MDCT with thin collimations (ranging<br />
from 1 to 3 mm) but with mAs setting similar to those used with SDCT, lead to an effective radiation dose<br />
increased by a factor of 2-3, typically around 15 mSv (compared to a typical range of 4-7 mSv using SDCT).<br />
Nickoloff and Alderson (2) reported that the dose is 30-50% higher with MDCT because of scan overlap,<br />
because the tube is closer to the patient and because of more scattered radiations. The pitch can be<br />
increased, but unfortunately on some MDCT units the tube current (mAs) is automatically increased to<br />
maintain the same dose level if the pitch is increased. As a result the measured radiation dose is identical for<br />
different pitch selections (3).<br />
Therefore investigators using MDCT usually lowered the tube current (mAs) to lower the corresponding dose<br />
(although image noise increases).<br />
Many solutions were suggested to lower the radiation dose with MDCT, both with the goal of getting a dose<br />
efficient scanner design (highest geometric efficiency, lowest overbeaming, low-noise data acquisition<br />
system) and of an automatic dose control and display (automatic exposure control, dynamic dose<br />
modulation). However initial decreases of mAs presets by the physician is the primary tool for radiation dose<br />
reduction (it saves up to 90% of the dose) while attenuation based online tube current modulation is a<br />
secondary tool (it saves up to 20% of the dose) (1).<br />
The problem is to what extent we can reduce the dose keeping a high diagnostic accuracy. Hamm et al (4)<br />
delivered with SDCT a mean effective dose at 70 mAs of 0.98-1.5 mSv and obtained a sensitivity of 96% and<br />
a specificity of 97% considering stone detection. Tack et al (1) delivered with MDCT a mean effective dose at<br />
30 mAs of 1.2-1.9 mSv and reported an accuracy of 93-98%. Therefore we can achieve a major radiation<br />
dose reduction still keeping a high stone detection accuracy. Nevertheless there is concern regarding the<br />
alternative and additional diagnoses that could be missed if the dose is lowered too much (5).<br />
47
UHCT – Cost analysis<br />
We analysed the cost of UHCT considering the activities performed within the Radiology Department (6). Our<br />
cost identification analysis assessed the differential cost of this procedure, its common cost and its full cost.<br />
The differential cost included equipment costs (depreciation and maintenance), variable costs (materials and<br />
related services) and personnel costs (radiologist, radiographer). The common costs are all costs for<br />
productive factors, within the Radiology Department, providing support services common to all investigations.<br />
The full cost is the sum of the differential and the common cost. The differential cost of SDCT was 68.00 €<br />
(equipment costs 12.20 €, variable costs 37.70 €, personnel costs 18.10 €), the common cost was 6.00 € and<br />
the resulting full cost was 74.00€. As a comparison, the full costs of the plain film of the abdomen, of<br />
ultrasonography of the urinary tract and of intravenous urography were 15.61, 28.60 and 80.90 €<br />
respectively.<br />
It is interesting that the full cost of SDCT is heavily dependent on the variable costs and in particular on the<br />
cost deriving from the number of shots of the X-ray tube. We considered the full cost of a 16-slice MDCT as<br />
well, which was 71.65 €. The higher purchase cost (when compared to our SDCT) was counterbalanced by<br />
the longer forecasted life of the X-ray tube.<br />
The results we achieved are a photograph of our Department at one point in time and cannot be simply<br />
exported to other Radiology Departments, because of multiple variables (purchase cost, number of films,<br />
personnel salaries, organizational choices....). Therefore the methodology we used can be considered a tool<br />
for similar cost analyses in other environments.<br />
References<br />
1. Tack D, Sourtzis S, Delpierre I et al (2003) Low-dose unenhanced multidetector CT of patients with suspected renal colic. AJR 180:<br />
305-311.<br />
2. Nickoloff EL, Alderson PO (2001) Radiation exposure to patients from CT: reality, public perception and policy AJR 176: 285-287.<br />
3. Mahesh M, Scatarige JC, Cooper J et al (2001) Dose and pitch relationship for a particular multislice CT scanner AJR 177: 1273-1275.<br />
4. Hamm M, Knopfle E, Wartenberg S et al (2002) Low dose unenhanced helical computerized tomography for the evaluation of acute<br />
flank pain. J Urol 167: 1687-1691.<br />
5. Kats DS, Venkataramanan N, Napel S et al (2003) Can low-dose unenhanced multidetector CT be used for routine evaluation of<br />
suspected renal colic? AJR 180: 313-315.<br />
6. Grisi G, Stacul F, Cuttin R et al (2000) Cost analysis of different protocols for imaging a patient with acute flank pain. Eur Radiol 10:<br />
1620-1627<br />
INVESTIGATION OF MICROSCOPIC HEMATURIA: A NEPHROLOGISTS’S<br />
PERSPECTIVE<br />
Jürgen Floege MD<br />
Div. Nephrology, University of Aachen, Germany; juergen.floege@rwth-aachen.de<br />
Asymptomatic, isolated microscopic hematuria (AMH) is very common in the general population and, given<br />
its prevalence, represents a diagnostic dilemma since extensive work-up is not justified in the majority of<br />
patients. From a nephrological point of view the following issues will be presented:<br />
1. AMH detection by dipstick is as sensitive as urinary sediments to predict urogenital pathology;<br />
2. Every dipstick-positive proteinuria accompanying AMH needs to be evaluated further, since it usually<br />
indicates significant glomerular/renal pathology and usually does not result from „urologic“ bleeding;<br />
3. AMH needs to be evaluated further by phase-contrast microscopy and/or determination of mean urinary<br />
red cell volume (the relative value of these two methods is unknown);<br />
4. About 50% of patients with AMH that is not explained by urologic causes exhibit glomerular<br />
abnormalities (i.e. the prognosis of AMH in general is obviously good);<br />
5. AMH is not a good predictor of urogenital malignancy but the risk of renal failure is increased 2-fold in<br />
patients with AMH;<br />
6. 5-10 years after the first diagnosis of AMH a significant percentage of patients will develop hypertension,<br />
proteinuria and/or GFR-reduction. Annual follow-up should therefore be done routinely.<br />
48
URINARY BLEEDING:<br />
IMAGING FOR SUSPECTED BENIGN AND MALIGNANT DISEASES<br />
Elaine M. Caoili, MD and Richard H. Cohan, MD<br />
University of Michigan, USA<br />
Introduction<br />
Traditionally, excretory urography with or without ultrasonography has been utilized as the initial imaging<br />
approach to evaluate patients with hematuria. However, over the past few years, CT urography (CTU) has<br />
emerged as the best single imaging test for comprehensive evaluation of the urinary tract. While CT is<br />
acknowledged to be superior to excretory urography (EU) and ultrasound (US) in its ability to detect and<br />
characterize renal masses [1] and to detect urinary tract calculi [2], it is now known that CTU is also accurate<br />
when evaluating the renal collecting systems, ureters, and bladder, with a sensitivity in detecting<br />
abnormalities that rivals, if not exceeds that of EU and even retrograde pyelography [3-7]. MR urography<br />
(MRU) is also being performed with increasing frequency, but is often reserved for patients who are not able<br />
to receive iodinated contrast material, such as those who have had prior reactions or those who have<br />
compromised renal function.<br />
CT urographic technique<br />
While many different CTU protocols are being used, the overwhelming consensus now is that the renal<br />
collecting systems, ureters, and bladder are best assessed when a large number of thin (1.25 mm or less)<br />
section axial CT images are acquired during renal excretion of intravenously administered contrast material.<br />
Support for other protocols involving combinations of standard CT and conventional radiography or CT and<br />
CT digital scout images (in lieu of any excretory phase axial images) has waned. Many CTU protocols<br />
currently include an unenhanced series (usually performed as a standard “renal stone” CT). In addition,<br />
nephrographic phase images are obtained either during a subsequent series of image acquisitions obtained<br />
several minutes before the excretory phase images [7, 8] or combined with the excretory phase series (in<br />
which case the contrast material must be administered as a split bolus, with the first dose utilized to evaluate<br />
the renal collecting systems and ureters and a second delayed dose utilized to evaluate the renal<br />
parenchyma at the same time [9]). There have been wide variations in the timing of both nephrographic and<br />
excretory phase image acquisition, with differences in the latter times ranging between a few minutes and 15<br />
minutes.<br />
CTU studies contain large numbers of axial images (often more than 1,000), which can take time and effort<br />
to review. The number of images can be reduced by reconstructing the data into thicker section images to<br />
be reviewed by the radiologist at the time of study interpretation, but using thinner section reconstructed<br />
images as source images for multiplanar reformatted and three-dimensional images that are created. For<br />
example, at our institution, on 16-row scanners, excretory phase images are reconstructed at 1.25 mm<br />
thickness and 0.625 mm intervals for reformatting, but at 2.5 mm thickness and 1.25 mm intervals for image<br />
review.<br />
Some institutions also supplement axial excretory phase images with excretory phase digital scout<br />
radiographs [10]. The rationale for obtaining these images is that they offer the opportunity to visualize<br />
segments of the ureters that may not be opacified during axial image acquisition (although not in as much<br />
detail).<br />
Most institutions performing CTU create coronal reformatted images and/or three-dimensional (3D) images<br />
(which can be obtained using volume rendering, average intensity projection or maximum intensity projection<br />
algorithms) [5]. The three-dimensional images are usually created in the coronal anteroposterior and both<br />
coronal oblique planes. As such, they effectively demonstrate the urinary tract in planes similar to that<br />
demonstrated by EU. However, they usually provide little additional information to that of the source axial<br />
images. In fact, in one study, when only three-dimensional reconstructed images were reviewed, 18 of 24<br />
detectable upper tract uroepithelial neoplasms could not be identified [11].<br />
49
MR Urographic Technique<br />
MRU of dilated renal collecting systems and ureters can be performed using heavily T2-weighted sequences,<br />
which allows for visualization of dilated, usually obstructed, collecting systems. In comparison, non-dilated<br />
renal collecting systems and ureters are best assessed by administering a gadolinium-based MR contrast<br />
agent and then obtaining T1-weighted images. Even then, it is helpful to administer low-dose furosemide<br />
(often 10 mg) to increase diuresis and improve visualization of the urinary tract [12, 13].<br />
CTU Image review<br />
CTU images must be reviewed utilizing wide windowing. Indeed, many small lesions will be missed if images<br />
are reviewed only at standard soft tissue windows [14]. Small urothelial masses and filling defects can be<br />
obscured by the dense, high attenuation, contrast material in the renal collecting systems and ureters when<br />
soft tissue windowing is employed utilized.<br />
Preliminary results using CT and MR urography<br />
Results with CTU and MRU are encouraging. A variety of collecting system and ureteral abnormalities have<br />
been detected (examples of which will be presented in these talks) [7].<br />
Detection of benign abnormalities (R. Cohan)<br />
Of the first 1,077 CT urograms performed at our institution, many diagnoses of benign upper tract<br />
abnormalities, once thought to be undetectable on CT and MR, have been made. Excluding urolithiasis,<br />
these have included 35 congenital abnormalities, such as horseshoe kidneys, 18 caliceal diverticula, 11<br />
patients with papillary necrosis, eight patients with renal tubular ectasia, and one patient with pyelo-ureteritis<br />
cystica. These abnormalities can are usually best detected on axial and reformatted images reviewed<br />
utilizing wide windows. In addition, a new benign ureteral abnormality has been described: diffuse urothelial<br />
wall thickening. This entity, which can be caused by pyelitits or ureteritis, is easily detected on axial CT or<br />
MR images, but not well seen on 3D reconstructed images or on conventional excretory urography, because<br />
it may not produce any intraluminal abnormality. To date, such benign circumferential urothelial wall<br />
thickening has been detected on CTU and MRU in patients who have had prior instrumentation (including<br />
insertion of still indwelling ureteral stents), and in patients with infectious ureteritis, retroperitoneal fibrosis,<br />
and amyloidosis. It is important to note that this appearance can also be produced by urothelial malignancy.<br />
The most common CTU or MRU detected benign bladder abnormality (producing hematuria) has been<br />
urothelial wall thickening, usually resulting from inflammation (cystitis) or outlet obstruction. Such thickening<br />
is usually mild and fairly uniform.<br />
Detection of malignancies (E. Caoili)<br />
The greatest benefit of CT and MR urography has been in its detection of urothelial neoplasms [i.e. - 15]. In<br />
one series, 24 of the first 27 subsequently diagnosed upper tract uroepithelial neoplasms were detected on<br />
CTU, several of which were quite small (measuring only a few mm in size) [11]. This includes a few patients<br />
whose cancers presented as diffuse circumferential ureteral wall thickening in the absence of ureteral<br />
dilatation, ureteral stricture, or filling defects [5, 11]. This newly recognized CT or MR manifestation would<br />
likely not produce any abnormality on EU, since the latter only demonstrates excreted contrast material in the<br />
renal collecting system and ureteral lumen. This finding is not specific for urothelial cancer. It has also been<br />
seen with benign entities as well as other malignancies, such as lymphoma.<br />
CTU and MRU are also very accurate in detecting bladder neoplasms. Of the first 44 bladder neoplasms in<br />
patients referred for CTU, 37 were prospectively identified, and only two were found to be retrospectively<br />
undetectable. While the ability of CTU or MRU to identify bladder pathology is not as important as its ability<br />
to evaluate the upper tracts, given the widespread use of cystoscopy, it may be possible to use CTU in some<br />
instances as a screening tool, helping to determine which patients at high risk for developing bladder<br />
neoplasms should undergo cystoscopy.<br />
Technical Limitations<br />
No matter what specific technique is employed, the most common CTU and MRU interpretive problem<br />
relates to non opacification of ureteral segments, a problem which can be observed in up to 25-33% of<br />
patients with non-dilated non-obstructed urinary tracts [16]. When the non opacification is due to delayed<br />
excretion resulting from urinary tract obstruction, the cause of the obstruction, whether it be a calculus,<br />
50
tumor, or stricture, is usually readily identified. In contrast, when there is non opacification of a portion of a<br />
non-dilated ureter, a small non-obstructing lesion could be missed in the non-opacified segment. One<br />
solution to this problem is to obtain repeat scans through the unopacified regions until opacification occurs.<br />
Another is to supplement the axial images with digital scout radiographs [10]. Yet a third is to obtain no<br />
additional imaging, but, instead, to assume that such segments do not harbor any pathology, with the<br />
understanding that in very rare instances a tiny non obstructing lesion will not be identified.<br />
Other considerations<br />
CTU and MRU are now being requested more frequently by clinicians. For example, at our institution, the<br />
number of requested CTUs each day now exceeds the number of requested EUs.<br />
CTUs and MRUs contain hundreds of axial images and are more time-consuming to interpret than are EUs.<br />
The most obvious solution to this potential problem is to devise a way in which a smaller number of images<br />
can be reviewed with the same accuracy as occurs with axial image review. As previously mentioned,<br />
standard 3D reconstruction techniques have already been found to be inadequate [11]. More recently,<br />
thinner section 3D reconstructions have also been found to be insensitive in identifying uroepithelial<br />
neoplasms [17]. Another approach must be considered. Recently, we assessed the utility of coronal<br />
reformatted images (obtained using the same image thickness and reconstruction intervals as the axial<br />
images). Since each image covers a much larger part of the renal collecting systems and ureters than does<br />
an axial image, the number of excretory phase images that must be reviewed can be reduced dramatically,<br />
from 500-700 to 80-120 [17]. Not surprisingly, the time required for coronal reformat image review is less<br />
than that needed for axial image review [14].<br />
Another important problem unique to CTU (compared with MRU) is increased patient radiation exposure.<br />
Utilizing a three-phase CTU protocol, CTU radiation dose has been observed to exceed that of a 10-15 film<br />
EU by a factor of 50% [8]. When the split-bolus technique is employed radiation exposure from the two<br />
studies is nearly the same. To minimize radiation dose to the most radiation susceptible patients, some have<br />
suggested that use of CTU be restricted to older patients (> 40 years of age) who are at high risk for urinary<br />
tract pathology, particularly malignancy [5]. Others have suggested that CTU should be used for all patients,<br />
regardless of age [i.e. - 4]. Most investigators agree, however, that further attempts must be made to reduce<br />
patient radiation exposure (by utilizing low mA technique on noncontrast scans, for example).<br />
Summary<br />
CTU and MRU have now begun to replace EU as the optimal study for evaluation of the kidneys, renal<br />
collecting systems, ureters, and bladder in patients with hematuria. CTU can demonstrate tiny benign and<br />
malignant abnormalities once thought to be undetectable by CT. Although there are a number of variations in<br />
technique across the country, these are diminishing. No matter what technique is employed, the greatest<br />
interpretive problem is the occasional lack of opacification of non-dilated ureteral segments. Other issues that<br />
also must be addressed are the increased number of generated images and the increased time required for<br />
study interpretation. Efforts to reduce the number of images that must be reviewed are underway. Attempts<br />
to reduce patient radiation exposure must also continue. Despite these concerns, the great success already<br />
achieved by CTU and (to a lesser extent) MRU will serve to facilitate the demise of the EU in the very near<br />
future.<br />
References<br />
1. Jamis-Dow CA, Choyke PL, Jennings SB, et al. Small (< 3-cm) renal masses: detection with CT versus US and pathologic correlation.<br />
Radiology, 1996;198:785-788.<br />
2. Smith RC, Verga M, McCarthy S, Rosenfield AT. Diagnosis of acute flank pain: value of unenhanced CT. AJR 1996;166:97-101.<br />
3. McCarthy CL, Cowan NC. Multidetector CT urography (MD-CTU) for urothelial imaging. Radiology 2002; 225(P):237.<br />
4. Lang EK, Macchia RJ, Thomas R, et al. Computerized tomography tailored for the assessment of microscopic hematuria. J Urol<br />
2002;167:547-554.<br />
5. Caoili EM, Cohan RH, Korobkin M, Platt JF, Francis IR, Faerber GJ, Montie JE, Ellis JH. Urinary tract abnormalities: initial experience<br />
with multi-detector row CT urography. Radiology 2002;222:353-360.<br />
6. O’Malley ME, Hahn PF, Yoder IC, Gazelle GS, McGovern FJ, Mueller PR. Comparison of excretory phase, helical computed<br />
tomography with intravenous urography in patients with painless hematuria. Clin Radiol 2003;58:294-300.<br />
7. Noroozian M, Cohan RH, Caoili EM. Cowan NC, Ellis JH. Multislice CT urography: state of the art. Br J Radiol, 2004; 77:S84-S86.<br />
8. Nawful RD, Judy PF, Schleipman AR, Silverman SG. Patient radiation dose at CT urography and conventional urography. Radiology<br />
2004; 232:126-132.<br />
51
9. Chow LC, Sommer FG. Multidetector CT urography with abdominal compression and three-dimensional reconstruction. AJR 2001;<br />
177:849-855.<br />
10. Sudakoff GS, Guralnick M, Langenstroer P, et al. AJR 2005; 184:131-138.<br />
11. Caoili EM, Inampudi P, Cohan RH, Ellis JH, Korobkin M, Platt JF, Francis IR. MDCTU of upper tract uroepithelial malignancy. In<br />
press, AJR, 2005.<br />
12. Kawashima A. Glockner JF, King, BF. CT urography and MR urography. Radiol Clin North Am. 2003; 41:945-61.<br />
13. Nolte-Ernsting CC, Staatz G, Tacke J, Gunther RW. MR urography today. Abdom Imaging. 2003; 28:191-209.<br />
14. Hilmes MA, Caoili EM, Cohan RH, Ellis JH, Nan B, Platt JF. Evaluation of the ability of individual phases of multi-detector CT<br />
urography and different windowing to detect urinary tract pathology. Presented at the 29 th annual scientific meeting of the Society of<br />
Uroradiology, March 6, 2004.<br />
15. Mueller-Lisse UG, Mueller-Lisse UL, Hinterberger J, Schneede P, Reiser MF. Tri-phasic MDCT in the diagnosis of urothelial cancer.<br />
Eur Radiol 2003;13(S1):146-147.<br />
16. Inampudi P, Caoili EM, Cohan RH, Ellis JH, Korobkin M, Platt JF, Francis IR. Effect of compression, saline administration, and<br />
prolonging acquisition delay on images obtained during multidetector CT urography (MDCTU). AJR 2003;180(S):71.<br />
17. Feng FY, Caoili EM, Cohan RH, et al. Coronal vs standard axial image review CT urography. Presented at the 30 th annual scientific<br />
meeting of the Society of Uroradiology, February 27, 2005.<br />
IMAGING THE PATIENT WITH HEMOSPERMIA<br />
Parvati Ramchandani, MD<br />
University of Pennsylvania, Medical Center<br />
Blood in the ejaculate<br />
Hematospermia or Hemospermia<br />
Objectives<br />
• review normal anatomy of the ejaculatory tract<br />
• review the imaging findings of pathologies that cause hematospermia<br />
• discuss management strategies<br />
Hematospermia<br />
• Peak incidence in 30-40 yr olds<br />
• >80% have repeated episodes<br />
• Brownish or red discoloration of ejaculate<br />
Semen production<br />
(and therefore blood in ejaculate)<br />
• From multiple sources<br />
- testes, epidydimis, vas deferens,<br />
- seminal vesicles and prostate<br />
• Majority of semen is from seminal vesicles and prostate<br />
Ejaculatory Tract Anatomy<br />
T2 W Coronal MR<br />
52
Ejaculatory Tract Imaging<br />
• Vasoseminal vesiculography<br />
• TRUS<br />
• MRI - modality of choice<br />
Vasoseminal Vesiculography “Vasogram”<br />
• Best study to demonstrate lumen of vas deferens<br />
• No role in hematospermia evaluation<br />
• Performed only in infertile men with suspected obstruction of vas deferens<br />
Normal VD<br />
Occluded bilat - post hernia repair<br />
TRUS<br />
• 5-7.5 MHZ transducers<br />
• SV are symmetrically hypoechoic, less echogenic than prostate<br />
• Non dilated vas deferens and ejaculatory ducts are not consistently demonstrated<br />
MRI of Ejaculatory Tract<br />
- Endorectal coil (E-coil) MRI provides best anatomic resolution<br />
MRI of Seminal Vesicle<br />
T1W- intermediate SI<br />
T2W- bright convoluted tube<br />
MRI of Seminal Vesicle<br />
T2W- bright convoluted tube superior to prostate<br />
blood low SI, depending on age<br />
MRI of Vas Deferens<br />
Ampulla of vas is dark on T2W images due to thick muscular wall<br />
53
Seminal Vesicle Pathology<br />
Congenital – agenesis, cysts<br />
Inflammatory, including calculi<br />
Neoplasms<br />
Congenital Seminal Vesicle Pathology<br />
• Frequent association with urinary tract anomalies<br />
because seminal vesicles, vas deferens and ureter are all derived from mesonephric (Wolfian) duct<br />
Seminal Vesicle Cysts and Agenesis<br />
• Association Ipsilateral renal anomalies very common agenesis, hypoplasia, ectopic ureteral insertion<br />
• Association with autosomal dominant polycystic kidney disease<br />
Seminal Vesicle Cysts<br />
• Association with autosomal dominant polycystic kidney disease<br />
• Present in young adulthood<br />
• Cysts contain viscous brownish fluid with dead sperm UNILOCULAR<br />
Cystic Lesions in Male Pelvis<br />
• SV cyst<br />
• Vas deferens cyst<br />
• Mullerian duct cyst<br />
• Prostatic utricle cyst<br />
• Ejaculatory duct cyst<br />
• Prostatic cysts<br />
Radiographics; 1990<br />
Stones and Inflammatory Disease<br />
Inflammatory Diseases<br />
• Seminal vesiculitis usually associated with prostatitis<br />
• May present with hematospermia<br />
• Clinically obvious<br />
• Can progress to abscess<br />
• Predisposing factors- Instrumentation, diabetes, UTI<br />
Hematospermia and Neoplasms<br />
• Seminal vesicle<br />
- usually secondary involvement by prostate, rectal, or bladder cancer<br />
- primary tumors are are<br />
• Prostate Ca can present with hematospermia<br />
Metastatic Disease of SV<br />
• E- coil MR<br />
• T2W images<br />
• Bright intensity of normal tubules replaced by low Intensity foci and tubular thickening<br />
54
Hematospermia<br />
Men < 40 years<br />
• usually due to inflammation in prostate, SV, epidydimis, or testicle<br />
• SV cysts or calculi<br />
• Rarely malignant or benign tumors e.g. urethral hemangioma<br />
Hematospermia<br />
• Men > 40 years<br />
• Benign causes predominate<br />
• 5-10% may be due to CA prostate, bladder or SV<br />
Hematospermia<br />
Work up if<br />
• Persistent<br />
• Associated with pain or hematuria<br />
• E-coil MR is imaging modality of choice<br />
Conclusion<br />
• Imaging is useful in evaluating patients with hematospermia and suspected ejaculatory tract abnormality<br />
• Both TRUS and MRI play a role in the management of these patients<br />
References:<br />
1. Schiff JD. Hematospermia. www.emedicine.com/med/topic3466.htm, 11.7.02<br />
2. Nghiem HT, Kellman GM, Sandberg SA, Craig, BM. Cystic lesions of the prostate. Radiographics 1990; 10: 635-650<br />
3. Weidner W, Schumacher JF, Schiefer HG, Meyhofer W. Recurrent haemospermia—underlying urogenital anomalies and efficacy of<br />
imaging procedures. British J of Urology 1991; 67: 317-323<br />
4. Alpern MB, Dorfman RE, Gross BH, Gottlieb CA, Sandler MA. Seminal vesicle cysts: association with adult polycystic kidney disease.<br />
Rdiology 1991; 180: 79-80<br />
5. Ramchandani P, Torigian D. Evaluating the male with hematospermia. Abdominal Imaging (In Press)<br />
6. Ganabathi K, Chadwick D, Feneley RCL, Gingell JC. Haemospermia. British J of Urology 1992; 69: 225-230<br />
7. Maeda H, Toyooka N, Kinukawa T, et al. Magnetic resonance imaging of hematospermia. Urology 1993; 41: 499-504<br />
8. Worischeck JH, Pasrra RO. Chronic hematospermia: assessment by transrectal ultrasound. Urology 1994; 43: 515-520<br />
9. Ramchandani P, Banner MP, Pollack HM: Imaging of Seminal Vesicles. Seminars in Roentgenology 1993; 28: 83-91.<br />
ARTERIAL EMBOLIZATION IN EMERGENCY URORADIOLOGY<br />
Tarek A. El-Diasty, MD<br />
Department of Radiology, Urology and Nephrology Center, Mansoura University<br />
Mansoura – Egypt<br />
Several traumatic and neoplastic causes may lead to significant renal hemorrhage and sever hematuria.<br />
Transcatheter selective arterial embolization is an effective parenchymal sparing procedure in management<br />
of life threatening renal hemorrhage.<br />
Traumatic injury to the renal vasculature is a well recognized and most worrisome complication of<br />
percutaneous renal procedures such as renal biopsy, percutaneous nephrostomy (PCN) and percutaneous<br />
nephrolitomy (1) . The most common causes of hemorrhage post percutaneous renal procedures are<br />
pseudoaneurysms and areterio-venous fistulas (2) . Percutaneous intra-arterial embolization is the treatment of<br />
choice, which not only is life saving but ultimately a kidney sparing procedure. Embolization of the peripheral<br />
vessels is preferable to frank exploration, even in a transplanted kidney (3,4) .<br />
Treatment of angiomyolipomas beneficial is in limiting the sometimes life-threatening complications of<br />
spontaneous bleeding (5) .<br />
55
Therapeutic embolization of the bladder may be an effective method of controlling persistent hematuria<br />
caused by radiation cystitis, chemical cystitis, or direct tumour invasion of the bladder in patients who are<br />
unresponsive to intravesical instillation of therapeutic agents or surgery (6,7) . Selective embolization of the<br />
anterior division of the hypogastric artery is required bilaterally, even if the bleeding can be predominantly<br />
localized to one wall of the bladder (8) .<br />
High flow arteriogenic priapism is uncommon and usually occurs after trauma to the genitoperineal area.<br />
Angiography in this case illustrated the causative arteriovenous fistulae or pseudoaneurysms. Treatment<br />
consists of superselective embolization of the feeding artery resulting in detumescene (9) .<br />
In this lecture, the techniques, types of embolic material and results of selective embolization in different<br />
urologic emergencies will be addressed.<br />
References<br />
1. Rao A, Pandey UC. Transarterial embolization of iatrogenic renal vascular injury. Ind J Radiol Imag 2004; 14, 3: 303-307.<br />
2. Kessaris D, Bellman G, Pardalidis N, Smith A. Management of hemorrhage after percutaneous renal surgery. J Urol 1995; 153: 604-<br />
608.<br />
3. Patterson D, Segura J, Leroy A, Benson R, May G. The etiology and treatment of delayed bleeding following percutaneous lithotripsy.<br />
J Urol 1989; 133: 447-451.<br />
4. Orans P, Zajko A. Angiography and interventional aspects of renal transplantation. Radiol Clin North Am 1995; 33: 461-471.<br />
5. Hamlin JA. Renal angiomyolipomas: long-term follow-up of embolization for acute hemorrhage. Can Ass Rad J 1997; 48: 191-198.<br />
6. Lang EK. Transcatheter embolization of pelvic vessels for control of intractable hemorrhage. Radiology 1981; 140: 331-339.<br />
7. Mcivor J, Williams G, Greswick Southcott R. Control of sever vesicle hemorrhage by therapeutic embolization. Clin Radiol 1982; 33:<br />
561-567.<br />
8. Ward JF, velin TE. Transcatheter therapeutic embolization of genitourinary pathology. Rev Urol 2000; 2 (4): 236-245.<br />
9. Gujral S, Mac Donagh RP, Cavanagh PM. Bilateral superselective arterial microcoil embolization in delayed post-traumatic high flow<br />
priapism postgrad. Med J 2001; 77: 193-194.<br />
UROGENITAL EMERGENCIES IN FEMALE PATIENTS:<br />
THE OBSTETRICIAN’S PERSPECTIVE<br />
Tanja Premru-Srsen,<br />
tanja.premru@guest.arnes.si<br />
University Department of Obstertics and Gynecology<br />
University Medical Centre, Ljubljana, Slovenia<br />
Postpartum hemorrhage remains a major cause of maternal morbidity and mortality throughout the world (1).<br />
In a review of maternal mortality statistics from 1980-1985, the Maternal Mortality Collaborative reported 11<br />
% of all deaths (from both direct and indirect causes) being caused by hemorrhage (2). In a Center for<br />
Disease Control (CDC) citation from late 1970s, hemorrhage was a direct cause of death in 13.4 % of cases<br />
(3). Other authors report this number may be as high as 28 % (4.5). What remains a concern is that despite<br />
increasing technologic advances in the hospital setting, progress in identification of at risk patients remains<br />
limited. In a report published in 1996 in London by the Confidential Enquiry into Maternal Deaths, 90 % of<br />
maternal mortality as a result of intractable hemorrhage was deemed to have been preventable.<br />
The definition of obstetric hemorrhage varies. Overall, excessive blood loss is considered to be greater than<br />
500 ml by completion of the third stage of a vaginal delivery or 1000 ml after cesarean section (6). However,<br />
most practitioners usually significantly underestimate blood loss and these criteria do not include significant<br />
antepartum bleeding. A better definition may be obstetric bleeding which places the patient at risk for<br />
hemodynamic instability (7). Severe obstetric hemorrhage is defined as estimated blood loss greater than<br />
1500 ml, peripartum fall in hemoglobin concentration > 40 g/l or acute transfusion of > 4 U of blood (8).<br />
Treatment is aimed at eradicating the source of bleeding while attempting to maintain intravascular volume to<br />
preserve perfusion and oxygenation (9).<br />
In the developed world, efforts to reduce maternal morbidity and mortality caused by obstetric hemorrhage<br />
need to focus on identification of at risk patients and establishing management protocols. In addition,<br />
extensive preoperative planning often needs to be implemented in caring for the most at risk patients,<br />
56
enabling the optimal use of technologic advances such as magnetic resonance imaging (MRI) in diagnosis of<br />
placenta accreta and of pelvic vessel embolization to control significant bleeding.<br />
Postpartum hemorrhage is a frequent condition, whose incidence in the literature varies between 7 and 24 %<br />
(1.10). Potential causes of hemorrhage include abnormal placentation, placental abruption, uterine rupture,<br />
uterine atony, retained placenta, lower gential tract injuries, uterine inversion, and coagulopathies, uterine<br />
atony and abnormal placentation/adherence being the major causes of primary postpartum hemorrhage. In<br />
most cases, primary postpartum hemorrhage can be managed with conservative treatment involving<br />
bimanual compression, uterine or vaginal packing and administration of uterotonic drugs (3,11). In case of<br />
persistent bleeding, vascular ligation or hysterectomy may be required with risk of surgical complications,<br />
including infection, bleeding and ureteral injury, and complications of general anaesthesia.<br />
The development of interventional radiology has offered a new approach for the management of persistent<br />
postpartum hemorrhage. In 1979, the first transcatheter embolization was performed in a patient with<br />
postpartum hemorrhage after hysterectomy and vascular ligation (12, 13). Since then, many publications<br />
have shown the usefulness of this procedure, whose success rate is around 90 % (14 -16). The incidence of<br />
failure is approximately 5 % (17), of which abnormal placentation corresponds to more than 50 % (18-20).<br />
The success rate of uterine artery embolization for management of abnormal placentation with postpartum<br />
hemorrhage was reported to be 62 – 71 % in the literature (18, 19).<br />
In some cases as in placenta previa/accreta abnormal adherence could be diagnosed antepartum by gray<br />
scale ultrasound, color Doppler and MRI (3). Postpartum hemorrhage in such cases could be prevented by<br />
multidisciplinary approach including also the interventional radiologist for possible preoperative arterial<br />
embolization catheter placement. Ballon catheters can first be used to generally tamponade the area, and if<br />
necessary can then be used to specifically embolize the vessel noted to have extravasation of blood (21).<br />
Treatment of placenta accreta conservatively by prophylactic bilateral uterine artery embolistaion and leaving<br />
in place the placenta that is partially or totally adhered to the myometrium has been reported successful in<br />
reducing the rate of hysterectomy in such cases (18, 22).<br />
Complications from uterine artery embolisation have likewise become more apparent as case reports have<br />
been published and as resultes from larger case series have become available. Reported complications<br />
mostly from uterine artery embolization of uterine fibroids include infection, absceses, sepsis, permanent<br />
amenorrhea, labial necrosis, focal bladder necrosis, vesicouterine fistula, uterine wall defects, groin<br />
hematoma, pulmonary emboli, and, rarely death (23). Overall complication rate reported was 5 % (24). The<br />
loss of ovarian function has been reported to be as high as 14 % with uterine artrey embolization (25).<br />
Approximately 50 cases of pregnancy have been reported in patients who have undergone elective uterine<br />
artery embolisation. Analysis of these 50 cases shows a 22 % rate of spontaneous abortion, a 17 % rate of<br />
malpresentation, a 7 % rate of small for gestational age infants, a 28 % rate of premature delivery, a 58 % of<br />
cesarean delivery rate, and a 13 % rate of postpartum hemorrhage (26). Reported rates in the general<br />
population for these events are lower except for small for gestational age infants which is higher (6, 27).<br />
Embolization of uterine arteries, used for more than 25 years to control persistent postpartum hemorrhage,<br />
has found an important role in the therapeutic arsenal of modern obstetrics. It should be used as soon as the<br />
obstetrician judges the primary measures used for management of postpartum hemorrhage to be ineffective.<br />
It could be used in all cases before surgery, because it does not preclude later surgery. It does not require<br />
general anaesthesia, is not disturbed by coagulation disorders, and is reproducible. Its main advantage is to<br />
preserve fertility. This technique requires the presence of an on-call radiologist familiar with interventional<br />
radiology techniques. The possibility of offering this technique to all women after delivery could become one<br />
of the challenges for the treatment of severe postpartum hemorrhage. This requires women at risk for<br />
postpartum hemorrhage to be sent to the centers with possibility of interventional radiology.<br />
Literature<br />
1. Gibert L, Porter W, Brown VA. Postpartum hemorrhage: a continuing problem. Br J Obstet Gynaecol 1987; 94:67-71.<br />
2. Rochat RW, Koonin LM, Atrash HK, et al. Maternal mortality in the United States: report from the Maternal Mortalita Collaborative.<br />
Obstet Gynecol 1988;72:91-97.<br />
3. Shevell T, Malone FD. Management of obstetric hemorrhage. Seminars Perinatol 2003; 27:86-104.<br />
57
4. Bonnar J. Massive obstetric hemorrhage. Bailliere’s Clin Obstet Gynaecol 2000; 14:1-18.<br />
5. Coueret Pellicier M, Bouvier Colle MH, Salavane Bet le groupe MOMS. Les causes obstétricales de décès expliquent-elles les<br />
differences de mortalité maternelle entre la France et l’Europe? J Gynecol Obstet Biol Reprod 1999;28:62-8.<br />
6. American College of Obtetricians and Gynecologists. Postpartum hemorrhage. ACOG educational bulletin number 234. Washington:<br />
American College of Obtetricians and Gynecologists, January 1998.<br />
7. Mason B. Postpartum hemorrhage and arterial embolisation. Curr Opin Obstet Gynecol 1998;10:475-9.<br />
8. Waterstone M, Bewley S, Wolfe C. Incidence and predictors of severe obstetric morbidity: case-control study. BMJ 2001;322:1089-94.<br />
9. Hunter SK, Weiner CP. Obstetric hemorrhage. In Repke JT, eds: Intrapartum obstetrics. Boston: Churchill Livingstone Inc., 1996;pp<br />
203-22.<br />
10. Newton M, Mosey LM, Egli GE, Gifford WB, Hull CT. Blood loss during and immediately after delivery. Obstet Gynecol 1961; 17:9-18.<br />
11. Hebert WP, Afalo RC. Management of pos-tpartum hemorrhage. Clin Obstet Gynecol 1984:27:139-45.<br />
12. Brown BJ, Heaston DK, Poulson AM, Gabert HA, Mineau DE, Miller FJ. Uncontrollable postpartum bleeding: a new approach to<br />
hemostasis through angiographic arterial embolization. Obstet Gynecol 1979; 54:361-5.<br />
13. Heaston DK, Mineau DE, Brown BJ, Miller FJ. Transcatheter arterial embolization for controle of persistent puerperal hemorrhage after<br />
bilateral surgical hypogastric artery ligation. AJR Am J Roentgenol 1979; 133:152-4.<br />
14. Tourné G, Collet F, Seffert P, Veyret C. Place of embolization of uterine arteries in the management of post-partum hemorrhage: a<br />
study of 12 cases. Eur J Obstet Gynaecol Reprod Biol 2002; 110:29-34.<br />
15. Jander HP, Russinovich NAE. Transcatheter Gelfoam embolization in abdominal. Radiology 1980:136:337-44.<br />
16. Sergent F, Resch B, Verspyck E, Rachet B, Clavier E, Marpeau L. Intractable postpartum hemorrhages: where is the palce of vascular<br />
ligatons, emergency peripartum hysterectomy or arterial embolization? Gynecol Obstet Fertil 2003; 32:320-9.<br />
17. Badawy SZA, Etman A, Singh M, Murphy K, Mayelli T, Philadelphia M. Uterine artery embolization: the role in obstetrics and<br />
gynecology. J Clin Imag 2001; 25:288-95.<br />
18. Descargues G, Douvrin F, Degre S, Lemoine JP, Marpeau L, Clavier E. Abnormal placentation and selective embolization of the<br />
uterine arteries. Eor J Obstet Gynecol Reprod Biol 2001;99:47-52.<br />
19. Pelage JP, Le Dref O, Mateo J, Soyer P, Jacob D et al. Life threatening primary postpartum hemorrhage: treatment with emergency<br />
selective arterial embolization. Radiology 1998;208:359-62.<br />
20. Pelage JP, Le Dref O, Jacob D, Soyer P, Herbreteau D et al. Selective arterial embolization of the terine arteries in the management<br />
of intractable post-partum hemorrhage. Acta Obstet Gynecol Scand 1999; 78:698-703.<br />
21. Hansch E, Chitkara U, McAlpine J et al. Pelvic arterial embolization for controle of obstetric hemorrhage: a five years experience. Am J<br />
Obstet Gynecol 1999; 180:1454-60.<br />
22. Kayem G, Pannier E, Goffinet F, Grangé G, Cabrol D. Fertility after conservative treatment of placenta accreta. Fertil Steril 2002;<br />
78:637-8.<br />
23. American College of Obtetricians and Gynecologists. Uterine artery embolization. ACOG educational bulletin number 293.<br />
Washington: American College of Obtetricians and Gynecologists, February 2004.<br />
24. Spies JB, Spector A, Roth AR, Baker CM, Mauro L, Murphy-Skrynarz K. Complications after uterine artery embolization of<br />
leiomyomas. Obstet Gynecol 2002:100:873-80.<br />
25. Chrisman HB, Saker MB, Ryu RK, Nemcek AA Jr, Gerbie MV, Milad MP et al. The impact of uterine fibroid embolization on<br />
resumption of menses and ovarian function. J Vasc Interv Radiol 2000; 11:699-703.<br />
26. Goldberg J, Pereira L, Berghella V. Pregnancy after uterine artery embolization. Obstet Gynecol 2002; 100:869-72.<br />
27. Gabbe SG, Niebyl JR, Simpson JL, eds. Obstetrics – normal and problem pregnancies. 4 th ed. New York: Churchill Livingstone Inc.,<br />
2002.<br />
UROGENITAL EMERGENCIES IN FEMALE PATIENT:<br />
GYNAECOLOGIC ASPECT<br />
Adolf Lukanovic<br />
Department of Gynecology and Obstetrics,<br />
University Medical Centre, Ljubljana, Slovenia<br />
Key words: urogenital radiology, imaging in urogynecology, modern perspective<br />
Abstract<br />
Background: The aim of this paper is to present the modern approach to different pathologies in everyday<br />
clinical practice of any gynecologist. Special interest is given to the diagnostic pitfalls. Radiology imaging<br />
techniques are beccomming of key importance for exact diagnostic protocol in all modern settings. They<br />
serve as the basis for good therapeutic outcomes.<br />
Conclusion: Undoubtless the future development in the diagnostic armamentarium of urogynecology imaging<br />
will bring new possibilities for treatments. By keeping in mind these principles outlined in the article the care<br />
provider will be able to achieve the desired result of the treatment while minimizing intra and postoperative<br />
complications.<br />
58
Introduction<br />
There is a variety of several possibilities to use all kinds of imaging techniques in the field of urogynecology.<br />
The radiologists have now more and more modalities from which to choose a rational approach to image the<br />
female genital organs and the neighbouring organs of the pelvic floor. However as new diagnostic<br />
possibilities arise, even they are new and sophisticated it does not mean one should ignore an older »low<br />
tech« procedure. But the advantages are not only in better diagnosing; new »hig tech« radiologic procedures<br />
are saving lives. This point is perhaps best understood by the enthusiasm of the participants in the recent<br />
radiological meetings worldwide. Obviously, personal experience, financial considerations and available<br />
equipment will influence what modality is used for the various pathologic conditions we meet in the field of<br />
urogynecology. However some broad guidelines may be of use. It is now clear that pelvic floor abnormalities,<br />
including all genitourinary pathologies, not only malignancies are best studied using sonography and<br />
magnetic resonance imaging. Consequently the radiologists must now learn or reacquaint themselves with<br />
the relevant anatomy and physiology in this expanding discipline.<br />
Imaging of benign uterine pathology<br />
Benign uterine lesions include malformations, pyometra, haematometra, lymphangiomas, vascular<br />
abnormalities, adenomyosis, adenomyomas, polyps, leiomyomas. Most of these pathologies might give<br />
similar symptoms such as pain and bleeding disturbances, symptoms that makes the woman to visit a<br />
gynecologist. He has to make a correct diagnose even some of these maladies cannot easily be<br />
discriminated between. Most gynecologists are prone to use transvaginal ultrasound as a routine<br />
examination. Doppler technology discriminates lesions with specific patterns of blood circulation from others<br />
with quite good accuracy. By combining vaginal ultrasound technique, hysteroscopy and laparoscopy most<br />
uterine lesions can be correctly diagnosed. There are, however, some cases left over where there are<br />
problems to decide the type and size of the lesion, whether it show invasive growth, what organs that may be<br />
involved etc. Magnetic resonance imaging is believed to have superior sensitivity and specificity for the<br />
diagnosis of uterine pathology compared with computed tomography and is therefore commonly used<br />
preoperatively to come as close as possible to a correct diagnose (1).<br />
Leiomyomas<br />
They occur in up to 70% of women in reproductive age and are the most frequent indication for hysterectomy<br />
in pre-menopausal women worldwide. In the last year in Slovenia, 650 hysterectomies were performed, 240<br />
out of them per laparatomiam. 33% were done because of uterine fibromas. A recently described treatment<br />
is uterine artery embolization. Ravina in 1995 published results from a pre-operative embolisation<br />
programme originally aimed at reducing haemorrhage during hysterectomy and myomectomy.(2) It has<br />
emerged as an effective minimal-invasive treatment alternative for women with symptomatic leiomyomata of<br />
the uterus with promising short and midterm results. It is known that approximately one third of women with<br />
uterine leiomyomas have symptoms that may eventually require medical or surgical intervention. As so, it<br />
may become the initial treatment of choice for symptomatic uterine fibroids that cause menorrhagia, (severe<br />
menstrual pain) dysmenorrhoea, dyspareunia, abdominal distention, pressure effects on adjacent structures<br />
and urinary frequency, infertility and pregnancy loss. If patient demand for uterine artery embolization<br />
increases and the procedure becomes more commonly performed, changes in work flow and reallocation of<br />
resources will be required in order to meet the demand (3). The great advantage of this treatment is that in<br />
the future it may be recommended unequivocally for those women desiring maintenance of fertility and future<br />
pregnancies. It is also likely there will be substantial cost savings with the increased use of uterine artery<br />
embolisation instead of surgery. It is well tolerated and has a shorter recovery time compared with surgical<br />
alternatives in most patients.<br />
At the Department of Radiology University Medical Center in Ljubljana, since the year 2004 we have done 27<br />
uterine embolisation procedures. 16 of them were performed due to uterine fibroids. Three times we have<br />
done it in order to stop bleeding in patients with cervical cancer stage III-IV. Once we successfully stopped<br />
bleeding in a case with endometrial cancer with contraindication for surgery. Once, bilateral uterine artery<br />
baloon obliteration saved the life of a 19 year old female patient who suffered serious damage of her pelvis<br />
after falling under a truck in a car accident. After reconstruction of her bony pelvis she had a sutured vagina<br />
and urethra which were cut off from her urinary bladder. In cases with uterine fibroids clinical results show<br />
that in more than 90 % of cases there is improvement of abnormal bleeding and a reduction of uterine<br />
volume in up to 50% (4).<br />
59
Postmenopausal bleeding<br />
The basic, noninvasive and cheap method to evaluate the aetiology of postmenopausal bleeding is<br />
transvaginal ultrasound. It is used to evaluate the thickness, texture and morphology of the endometrium.<br />
The normal postmenopausal uterus has a thin homogeneous endometrial basal bilayer of < 5 mm. This is<br />
normal and no biopsy is needed (5). Any patient with postmenopausal bleeding and endometrial bilayer<br />
thickness >5mm, heterogeneity, or focal mass/thickening should get further assessment with saline infusion<br />
hysterosonography, biopsy, or hysteroscopy. If the thickening is diffuse on saline infusion<br />
hysterosonography, then biopsy may be performed. If there is focal thickening, then hysteroscopy is<br />
preferred to localize polyps, focal hyperplasia, or cancer in order to guide tissue sampling (6). 85-90% of<br />
women presenting with postmenopausal bleeding have benign conditions such as atrophy, hyperplasia, or<br />
anatomic reasons such as polyps or fibroids.<br />
Endometrial carcinoma<br />
10-15% of women with postmenopausal bleeding have endometrial carcinoma. It is the most common<br />
gynecologic malignancy, and the fourth most common female cancer behind breast, lung and colorectal<br />
cancers. Most patients present with vaginal bleeding at an early and treatable stage. Preoperative staging of<br />
endometrial carcinoma is important for treatment planning and prognosis. Accurate pretreatment assessment<br />
of endometrial cancer at imaging can potentially optimize surgical and non surgical treatment. Imaging<br />
findings are diffuse thickening of the endometrium, heterogeneous texture, focal irregularity, distortion of the<br />
myometrial interface, significant endometrial fluid, and poor distensibility of the endometrial canal on saline<br />
infusion hysterosonography. Diagnosis requires tissue sampling. Hysteroscopy is the gold standard for<br />
guided biopsy of endoluminal masses (7).<br />
Cervical cancer<br />
Is the most common cancer in females of undeveloped countries. The incidence of cervical cancer in<br />
Slovenia in the year 2000 was 19,6/100000 women and is increasing till now. It presents 4% of all female<br />
malignancies. As a result of increased understanding of the natural history of cervical cancer, the surgical<br />
approach to early invasive cervical carcinoma has been changing gradually from a radical approach to a<br />
conservative procedure resulting in decreased mortality and morbidity, as well as better quality of life. A<br />
proper preoperative consideration involves beside history and careful physical examination a valuable<br />
morphologic assessment of changes of pelvic anatomy. MR imaging is of great value in decision making for<br />
surgery or radiation therapy in the treatment of cervical cancer. It has an excellent accuracy for the<br />
assessment of tumor size, parametrial invasion and presence of lymph nodes enlargement. Staging of<br />
cervical cancer larger than 1,5 cm using MRI of the pelvis has been shown to be cost-effective and more<br />
accurate than with computed tomography, particularly in the diagnosis of parametrial invasion (8).<br />
Endometriosis<br />
The prevalence varies in different groups of women, rising from 2,5 to 5,9 % in fertile premenopausal<br />
women to 20-50 % in infertile women, overall figures ranging from 6 to 44 %.<br />
One of the difficulties in determining the prevalence of this disease in the general population is that<br />
laparascopy or surgery is needed to make a definitive diagnosis. Evidence suggests that the current<br />
treatment pathway for endometriosis typically involves a diagnostic delay of up to 7 years for women<br />
suffering from a debilitating and painful disease, and that then patients no longer trust the advice they<br />
receive or the healthcare professional giving it (9).<br />
The extent of endometriosis varies from very small unseen endometrial glandular tissue growth to large<br />
endometriomas the size of fetal head. Ultrasound is still the golden standard in everyday clinical practise for<br />
the detection of cystic adnexal formations. MR imaging has a potential to detect lesions larger than one cm<br />
in diameter with a sensitivity of more than 80 %,<br />
but has low sensitivity for diagnosing implants and adhesions<br />
Pelvic floor dysfunction and female stress urinary incontinence<br />
Expanding clinical interest in urogynecology results in increasing imaging needs and better imaging<br />
techniques result in increased utilization. The knowledge of the anatomy of pelvic floor organs has improved.<br />
What was an unfortunately poorly understood and underserved area of female anatomy is now center of<br />
attention of the new subspecialty of urogynecology. Besides traditional there are numerous new imaging<br />
60
modalities for evaluation of pelvic pathology. Intravenous urography is still useful to rule out upper urinary<br />
tract pathology. Voiding cystourethrography is a simple and low cost procedure that may be helpful in initially<br />
studying complex pelvic floor anomalities, congenital anomalies, large and/or wide necked diverticula,<br />
adjacent masses, fistulae and the results of urethral surgery. Vaginography can be helpful in situations when<br />
an urethrovaginal fistula is difficult to demonstrate on voiding cystourethrography or a double balloon<br />
urethrogram. Double balloon retrograde urethrography allows better visualization of diverticula, fistulae and<br />
other abnormalities. Ultrasound measurement of postmictional residual urine volume is today routine clinical<br />
necesity. Stress urinary incontinence as a consequence of bladder neck hypermobility is morphologically<br />
evaluated by ultrasound or MRI. Perineal ultrasound diagnostic echoscopy has several significant<br />
advantages over radiologic methods which have been in common use till now. Perineal ultrasound is a<br />
simple, non-invasive, cheap, safe and reproducible diagnostic method for evaluation of bladder neck<br />
hypermobility. It is recomended to be used as a routine clinical preoperative assessment of female urinary<br />
incontinence. Patients with stress urinary incontinence have a statistically significant greater downward<br />
displacement of the bladder neck during stress as continent ones. Doppler techniques permit assessment of<br />
vascularity, 3 D modality better space orientation; CT and MRI better preoperative visualisation of structures<br />
visible before only to anatomists and pathologists. Dynamic MRI is used for grading pelvic floor relaxation<br />
(10).<br />
Investigation of female infertility<br />
The oldest method of evaluating the uterine cavity and tubal passage is hysterosalpingography (HSG).<br />
Comparing it with hysterosalpingosonography the later has the advantage because the investigation could be<br />
performed by the gynecologyst and gives immediate results in contrast with HSG which is done by the<br />
radiologist. Hysterosalpingosonography includes like HSG both evaluation of the uterine cavity, tubal<br />
passage however the difference being that transvaginal ultrasound is used instead of X-ray. The uterine<br />
cavity is evaluated with instillation of saline by a cervical catheter while the tubes are reproduced white by a<br />
positive contrast solution containing galactose. MR imaging is suitable for evaluation of uterine factors, but is<br />
not able to assess tubal patency and peri-tubular adhesions (11).<br />
Female genital anomalies<br />
Transabdominal and transperineal ultrasound are of paramount value in diagnosing female genital<br />
anomalies. The use of sterile saline as a contrast agent to outline the vagina, rectum or urogenital sinus may<br />
be very helpful in the evaluation of the pediatric patient with complex congenital anomalies of the<br />
genitourinary tract. Congenital anomalies of the genital tract result from Műllerian duct anomalies and/or<br />
abnormalities of the urogenital sinus or cloaca. Failure of fusion of the Műllerian duct results in a wide variety<br />
of fusion abnormalities of the uterus, cervix and vagina. Műllerian duct abnormalities may occur alone or in<br />
association with urogenital sinus or cloacal malformations. Persistence of the cloaca is believed to be caused<br />
by an abnormal development of the dorsal part of the cloaca and the urorectal septum. Urogenital sinus<br />
malformations occur after the cloaca has been organized into urogenital sinus and the anus. Due to the close<br />
embryologic relationship between the urinary and the genital tract malformations involving both organ<br />
systems are very common (12).<br />
Fetal imaging modalities<br />
Ultrasound is the imaging modality of choice for prenatal screening and assessment of fetal deformities. It<br />
has long been accepted that an alternative imaging tool is needed in cases where sonographic diagnosis is<br />
difficult. MRI, which like ultrasound, lack ionizing radiation is especially appealing in the pregnant patient but<br />
until recently has been limited by motion artefact. With the development of ultrafast MR imaging technique,<br />
such as single-shot fast spin-echo, high quality fetal images are possible without the need for sedation. At<br />
present, there is no conclusive evidence that exposure to clinical MRI conditions is harmful to the fetus.<br />
Anyhow more work is needed including cost analysis, before the role of MRI in antenatal diagnosis is clearly<br />
defined (13).<br />
Surgical intraoperative complications<br />
Iatrogenic ureteral injuries are among the most serious complications of gynecological operations. Ureteral<br />
injuries may complicate 0,5 to 1 % of all pelvic operations and are usually complicated by a delay in<br />
diagnosis (14). Ureteral injuries complicate postooperative course, compromise final results, require<br />
secondary surgical treatment and could jeopardize patient life. Although the risk for ureteral lesion is<br />
61
increased in malignancy, after previous pelvic operations or radiotherapy, in the presence of endometriosis<br />
and pelvic inflammatory disease, the majority of the injuries occur during rutine hysterectomy for benign<br />
conditions, usually described as »uncomplicated«. Pelvic surgeons, particularly gynecologists should be<br />
comfortable with the ureteral course and familiar with the sites of frequent injuries during pelvic surgery. The<br />
gynecologist must be familiar with safe techniques for routine identification of the ureter. In addition all<br />
gynecologists should be familiar with techniques to identify urinary tract injuries and be able to perform<br />
simple temporizing procedures and repairs while complex reconstruction procedures usually are left to the<br />
urologist. Contrast X ray morphologic diagnostic investigations are crucial for the exact diagnosis.<br />
Intravenous urography and retrograde ureteropyelography are of special value(15,16).<br />
Conclusion<br />
Gynecologists are aware of the important need for an evidence-based diagnostic pathway for the special<br />
pathology in this field. In the future clinicians will search for simple, safe, time-effective and reproducible<br />
imaging modalities which will avoid multiple separate diagnostic procedures, which in the sum are obviously<br />
costly, time-consuming and sometimes even invasive, what is in gynecological aspect of special importance.<br />
Precise pretreatment diagnostic evaluation respecting intimacy and patient integrity are our future<br />
expectations.<br />
References<br />
1. Hamm B, Kubik-Huch RA, Fleige B. MR imaging and CT of the female pelvis:<br />
radiologic-pathologic correlation. Eur Radiol. 1999; 9(1):3-15.<br />
2. Cramer SF, Patel A. The frequency of uterine leiomyomas. American Journal<br />
of Clinical Pathology 1990; 94: 435-438.<br />
3. Cowan NC, Tattersall DJ, Holt SJ, Dobson D, Rees MC, Barlow DH. Uterine artery embolization for leiomyomas and adenomyosis:<br />
Mid-term results from a prospective clinical trial. Radiology (P) 2001; 221:30.<br />
4. Watson GMT, Walker WJ. Uterine artery embolisation for treatment of symptomatic fibroids in 114 women: reduction in size of the<br />
fibroids and women's view of the success of the treatment. British J of Obstetrics and Gynecology 2002; 189: 129-35.<br />
5. Ferazzi E, Torri V, Trio D, et al. Sonographic endometrial thickness: a useful test to predict atrophy in patients with postmenopausal<br />
bleeding – an Italian multicenter study. Ultrasound Obstet Gynecol 1996; 7: 315-321.<br />
6. Goldstein RB, Bree RL, Benson CB, et al. Evaluation of the woman with postmenopausal bleeding: Society of Radiologists in<br />
Ultrasound sponsored consensus conference statement. J Ultrasound Med. 2001; 20: 1025-1036.<br />
7. Levine DA, Hoskin WJ. Update in the management of endometrial cancer. Cancer J 2002; 8, Suppl: 1: 531-40.<br />
8. Monsonego J, Franco E, editors. Cervical cancer conrol. General statements and Guidelines. Eurogin-WHO International Joint<br />
meeting. Unesco Paris, March 24-27,1997.<br />
9. Thomas EJ. The clinician's view of endometriosis. International J of Gynecology and Obstetrics. 1999, Vol 64, Suppl 1: S1-S3.<br />
10. Schaer GN, Koechli OR, Schuessler B, Haller U. Perineal ultrasound for evaluating the bladder neck in urinary incontinence. Obstet<br />
Gynecol 1995; 85: 220-224.<br />
11. Schwartz LB, Panageas E, Lange R, Rizzo J, Comite F, Mc Carthy S. Female pelvis: Impact of MR imaging on treatment decision and<br />
net cost analysis. Radiology 2000; 214: 39-46.<br />
12. Gassner I, Geley T. Ultrasound of female genital anomalies. Eur Radiol. 2004; 14: L107-L122.<br />
13. Garden AS. Fetal and fetal organ volume estimation with magnetic resonance imaging. Am Journal of Obstetrics and Gynecology<br />
1996; 175: 442-448.<br />
14. Higgins CC. Ureteral injuries during surgery. Jama 1976, 199: 118-124.<br />
15. Bright TC, Peters PC. Ureteral injuries secondary to operative procedures. Urology 1977; 9: 22.<br />
16. Witters C, Cornelissen M, Vereecken R. Iatrogenic ureteral injury: aggressive or Conservative treatment. Am J Obstet Gynecol, 1986;<br />
155: 582-4.<br />
PREOPERATIVE ASSESSMENT OF BENIGN DISEASES OF THE FEMALE<br />
PELVIS: ENDOMETRIOSIS<br />
PD, Dr. med Karen Kinkel,<br />
Clinique des Grangettes, Chêne-Bougeries, Geneva, Switzerland<br />
Endometriosis corresponds to ectopic growth of functional endometrial glands associated with stromal tissue.<br />
Pain is the cardinal symptom of endometriosis. Various types of pain are associated with the disease;<br />
dysmenorrhoea, deep dyspareunia, and pelvic pain unrelated to intercourse or menstruation. Infertility is<br />
another commonly associated complaint. The diagnosis of endometriosis still presents several problems<br />
resulting from similarities in clinical symptoms to other benign or malignant gyneaecological diseases.<br />
62
Imaging techniques currently used to diagnose endometriosis are sonography, computerized tomography<br />
(CT) and magnetic resonance imaging (MRI). Sonographic examination of the pelvis is the initial method of<br />
choice to identify and characterize adnexal cystic structures. Medical or surgical treatment options depend on<br />
the patient’s age and pregnancy desire, the importance and recurrence of symptoms, the extent of disease<br />
and history of prior treatment.<br />
Endometriosis of the pelvis includes a variety of different anatomic location and degrees of disease such as<br />
superficial or peritoneal endometriosis, endometriomas or endometriosis of the ovary and deep peritoneal<br />
endometriosis divided into anterior and posterior endometriosis [1]. Ovarian endometriosis can be detected<br />
by ultrasound, using a combined transabdominal and transvaginal approach. Characteristic sonographic<br />
features of endometriomas are diffuse, low-level internal echoes, multilocularity and hyperechoic foci in the<br />
wall [2]. Differential diagnoses include corpus luteum, teratoma or dermoid cyst, cystadenoma, ovarian<br />
fibroma, tubo-ovarian abscess and carcinoma. Repeated ultrasound is highly recommended for unilocular<br />
cysts with low-level internal echoes to differentiate functional corpus luteum from neoplastic ovarian cysts<br />
such as endometriomas. At magnetic resonance imaging (MRI) endometriomas appear as homogeneously<br />
high-signal intensity cysts at T1-weighted fat suppressed images and as low-signal intensity cysts with focal<br />
high-signal intensity areas at T2-weighted images[3]. Gradual variation of signal intensity at T2-weighted<br />
images has been described as “shading” and is due to chronic bleeding with accumulation of high<br />
concentration of iron and protein in endometriomas [3]. Frequently the cyst is filled with blood of different<br />
ages. However the purpose of MRI is not detection of endometriomas easily diagnosed at ultrasound but the<br />
identification of peritoneal and subperitoneal disease.<br />
Superficial endometriosis of peritoneal implants is hardly detected by any imaging method due to their size<br />
smaller than 5mm. MRI using fat suppressed sequences my detect 75% of peritoneal implants larger than<br />
5mm demonstrating signal intensities similar to “microendometriomas” according to the age of hemorrhage.<br />
Subsequent adhesion formation is identified at MRI only in patients with severe adhesion. Angulation of<br />
bowel structures or hypointense lines in the surrounding fat converging in spicules towards the fixed organ,<br />
are suggestive of adhesions. Hematosalpinx can be identified at both, ultrasound and MR imaging as tubular<br />
structures with interrupted septa and signal intensity of blood. However tubal obstruction without tubal<br />
dilatation will not be identified with these imaging techniques without the use of intrauterine fluid currently<br />
under investigation. Therefore hysterosalpingography remains the first imaging technique in patients with<br />
infertility.<br />
The assessment of the pouch of Douglas can be impaired during diagnostic laparoscopy for infertility by<br />
severe adhesions covering the posterior pelvis. The main benefit of MRI in patients with pelvic pain is the<br />
diagnosis of extra-ovarian endometriosis which can be located anteriorly between the bladder and the uterus,<br />
or posteriorly at the level of the uterosacral ligaments, the torus uterinum (posterior part of the uterine<br />
isthmus between the insertions of both uterosacral ligaments), the posterior vaginal fornix or the rectosigmoid<br />
[4, 5]. Endometriosis of the bladder corresponds to nodular wall thickening, easily identified at ultrasound and<br />
mimicking bladder cancer. At MRI, bladder endometriosis associates T2 hypointense posterior wall<br />
thickening and T1 and T2 hyperintense spots. Extension to the ureters is crucial before planning partial<br />
cystectomy. Axial T2-weighted 3mm sections and MR urography are superior to intravenous pyolography to<br />
diagnose internal or external endometriosis of the ureter. Symptoms of posterior endometriosis depend on<br />
lesion location and include dyspareunia, dysmenorrhea and painful defecation. Endometriosis of uterosacral<br />
ligaments include their hypointense thickening above 7mm, often associated with nodularity. T2 hypointense<br />
nodules with decreased contrast uptake after intravenous administration of Gadolinium compared to normal<br />
surrounding structures. Endometriosis of the bowel can be located at the rectosigmoid colon, the appendix,<br />
the cecum and the distal ileum. The lesion invades the serosa, subserosa and muscularis propria reacting<br />
with hypertrophia and fibrosis. Due to the normal appearance of the mucosa in most patients with bowel<br />
endometriosis diagnosis by colonoscopy is often false negative. Diagnostic criteria of rectal invasion at MRI<br />
included colorectal wall thickening with anterior triangular attraction of the rectum towards the torus uterinum<br />
or thickening of the lower surface of the sigmoid [5]. Evaluation of the distance of the lower border of the<br />
lesion up to the junction of the pelvic and perineal rectum was possible in all patients with rectal involvement.<br />
This information is important for surgical decision making.<br />
63
MRI represents the optimal method to diagnose and define the extent of all lesion locations, particularly at<br />
the torus uterinum, the utero-sacral ligaments, the upper vagina or the bowel. Surgical management of deep<br />
endometriosis is a complex and high risk procedure. A satisfactory preoperative work-up is necessary to<br />
precise exactly the locations of all the deep lesions. Because of the difficulties of these surgical procedures, it<br />
is strongly recommended to refer patients with suspected or diagnosed deep endometriosis to specific<br />
centers with a multidisciplinary approach. In patients who do not undergo surgery, MRI of the pelvis can be<br />
used to monitor response to medical treatment.<br />
References<br />
1. Chapron C, Fauconnier A, Vieira M, Barakat H, Dousset B, Pansini V, Vacher-Lavenu MC, Dubuisson JB. Anatomical distribution of<br />
deeply infiltrating endometriosis: surgical implications and proposition for a classification. Hum Reprod 2003, 18: 157-161.<br />
2. Patel MD, Feldstein VA, Chen DC, Lipson SD, Filly RA. Endometriomas: diagnostic performance of US. Radiology 1999, 210: 739-<br />
745.<br />
3. Togashi K, Nishimura K, Kimura I, Tsuda Y, Yamashita K, Shibata T, Nakano Y, Konishi J, Konishi I, Mori T. Endometrial cysts:<br />
diagnosis with MR imaging. Radiology 1991, 180: 73-78.<br />
4. Kinkel K, Chapron C, Balleyguier C, Fritel X, Dubuisson JB, Moreau JF. Magnetic resonance imaging characteristics of deep<br />
endometriosis. Hum Reprod 1999, 14: 1080-1086.<br />
5. Bazot M, Darai E, Hourani R, Thomassin I, Cortez A, Uzan S, Buy JN. Deep Pelvic Endometriosis: MR Imaging for Diagnosis and<br />
Prediction of Extension of Disease. Radiology 2004, 232: 379-389 Epub 2004 Jun 2017.<br />
PREOPERATIVE ASSESSMENT OF BENIGN DISEASES OF THE FEMALE<br />
PELVIS: ADNEXAL DISEASES<br />
Izumi Imaoka, MD, PhD.<br />
Department of Radiology, Tenri Hospital, Japan<br />
Transvaginal ultrasonography (TVS) has been foremost modality for the detection and characterization of<br />
adnexal masses. Computed tomography (CT) or magnetic resonance imaging (MRI) can be considered<br />
when the sonographic findings are indeterminate. MRI is especially capable of characterizing adnexal<br />
masses as hemorrhagic, fatty, cystic, or solid.<br />
This presentation addresses CT and MR findings of benign adnexal diseases as a practical preoperative<br />
assessment.<br />
1. Adnexal masses vs. non-adnexal masses<br />
Differential diagnosis for pelvic masses includes adnexal and non-adnexal masses. First, uterine subserosal<br />
leiomyomas can mimic solid adnexal tumor (i.e., fibrothecoma). Splaying of the uterine myometrium indicate<br />
uterine leiomyomas. MR imaging is appreciated to diagnose subserosal leiomyomas by demonstrating<br />
vascular signal voids between the uterus and the mass (flow void sign) (1). Next, the mass arisen from nonreproductive<br />
system is another consideration. Diseases of peritoneal origin, retroperitoneal origin, and<br />
gastrointestinal origin can be misinterpreted as gynecologic masses. CT and MR findings of displacement of<br />
ureter and iliac vessels (2), effacement of pelvic wall (2), tracking of tumor vessels and ovarian veins (3) are<br />
helpful to differentiate extragonadal pelvic masses from adnexal diseases.<br />
2. Neoplasm vs. non-neoplasm<br />
Some of the non-neoplastic conditions are required observation or medication rather than operation.<br />
Solitary follicle cysts and corpus lutem cysts, so called ‘functional cysts’, are common in women of<br />
reproductive age. They usually range from 3 to 8 cm in diameter (4) and almost always regress within two<br />
months. Therefore, cystic and unilocular adnexal masses less than 4-5cm in their dimension may be<br />
observed with repeated sonography (5). They are well circumscribed cystic masses of near water density on<br />
CT. MR demonstrates cystic masses of low signal intensity on T1-weighted images and high signal intensity<br />
on T2-weighted images when they are uncomplicated.<br />
Patients with tubo-ovarian abscess (TOA) present an adnexal mass. The diagnosis of pelvic inflammatory<br />
disease (PID) and TOA is usually based on clinical findings. MR imaging also can be helpful for the<br />
assessment of PID, by showing TOA, dilated fluid-filled tubes, and free pelvic fluid (6). Contrast enhanced<br />
CT has advantages to assess PID extended to perihepatitis (Fitz-Hugh-Curtis syndrome: FHCS). Hepatic<br />
and splenic capsular enhancement was reported as characteristic findings of FHCS (7).<br />
64
Peritoneal inclusion cysts are caused by accumulation of ovarian fluid associated with peritoneal adhesion.<br />
They may be misinterpreted as complex cystic adnexal masses, however, accurate preoperative diagnosis<br />
allows conservative therapy rather than surgical resection. The entrapped ovary inside the cyst can be<br />
shown on CT and MR imaging (8).<br />
3. Benign vs. malignant<br />
Appropriate preoperative assessment may helps gynecologist for preparing ystectomy and/or laparoscopic<br />
management rather than oophorectomy or salpingi-ophorectomy, or transabdominal procedure in patients<br />
with benign adnexal masses.<br />
Mature cystic teratoma (dermoid cyst) is the most common ovarian tumor. The cyst is lined with keratinized<br />
squamous epithelium and skin appendages. Therefore sebaceous contents are quite common within mature<br />
cystic teratomas. Fat attenuation within the cyst is a diagnostic finding on CT. MR imaging demonstrates<br />
the fat material as high signal intensity component parallelling that of subcutaneous fat tissue on T1- and fast<br />
spin echo T2-weighted images. A selective chemical fat-suppression technique improves diagnostic<br />
confidence (9, 10).<br />
Endometriosis is characterized as the presence of tissue resembling endometrium outside the uterus.<br />
Endometriotic cysts usually have thick, fibrotic wall with chocolate-colored hemorrhagic material. CT findings<br />
are sometimes nonspecific ovarian masses. Methemoglobin in the aged cyclic hemorrhage causes T1-<br />
shortening, therefore, (a) adnexal cysts of high signal intensity on both T1- and T2-weighted images or (b)<br />
high signal intensity on T1-weighted images and low signal intensity on T2-weighted images, are diagnostic<br />
findngis on MR imagings (11). The details will be presented by Dr. Kinkel in 'Endometriosis' session.<br />
Finally, one of the major goals of the evaluation of adnexal diseases is to exclude a malignancy. The use of<br />
intravenous contrast is essential to differentiate malignant from benign ovarian tumors. CT features of<br />
ovarian malignancy include a cystic mass with thick internal septations and solid mural components, a cystic<br />
and solid mass, and a lobulated/ papillary solid mass. The primary MR criteria are (a) solid mass or large<br />
solid component, (b) wall thickness>3mm, (c) septal thickness>3mm and/or vegetations or nodularity, and (d)<br />
necrosis (12, 13). Completely cystic and unilocular masses suggest benigncy, including functional cysts,<br />
paraovarian cysts, and serous cystadenomas. Cystic and multilocular masses without any solid components<br />
or vegetations/ nodularity include mucinous cystadenomas. Solid ovarian masses include various<br />
pathologies. Of these, fibrothecomas are the most common solid benign tumors of the ovary.<br />
Fibrothecomas and Brenner tumors can be diagnosed when solid masses show low signal intensity on T2-<br />
weighted images because of extensive fibrous tissue and calcification (14, 15).<br />
References<br />
1. Torashima M, Yamashita Y, Matsuno Y, et al. The value of detection of flow voids between the uterus and the leiomyoma with MRI. J<br />
Magn Reson Imaging 1998; 8: 427-431.<br />
2. Foshager MC, Hood LL, Walsh JW. Masses simulating gynecologic diseases at CT and MR imaging. Radiographics 1996; 16: 1085-<br />
1099.<br />
3. Saksouk FA, Jhonson SC. Recognition of the ovaries and ovarian origin of pelvic masses with CT. Radiographics 2004; 24: S133-<br />
S146.<br />
4. Clement PB. Nonneoplastic lesions of the ovary. In: Blaustein’s Pathology of the female genital tract, 5th ed, Kurman RJ ed. Springer,<br />
New York, 2002, 675-727.<br />
5. Fleischer AC. Sonographic evaluation of adnexal masses with transabdominal and Transvaginal sonography. In: Fleischer AC, et al<br />
(eds) Clinical gynecologic imaging. Philadelphia: Lippincott-Raven Publishers, 1997; 48-86.<br />
6. Tukeva TA, Aronen HJ, Karjalainen PT, Molander P, Paavonen T, Paavonen J. MR imaging in pelvic inflammatory disease:<br />
comparison with laparoscopy and US. Radiology 1999; 210: 209-216.<br />
7. Nishie A, Yoshimitus K, Irie H, et al. Fitz-Hugh-Curtis syndrome. Radiologic manifestation. Comput Assist Tomogr 2003; 27: 786-791.<br />
8. Jain KA. Imaging of peritoneal inclusion cyst. Am J Roentgenol 2000; 174: 1559-1563.<br />
9. Stevens SK, Hricak H, Campos Z. Teratomas versus cystic hemorrhagic adnexal lesions: differentiation with proton-selective fatsaturation<br />
MR imaging. Radiology 1993; 186: 481-488.<br />
10. Imaoka I, Sugimura K, Okizuka H, Iwanari O, Kitao M, Ishida T. Ovarian cystic teratomas: value of chemical fat saturation magnetic<br />
resonance imaging. Br J Radiol 1993; 66: 994-997.<br />
11. Togashi K, Nishimura K, Kimura I, et al. Endometrial cysts: diagnosis with MR imaging. Radiology 1991; 180: 73-78.<br />
12. Stevens SK, Hricak H, Stern JL. Ovarian lesions: detection and characterization with gadolinium-enhanced MR imaging at 1.5 T.<br />
Radiology 1991; 181: 481-488.<br />
13. Hricak H, Chen M, Coakley FV, et al. Complex adnexal masses: detection and characterization with MR imaging- multivariate<br />
analysis. Radiology 2000, 214: 39-46.<br />
14. Troiano RN, Lazzarini KM, Scoutt LM, Lange RC, Flynn SD, McCarthy S. Fibroma and fibrothecoma of the ovary- MR imaging<br />
findings. Radiology 1997;204:795-798.<br />
15. Outwater EK, Siegelman ES, Kim B, Chiowanich P, Blasbalg R, Kilger A. Ovarian Brenner tumors: MR imaging characteristics. Magn<br />
Reson Imaging 1998; 16: 1147-1153.<br />
65
CLINICAL ASPECTS OF URINARY TRACT INFECTIONS<br />
Andrej Bren<br />
Department of Nephrology, University Medical Center, Ljubljana<br />
Acute urinary tract infections (UTI) are divided into lower tract infections (urethritis and cystitis) and upper<br />
tract infections (acute pyelonephritis, prostatitis, and intrarenal and perinephric abscesses). In most cases,<br />
growth of >10 5 organisms per milliliter from a properly collected midstream “clean-catch” urine sample<br />
indicates infection. Chronic pyelonephritis refers to chronic interstitial nephritis believed to result from<br />
bacterial infections of the kidney. UTI are subdivided into catheter-associated (or nocosomial) infections and<br />
non-catheter-associated (or community acquired) infections. Infections in either category may be<br />
symptomatic or asymptomatic. The vast majority of acute symptomatic community-acquired UTIs involve<br />
young women.<br />
The most common microorganisms that infect urinary tract are gram-negative bacilli. Escherichia coli cause<br />
80% of acute infections in patients without catheters, urologic abnormalities, or calculi. Proteus, Klebsiella<br />
and Enterobacter account for smaller proportion of uncomplicated infections. These organisms, plus Serratia<br />
an Pseudomonas are important in recurrent infections and infections associated with urologic manipulation,<br />
calculi, or obstruction. They play the major role in nocosomial, catheter-associated infections. In the vast<br />
majority of UTIs, bacteria gain access to the bladder via urethra. Ascent of bacteria from the bladder may<br />
follow and is probably the pathway for most renal parenchymal infections. The female urethra appears to be<br />
particularly prone to colonization with colonic gram-negative bacilli, because of its proximity to the anus.<br />
Sexual intercourse causes introduction of bacteria into the bladder and is temporally associated with the<br />
onset of cystitis. In pregnancy 20-30% of women with untreated asymptomatic bacteriuria subsequently<br />
develop pyelonephritis. Any obstruction of the urinary tract and impediment to the free flow of urine (tumor,<br />
stricture, stone, or prostatic hypertrophy)-results in hydronephrosis and a greatly increased frequency of UTI.<br />
Neurogenic bladder dysfunction (spinal cord injury, tabes dorsalis, multiple sclerosis, diabetes, etc) may be<br />
associated with UTI. Vesicoureteral reflux is common among children with anatomic abnormalities of the<br />
urinary tract as well as among children with anatomically normal but infected urinary tract.<br />
Patients with cystitis usually report dysuria, frequency, urgency, and suprapubic pain. Symptoms of acute<br />
pyelonephritis generally develop rapidly over a few hours or a day and include fever, shaking, chills, nausea,<br />
vomiting, and diarrhea. In some patients, signs and symptoms of gram-negative sepsis predominate. About<br />
30% of women with acute dysuria, frequency, and pyuria have midstream urine cultures that show either no<br />
growth or insignificant bacterial growth. A distinction should be made between infection with sexually<br />
transmitted p0athogen (CV. Trachomatis, N. gonorrhoeae, or herpes simplex virus, and those with low-count<br />
E. coli or staphylococcal infection of the urethra or bladder. Bacteriuria develops in at least 10 -15% of<br />
hospitalized patients with indwelling urethral catheters. The risk of infections is 3-5% per day of<br />
catheterization. Clinically, most catheter-associated infections cause minimal symptoms and no fever and<br />
often resolve after removal of the catheter. Gram-negative bacteriemia occurs in 1-2% of cases with<br />
catheter-associated infections. The catheterized urinary tract has repeatedly been demonstrated to be the<br />
most common source of gram-negative bacteremia in hospitalized patients, generally accounting for 30% of<br />
cases.<br />
Diagnostic testing includes determination of the number and type of bacteria in the urine. Pyuria is<br />
demonstrated in nearly all acute bacterial UTIs, and its absence calls the diagnosis into question. Elevate<br />
level of C-reactive protein often accompanies acute pyelonephritis.<br />
Except in acute uncomplicated cystitis in women, a quantitative urine culture should be performed to confirm<br />
infection. Factors predisposing infections should be corrected. Relief of clinical symptoms does not always<br />
indicate bacteriological cure. Each course of treatment should be classified after its completion as a failure or<br />
a cure. Lower uncomplicated infections in general respond to short course of therapy, while upper tract<br />
infections require longer treatment.<br />
Very few women with recurrent UTIs have correctable lesions discovered at cystoscopy or upon intravenous<br />
pyelography, and these procedures should not be undertaken routinely in such cases. Urologic evaluation<br />
should be performed in selected instances- namely in women with relapsing infections, a history of childhood<br />
infections, stones or painless hematuria, or recurrent pyelonephritis. Most males with UTI should be<br />
considered to have complicated infection and should be evaluated urologicaly. Any patient presenting with<br />
acute infection and signs or symptoms suggestive of an obstruction or stones should undergo prompt<br />
urologic evaluation, generally by means of ultrasound.<br />
66
In patients with uncomplicated cystitis or pyelonephritis, treatment ordinarily results in complete resolution of<br />
symptoms. Acute uncomplicated pyelonephritis in adults rarely progresses to renal function impairment and<br />
chronic renal disease. Repeat symptomatic UTIs with obstructive uropathy, neurogenic bladder, structural<br />
renal disease, or diabetes progress to chronic renal disease with unusual frequency.<br />
Women with frequent symptomatic UTIs are candidates for long-term administration of low-dose antibiotics<br />
directed at preventing recurrences.<br />
DIAGNOSTIC IMAGING OF PYOGENIC INFECTIONS IN THE URINARY TRACT<br />
Takehiko Gokan<br />
Radiology, Showa University School of Medicine, Tokyo, JAPAN<br />
Acute urinary tract infections usually are diagnosed and treated on the basis of clinical symptoms and<br />
laboratory findings. With appropriate antibiotics, symptoms generally abate within 48 to 72 hours, and<br />
radiological evaluation is not necessary. The use of diagnostic imaging is usually reserved for patients whose<br />
clinical diagnosis is unclear, patients who fails to respond to conventional medical treatment, diabetic<br />
patients, and other immunocompromised patients.<br />
In chronic urinary infection, diagnosis may be delayed because of the non-specific presentation and rarity of<br />
these processes. With the ability of newer imaging method, such as ultrasonography and CT, as early<br />
diagnosis of s specific chronic infection may be made. However, this requires that the radiologist be aware of<br />
the specific radiological findings of the various chronic infections.<br />
Acute Pelonephritis<br />
Acute pyelonephritis refers to infection of the kidney by haematogenous spread of organism or by ascending<br />
spread of infection from the bladder. There are two legitimate but distinct definitions of acute bacterial<br />
pyelonephritis. One is clinical definition that is based on clinical and laboratory findings . The other is the<br />
pathologic definition that is based on a set of macroscopic and microscopic abnormalities. Some patients<br />
whose kidneys fulfil the pathologic criteria for acute pyelonephritis lack clinical or laboratory evidence of<br />
disease.<br />
In most cases of acute pyelonephritis, the inflammatory process is reversible, but severe vasospasm and<br />
inflammation may occasionally result in liquefactive necrosis and abscess formation.<br />
Intravenous urography or ultrasound generally occasionally fails to show any abnormality in acute<br />
pyelnephritis. Precontrast CT shows renal enlargement or focal swelling without abnormality of attenuation.<br />
Postcontrast CT wedge-shaped or streaky zones of low attenuation extending from papilla to kidney capsule.<br />
Zone of low attenuation on contrast-enhanced scans are almost caused by focal ischemia, obstructed tubles,<br />
and interstitial inflammation. Clinically mild and uncomplicated acute pyelonephritis may show no abnormality<br />
on CT.<br />
Emphysematous Pyelonephritis<br />
The presence of gas within the renal parenchyma has been referred to as emphysematous pyelonephritis,<br />
which represents a severe life-threatening infection of the renal parenchyma with gas-forming bacteria.<br />
Underlying poorly controlled diabetes mellitus is present in up to 90 % of patients and urinary collecting<br />
system obstruction from pathologic conditions such as stone disease, urothelial neoplasm, or sloughed<br />
papilla is also commonly present. Women are affected more often than men and the average age at<br />
presentation is in the mid-50s. The clinical presentation includes features typical of a severe acute<br />
pyelonephritis including fever and chills, flank or abdominal pain, and nausea and vomiting. Mortality rates<br />
are high for medical therapy alone. E. coli is the causative bacterial source in approximately 70 % of cases.<br />
Plain films of the abdomen and IVU have been reported ton suggest the presence of gas in 85% of cases.<br />
However, the use of intravenous contrast is often contraindicated in these patients in part because of high<br />
frequency of underlying renal dysfunction. Ultrasound has been used in the evaluation of these patients and<br />
may show hyperechoic foci with posterior acoustic shadowing from gas within or surrounding the kidney.<br />
67
However, ultrasound often fails to show the full extent of the disease and in some cases may miss the<br />
relevant findings completely. CT scan is the imaging procedure of choice in evaluating the presence and<br />
extent of disease in patients suspected of having emphysematous pyelonephritis. Wan et al divides<br />
emphysematous pyelonephritis into two types and has prognostic significance. Type I is characterized by<br />
parenchymal destruction with streaky or mottled gas collections but no significant fluid collection. Type II is<br />
characterized by bubbly or loculated gas within the parenchyma or collecting system with associated renal or<br />
perirenal fluid collections that are thought to represent a favourable immune response. Type I has a 69%<br />
mortality rate versus 18% for type II, although transformation from type I to Type II has been observed<br />
following conservative treatment.<br />
Emphysematous Cystitis<br />
Emphysematous cystitis represents a rare form of acute inflammation of bladder mucosa and underlying<br />
musculature. Clinical symptoms of dysuria, increased urinary frequency, and hematuria are common. The<br />
presence of pneumaturia is rare, although more specific, clinical findings. Underlying diabetes mellitus is<br />
present in over half of reported cases, with women being affected twice as often as men.<br />
CT is a highly sensitive examination that allows early detection of intraluminal or intramural gas. It is also<br />
useful in evaluating other causes of intraluminal gas such as enteric fistula formation from adjacent bowel<br />
carcinoma or inflammatory disease.<br />
Renal abscess<br />
Renal abscess is a collection of purulent material confined to the renal parenchyma. Before the antimicrobial<br />
era, 80% of renal abscess were attributed to haematogenous seeding by staphylococci. Since about 1970,<br />
gram-negative organisms have been implicated in the majority of adults with renal abscess. Ascending<br />
infection associated with tubular obstruction from prior infection or calculi appears to be the primary pathway<br />
for the establishment of gram-negative abscess.<br />
IVU or Ultrasonography may show a abscess but lack of sensitivity to show extent of infection adequately.<br />
CT is currently the most accurate modality for detection and follow-up of renal abscess. An abscess usually<br />
appears as a well-defined mass of low attenuation with a thick, irregular wall or pseudocapsule, which is<br />
better imaged with contrast enhancement. Gas within a low-attenuating or cystic mass strongly suggests<br />
abscess formation. Fascial and septal thickening and perinephric fat obliteration are usually present. A<br />
perinephric abscess may result from rupture of a renal abscess into the perirenal space but most often<br />
develops directly from acute pyelonephritis.<br />
Pyonephrosis<br />
The term pyonephrosis refers to an obstructed, infected collecting system with grossly purulent contents. Any<br />
cause of chronic ureteral obstruction predisposes to pyonephrosis. Patients may present with signs and<br />
symptoms of acute infection, or with low-grade fever, weight loss, and dull pain. However, as many as 15%<br />
of patients have no symptoms and others have a more indolent, chronic presentation.<br />
Ultrasonography has greatly aided the diagnosis, since the contents of dilated collecting system can be<br />
shown even when function is nil. The classic US findings in pyonephrosis is the presence of echogenic<br />
material in a dilated collecting system. By CT scan, the most frequently encountered findings is thickening of<br />
the renal pelvic wall. Other findings include stranding of the perirenal fat and a striated nephrogram, findings<br />
suggestive but not specific for renal infection is general. Although uncommon, in one series, air in the<br />
collecting system was the most specific findings. Most authors stress the need for aspiration of the collecting<br />
system in appropriate clinical setting.<br />
Xanthogranulomatous Pyelonephritis<br />
Xanthogranulomatous pyelonephritis is an uncommon complication of long-standing urinary tract obstruction<br />
with a superimposed chronic infection, usually with P mirabilis or E coli. Most cases are unilateral and result<br />
in a non-functioning, enlarged kidney associated with obstructive uropathy secondary to nephrolithiasis.<br />
CT is probably the most useful radiological technique in evaluating patients with xanthogranulomatous<br />
pyelonephritis. CT usually demonstrates a large, reniform mass with the renal pelvis tightly surrounding a<br />
68
central calcification but without pelvic dilatation. Renal parenchyma is replaced by multiple water-density<br />
masses representing dilated calyces and abscess cavities filled with varied amounts of pus and debris. On<br />
enhanced CT, the walls of these cavities demonstrate a prominent blush owing to the abundant vascularity<br />
within the granulation tissue. Xanthogranulomatous pyelonephritis is usually diffuse but may be focal or<br />
segmental.<br />
Chronic Pyelonephritis<br />
Chronic pyelonephritis is a chronic interstitial nephritis caused by infection, although some of the damage<br />
may be autoimmune mechanism. The bacteriology of the disorder is the same as for acute pyelonephritis,<br />
and in fact most cases of chronic pyelonephritis are cases of scarring from prior infections.Chronic<br />
pyelonephritis scarring most often results from lower urinary tract infestation and vesicoureteral reflux,<br />
usually in childhood. Chronic pyelonephritis can occur in other clinical setting. The most common are in the<br />
presence of calculi and chronic obstruction.<br />
In Intravenous urography, the involved kidneys are usually small and atrophic. Focal coarse renal scarring<br />
with clubbing of the underlying calyx is characteristic. Since the renal scarring and atrophy commonly affect<br />
the renal poles, the renal parenchyma is especially thin in these areas. Ultrasonography may be used to<br />
make the diagnosis, especially in children. Focal scars and blunted calices are recognized less readily with<br />
ultrasonography than with urography. CT is helpful in identifying focal areas of compensatory hypertrophy<br />
adjacent to the areas of renal scars; such hypertrophy may simulate a mass at excretory urography or renal<br />
ultrasonography.<br />
TUBERCULOSIS AND UNCOMMON INFECTIONS OF THE UROGENITAL<br />
TRACT<br />
Tarek A. El-Diasty, MD<br />
Department of Radiology, Urology and Nephrology Center<br />
Mansoura University, Mansoura – Egypt<br />
Genitourinary Tuberculosis<br />
Genitourinary tuberculosis is the most common manifestation of extrapulmonary tuberculosis.<br />
Mycobacterium tuberculosis reaches the genitourinary tract as a secondary site following hematogenous<br />
dissemination from the lung. The kidneys and possibly the prostate and seminal vesicles are often the<br />
primary sites of genitourinary tuberculosis (1) . All other genital organs become involved by ascent or descent<br />
of M tuberculosis. The testis may become involved by direct extension from an epididymal infection, but<br />
hematogenous spread to the testicle is rarely seen (2) .<br />
Renal tuberculosis:<br />
Tuberculosis of the kidney results from hematogenous seeding of M tuberculosis in the glomerular and<br />
peritubular capillary bed from a pulmonary site of primary infection (3) . Radiography may demonstrate<br />
calcification within the renal parenchyma. The calcification may be amorphous, granular, curvilinear, or lobar<br />
(putty kidney) (4,5) . Intraverous urography demonstrates a variety of findings depending on the extent of renal<br />
involvement. The earliest urographic abnormality is a “moth-eaten” calyx due to erosion. This finding is<br />
followed by papillary necrosis. Poor renal function, dilatation of the pelvicalyceal system due to a stricture of<br />
the ureteropelvic junction, or destructive dilatation or localized hydrocalycosis related to an infundibular<br />
stricture. Infundibular stenosis may lead to incomplete opacification of the calyx (phantom calyx) (6) . Cavitation<br />
within the renal parenchyms may be detected as irregular pools of contrast material. Cicatricial contracture of<br />
fibrotic parenchyma may lead to caliceal or renal pelvic traction. Calculi may be present within the renal<br />
collecting system. End-stage fibrosis and subsequent obstructive uropathy produce autonephrectomy. At this<br />
time, renal assessment is best achieved with US, CT or MR imaging (7-9) .<br />
CT is helpful in identifying the manifestations of renal tuberculosis (e.g. calcification). Various patterns of<br />
hydronephrosis may be seen at CT depending on the site of the stricture. Other findings include parenchymal<br />
69
scarring and low attenuation parenchymal lesions. CT is also useful in depicting the extension of disease into<br />
the extrarenal space (2,9) .<br />
The radiologic differential diagnosis of renal tuberculosis includes acute focal bacterial nephritis,<br />
xanthogranulomatous pyelonephritis, other causes of papillary necrosis and small benign or malignant<br />
tumors (10) .<br />
Ureteral tuberculosis:<br />
Ureteral involvement is seen in 50% of patients with genitourinary tuberculosis (7) . Dilatation and a ragged<br />
irregular appearance are the first signs of ureteral tuberculosis. In advanced disease, ureteral strictures,<br />
ureteral shortening, ureteral filling defects, or ureteral wall calcifications may be seen (5,7) . CT may<br />
demonstrate thickening of the ureteral wall and periureteral inflammatory changes.<br />
Bladder tuberculosis:<br />
Typically, tuberculous cystitis manifests as shrunken bladder with wall thickening (11) . Occasionally, filling<br />
defects due to multiple granulomas may also be seen. In advanced disease, the bladder may be diminutive<br />
and irregular (thimble bladder). Advanced bladder involvement may be complicated by vesicoureteral reflux<br />
due to fibrosis involving the ureteral orifice. Calcification of the bladder is rarely seen (10) .<br />
Calcified tuberculous cystitis must be differentiated from shistosomiasis, cystitis due to cyclophosphamide,<br />
radiation induced changes, calcified bladder carcinoma and encrusted foreign material. Bladder tuberculoma<br />
may mimic transitional cell carcinoma.<br />
Male genital tuberculosis:<br />
The most common findings of tuberculous prostatitis, on transrectal US, is hypoechogenic areas with an<br />
irregular pattern in the peripheral zone of the prostate. Contrast-enhanced CT shows hypoattenuating<br />
prostate lesions which represent foci of caseous necrosis and inflammation. Nontuberculous pyogenic<br />
prostatic abscess have a similar CT appearance (7) . At MR imaging, a prostatic abscess demonstrates<br />
peripheral enhancement. This finding helps differentiate an abscess from prostatic malignancy. In addition,<br />
MR imaging shows diffuse, radiating, streaky areas of low signal intensity in the prostate (“Watermelon Skin”<br />
sign) on T2-weighted images (12) .<br />
Tuberculous involvement of seminal vesicles may lead to necrosis, calcification, caseation and<br />
cavitation (13,14) . Tuberculous epididymo-orchitis usually manifests at US as focal or diffuse areas of<br />
decreased echogenicity with epididymal involvement (15) .<br />
Female genital tuberculosis:<br />
Fallopian tubes are affected in 94% of women with genital tuberculosis. Salpingitis caused by hematogenous<br />
dissemination is almost always bilateral. A tubo-ovarian abscess that extends through the peritoneum into<br />
the extraperitoneal compartment suggest tuberculosis (1) . Other diagnostic criteria for female genital<br />
tuberculosis include endometrial adhesions with deformity and obliteration of the endometrial cavity,<br />
obstruction of the fallopian tubes with multiple areas of constriction, and calcified lymph nodes in the adrexal<br />
region (7) . Advanced tuberculous endometritis may mimic sever uterine adhesions as seen in Asherman<br />
syndrome (10) .<br />
The clinical and radiologic features of genitourinary tuberculosis and other rare infection may mimic those of<br />
many diseases. A high index of suspicion is required, particularly in high-risk populations. Although a positive<br />
culture or histologic evidence is still required in many patients to yield a definitive diagnosis, recognition and<br />
understanding of the spectrum of imaging features of genitourinary tuberculosis, which will be outlined in this<br />
lecture, are crucial for diagnosis.<br />
References<br />
1. Engin G, Acunas B, Acunas G, Tunaci M. Imaging of extrapulmonary tuberculosis. Radiographics 2000; 20: 471-488.<br />
2. Chung J, Kin M, Lee T, Yoo H, Lee J. Sonographic findings in tuberculous epidymitis and epididymo-orchitis. J Clin Ultrasound 1997;<br />
25: 390-394.<br />
3. Gibson M, Puckett M, Shelly M. Renal tuberculosis. Radiographics 2004; 24: 251-256.<br />
70
4. Premkumar A, Lattimer J, Newhouse JH. CT and sonography of advanced urinary tract tuberculosis. Am J Roentgenol 1987; 148: 65-<br />
69.<br />
5. Wang L, Wong Y, Chen C. CT features of genitourinary tuberculosis. J Comput Assis Tomogr 1997; 21: 254-258.<br />
6. Brennan R, Pollack H. Nonvisualized “Phantom” renal calyx: causes and radiological approach to diagnosis. Urol Radiol 1979; 1: 17-<br />
23.<br />
7. Leder R, Low VH. Tuberculosis of the abdomen. Radiol Clin North Am 1995; 33: 691-705.<br />
8. Das K, Indudhara R, Vaidyanathan S. Sonographic features of genitourinary tuberculosis. AJR 1992; 158: 327-329.<br />
9. Goldman S, Fishman E, Hartman D. Computed tomography of renal tuberculosis and its pathological correlates. J Comput Assist<br />
Tomogr 1985; 9: 771-776.<br />
10. Harisinghani M, McLoud T, Shepard A, Ko FR, Shroff M, Muller P. Tuberculosis from head to tow. Radiographics 2000; 20: 449-470.<br />
11. Roylance J, Penry JB, Davis ER, et al. The radiology of tuberculosis of the urinary tract. Clin Radiol 1970; 21: 163-170.<br />
12. Wang JH, Sheu MH, Lee RC. Tuberculosis of the prostate: MR appearance. J Comput Assist Tomogr 1997; 21: 639-640.<br />
13. Premkumar A, Newhouse JH. Seminal vesicle tuberculosis: CT appearance. J Comput Assist Tomogr 1988; 12: 676-677.<br />
14. Wang JH, Chang T. Tuberculosis of the prostate: CT appearance. J Comput Assist Tomogr 1991; 15: 269-270.<br />
15. Heaton ND, Hogan B, Michell M, et al. Tuberculous epididymo-orchitis: clinical and ultrasound observations. Br J Urol 1989; 64: 305-<br />
309.<br />
CLINICAL EVALUATION OF ACUTE RENAL FAILURE<br />
Rafael Ponikvar<br />
Department of Nephrology, University Medical Center Ljubljana<br />
Introduction<br />
The kidney is remarkable among organs of the body in its ability to recover from almost complete loss of<br />
function, and most acute renal failure is reversible, although with subclinical residual defects in tubule and<br />
glomerular function. Acute renal failure occurring as an isolated clinical condition has favourable prognosis.<br />
In the last decades the epidemiology of acute renal failure has changed and the majority of nowadays cases<br />
occur in intensive care units, where acute renal failure is a part of multiorgan failure. Prognosis in such<br />
patients is less favourable, with mortality rates ranging from 40-90%, in different series. The cause of death<br />
in such patients is not renal failure itself, but failure of the other organs, as hemodialysis can provide survival<br />
to end stage renal disease patients for more than 30 years.<br />
Etiology and pathogenesis of acute renal failure<br />
Acute renal failure is a clinical syndrome characterized by a rapid decline of glomerular filtration rate and<br />
retention of nitrogen waste products such as urea and creatinine. Oliguria (urin output
Imaging in acute renal failure<br />
Ultrasonography of the urinary system (kidneys and bladder) is the essential imaging procedure required in<br />
the diagnostic evaluation of acute renal failure. It provides information on the presence and volume of urine<br />
in bladder, the position and size of the kidneys, the quality and width of renal parenchyma, presence or<br />
absence of hydronephrosis. Although some authors say that renal ultasonography is not necessarily required<br />
in acute renal failure, arguing that the main task of ultrasonography is to exclude obstruction that is very rare<br />
in the absence of clinical suspicion, our policy is that every patient with acute renal failure requires urgent<br />
ultrasonography of the urinary system. Obstruction can occur in the absence of clinical suspicion and missing<br />
that diagnosis has serious consequences. In addition, a significant number of patients has acute renal failure<br />
superimposed on chronic renal failure or even end-stage renal failure that was clinically presented as acute<br />
renal failure and ultrasonography is indispensable in clarifying such conditions and helping to plan<br />
therapeutic strategy.<br />
Doppler ultrasonography is nowadays frequently added to standard two-dimensional ultrasonography. It<br />
provides information about presence or absence of blood flow in the kidneys and the resistance to arterial<br />
blood flow (measured by the resistance index). A very high resistance index (> 1.0) with the reversion of<br />
blood flow in the diastole is a characteristic sign of venous thrombosis/occlusion, a rare but important<br />
condition. Doppler follow-up in such patients can help to assess the success of therapy.<br />
Other imaging procedures are rarely required in patients with acute renal failure. Sometimes computerized<br />
tomography and/or angiography in required in trauma patients or patients where ultrasonography did not<br />
provide sufficient information.<br />
Renal biopsy<br />
Renal biopsy is the ultimate diagnostic procedure in glomerulonephritis, vasculitis and to much lesser extent<br />
in acute renal failure and interstitial nephritis. It is mandatory when specific therapy depends on its result.<br />
Treatment of acute renal failure<br />
Treatment of acute renal failure consists of symptomatic and also more specific therapy when it is indicated.<br />
In prerenal azotemia improvement of renal perfusion is essential in order to prevent acute tubular necrosis.<br />
In tubular necrosis there is no specific therapy which could significantly influence the course and outcome.<br />
There are few drugs which can be recommended like furosemid and diltiazem or verapamil. It is still very<br />
important to maintain normal fluid, electrolyte and acid-base balance. When the latter goal cannot be<br />
achieved by drugs and infusion therapy, dialysis should be instituted.<br />
Application of radiocontrast agents, especially in patients with preexistent renal injury, may lead to acute<br />
tubular necrosis due to renal vasoconstriction and due to toxicity on tubular cells. N-acetyl cistein failed to<br />
prevent toxic effect of radiocontrast agent, while 0.9% saline solution had favourable effect in preventing<br />
acute tubular necrosis when applied 12 hours before and 12 hours after the application of contrast agent in<br />
the dose of 1ml/kgBW/hour.<br />
Conclusion<br />
Acute renal failure is unique in the ability of restoring a completely lost renal function. The most important<br />
part of acute renal failure is prerenal azotemia which can be efficiently treated by improving hypoperfusion of<br />
the kidneys. In intrinsic acute renal failure, symptomatic therapy with application of furosemid and<br />
nondihidropiridin calcium channel blockers is the treatment which is usually introduced. In anuric patients,<br />
dialysis treatment should be instituted.<br />
Ultrasound and Doppler sonography are imaging procedures of choice in acute renal failure. Other imaging<br />
procedures with the use of nephrotoxic radiocontrast agents should be used only in strict indications.<br />
72
EMERGENCIES IN KIDNEY TRANSPLANTATION: CLINICAL EVALUATION<br />
AND THE NEPHROLOGIST'S PERSPECTIVE<br />
Marko Malovrh<br />
Department of Nephrology, University Medical Centre Ljubljana, Slovenia<br />
1. Renal artery thrombosis occurs in about 1% (1) of transplants, usually in small-calibre arteries.<br />
Nephrectomy generally is indicated, especially if the thrombosis occurs in the perioperative period.<br />
2. Arterial stenosis occurs in 1-12% of cases, it may occur within months or years following transplantation,<br />
and it is associated with the abrupt onset of hypertension. It can be suspected based on findings on<br />
Doppler ultrasound; confirmation generally requires angiography to confirm the presence of the stenosis<br />
and exclude proximal vascular disease. Management of arterial stenosis has increasingly turned to<br />
percutaneous techniques, including angioplasty and stent placement. Renal transplantation is the<br />
treatment of choice for patients with chronic renal failure from most causes. This recommendation is<br />
born of its success from several points of view. With recent 1-year graft survival rates approaching 90%<br />
and average graft lifetimes in excess of 10 years, this procedure is a cost-effective alternative to dialysis.<br />
Recent studies show that renal transplantation prolongs patient lifespan relative to dialysis.<br />
Early or late complications associated with renal transplantation may occur. Perioperative complications<br />
occur in 15-20% of renal transplants. Early postoperative complications include the following:<br />
Delayed graft function (DGF) varies based on donor, recipient, and transplant characteristics. Some<br />
rules are generally applicable. DGF is rare with living donor grafts, probably because of the short cold<br />
ischemia time (CIT), i.e. the time between perfusion of the graft with ice-cold preservative solution and<br />
reperfusion with blood in the recipient. For cadaver kidneys, CIT remains the best predictor of DGF.<br />
While most DGF kidneys eventually function, they do have a somewhat diminished lifespan compared to<br />
kidneys that function immediately.<br />
Vascular-related and ureter-related complications are possible:<br />
3. Venous thrombosis occurs in 0.5-4% of cases. Thrombosis of the main renal vein has been treated<br />
successfully in rare instances with thrombolytic agents, although typically the graft has infarcted by the<br />
time the thrombosis is detected. Graft infarction may occur with patent main arteries and veins;<br />
nephrectomy generally is required. Graft thrombosis associated with sepsis carries a significant recipient<br />
mortality rate. Prompt nephrectomy is indicated.<br />
4. Peritransplant fluid collections: sonographic evaluation of renal transplant complications is often<br />
successful because many of the potential peritransplant complications are associated with fluid<br />
collections. The superficial nature of a typical renal transplant allows good resolution with relatively few<br />
reverberation echoes. During the immediate postoperative transplant period, most fluid collections in and<br />
around the bed of the transplant are haematomas or urinomas. A hyperacute haematoma often presents<br />
as a hypoechoic fluid-filled mass near the surgical site. Hematomas may be stable in size but can<br />
enlarge rapidly. The enlarging haematoma may compress the kidney, resulting in a reduction of urine<br />
output. Later, a haematoma becomes complex with both hypoechoic and echoic areas.<br />
5. Ureteral obstruction is the most common urinary tract problem associated with transplantation. The<br />
reported incidence of obstruction is 1.3 to 10.2% (2-4). It may occur early or late. Early obstruction may<br />
result from distal obstruction, clot, oedema, or technical problems associated with the<br />
ureteroneocystostomy. When Foley catheter placement and expectant management does not resolve<br />
the problem, surgical revision of the ureteroneocystostomy over a stent may be required. Late<br />
obstruction, when not caused by external compression (e.g. lymphocoele, pregnancy), is associated<br />
most typically with fibrosis or nephrolithiasis. Management typically is by radiological or cystoscopic<br />
stent placement and stricture dilatation.<br />
73
6. Urine leak can occur at any level of the urinary tract, from the renal pelvis to the urethra. The reported<br />
incidence of urinary leak is 1.2 to 8.9% (4-7). Fluid around the transplant during the first 24 hours<br />
following transplantation is an urinoma and results from a leak between the renal transplant ureter and<br />
the recipient's bladder. Patient is oliguric or even anuric. Such a leak may be the result of surgical failure<br />
or from necrosis of the distal portion of the transplant ureter. An urinoma enlarges more slowly and<br />
remains hypoechoic. If the urinoma becomes infected the quality of the fluid may become more complex<br />
as an abscess forms. After several weeks a spontaneous haematoma or an urinoma becomes less<br />
likely. Suspect urine leak when a patient with good or improving graft function develops a fluid leak from<br />
the wound or abdominal pain or perineal swelling, typically within a month of transplantation. Fluid<br />
leaking from the wound can be collected and assayed for creatinine. Nuclear renal scan probably is the<br />
most sensitive test for urine leak. Small bladder leaks often can be managed by bladder decompression<br />
with a Foley catheter. Larger and more proximal leaks typically require exploration and repair.<br />
7. Leakage from perivascular lymphatic vessels can lead to significant collections of lymph between the<br />
lower pole of the transplanted kidney and the bladder. A lymphocoele may form anywhere in the general<br />
area of the renal transplant. While lymphocoeles are more likely to occur soon after the transplant, they<br />
may develop long after the skin wound has healed. An uncomplicated lymphocoele is hypoechoic and<br />
remains hypoechoic unless it becomes infected. While lymphocoeles are slow to develop, a<br />
lymphocoele can create significant pressure resulting in urinary or venous obstruction. Lymphocoele<br />
can manifest as swelling, pain, and impaired renal function within the first year following transplantation.<br />
Frequency of lypmphocoeles varies from 5 to 36% (1,8-9). Ultrasonography (US) or CT scan<br />
demonstrates the collect well and facilitates planning treatment. Aspiration occasionally resolves the<br />
problem, but prolonged catheter drainage is associated with a significant risk of infection. Sclerotherapy<br />
with 10% povidone-iodine solution may be successful in small unloculated collections, but lymphocoele<br />
has a high rate of recurrence. Some early success has been observed on instilling fibrin glue containing<br />
gentamicin and iodine solution. However, the current standard of care is internal drainage of the<br />
lymphocoele into the abdominal cavity. This increasingly is performed laparoscopically.<br />
8. Infection of transplanted kidney or wound and other tissue infections are possible. An abscess may<br />
develop at any time during the life history of a renal transplant recipient. Abscesses may be around the<br />
kidney, within the transplant, or in the abdominal cavity remote from the transplant. Most abscesses<br />
have complex sonographic qualities. An abscess can be diagnosed best by comparing the sonographic<br />
texture of a fluid collection to the white blood cell count and the patient's fever curve. In cases in which<br />
an abscess is considered likely, sonographically guided aspiration is recommended. Diagnostic<br />
ultrasound may both initially diagnose the fluid mass as well as guide the surgical or radiologically based<br />
drainage. If percutaneous drainage results in a recurrence of a lymphocoele, laparoscopic drainage is<br />
indicated.<br />
9. With improved immunosuppression, acute rejection has become less of a problem following<br />
transplantation. In the first year following transplantation, acute rejection is observed in approximately<br />
25% of patients( 5,12). Rejection usually is asymptomatic, although it sometimes presents with fever and<br />
pain at the graft site. Rejection usually presents as an unexplained rise in serum creatinine and can be<br />
confirmed with biopsy. Biopsy under ultrasonography control should be performed. Typical biopsy<br />
findings of acute cellular rejection include a lymphoplasmacytic infiltration of the renal interstitial areas<br />
with occasional penetration of the tubular epithelium by these cells. Most rejection episodes can be<br />
treated successfully with a short course of increased steroids. Failure to respond to steroid therapy for a<br />
particularly aggressive appearance on biopsy may prompt a change of treatment strategy (e.g.<br />
antilymphocyte antibody agents).<br />
10. Chronic rejection appears to have both immunologic and nonimmunologic components. As a broad<br />
classification for progressive graft failure, risk factors include initial poor function of the graft and a<br />
history of acute rejection episodes (12).<br />
Most initial complications can be corrected if detected promptly. The radiologist should help to select the<br />
most effective imaging methods for evaluating the many problems encountered in renal transplantation.<br />
74
In the author's experience, ultrasonography (US) is a safe, rapid, and portable means to first detect most<br />
surgical emergencies.<br />
Nuclear medicine scanning and flow studies remain the primary means for evaluating vascular supply to the<br />
transplant after surgery and for confirming urinoma. The main advantage of nuclear medicine scans is that<br />
they demonstrate the pathophysiology involved. Recent developments in Doppler US and MRI show promise<br />
in improving the quality of renal vascular imaging without the use of potentially nephrotoxic intravenous (IV)<br />
contrast materials.<br />
CT scanning and CT-guided interventions remain an important means for examining the preoperative renal<br />
donor candidate and for evaluating the complications that develop in patients who undergo renal transplants.<br />
The complementary nature of nuclear medicine studies and US in the imaging evaluation of hydronephrosis,<br />
renal artery stenosis, flank pain, renal masses, pyelonephritis, and kidney transplant was confirmed. In more<br />
recent years, MRI of the abdomen has evolved into an excellent alternative means for the diagnosis of most<br />
renal transplantation complications and for the examination of the living related donor. The contrast agents<br />
used for MRI are nontoxic to the transplanted kidney, and MRI often can be used to assess renal function,<br />
vascular supply, and postoperative complications. However, MRI remains expensive and may be<br />
contraindicated in certain patients. Whenever two or more diagnostic techniques are used in the diagnosis of<br />
renal transplantation, comparison between the techniques is often very useful. Comparison of recent, current<br />
studies with remote, prior examinations is critical. New fluid collects are of greater significance than are<br />
slowly resolving fluid collections.<br />
References<br />
1. Surlan M, Popovic P. The role of interventional radiology in management of patients with end-stage renal disease. Eur J Radiol. 2003<br />
46:96-114.<br />
2. Riggk M, Proud FG, Taylor RM. Urological complications following renal transplantation: a study of 1016 consecutive transplants from<br />
a single center. Transplant Int 1994;7:120-126.<br />
3. Bachar GN, Mor E, Bartal G, Atar E, Goldberg N, Belenky A.Percutaneous balloon dilatation for the treatment of early and late ureteral<br />
strictures after renal transplantation: long-term follow-up. Cardiovasc Intervent Radiol. 2004; 27: 335-338.<br />
4. Streeter EH, Little DM, Cranston DW, Morris PJ. The urological complications of renal transplantation: a series of 1535 patients. BJU<br />
Int 2002; 90:627-634.<br />
5. Singer J, Gritsch AH, Rosenthal J. The transplant operation and its surgical complications. In: Danovitch GM, ed. Hand<strong>book</strong> of kidney<br />
transplantation.4 th ed. Philadelphia: Lippincott Williams&Wilkins; 2005: 193-211.<br />
6. Ghaseiman SMR, Guleria AS, Khawand NY, Light JA. Diagnosis and management of the urologic complications of renal<br />
transplantation. Clin Transplant 1996; 10:218-223.<br />
7. Tzimas GN, Hayati H, Tchervenkov JI, Metrakos PP. Ureteral implantation technique and urologic complications in adult kidney<br />
transplantion Transplant Proc 2003; 35:2420-2422.<br />
8. Malovrh M, Kandus A, Buturovic-Ponikvar J, Lindic J, Knap B, Fliser D, Drinovec J. Frequency and clinical influence of lymphoceles<br />
after kidney transplantation. Transplant Proc 1990; 22:1423-1424.<br />
9. Atray NK, Moore F, Zaman F, Caldito G, Abreo K, Maley W, Zibari GB Post transplant lymphocele: a single centre experience. Clin<br />
Transplant 2004; 18 Suppl 12:46-49.<br />
10. Beyga ZT, Kahan BD: Surgical complications of kidney transplantation. J Nephrol 1998; 11:137-145.<br />
11. Kräłl R, Cierpka L, Ziaja J, et al: Surgically treated early complications after kidney transplantation. Transplant Proc 2003; 35: 2241-<br />
224.<br />
12. Amend WJC, Jr, Vincenti F, Tomlanovitch JS. The first three posttransplant months. In: Danovitch GM, ed.Hand<strong>book</strong> of kidney<br />
transplantation.4 th ed. Philadelphia: Lippincott Williams&Wilkins; 2005: 212-233.<br />
ACUTE RENAL FAILURE: IMAGING EVALUATION OF NATIVE KIDNEYS<br />
O Hélénon and JM Correas<br />
Necker hospital, Paris, France<br />
Acute renal failure (ARF) is a clinically defined syndrome characterized by a rapid (over a period of hours of<br />
days) decline in renal function. From a clinical and pathophysiological point of view, it is subclassified into<br />
three distinct categories: 1) prerenal failure defined by a reversible physiologic response to renal<br />
hypoperfusion with preserved renal integrity; 2) intrinsic renal failure secondary to a disease of the renal<br />
parenchyma or vasculature; 3) postrenal failure due to an obstructive uropathy.<br />
Among imaging techniques, ultrasonography plays an important role in the first step evaluation of ARF.<br />
Doppler ultrasound (US) and contrast-enhanced MR imaging also can give an effective assistance in the<br />
75
differential diagnosis of ARF, especially in patients with suspected acute intrinsic renal failure of renovascular<br />
origin.<br />
1 First step US evaluation of ARF<br />
A review of the clinical history and symptoms, the laboratory data (urinalysis, urine and serum chemistry<br />
levels) and the result of ultrasound (US) commonly identify the mechanism that is involved in the<br />
development of ARF. In this first step clinical approach the morphological informations needed are simply<br />
and promptly obtained by gray scale US that determine the size of the kidneys and screen for urinary tract<br />
obstruction. Usually the size of the kidneys is normal or moderately increased with smooth margins. The<br />
presence of small kidneys suggests underlying chronic nephropathy.<br />
1.1 Diagnosis of obstructive renal failure (postrenal ARF)<br />
Whereas the dilatation of the excretory system does not necessarily mean obstruction (ie. elevation of the<br />
collecting-system pressure), bilateral dilatation or a dilated collecting-system in a solitary kidney at US in a<br />
patient with ARF strongly suggest a postrenal mechanism. Unilateral dilatation also may be responsible for<br />
ARF when it occurs in patients with underlying chronic renal disease involving both kidneys or the contra<br />
lateral kidney. US has an excellent sensitivity for diagnosing hydronephrosis especially in the screening for<br />
obstructive ARF since most of false negatives are due to the lack of dilatation in very early acute renal<br />
obstructions. On the other hand pitfalls such as parapelvic cysts and normal variants including extrarenal<br />
pelvis, megacalyces and enlarged lobar venous system, may mimic a dilatation of the intrarenal collecting<br />
system and lead to a false positive result. The recognition of a dilated collecting system therefore relies on<br />
the presence of dilated calyces within mid and polar portions of the sinus with continuity toward a dilated<br />
renal pelvis in a central position. Color Doppler US may help rule out prominent vessels within the renal sinus<br />
in some difficult cases.<br />
1.2 Diagnosis of the obstructive disease<br />
Since postrenal failure is suspected, US should provide additional information on the level and the<br />
mechanism of obstruction on the urinary tract. The cause sometimes can be identify by US such as bladder<br />
outlet obstruction due to BPH, infiltrative bladder carcinoma with bilateral ureteral involvement, pelvic<br />
neoplasm or enlarged lymph nodes with ureteral compression or tumor invasion. Usually the results of this<br />
first step US and clinical evaluation in a patient presenting with postrenal failure lead to appropriate treatment<br />
which consists in the mechanical relief of obstruction using foley catheterization, retrograde ureteral<br />
catheterization or percutaneous nephrostomy depending on the level and the mechanism of obstruction.<br />
Following relief of obstruction and management of postobstructive diuresis accurate diagnosis and evaluation<br />
of the obstructive uropathy can be obtained using contrast-enhanced CT or MRI especially in gynaecologic<br />
etiologies.<br />
2 Differential diagnosis of nonobstructive ARF<br />
The demonstration of a non dilated urinary tract leads to differential diagnosis among prerenal ARF and<br />
different causes of intrinsic acute renal failure.<br />
Alteration of the parenchymal echogenicity and especially increased echoginicity of the renal cortex (with<br />
increased corticomedullary contrast gradient) indicates a renal parenchymal disease but without information<br />
on its specific nature. Recognition of such a pattern is based on the subjective interpretation of the examiner<br />
and has a poor clinical interest in routine practice.<br />
At this stage of the diagnostic strategy, US using color and pulsed Doppler plays a major role especially in<br />
the diagnosis of vascular disorders. In such an indication it requires an experienced operator and skill hands<br />
to obtain efficient information and discriminate renal parenchymal diseases from vascular disorders.<br />
2.1 Renal parenchymal diseases versus prerenal azotemia<br />
Whereas, the diagnosis of prerenal ARF is commonly based on anamnesis, laboratory data and the<br />
response to treatment (restored plasma volume or pressure), Doppler US may help differentiate acute<br />
tubular necrosis (ATN) from prerenal azotemia. Elevation of resistive indices (RIs) greater than or equal to<br />
0.75 is reported to occur in 91% of patients with ATN whereas RI remains normal (< 0.70) in most of patients<br />
with prerenal azotemia except patients with severe liver disease responsible for hepatorenal syndrome. RI<br />
values also may help discriminate micro vascular causes of ARF including renal vasculitis, ARF<br />
accompanying malignant hypertension and drug-induced interstitial nephritis, associated with markedly<br />
76
elevated RI, from prerenal pathologic conditions (with the exception of hepatorenal syndrome) and acute<br />
glomerulonephritis which do not significantly increase RI values (table 1). Such information on renal arterial<br />
resistance is however non specific and does not obviate renal needle biopsy which remains indicated to<br />
establish the correct diagnosis and its histopathologic nature.<br />
2.2 Vascular disorders vs renal parenchymal diseases<br />
Among vascular causes of ARF (other than micro vascular disorders), the diagnosis of ischemic disorders<br />
including cortical necrosis and infarction, can benefit from US using color Doppler imaging and contrastenhanced<br />
non linear gray-scale US, and contrast-enhanced MRI. Both techniques can provide accurate<br />
assessment of renal perfusion defects either with segmental or more diffuse distribution.<br />
Acute pedicular arterial lesions such as acute renal artery dissection or atherosclerotic thrombosis also can<br />
be responsible for ARF especially in patients with underlying chronic renal failure. In such circumstances<br />
Doppler US reveals absence or a marked decrease in color Doppler signal or a tardus-parvus Doppler<br />
waveform (ie. Slowed flow and loss of systolic-diastolic modulation from interlobar arteries) distal to the<br />
arterial occlusion.<br />
In acute renal vein thrombosis that is suspected in case of nephrotic syndrome associated with ARF and<br />
inconstant lumbar pain Doppler US may reveal increased RIs in the involved kidney, sometimes with<br />
reversed diastolic flow. However, the correct diagnosis relies on the demonstration of a non or partially<br />
flowing renal vein with echoic material lying within the lumen usually without venous enlargement.<br />
Arterial intrarenal Doppler spectrum<br />
Causes of non obstructive ARF<br />
PRERENAL AZOTEMIA<br />
Absolute blood volume depletion<br />
Normal<br />
Elevated<br />
RI<br />
Tardusparvus<br />
Hemorrhage +<br />
Gastrointestinal losses (diarrhea,..)<br />
Renal losses (diuretics,..) +<br />
Third spacing (burns,..) +<br />
Relative decrease in blood volume<br />
Peripheral vasodilatation (shock,..) +<br />
Hepatorenal syndrome +<br />
Compromised cardiac function<br />
Recent myocardial infarction +/-<br />
Cardiac tamponade +/-<br />
Cardiac or arrhythmia +/-<br />
Disruption in renal autoregulation<br />
ACE inhibitor +/-<br />
ACUTE INTRINSIC RENAL FAILURE<br />
No signal<br />
Acute tubular necrosis +<br />
Drug-induced nephritis +<br />
Acute glomerulonephritis +<br />
Microvascular diseases and vasculitis<br />
Nodose panarteritis +<br />
Hemolytic-uremic syndrome +<br />
Thrombotic thrombocytopenic purpura +<br />
Cholesterol emboli +<br />
Malignant hypertension +<br />
Renal cortical necrosis +<br />
Large renal vessels occlusion<br />
Acute RA dissection +<br />
Acute RA embolism + + (necrosis)<br />
Atherosclerotic RA occlusion<br />
+ (necrosis)<br />
Large segmental infarction +<br />
Acute RV thrombosis + + (necrosis)<br />
Table 1: Causes of non obstructive ARF with Doppler US correlation (pulsed Doppler from intrarenal<br />
arteries). RI: resistive index; ACE: angiotensin converting enzymz; RA: renal artery; RV: renal vein.<br />
77
THE TRANSPLANTED KIDNEY: RENAL EMERGENCIES<br />
Jarl Å. Jakobsen<br />
MD, PhD, MHA, Department of Radiology, Rikshospitalet University Hospital,<br />
N-0027 Oslo, Norway.<br />
INTRODUCTION<br />
It is a continuous challenge to make donor kidneys available. Further, undergoing transplantation is a major,<br />
stressful event for the patients, the donor, and the family of a donor. Therefore, nothing should be avoided to<br />
make the correct diagnosis and give the right treatment to prevent acute loss of graft function.<br />
THE CLINICAL PROBLEMS<br />
The most common findings prompting an emergency radiological procedure are increased serum creatinine<br />
(more than 20 %), oliguria or tenderness and swelling over the transplanted kidney. Severe, new, and<br />
progressive hypertension resistant to medication may also cause examinations for renal artery stenosis.<br />
Occasionally, hematuria can be the indication for acute imaging.<br />
During the immediate postoperative period (up to 1 week posttransplantation), failure of the graft function is<br />
usually due to surgically related problems, to acute tubular necrosis (ATN), and hyperacute rejection. The<br />
early problems occur between 1 and 4 weeks after transplantation. Acute rejection and urinary leakage are<br />
most common. Thrombosis of the renal artery or vein can also be found. Later (after 1 month), acute and<br />
chronic rejection as well as lymphocoeles, ureteric stricture, renal artery stenosis, intercurrent infections and<br />
recurrence of primary kidney disease dominate the pathological findings. Medication toxicity is usually well<br />
controlled for now.<br />
IMAGING<br />
Ultrasonography<br />
Ultrasonography with Doppler is usually the first examination of the failing graft, allowing a quick and noninvasive<br />
assessment of the kidneys form and size, echogenicity, dilatation of the collecting system, and any<br />
fluid collections or mass lesions in the lower abdomen.<br />
In ATN, the kidney may appear normal, but findings in severe cases include enlarged and hypoechoic kidney<br />
with loss of the normal cortico-medullary junction. The renal sinus echoes may be compressed.<br />
The findings in acute kidney transplant rejection consist of globular enlargement of the kidney, swelling and<br />
hypoechogenicity of the medullary pyramids, indistinct cortico-medullary junction, foci in the renal cortex and<br />
oedema of the collecting system wall.<br />
Dilatation of the calyces and the renal pelvis is easily seen, but a slight dilatation is common in the<br />
transplanted kidney without obstruction. When dilatation is diagnosed, the cause is often found during further<br />
scanning of the surrounding tissue and the urinary bladder. In any case of dilatation concomitant with a full<br />
urinary bladder, scanning must be performed immediately after voiding.<br />
Doppler<br />
Both spectral, colour, and power Doppler may give important information about the transplanted kidney. The<br />
main use of Doppler is to assess open arteries and veins, and provide the location of interlobar vessels for<br />
further evaluation with spectral Doppler. Stenosis at the site of the arterial anastomosis occurs in 1 % - 23 %,<br />
and is diagnosed the same way as stenoses to a renal artery in an in-situ kidney, often with 1.8 m/s as the<br />
upper normal limit of velocities. Arterio-venous (AV) fistulas occur after renal transplant biopsies with a<br />
frequency between 10 % - 20 %, while pseudoaneurysms are uncommon. Colour Doppler is probably best<br />
for detection of the vascular lesion as the focus with colour aliasing is easily seen. Spectral analyses of the<br />
feeding artery, the fistula and the vein is necessary to confirm the specific diagnosis.<br />
The spectral Doppler curves, usually from interlobar arteries, are used for calculating resistance index (RI).<br />
Changes in RI are sensitive, but not specific for the most important causes, namely acute rejection. Reasons<br />
for increased RI can be simplified into prerenal, intrarenal, perirenal or postrenal categories (Table 1).<br />
A cut-off at 0.75 for RI seem to have a good sensitivity and fairly acceptable specificity for detection of acute<br />
rejection, given that other causes are eliminated. Some authors regard the range between 0.70 and 0.79 as<br />
an indeterminate group. In one large study, an RI index of 0,80 or higher was shown to indicate increased<br />
risk for graft failure and increased patient mortality in the long term. However, ATN can also increase RI.<br />
78
Diagnosis of rejection based on an elevated resistance index should be made with caution in the presence of<br />
a perinephric mass or hypotension. Furthermore, care should be taken while performing the study not to use<br />
excessive manual pressure on the kidney because this may yield a falsely elevated resistive index.<br />
An increase in heart rate will decrease the RI. Transplant renal artery stenosis (TRAS) may also result in a<br />
low RI. However, although it is a highly specific finding, the sensitivity for the diagnosis of TRAS is low.<br />
Infarctions in the renal poles may occur, and is seen as areas without flow on colour and power Doppler.<br />
Contrast-specific sequences together with ultrasound contrast agents (USCA) can improve the sensitivity<br />
and accuracy. Techniques are now available using USCA to assess perfusion in the transplant, but the<br />
clinical use is not yet established.<br />
In chronic rejection can loss of cortical flow be demonstrated with colour Doppler, and especially using power<br />
Doppler due to the increased sensitivity for flow.<br />
Magnetic Resonance Imaging (MRI)<br />
With MRI, good images differentiating the cortex from the pyramids are usually obtained. Using MR contrast<br />
in combination with fast sequences provides perfusion images, and is a supplement to indeterminate Doppler<br />
findings when a segmental infarction is suspected.<br />
MR urography (hydrography, MRU) is<br />
performed without any contrast Table 1. Reasons for elevated resistance index.<br />
agents, using fast, heavily T2-<br />
weighted sequences. In addition, a fatsuppression<br />
pulse can be used to<br />
Level of pathology<br />
Prerenal<br />
Pathology<br />
Hypotension<br />
minimize unwanted effects of<br />
Renal vein thrombosis<br />
surrounding retroperitoneal fat. MRU<br />
Bradycardia<br />
can provide excellent overview of the<br />
Intrarenal<br />
Acute tubular necrosis<br />
urinary collecting system including any<br />
Acute vascular rejection<br />
filling defects in the urinary bladder.<br />
Chronic vascular rejection<br />
The site of urinary leakage can usually<br />
be diagnosed more often by MR than<br />
Cyclosporine toxicity<br />
by ultrasound.<br />
MR angiography (MRA), both without<br />
and with MR contrast agents, may also<br />
be used to evaluate the vascular<br />
pedicle. A negative finding when<br />
suspecting renal artery stenosis has<br />
high accuracy, but one should be<br />
aware of false positive diagnoses<br />
when estimating the degree of a<br />
stenosis found.<br />
Computed Tomography (CT)<br />
Perirenal<br />
Postrenal<br />
Glomerulonephritis<br />
Pyelonephritis<br />
Hematoma<br />
Manual compression of transducer<br />
Acute obstruction<br />
Due to the potential nephrotoxicity of contrast media, CT is seldom used. CT gives, however, a good<br />
visualisation of fluid collections, and can also be indicated in order to assess mass lesions within the kidney.<br />
CT angiography with multislice equipment can be used for assessing vascular complications like renal artery<br />
stenosis.<br />
Conventional angiography<br />
Angiography should be reserved for those patients where vascular intervention is needed to treat a condition<br />
diagnosed using non-invasive modalities.<br />
INTERVENTION<br />
Biopsy<br />
Biopsy is the most common percutaneous procedure on the renal transplant. The biopsy is needed to<br />
differentiate between various important parenchymal causes for acute failure. The biopsy is performed under<br />
ultrasound guidance, and taken with an automated biopsy gun and an 18 G thru-cut needle. The biopsy is<br />
taken from the cortex at the lower pole, and not from any part of the medulla. Prior to the puncture, colour<br />
Doppler is always done to confirm circulation of the area, and to avoid puncturing interlobar and segmental<br />
arteries or arterio-venous fistulas from previous biopsies.<br />
The quality of the biopsy should be assessed immediately by counting glomeruli using a suitable microscope,<br />
so that enough material is obtained in one procedure. Usually, one to three specimens are needed. The<br />
79
iopsies can be evaluated by pathologists using light and electronic microscopy. Recently, it has been shown<br />
that similar appearance in light microscopy can be further classified due to their gene expression into three<br />
classes that are predictive for the long-term prognosis.<br />
In a few patients complications to biopsy, like arterio-venous fistulas, perirenal and subcapsular hematomas,<br />
occur. While the AV-fistulas usually heal spontaneously, some of them require embolisation. Hematomas<br />
may often require percutaneous or surgical drainage.<br />
Pyelography, intervention to the ureter, and nephrostomy<br />
These methods are usually applied for diagnosis and treatment of dilated collecting systems and fluid<br />
collections, and will be covered elsewhere. This includes also ureteral strictures.<br />
Vascular intervention<br />
Vascular intervention can be used to treat renal artery stenosis, AV-fistulas, and bleeding after biopsy or<br />
pyelostomy.<br />
Conclusion<br />
Imaging of the acute failing transplanted kidney is usually based on ultrasound and Doppler examinations.<br />
Ultrasound contrast agents have a potential to further sophisticate the examination. Pecutaneous biopsy is<br />
frequently necessary. Comprehensive MR examinations are very promising. However, all the other<br />
modalities must be used to some extent. Most of the percutaneous interventional procedures and advanced<br />
vascular intervention should be available.<br />
THE TRANSPLANTATED KIDNEY: EXTRARENAL EMERGENCIES<br />
Nicolas Grenier<br />
Service de Radiologie, Groupe Hospitalier Pellegrin, Bordeaux, France<br />
Progress in immunotherapy allowed increasing the number of transplanted kidneys in the recent years.<br />
Ultrasonography (US) (using B-mode and Doppler techniques) and magnetic resonance imaging (MRI) are<br />
the two major techniques for follow-up of transplanted kidneys, making it possible to avoid nephrotoxic<br />
contrast agents. Clinical emergencies following transplantation related to extrarenal causes include anuria<br />
secondary to acute obstruction of the pyelocaliceal system by urolithiasis or retroperitoneal collection,<br />
retroperitoneal hemorrhage related to arterial complication, sepsis related to retroperitoneal abcesses,<br />
thrombophlebitis on the side of transplant. Most causes of extrarenal emergencies are important to recognize<br />
because often require a surgical management.<br />
RETROPERITONEAL HEMORRHAGE<br />
Hematomas account for approximately 9% of peritransplant collections and occur usually in the postoperative<br />
course, due to surgery. The other main causes are:<br />
- early renal biopsy complicated by a cortical pseudoaneurysm which may enlarge and subsequently<br />
rupture in the perirenal space; this complication occurs immediately (24-48h) or several weeks after biopsy;<br />
- a graft rupture secondary to severe acute rejection. It occurs in 3% to 6% of renal transplants and the<br />
first two weeks after transplantation. This diagnosis must be suspected when are associated to anuria, an<br />
abdominal pain at the graft level, swelling upon the graft and hypotension or shock.<br />
- some causes are more exceptional as breakdown of the arterial anastomosis or rupture of an arterial<br />
aneurysm (mycotic or not).<br />
Hematomas appear as perirenal iso- or hyperechoic collections, without flow on color flow sonography, with<br />
an intermediate SI and a mixed and inhomogeneous SI on T1w and on T2W images, respectively. An<br />
extravasation of contrast agent can be visualized either with sonography, after injection of microbubbles or<br />
with MR imaging, after Gd injection. Pretherapeutic MR-angiography is useful to demonstrate the cause of<br />
hematoma, and more specifically, the arterial complications as aneurysms or pseudoaneurysms.<br />
According to the cause, these hemorrhagic complications must be managed either surgically if the cause is a<br />
rupture of the graft or a rupture of the arterial anastomosis, or radiologically, by embolisation, if the cause is a<br />
ruptured pseudoaneurysm or an arteriovenous fistula. If the hematoma is sufficiently large to produce<br />
ureteral obstruction, surgical evacuation is mandatory.<br />
80
ANURIA<br />
Anuria following transplantation can be due to an intrarenal or to extrarenal causes. Among extrarenal<br />
causes, post-operative hematomas and necrosis of the low ureter are the most frequent in the acute phase<br />
after transplantation and ureteral obstruction in the later phase.<br />
Causes of early obstructive anuria<br />
Necrosis of the lower ureter may occur in the early post-operative period. It produces a retroperitoneal<br />
urinoma or, exceptionally, an intraperitoneal extravasation of urine. Post-operative ischemia and subsequent<br />
necrosis of the lower ureter due to impairment of its arterial blood supply during organ removal. The<br />
incidence of this complication varies between 3 % and 10%. It. The other cause of massive urine<br />
extravasation is the breakdown of the ureteroneocystostomy which is more unusual. Whereas separation of<br />
the two causes is difficult radiologically, both require an urgent surgical correction.<br />
Sonography finds an anechoic collection at the lower pole of the kidney or intraperitoneal fluid. This fluid<br />
appears simple on non-enhanced MR T1 and T2w sequences. T2w-MR urography shows the collection and<br />
the entire dilated excretory system. However, the diagnosis requires to demonstrate extravasation of contrast<br />
medium after IV injection. This can be obtained using Gd-enhanced MRI or iodine-enhanced CT.<br />
Contamination of urine collection by the contrast agent requires often delayed imaging (5 to 15 minutes after<br />
injection).<br />
These other causes of early obstructive anuria are infrequent: obstruction by a clot during hematuria, edema<br />
of ureteral anastomosis, twist of the ureter after intraperitoneal implantation, acute hematoma (see above).<br />
Causes of delayed obstructive anuria<br />
Causes of delayed ureteral obstruction can be acute, dominated by migrated urolithisasis, or chronic,<br />
dominated by delayed collections, ureteral stricture or extrinsic obstruction. Both require an adequate<br />
urological or radiological treatment to restore a normal renal function. Urolithiasis is an unusual complication<br />
occurring in less than 1% of recipients, at least 6 months after transplantation. When ureteral, it may be<br />
complicated by acute obstruction, infection, or urinary leak secondary to erosion of the uroterovesical<br />
junction by the stone. Stones can be detected by sonography, CT or MRI.<br />
The other causes of obstruction (lymphoceles, perirenal or hilar fibrosis, urothelial tumors…) usually o not<br />
produce acute anuria and are not considered as emergencies.<br />
ACUTE SEPSIS<br />
Post-operative infection can be responsible for perirenal septic collections. Pelvic pain and graft tenderness<br />
are associated with fever and increased blood white cells. However, immunosuppression may attenuate<br />
these clinical and biological changes. Sonography shows a perirenal collection with thin or coarse echoes,<br />
often extended towards superficial planes. Exact extension of such collections must be assessed by MR<br />
imaging: the content appears as slightly hyperintense on T1w images and intermediate on T2w images; Gdenhanced<br />
sequences shows a peripheral wall enhancement, characteristic of septic collections. Treatment<br />
can be performed surgically or percutaneously with catheter drainage and general antibiotherapy.<br />
THROMBOPHLEBITIS<br />
Acute venous thrombosis of lower limbs may occur postoperatively. The risk of this complication is the<br />
extension of thrombus to the graft renal vein with a risk of graft loss if the diagnosis and the treatment are<br />
delayed. Ipsilateral acute thrombosis is the main cause of renal vein thrombosis after transplantation.<br />
Therefore, such clinical suspicion must justify the realization of sonography including the veins of lower<br />
limbs, iliac veins and the renal vein. The diagnosis of renal vein thrombosis is difficult. On sonography, the<br />
direct extension of the iliac thrombus can be visualized, causing a severe increase of resistive index with a<br />
decreased flow and a protodiastolic or a holodiastolic reflux.<br />
EXTRAURINARY EMERGENCIES<br />
Other intra-abdominal emergencies, mainly digestive, are very unususal and can be observed after<br />
intraperitoneal implantation of renal grafts. These are non specific of renal transplantation.<br />
81
Chest<br />
The immunocompromized transplanted patient is susceptible to pulmonary infections due to either common<br />
pathogens, viruses or rare opportunistic germs. Cytomegalovirus is the most common virus associated with<br />
pulmonary infections inthese patients. Viral pneumonia begin by patchy interstitial infiltrate, progressing to<br />
lobular consolidation.<br />
Abdomen<br />
Adynamic ileus is possible in the post-operative period. Main digestive complications are gastroduodenal<br />
ulcerations and acute pancreatitis. Colonic perforation due to diverticulitis is most frequent in patients with<br />
autosomic dominant polycystic disease. Finally, involvement of the large bowel by CMV may cause<br />
ulceration and colonic bleeding.<br />
CONCLUSION<br />
Diagnostic imaging plays a major role in identification of extrarenal emergencies using US and MRI for<br />
urinary complications and other techniques for extra-urinary complications. Interventional procedures can be<br />
proposed as an alternative to surgery in many circumstances.<br />
References<br />
- Letourneau JG, Day DL, Ascher NL. Radiology of organ transplantation. Mosby, St Louis, 1991<br />
- Dodd GD, Tublin ME, Shah A, Zajko AB. Imaging of vascular complications associated with renal transplants. AJR 1991; 157:449-459<br />
- N. Grenier, M. Claudon, H. Trillaud, C. Douws, O. Levantal Noninvasive imaging of vascular complications in kidney transplants. Eur<br />
Radiol 1997; 7:385-391<br />
- Neimatallah MA, Dong Q, Scheonberg S, Cho KJ, Prince MR. Magnetic resonance in renal transplantation. JMRI 1999; 10 :357-368<br />
82
WORKSHOPS<br />
RF ABLATION OF RENAL TUMORS<br />
Peter L. Choyke, M.D.<br />
National Cancer Institute, Bethesda, Maryland, USA<br />
The advent of cross sectional imaging radically changed the nature of renal cancer therapy. Whereas, prior<br />
to cross sectional imaging renal tumors presented with clinical symptoms, often at an advanced stage, after<br />
the introduction of cross sectional imaging, the number of small and asymptomatic renal tumors dramatically<br />
increased and the 5 year survival statistics for renal cancer similarly improved. Many of these incidental<br />
tumors were cured by surgical removal. As more of these tumors were removed by radical nephrectomy,<br />
surgeons and patients rapidly began to question whether nephron sparing procedures might not make more<br />
sense. The introduction of laparoscopic partial nephrectomy meant even less invasive procedures for the<br />
patient. The logical next step was the introduction of minimally invasive treatments requiring only light<br />
sedation and no hospital stay. Thus, was born Radiofrequency ablation (RFA) and cryotherapy for renal<br />
tumors.<br />
Radiofrequency ablation is itself an extension of a well known property of tissue to undergo coagulative<br />
necrosis when exposed directly to high frequency energy if the body is electrically grounded. The Bovie<br />
coagulator, operating on the same principle has been used for over 30 years during surgical procedures to<br />
stem the loss of blood by coagulation. The technical challenge for RFA was to build radiofrequency probes<br />
that created a uniform sphere of evenly heated tissue without charring the tissue. Charring leads to an<br />
insulating effect that inhibits heat transfer, limiting the killing of cells. Pulsed RF and cooled RF were<br />
developed to prevent charring. With sufficient power these probes can effectively ablate fairly large spheres<br />
of tumor [1].<br />
A companion method of ablation, cryotherapy, involves the installation of liquid nitrogen through a heat<br />
transfer probe. A spherical iceball forms at the tip of the probe. The freezing of the cytoplasm leads to<br />
expansion and crystallization of intracellular contents both of which tend to rupture cell membranes, however,<br />
the true killing effect does not occur until thawing occurs. Thus freeze-thaw cycles are required for effective<br />
cell killing [2].<br />
Image Guidance<br />
Both RFA and Cryoablation require image guidance. Some centers rely exclusively on ultrasound but most<br />
centers utilize some combination of CT, MRI or Ultrasound to place the probe accurately. In our center, CT<br />
is mostly used to guide the probe into the tumor. For RFA there is no means of monitoring heat generation in<br />
real time for CT or ultrasound. Research has suggested that MRI (observing changes in the T1 or phase of<br />
heated tissue)could provide real time heating assessment of the RFA, however, there are substantial<br />
technical challenges simply to make MR compatible RF probes and then to operate such probes in the MR<br />
environment [3]. Cryotherapy has the distinct advantage of demonstrating changes, obvious on MRI by the<br />
absence of signal or on CT as a decrease in attenuation during the ice ball. Both MRI and CT aid in the<br />
guidance of these minimally invasive therapies [4].<br />
Patient Selection<br />
Like all procedures in medicine, care should be exercised in selecting patients. Even with the considerable<br />
experience of RFA and cryotherapy worldwide, these procedures are still not considered the gold standard<br />
for therapy of renal cancer. However, they have become more universally accepted in a variety of situations.<br />
Patients with hereditary renal cancers in whom repeated surgical procedures would otherwise be necessary<br />
are good candidates for RFA/cryo [5]. Similarly, elderly patients who require treatment but who are high risk<br />
for surgery and patients with single kidneys in whom surgery could result in loss of the remaining kidney are<br />
good candidates for RFA/cryo. Other indications include massive hematuria due to tumor bleeding [6].<br />
83
Tumor location plays a role in patient selection. Peripheral lateral tumors are ideal as a clear path to kidney<br />
tumor can be found without interfering structures. Deeper tumors can be problematic because of the heat<br />
sink effect caused by large vessels in the renal sinus. The patient must be prepared to undergo surgery of<br />
this lesion if it recurs after RFA/cryo. Another complication of treating deep lesions is the trapped calyx<br />
caused by the inadvertent occlusion of the upper or lower pole collecting system. Similarly lower pole<br />
exophytic tumors or tumors near the renal hilum can lead to hydronephrosis and obstruction if the ureter or<br />
pelvis is included in the treatment field [7]. This complication can be difficult to treat and may require<br />
extended stenting and/or surgical repair.<br />
Patients with bleeding disorders or immunologic disorders are relatively contraindicated as bleeding and/or<br />
infection can occur.<br />
Procedure<br />
The RFA/cryo procedure usually takes less than one hour. Intravenous conscious sedation with local<br />
anesthesia is desirable. The skin is prepped and draped and a biopsy needle is placed within the tumor. This<br />
material is sent for histologic analysis. In some centers RFA/cryo does not proceed until the diagnosis has<br />
been made by the pathologist [8]. Our approach is to obtain the biopsy but proceed to the treatment at the<br />
same time. It should be noted however, that a high percentage (up to 20% in one study) of incidentally<br />
detected renal masses were benign. For lesions adjacent to bowel a “cushion” of fluid can be instilled to<br />
separate the lesion from the bowel [9].<br />
Treatment with RFA/cryo is dependent on the success of tissue heating/freezing. Thermistors in the RF<br />
probe indicate the temperature at the periphery of the treated tissue but can be misleading. Imaging can be<br />
used to ascertain the size and shape of the iceball during cryo. It is possible to treat multiple lesions at one<br />
session.<br />
The patient is observed for a period of hours after the procedure. Generally, after recovery from anesthesia<br />
they can be discharged home. Some are better off with an overnight stay if the procedure begins in the<br />
afternoon. Usually discharge is possible by the next day. Occasionally, the patient may have pain associated<br />
with procedure, usually it is relieved by analgesics.<br />
Follow-up<br />
It is vital that the patient be checked periodically to insure that the lesion was satisfactorily treated. We<br />
generally obtain our first post treatment study at 3 months. We perform pre and post contrast scans (arterial<br />
and venous phase). A successful treatment will demonstrate a lesion slightly denser than renal parenchyma<br />
(40-55HU) on pre contrast scans with minimal (
treatment to the size and shape of the lesion rather than having a “one size fits all” approach. Furthermore,<br />
methods of amplifying the effect within the kidney tumor while minimizing the effect in normal tissue is being<br />
considered with certain targeted therapies that render the tumor more vulnerable to heating or freezing.<br />
Better methods of monitoring kidneys for early recurrent disease such as with PET scanning are under<br />
evaluation. The minimally invasive treatment of larger renal tumors is also being considered using multiprobe<br />
arrays. These developments offer hope for the future that therapies can be delivered with minimal<br />
discomfort and inconvenience to the patient.<br />
1. Mayo-Smith WW, Dupuy DE, Parikh PM, Pezzullo JA, Cronan JJ. Imaging-guided percutaneous radiofrequency ablation of solid renal<br />
masses: techniques and outcomes of 38 treatment sessions in 32 consecutive patients. AJR Am J Roentgenol. 2003 Jun;180(6):1503-<br />
8.<br />
2. Finelli A, Rewcastle JC, Jewett MA. Cryotherapy and radiofrequency ablation: pathophysiologic basis and laboratory studies. Curr<br />
Opin Urol. 2003 May;13(3):187-91.<br />
3. Lewin JS, Nour SG, Connell CF, Sulman A, Duerk JL, Resnick MI, Haaga JR. Phase II clinical trial of interactive MR imaging-guided<br />
interstitial radiofrequency thermal ablation of primary kidney tumors: initial experience. Radiology. 2004 Sep;232(3):835-45.<br />
4. Hinshaw JL, Lee FT Jr. Image-guided ablation of renal cell carcinoma. Magn Reson Imaging Clin N Am. 2004 Aug;12(3):429-47<br />
5. Pautler SE, Pavlovich CP, Mikityansky I, Drachenberg DE, Choyke PL, Linehan WM, Wood BJ, Walther MM. Retroperitoneoscopicguided<br />
radiofrequency ablation of renal tumors. Can J Urol. 2001 Aug;8(4):1330-3<br />
6. Neeman Z, Sarin S, Coleman J, Fojo T, Wood BJ. Radiofrequency ablation for tumor-related massive hematuria. J Vasc Interv Radiol.<br />
2005 Mar;16(3):417-21.<br />
7. Rhim H, Dodd GD 3rd, Chintapalli KN, Wood BJ, Dupuy DE, Hvizda JL, Sewell PE, Goldberg SN. Radiofrequency thermal ablation of<br />
abdominal tumors: lessons learned from complications. Radiographics. 2004 Jan-Feb;24(1):41-52<br />
8. Farrell MA, Charboneau JW, Callstrom MR, Reading CC, Engen DE, Blute ML. Paranephric water instillation: a technique to prevent<br />
bowel injury during percutaneous renal radiofrequency ablation. AJR Am J Roentgenol. 2003 Nov;181(5):1315-7<br />
9. Tuncali K, vanSonnenberg E, Shankar S, Mortele KJ, Cibas ES, Silverman SG. Evaluation of patients referred for percutaneous<br />
ablation of renal tumors:importance of a preprocedural diagnosis.AJR Am J Roentgenol. 2004 Sep;183(3):575-82<br />
10. Goldberg SN, Grassi CJ, Cardella JF, Charboneau JW, Dodd Iii GD, Dupuy DE, Gervais D, Gillams AR, Kane RA, Lee FT Jr, Livraghi<br />
T, McGahan J, Phillips DA, Rhim H, Silverman SG. Image-guided Tumor Ablation: Standardization of Terminology and Reporting<br />
Criteria. Radiology. 2005 Apr 21; epub<br />
DIAGNOSIS OF PROSTATE CARCINOMA: (IS THERE A) ROLE FOR THE<br />
RADIOLOGIST (?)<br />
R.H. Oyen<br />
Department of Radiology, University Hospitals Gasthuisberg<br />
Katholieke Universiteit Leuven<br />
Raymond.oyen@uzleuven.be<br />
The current situation<br />
The current situation in prostate imaging, in particular in transrectal ultrasound (TRUS) of the prostate gland<br />
is different in different countries, and in the same country there are differences amongst the hospitals. Most<br />
often, TRUS of the prostate is performed by urologists. Their major arguments include a) their experience in<br />
performing digital rectal examination of the prostate gland, b) the fact that it is an ‘endoluminal’ procedure,<br />
and c) the fact that TRUS-guided-biopsies of the prostate are an essential part of the procedure. Indeed, the<br />
ultimate diagnosis or confirmation of prostate carcinoma is still based on histological examination of TRUSguided<br />
biopsy cores either targeted at hypoechoic peripheral zone lesions or/and obtained by any set of at<br />
random biopsies.<br />
CT and MR imaging of the prostate glands or in men with prostatic carcinoma is almost exclusively<br />
performed by radiologists.<br />
Radiologists and TRUS<br />
Even though the majority of TRUS-examinations of the prostate is in the hands of urologists, radiologists<br />
must gain experience with TRUS to serve referred patients for prostatic ultrasonography in the best possible<br />
way, including the performance of TRUS-guided biopsies.<br />
The prostate is a parenchymatous organ comparable to other organs prone to ultrasound examinations<br />
(perhaps best comparable to another urological structure, the kidney). Therefore, as with other organs and<br />
structures, knowledge of the normal anatomy, the understanding of different disease processes involving the<br />
85
prostate gland, and the use of dedicated equipment are essential prerequisites to achieve high quality<br />
examinations and reports.<br />
Radiologists are trained to detect focal lesions in parenchymal organs. This experience can be extended to<br />
the prostate gland to detect focal lesions in the peripheral zone to improve the sensitivity of TRUS and to<br />
improve the yield of TRUS-guided biopsies.<br />
Many radiologists have large experience in ultrasound guided biopsies of organs and mass lesions. Again,<br />
this experience can be extended to prostate biopsies.<br />
Radiologists are trained to use color-Doppler in different organs and areas. This experience can be beneficial<br />
for prostatic ultrasound to detect isoechoic hypervascular ‘lesions’ and to target biopsies at this areas.<br />
Since US contrast agents are more generally used by radiologists, and since there are promising data on the<br />
use of contrast agents in prostate ultrasonography, patients could benefit from radiologists experience to<br />
perform contrast enhanced ultrasonography, to further improve lesion detection, lesion characterization, and<br />
to target biopsies.<br />
Radiologists and MRI<br />
MRI and the diagnosis of prostatic carcinoma<br />
Perhaps MR imaging of the prostate has become a greater challenge for radiologists. With the growing<br />
awareness of prostate cancer and the tendency towards its earlier detection, probably more patients will be<br />
referred for MRI-detection of prostatic carcinoma, in particular patients with repeatedly negative biopsies and<br />
increased or increasing PSA.<br />
Radiologists should know what can be expected from MRI (i.e. detection of peripheral zone lesions), and<br />
what is state-of-the-art MR-examination of the prostate, including the performance of contrast-enhanced MRI<br />
(i.e. dynamic contrast-enhanced MRI). Only a dedicated technique enables differentiation between benign<br />
and malignant focal lesions in the peripheral zone. With optimized technique, MR may be indicated for<br />
detection and characterization of carcinoma originating in the central gland.<br />
In addition, with appropriate material, MR-guided biopsies of suspicious areas can be performed. It can be of<br />
great advantage that the radiologist reading the MR, performs the biopsies TRUS-guided with the knowledge<br />
of the results of the MR-study. This safes considerable MR-time.<br />
MR-spectroscopy is another modality enabling lesion detection and characterization. This technique,<br />
however, needs additional support of physicists to achieve reliable and reproducible data.<br />
MRI and staging of prostatic carcinoma<br />
Radiologists should guide the clinicians to proper indications and patient selection for MR-imaging for T- and<br />
N-staging, including the use of USPIO’s for N-staging in selected patients.<br />
MRI and radiation therapy and other types of local therapy<br />
Radiologists should gain experience in the communication of MR-data (fused data of imaging, dynamic<br />
contrast-enhanced studies and spectroscopy) to radiotherapists for dose calculation for external beam<br />
radiotherapy, intensity modulated radiotherapy, and brachytherapy. Likewise, similar information can be<br />
communicated to urologists to direct other types of therapy (cryotherapy, radio frequency ablation.<br />
Radiologists and CT<br />
Radiologists should outline indications for CT in men with histology proven prostate carcinoma (N-staging).<br />
Radiologists and PET-CT<br />
Radiologists should carefully follow the evolution of PET-CT for the detection and staging of prostatic<br />
carcinoma. Preliminar data suggest that specific agents used for PET are likely to become the future CT-<br />
‘contrast agents’.<br />
86
ASSESSMENT OF LOCAL EXTENSION OF PROSTATE CANCER BY TRUS<br />
AND TRUS-GUIDED BIOPSY<br />
François Cornud<br />
Service de Radiologie, Hôpital Cochin, 27 rue du Faubourg St Jacques, 75014.<br />
Several parameters are used to detect or predict occult extraprostatic spread of clinically confined prostate<br />
cancer. The poor accuracy of rectal examination can be substantially improved by two means. The first is<br />
TRUS-guided biopsies of the extraprostatic fat and/or the seminal vesicles in selected cases of clinically<br />
localized palpable tumor. The second is a combined use of rectal examination, Gleason score and PSA level<br />
to establish a mathematical model (nomograms or Partin Tables (1)) which can classify patients in low,<br />
intermediate and high-risk groups for extraprostatic spread. Moreover, the measurement of the amount of<br />
cancer tissue present in biopsy cores, assessed by the calculation of the number of sextants involved by<br />
tumor (2) and/or the length of tumor tissue (3), has been added to better assess the risk of pT3 stage,<br />
particularly in patients of the intermediate-risk group in the tables of Partin.<br />
TRUS signs of extensive T3 stage tumors are visible in large volume tumors (≥ stage T2b-c, i.e involving<br />
at least an entire lobe or both lobes),<br />
The prostatic contour is markedly irregular, or the tumor is visible within the periprostatic fat, often at the level<br />
of the posterolateral neurovascular bundles at the prostatic apex or base. When ECE is visible across the<br />
posterior aspect of the prostate, the tumor is generally a clinical stage T3. Extensive signs of ECE are<br />
observed in a minority of cases in patients with a newly diagnosed prostate cancer, owing to the fact that<br />
most cancers are diagnosed, since the PSA era, at an earlier stage.<br />
TRUS extensive or direct signs of SVI are very rarely observed. The seminal vesicles are enlarged and have<br />
an altered echotexture. Direct tumor growth through a dilated SV is often observed in cases where stage T3b<br />
was clinically suspected.<br />
TRUS signs of presumptive T3 stage tumors.<br />
Presumptive or indirect signs of ECE. A broad contact (> 23 mm) between the tumor and the prostate<br />
contour is a represents a presumption sign of ECE which indicates biopsy of the periprostatic fat. This policy<br />
should be extended to any focal bulging of the prostate contour by a visible or palpable hypoechoic lesion.<br />
However, the bulging can be subtle and should be thoroughly searched to perform one or several biopsies of<br />
the extraprostatic spaces. Lee et al. (4) highlighted the value of sampling the periapical fat around the<br />
neurovascular bundles to detect occult ECE and Ravery et al. (5) showed that the specificity of the technique<br />
was 100%. Endorectal MRI contributes to the prognostication of these biopsy stage T3 tumors. In our<br />
experience (unpublished data), approximately half these tumors show no ECE on endorectal MRI. The<br />
prognosis of these forms is better, as it has been reported that MRI T2 stage tumors show established<br />
pathological ECE in no more than 15% of cases (6), compared to 94% of MRI T3 stage tumors (6).<br />
Seminal vesicle invasion (SVI) is very rarely detected on TRUS without the contribution of TRUS-guided<br />
biopsies of the seminal vesicles. Indications of SV biopsy depend strongly on TRUS findings. The first sign is<br />
close contact between the nodule and the caudal junction of the seminal vesicle and the vas deferens (4, 7).<br />
When the junction has a normal TRUS appearance, i.e. separated from the tumor by a strip of isoechoic<br />
prostatic tissue, SVI is very unlikely (7). The second sign is visible in the parasagittal plane when the tumor<br />
obscurs the prostato-seminal angle. This sign can indicate ECE followed by a direct invasion of the wall of<br />
the ipsilateral seminal vesicle.<br />
There are other reported factors predictive of a positive SV biopsy result. The positive biopsy rate of SV<br />
biopsy is 20% in case of PSA level >10 ng/ml versus 6% in case of PSA level ≤10 ng/ml. In patients with a<br />
Gleason score ≥7, the positive biopsy rate is 35-40% compared to 7% for patients with a lower grade (8). As<br />
mentionned above, tumor location plays a key role and involvement of the prostate base on biopsies is<br />
predictive of SVI (9). This approach requires second set of biopsies which can be avoided if presumptive<br />
signs of SVI are detected at the time of the first set of biopsies.<br />
87
Sextant biopsies and extraprostatic spread. A different approach for staging a newly diagnosed prostate<br />
cancer is to combine the results of rectal examination, PSA level and Gleason score which are then<br />
integrated in nomograms (10) which give a statistical risk of extraprostatic spread. The main value of the<br />
nomogram is to select patients at low risk (≤ 20%) and high risk (≥80%) of extraprostatic spread. However,<br />
between these extremes, the risk of extraprostatic spread ranges from 25 to 72% and the nomogram does<br />
not offer enough accuracy to choose a therapeutic option, as underlined by D'Amico et al.(2). The nomogram<br />
carries a risk of pitfalls at each clinical stage (1). To improve accuracy of nomograms, it has been proposed<br />
to indirectly estimate tumor volume by two means: the first is to calculate the number of sextants involved on<br />
biopsies and the second is to measure the length of cancer tissue on biopsy cores.<br />
Numerous reports have confirmed that the number of involved sextants is a powerful independent prognostic<br />
factor – even more powerful than the PSA level and the Gleason score. In patients with three or more<br />
involved sextants the risk of postoperative failure (i.e. pT3 stage, positive margins or biological progression<br />
after radical prostatectomy) is at least 45% (2, 5, 11-18). The number of positive biopsy specimens can also<br />
be used to identify patients with a risk of extensive (i.e. established) pT3 tumors, who have a poor outcome<br />
after surgery(19, 20). The percentage of extensive pT3 tumors is only 7% among patients with one or two<br />
invaded sextants and almost five times higher (33%) when the number of involved sextants reaches three<br />
(6). These findings have important implications with regard to the indications for endorectal MRI, which can<br />
depict only extensive pT3 tumors (6).<br />
The amount of cancer in biopsy cores. Three measurements are performed (21), namely the total length of<br />
cancer (sum in mm of cancer present on all the cores), the maximum length observed on one core, and<br />
percentage of cancer tissue (ratio of the sum in mm of cancer tissue on all biopsies to the total length of the<br />
samples). Some studies have concluded that measurement of the amount of cancer more accurately predict<br />
pT3 stage than the number of involved sextants (22-26), but others have found no such difference (27, 28).<br />
As quantitative measurement of tumor and core length represents substantial work for the pathologist, further<br />
studies are needed before recommending routine use of this method.<br />
Conclusion<br />
Local staging by TRUS-guided biopsy of the periprostatic spaces or seminal vesicles are strongly<br />
recommended when indirect signs of T3a or T3b disease are detected by TRUS, which is only observed in<br />
case of large tumors that are visible by TRUS and clinically palpable in most cases. When this direct staging<br />
is not possible, the risk of extraprostatic disease can be estimated by counting the number of sextants<br />
involved by the tumor and/or by measuring the mm of cancer tissue in biopsy cores (the latter method is still<br />
under evaluation). This "quantitative histology" represents an excellent tool for selecting patients at<br />
intermediate or high risk of extraprostatic spread, who need further imaging investigations (i.e endorectal<br />
MRI) to detect an established occult extraprostatic spread.<br />
References<br />
1. Partin AW, Mangold LA, Lamm DM, Walsh PC, Epstein JI, Pearson JD. Contemporary update of prostate cancer staging nomograms<br />
(Partin Tables) for the new millennium. Urology 2001;58(6):843-8.<br />
2. D'Amico AV, Whittington R, Malkowicz SB, Schultz D, Schnall M, Tomaszewski JE, et al. Role of percent positive biopsies and<br />
endorectal coil MRI in predicting prognosis in intermediate-risk prostate cancer patients. Cancer J Sci Am 1996;2(6):343-350.<br />
3. Freedland SJ, Aronson WJ, Terris MK, Kane CJ, Amling CL, Dorey F, et al. Percent of prostate needle biopsy cores with cancer is<br />
significant independent predictor of prostate specific antigen recurrence following radical prostatectomy: results from SEARCH<br />
database. J Urol 2003;169(6):2136-41.<br />
4. Lee F, Torp-Pedersen ST, Siders DB, Littrup PJ, McLeary RD. Transrectal ultrasound in the diagnosis and staging of prostatic<br />
carcinoma. Radiology 1989;170(3 Pt 1):609-15.<br />
5. Ravery V, Boccon-Gibod LA, Dauge-Geffroy MC, Billebaud T, Delmas V, Meulemans A, et al. Systematic biopsies accurately predict<br />
extracapsular extension of prostate cancer and persistent/recurrent detectable PSA after radical prostatectomy. Urology<br />
1994;44(3):371-6.<br />
6. Cornud F, Flam T, Chauveinc L, Hamida K, Chretien Y, Vieillefond A, et al. Extraprostatic spread of clinically localized prostate cancer:<br />
factors predictive of pT3 tumor and of positive endorectal MR imaging examination results. Radiology 2002;224(1):203-10.<br />
7. Cornud F, Belin X, Fromont G, Chretien Y, Helenon O, Boisrond L, et al. [What may be expected from endorectal ultrasonography and<br />
magnetic resonance imaging in the assessment of local extension of cancer of the prostate?]. J Urol 1991;97(4-5):179-88.<br />
8. Stock RG, Stone NN, Ianuzzi C, Unger P. Seminal vesicle biopsy and laparoscopic pelvic lymph node dissection: implications for<br />
patient selection in the radiotherapeutic management of prostate cancer. Int J Radiat Oncol Biol Phys 1995;33(4):815-21.<br />
9. Guillonneau B, Debras B, Veillon B, Bougaran J, Chambon E, Vallancien G. Indications for preoperative seminal vesicle biopsies in<br />
staging of clinically localized prostatic cancer. Eur Urol 1997;32(2):160-5.<br />
88
10. Partin AW, Kattan MW, Subong EN, Walsh PC, Wojno KJ, Oesterling JE, et al. Combination of prostate-specific antigen, clinical stage,<br />
and Gleason score to predict pathological stage of localized prostate cancer. A multi-institutional update [see comments] [published<br />
erratum appears in JAMA 1997 Jul 9;278(2):118]. Jama 1997;277(18):1445-51.<br />
11. Badalament RA, Miller MC, Peller PA, Young DC, Bahn DK, Kochie P, et al. An algorithm for predicting nonorgan confined prostate<br />
cancer using the results obtained from sextant core biopsies with prostate specific antigen level. J Urol 1996;156(4):1375-80.<br />
12. Borirakchanyavat S, Bhargava V, Shinohara K, Toke A, Carroll PR, Presti JC, Jr. Systematic sextant biopsies in the prediction of<br />
extracapsular extension at radical prostatectomy. Urology 1997;50(3):373-8.<br />
13. Egawa S, Suyama K, Matsumoto K, Satoh T, Uchida T, Kuwao S, et al. Improved predictability of extracapsular extension and seminal<br />
vesicle involvement based on clinical and biopsy findings in prostate cancer in Japanese men. Urology 1998;52(3):433-40.<br />
14. Narayan P, Gajendran V, Taylor SP, Tewari A, Presti JC, Jr., Leidich R, et al. The role of transrectal ultrasound-guided biopsy-based<br />
staging, preoperative serum prostate-specific antigen, and biopsy Gleason score in prediction of final pathologic diagnosis in prostate<br />
cancer. Urology 1995;46(2):205-12.<br />
15. Peller PA, Young DC, Marmaduke DP, Marsh WL, Badalament RA. Sextant prostate biopsies. A histopathologic correlation with radical<br />
prostatectomy specimens. Cancer 1995;75(2):530-8.<br />
16. Wills ML, Sauvageot J, Partin AW, Gurganus R, Epstein JI. Ability of sextant biopsies to predict radical prostatectomy stage. Urology<br />
1998;51(5):759-64.<br />
17. D'Amico AV, Whittington R, Malkowicz SB, Schultz D, Fondurulia J, Chen MH, et al. Clinical utility of the percentage of positive prostate<br />
biopsies in defining biochemical outcome after radical prostatectomy for patients with clinically localized prostate cancer [see<br />
comments]. J Clin Oncol 2000;18(6):1164-72.<br />
18. Huland H, Hammerer P, Henke RP, Huland E. Preoperative prediction of tumor heterogeneity and recurrence after radical<br />
prostatectomy for localized prostatic carcinoma with digital rectal, examination prostate specific antigen and the results of 6 systematic<br />
biopsies. J Urol 1996;155(4):1344-7.<br />
19. Partin AW, Borland RN, Epstein JI, Brendler CB. Influence of wide excision of the neurovascular bundle(s) on prognosis in men with<br />
clinically localized prostate cancer with established capsular penetration. J Urol 1993;150(1):142-6; discussion 146-8.<br />
20. Ohori M, Scardino PT, Lapin SL, Seale-Hawkins C, Link J, Wheeler TM. The mechanisms and prognostic significance of seminal<br />
vesicle involvement by prostate cancer. Am J Surg Pathol 1993;17(12):1252-61.<br />
21. Bismar TA, Lewis JS, Jr., Vollmer RT, Humphrey PA. Multiple measures of carcinoma extent versus perineural invasion in prostate<br />
needle biopsy tissue in prediction of pathologic stage in a screening population. Am J Surg Pathol 2003;27(4):432-40.<br />
22. Egan AJ, Bostwick DG. Prediction of extraprostatic extension of prostate cancer based on needle biopsy findings: perineural invasion<br />
lacks significance on multivariate analysis. Am J Surg Pathol 1997;21(12):1496-500.<br />
23. Ravery V, Chastang C, Toublanc M, Boccon-Gibod L, Delmas V. Percentage of cancer on biopsy cores accurately predicts<br />
extracapsular extension and biochemical relapse after radical prostatectomy for T1-T2 prostate cancer. Eur Urol 2000;37(4):449-55.<br />
24. Freedland SJ, Csathy GS, Dorey F, Aronson WJ. Percent prostate needle biopsy tissue with cancer is more predictive of biochemical<br />
failure or adverse pathology after radical prostatectomy than prostate specific antigen or Gleason score. J Urol 2002;167(2 Pt 1):516-<br />
20.<br />
25. Freedland SJ, Aronson WJ, Csathy GS, Kane CJ, Amling CL, Presti JC, Jr., et al. Comparison of percentage of total prostate needle<br />
biopsy tissue with cancer to percentage of cores with cancer for predicting PSA recurrence after radical prostatectomy: results from the<br />
SEARCH database. Urology 2003;61(4):742-7.<br />
26. Naya Y, Slaton JW, Troncoso P, Okihara K, Babaian RJ. Tumor length and location of cancer on biopsy predict for side specific<br />
extraprostatic cancer extension. J Urol 2004;171(3):1093-7.<br />
27. Sebo TJ, Bock BJ, Cheville JC, Lohse C, Wollan P, Zincke H. The percent of cores positive for cancer in prostate needle biopsy<br />
specimens is strongly predictive of tumor stage and volume at radical prostatectomy [see comments]. J Urol 2000;163(1):174-8.<br />
28. Linson PW, Lee AK, Doytchinova T, Chen MH, Weinstein MH, Richie JP, et al. Percentage of core lengths involved with prostate cancer<br />
does it add to the percentage of positive prostate biopsies in predicting postoperative prostate-specific antigen outcome for men with<br />
intermediate-risk prostate cancer? Urology 2002;59(5):704-8.<br />
WHAT TO DO WITH SUSPICIOUS ADENEXAL MASS AT US?<br />
Kaori Togashi<br />
Kyoto university<br />
INTRODUCTION<br />
Ovarian cancer is the second most common gynecologic malignancy, but has the highest mortality rate of all<br />
of the gynecologic malignancies with an overall 5-year survival rate of 46% [1]. In spite of diagnostic and<br />
therapeutic advances in the care of women with ovarian cancer, the overall 5-year survival rate has changed<br />
little [1, 2]. The major reason for this poor prognosis is that roughly 75% of patients have diseases at an<br />
advanced stage [1, 2]. Early detection with accurate staging is of paramount importance to improve<br />
prognosis. This presentation briefly discusses the clinical roles of imaging studies, including computed<br />
tomography (CT) and magnetic resonance (MR) imaging, and Posittron computed Tomogrraphy (PET) in the<br />
course of diagnosis, staging, and treatment of suspicious adnexal masses at US.<br />
The role of IMAGING EVALUATION OF SUSPICIOUS ADNEXAL MASSES AT US<br />
For uncertain or problematic cases at US to determine the degree of malignancy, follow up US, a serum CA-<br />
125 level, and MR imaging narrow the differential diagnosis. In postmenopausal women, we should be<br />
89
careful as levels exceeding 65 U/ml are predictive of malignancy in 75% of women with pelvic masses,<br />
although in premenopausal women with more than 90% of findings being false-positive[3]. MR imaging<br />
helps to distinguish benign from malignant, with an overall accuracy for the diagnosis of malignancy of 93 %.<br />
The MR findings most predictive of malignancy are vegetation in a cystic tumor and necrosis in a solid tumor<br />
[4] . Dissemination and adenopathy should also be carefully evaluated, as they can be a strong indicator of<br />
malignancy. MR imaging is frequently helpful in the further characterization of adnexal masses. The<br />
accuracy of MR imaging in the confident diagnosis of mature cystic teratoma, endometrial cysts, and<br />
leiomayomas is very high. CT is not indicated for differential diagnosis of adnexal masses because of poor<br />
soft tissue discrimination, except for fatty tissue and for calcification, and the disadvantages of irradiation.<br />
PET is not indicated to determine the degree of malignancy [5].<br />
If MR imaging confirms a dermoid or endometrial cyst, further diagnostic procedures are unnecessary [5]. If<br />
MR findings allow the unequivocal diagnosis of a dermoid or endometrial cyst, laparoscopy will safely be<br />
referred [5]. In all other cases, surgical evaluation should be considered at the time, and an intraoperative<br />
frozen section is the golden standard for patients with ovarian tumors. Patients with advaced stage ovarian<br />
cancer experience a significant survival advantage when a gynecologic oncologist is involved in their<br />
treatment [6]. However, unfortunately, gynecologic oncologists see less than half of ovarian cancer patients<br />
at present [6]. Whatever the modality used, imaging studies is important in the determination of the<br />
appropriate referral to gynecololgic oncologists, and thus to obtain a longer survival [7].<br />
STAGING<br />
The majority of ovarian cancers present as advanced stage III-IV. The role of imaging in staging ovarian<br />
cancer has been considered to be of limited use previously. However, surgical staging itself has an inherent<br />
weakness. Even with a laparotomy, the detection of all tumors is not feasible; up to 50% of patients who<br />
have a negative second-look surgery result eventually develop a recurrent tumor [8,9]. An accurate<br />
preoperative depiction of possible sites of dissemination with imaging studies is mandatory for determining<br />
the sites for biopsy during surgery, in addition to referring the patient with an advanced stage of the disease<br />
to a cancer center [10].<br />
CT has been demonstrated to be reasonably accurate in determining which patients may have tumor<br />
implants that can be optimally surgically debulked [11,12]. Excellent results are recently shown in CT and<br />
contrast-enhanced MR imaging in delineating small peritoneal diseases, with sensitivities of 95% and 92%,<br />
respectively [10]. Both modalities are equally accurate, and can be used to stage advanced ovarian cancer<br />
[10]. The most common sites of peritoneal disease are the omentum, followed by subphrenic spaces, the<br />
mesentery (large and small bowel), the anterior part of the abdomen, and the paracolic gutters [10]. US is<br />
generally considered to be of limited use to help evaluate hepatic substances and the lymph nodes, however,<br />
a large study has shown little difference between US, CT, and MRI in the staging of ovarian cancer with the<br />
highest specificity of 96% and the lowest sensitivity of 75% for US [7]. If an abdominal spread is detected<br />
with US, the accuracy of a diagnosis of a stage III disease is high. Because of the importance of not<br />
understaging the abdominal malignancy as a disease limited to the pelvis, if stage III cancer is not detected<br />
at the initial abdominal US, CT or MR, imaging should be performed because of their higher sensitivities in<br />
staging [7]. The role of PET in staging ovarian cancer is still under debate. Several studies have shown its<br />
value in the evaluation of recurrent ovarian tumor, however the data is limited for fresh ovarian tumors [13] .<br />
Larger study will be necessary to conclude the role of PET or CT-PET in staging ovarian cancer.<br />
CONCLUSION<br />
Although it is difficult to suggest a simple strategy for evaluating the state of women with adnexal masses,<br />
the correct preoperative diagnosis of ovarian cancer with the use of any of imaging studies will lead to an<br />
appropriate referral to a specialist in gynecologic oncology and offer a significant survival advantage for<br />
patients with ovarian cancer.<br />
References<br />
1. American Cancer Society (1998) Cancer facts and figures: 1998. American Cancer Society 13<br />
2. Pecorelli S (1998) FIGO annual report on the results of treatment in gynaecological cancer, volume 23. J Epidemiol Biostatistics 3: 1-<br />
135<br />
3. Bohm-Velez M, Mendelson E, Bree R, Finberg H, Fishman EK, Hricak H, Laing F, Sartoris D, Thurmond A, Goldstein S (2000)<br />
Ovarian cancer screening. American College of Radiology. ACR Appropriateness Criteria. Radiology 215 Suppl: 861-871<br />
90
4. Hricak H, Chen M, Coakley FV, Kinkel K, Yu KK, Sica G, Bacchetti P, Powell CB (2000) Complex adnexal masses: detection and<br />
characterization with MR imaging-- multivariate analysis. Radiology 214: 39-46<br />
5. Rieber A, Nussle K, Stohr I, Grab D, Fenchel S, Kreienberg R, Reske SN, Brambs HJ (2001) Preoperative diagnosis of ovarian tumors<br />
with MR imaging: comparison with transvaginal sonography, positron emission tomography, and histologic findings. Am J Roentgenol<br />
177: 123-129<br />
6. Carney ME, Lancaster JM, Ford C, Tsodikov A, Wiggins CL (2002) A population-based study of patterns of care for ovarian cancer:<br />
who is seen by a gynecologic oncologist and who is not? Gynecol Oncol 84: 36-42<br />
7. Kurtz AB, Tsimikas JV, Tempany CM, Hamper UM, Arger PH, Bree RL, Wechsler RJ, Francis IR, Kuhlman JE, Siegelman ES, Mitchell<br />
DG, Silverman SG, Brown DL, Sheth S, Coleman BG, Ellis JH, Kurman RJ, Caudry DJ, McNeil BJ (1999) Diagnosis and staging of<br />
ovarian cancer: comparative values of Doppler and conventional US, CT, and MR imaging correlated with surgery and histopathologic<br />
analysis--report of the Radiology Diagnostic Oncology Group. Radiology 212:19-27<br />
8. Friedman JB, Weiss NS (1990) Second thoughts about second-look laparotomy in advanced ovarian cancer. N Engl J Med 322: 1079-<br />
1082<br />
9. Podratz KC, Malkasian GD, Jr., Wieand HS, Cha SS, Lee RA, Stanhope CR, Williams TJ (1988) Recurrent disease after negative<br />
second-look laparotomy in stages III and IV ovarian carcinoma. Gynecol Oncol 29: 274-282<br />
10. Tempany CM, Zou KH, Silverman SG, Brown DL, Kurtz AB, McNeil BJ (2000) Staging of advanced ovarian cancer: comparison of<br />
imaging modalities-- report from the Radiological Diagnostic Oncology Group. Radiology 215: 761-767<br />
11. Forstner R, Hricak H, Occhipinti KA, Powell CB, Frankel SD, Stern JL (1995) Ovarian cancer: staging with CT and MR imaging.<br />
Radiology 197:619-26<br />
12. Meyer JI, Kennedy AW, Friedman R, Ayoub A, Zepp RC (1995) Ovarian carcinoma: value of CT in predicting success of debulking<br />
surgery. Am J Roentgenol 165:875-8<br />
13. Nakamoto Y, Saga T, Ishimori T, Mamede M, Togashi K, Higuchi T, Mandai M, Fujii S, Sakahara H, Konishi J (2001) Clinical value of<br />
positron emission tomography with FDG for recurrent ovarian cancer. Am J Roentgenol 176: 1449-1454<br />
IMAGING OF ENDOMETRIAL CANCER: THE YORKSHIRE CANCER<br />
NETWORK GUIDELINES<br />
Sarah E Swift, Michael J Weston and John A Spencer<br />
Consultant Radiologists, The Leeds Cancer Centre at St James’s University Hospital, Leeds LS9 7TF, UK<br />
Endometrial cancer is a disease of older women. Less than 5% of cases occur in premenopausal women. It<br />
has similar incidence to ovarian and cervical cancer but much lower mortality as most women present with<br />
early stage disease (appendices 1, 2) since unexpected vaginal bleeding is a worrying symptom. Prompt<br />
assessment is required to distinguish those women with cancer from those with other benign, senile and<br />
atrophic pathologies. In this brief review we describe our practical approach to imaging of endometrial<br />
cancer.<br />
The main role of ultrasound (US), in women suspected of having endometrial cancer, is to identify those who<br />
do not require hysteroscopy and guided biopsy. There is also no role for ultrasound in women who will<br />
undergo hysteroscopy and biopsy irrespective of the findings of US.<br />
Primary indications for ultrasound or hysteroscopy<br />
• Post-menopausal bleeding (PMB): bleeding after six months amenorrhoea is the cardinal symptom of<br />
endometrial cancer<br />
• Persistent unexpected bleeding with hormone replacement therapy<br />
• Persistent unexplained vaginal discharge in a postmenopausal woman<br />
• Pre-menopausal bleeding: persistent or heavy intermenstrual bleeding, symptoms which demand<br />
consideration of cervical cancer<br />
Women should attend with a full bladder. Before the scan the menstrual state should be recorded, as well as<br />
any history of gynaecological surgery, IUCD and any medications such as Tamoxifen, HRT etc. If cyclical<br />
HRT is being taken, the scan should be timed for the withdrawal bleed.<br />
A transabdominal scan is done first. This is so that large masses that extend out of the pelvis, omental cake<br />
or ascites are not overlooked. The kidneys should be examined looking primarily for hydronephrosis as an<br />
integral part of any pelvic scan. A transvaginal scan is essential to assess the endometrium and requires the<br />
bladder to be emptied. A transvaginal scan is a dynamic investigation in that the relative mobility of the<br />
91
pelvic structures can be assessed. The free hand can also be used to press gently on the lower abdomen to<br />
bring structures into view.<br />
Minimum imaging protocol of the endometrium<br />
• Uterus in longitudinal and transverse sections ( LS and TS)<br />
• Endometrium in LS and TS<br />
• Measure double layer thickness of endometrium in LS excluding any fluid<br />
• Both ovaries and any other adnexal lesion<br />
• Both kidneys<br />
Detailed questions and extended protocol if abnormality found<br />
• Is the endometrium uniformly or focally enlarged?<br />
• Is the endometrium cystic or not?<br />
• Is there any fluid in the endometrial cavity?<br />
• Is the subendometrial darker halo intact?<br />
• Are any submucosal fibroids or endometrial polyps identifiable?<br />
• What is the relative width of endometrium compared to overall uterine width?<br />
• Colour Doppler of the endometrium and uterine arteries<br />
• A search for distant spread in abdomen<br />
Criteria for assessment<br />
A postmenopausal endometrial double layer thickness of 4mm or less effectively excludes endometrial<br />
cancer and in these women hysteroscopy can usually be avoided.<br />
Colour flow Doppler signal present within the postmenopausal endometrium raises the likelihood of cancer.<br />
Low impedance flow (RI less than 0.5) and high peak systolic velocities (over 40cm/s) in a postmenopausal<br />
fibroid raise the possibility of sarcomatous change.<br />
Investigation after abnormal ultrasound<br />
Hysteroscopy and guided biopsy are required for women with postmenopausal bleeding and a thickened<br />
endometrium.<br />
If hysteroscopy is not readily available, then saline infusion sonohysterography and pipelle biopsy may help<br />
select those who need further intervention.<br />
MRI can help with local spread but is not routinely indicated (see MR imaging protocol.<br />
A chest radiograph (CXR) completes staging and as many women have co-morbidity may be required as<br />
part of the anaesthetic assessment.<br />
Multidisciplinary discussion between specialist gynaecological surgeons, oncologists, pathologists and<br />
radiologists is central to defining treatment options and usually follows staging examinations but may occur<br />
earlier if there are problems such as co-morbidity which limit investigation and treatment options. It is<br />
particularly important that women with high grade disease (G3) and pathologies other than endometrial<br />
cancer e.g. papillary serous, small cell and clear cell carcinoma or sarcoma are assessed in cancer centres.<br />
It is unclear whether all women with endometrial cancer require staging with MR imaging.<br />
Indications for MR imaging with proven or suspected endometrial cancer<br />
• Histologically high grade (G3) tumour<br />
• Suspicion for advanced disease, especially cervical involvement<br />
92
• Patients who represent a poor operative risk and will not undergo surgical staging<br />
• Inability to properly assess the endometrium hysterocopically e.g with cervical stenosis<br />
Surgical management of endometrial cancer may be influenced by the findings of MR imaging in two<br />
situations. Deep myometrial invasion (stage IC) and high grade tumour increase the risk of nodal<br />
metastases. These patients require nodal dissection for adequate surgical staging. Involvement of the<br />
cervical stroma (stage 2B) indicates the need for radical hysterectomy.<br />
Technique for MR imaging of endometrial cancer<br />
• Avoid vaginal tampon<br />
• Intravenous anti-peristaltic agent – Glucagon or Buscopan<br />
• Phased array pelvic coils<br />
• Sagittal SFOV (20 cm) T2W sequence through the pelvis<br />
• ‘Inclined axial’ SFOV T2W sequence perpendicular to the endometrial cavity<br />
• 3 or 4mm sections with SFOV, ideally 512 matrix size<br />
• LFOV axial FISP and coronal T1W sequences through the retroperitoneum and pelvis to assess nodal<br />
disease and hydronephrosis<br />
• Supervision of the examination by radiologist experienced in gynaecological MR<br />
Invasive endometrial carcinoma disrupts the low SI junctional zone (JZ) on the T2W sequences, extending<br />
for a variable depth into the myometrium. Invasion of the JZ in dicates stage 1B and of the outer half of the<br />
myometrium as stage 1C. The JZ may be indistinct in post-menopausal women and in this group dynamic<br />
gadolinium enhanced T1W sagittal and ‘inclined’ axial SFOV images are helpful in defining tumour and<br />
assessing depth of invasion. Fat suppressed gradient echo sequences are used. With this technique the<br />
tumour is hypointense, less vascular, than myometrium and there is a sub-endometrial enhancement (SEE)<br />
which defines the tumour margin.<br />
The key role of staging is to define women with deep muscle invasion from superficial disease, those with<br />
cervical invasion and with locally advanced disease. MR imaging is best at assessment of myometrial<br />
invasion and cervical invasion but still relatively insensitive to nodal metastasis.<br />
The role of CT in Endometrial Carcinoma<br />
Where MRI is available there is no role for CT in initial staging. CT is inferior to both US and MR imaging for<br />
early stage disease assessment but has value in other circumstances. With known advanced disease, CT is<br />
the modality of choice to provide information about disease beyond the pelvis, assessment of the thorax and<br />
upper abdomen, identification of marker lesions. CT is used in many centres for radiotherapy planning and<br />
also for treatment assessment in women receiving chemotherapy for advanced or recurrent disease.<br />
Appendix 1: FIGO Staging – Carcinoma of the Corpus Uteri<br />
Carcinoma of the corpus uteri: Pathological staging FIGO nomenclature (Rio de Janeiro 1994)<br />
Stage Ia<br />
Stage Ib<br />
Stage Ic<br />
Stage IIa<br />
Stage Iib<br />
Stage IIIa<br />
Stage IIIb<br />
Stage IIIc<br />
Stage IVa<br />
Stage IVb<br />
Tumour limited to the endometrium.<br />
Invasion to less than half of the myometrium.<br />
Invasion equal to or more than half the myometrium.<br />
Endocervical glandular involvement only.<br />
Cervical stromal invasion.<br />
Tumour invades the serosa of the corpus uteri and/or adnexae and/or positive peritonial cytological<br />
findings.<br />
Vaginal metastases.<br />
Metastases to pelvic and/or paraaortic lymph nodes.<br />
Tumour invasion of bladder and/or bowel mucosa.<br />
Distant mestastases, including intra-abdominal metastasis and/or inguinal lymph nodes.<br />
93
Appendix 2: Stage grouping for endometrial cancer, FIGO cf UICC<br />
FIGO<br />
UICC<br />
Stage T N M<br />
0 Tis N0 M0<br />
Ia T1a N0 M0<br />
Ib T1b N0 M0<br />
Ic T1c N0 M0<br />
Iia T2a N0 M0<br />
IIb T2b N0 M0<br />
IIIa T3a N0 M0<br />
IIIb T3b N0 M0<br />
IIIc T1 N1 M0<br />
T2 N1 M0<br />
T3a N1 M0<br />
T3b N1 M0<br />
Iva T4 Any N M0<br />
IVb Any T Any N M1<br />
KEY REFERENCES<br />
US in diagnosis<br />
Gull B et al. Am J Obstet Gynecol 2003; 188: 401-408.<br />
Gupta JK et al. Acta Obstet Gynecol Scand 2002; 81: 799-816.<br />
MR in staging<br />
Kinkel K et al. Radiology 1999; 212: 711-718.<br />
Frei KA et al. Radiology 2000; 216: 444-449.<br />
Manfredi R et al. Radiology. 2004; 231:372-378.<br />
PEDIATRIC UROLOGIC EMERGENCIES: IMAGING IN ACUTE URO-GENITAL<br />
TRAUMA, TESTICULAR AND OVARIAN TORSION<br />
Riccabona Michael<br />
Department of Radiology, Division of Pediatric Radiology<br />
University Hospital Graz, Austria<br />
Abstract<br />
Basic imaging strategies in pediatric urogenital trauma resemble the common algorithms in adults - however,<br />
there are differences injury patterns and risks that impact imaging strategies. The objective of this<br />
presentation is to basically list, explain, and discuss these differences.<br />
When one thinks about imaging there are some basic aspects that have to be considered: what are the<br />
information we need to decide on patient handling, therapy and prognosis, and which imaging modality or<br />
algorithm can reliably provide this at lowest achievable patient burden within the time span necessary for<br />
decision making. Additionally we have to consider availability of the various methods and economic aspects.<br />
Eventually only evidence based and efficacy oriented algorithms will prove valid and acceptable. Therefore -<br />
when discussing pediatric urogenital trauma - we must focus on scenarios with a significant risk for an injury<br />
that need urgent treatment or close monitoring to achieve optimal results or to improve outcome. And we<br />
have to reflect the specific aspects of children needs: the task to use non-ionising imaging modalities when<br />
ever possible (ALARA principle), the specific pediatric circulation physiology and topographic anatomy, the<br />
problems with communication and history, and the different trauma mechanisms with their consequences on<br />
the type of a potential injury.<br />
There are some basic facts: children stay stable for a long time even in severe injury and may suddenly<br />
deteriorate dramatically; the kidneys are much more mobile than in adults and far less protected which<br />
94
increases the risk for particularly hilar injuries; the child’s bladder is positioned much higher, with a larger<br />
peritoneal surface increasing the risk for intraperitoneal bladder rupture. Child abuse is another topic on the<br />
list. Ovarian torsion in prepubertal girls is often associated with an underlying condition (tumor, infiltration),<br />
and testicular torsion in neonates differs from the “adult” torsion mechanism (intra- versus extratesticular).<br />
And – due to the different imaging conditions in infancy and childhood – imaging approaches differ: US as a<br />
non-ionizing, but - in infants and children - highly sufficient imaging tool is used much more, whereas CT is<br />
used more reluctantly in certain settings.<br />
In conclusion this presentation shall try to demonstrate typical pediatric urogenital tract trauma settings and<br />
conditions, show some typical findings, and suggest imaging algorithms for common clinical queries.<br />
IMAGING IN ACUTE PEDIATRIC URINARY TRACT INFECTIONS<br />
Prof. Kassa Darge<br />
Department of Pediatric Radiology, Institute of Radiodiagnostic, University Hospital Wuerzburg, Josef-<br />
Schneider-Str. 2/D31, 97080 Wuerzburg, Germany<br />
[darge@roentgen.uni-wuerzburg.de]<br />
Urinary tract infections (UTI) are the most common serious bacterial infections in infants and young children.<br />
They are even more common than bacterial pneumonia. By the age of 7 years about 8% of girls and 2% of<br />
boys would have had at least one episode of UTI. The UTI may be limited to the bladder, one or both<br />
kidneys, or both sites. In general, infections of the bladder i.e. cystitis, although they cause substantial<br />
morbidity, are not regarded as serious bacterial infections. In contrary, infections that involve the kidney,<br />
namely pyelonephritis may cause both acute morbidity and lead to scarring with the consequences of<br />
hypertension, preeclampsia and chronic renal disease that may necessitate dialysis or renal transplantation.<br />
Accordingly, differentiation of site of infection has received considerable attention.<br />
Urinalysis is very useful for detecting infection but not for determining the location of the infection within the<br />
urinary tract – upper tract vs. lower tract. To determine the site of infection – kidney vs. bladder – attempts<br />
are made to use the discriminatory ability of C-reactive protein (CRP), erythrocyte sedimentation rate, total<br />
peripheral WBC and more recently serum procalcitonin (PCT). Imaging studies also play an important role in<br />
this regard.<br />
The aim of this presentation is to discuss in detail the use of US in the initial evaluation of a pediatric patient<br />
presenting with UTI. Other imaging studies are usually not performed in the acute stage and will only be<br />
handled briefly. The questions to be answered by the first US examination are the following:<br />
1. Is there renal parenchymal involvement?<br />
2. Is there accompanying obstruction that requires immediate surgical intervention?<br />
3. Are there morphological peculiarities or abnormalities of the urinary tract?<br />
A systematic performance of the US examination will make it possible to pick up all important findings:<br />
[a] Bladder:<br />
It is essential to start the US examination with the bladder so as not to miss the opportunity to examine the<br />
bladder while it is full. Particularly, infants and small children may void when undressed and exposed to a<br />
cold surrounding or irritated by the whole examination. An empty bladder may render the evaluation of the<br />
bladder content, the terminal ureters and the status of the renal pelvis incomplete. It is important to note<br />
whether floating echoes are present which may indicate purulent content. The bladder wall thickness should<br />
not exceed 3 mm when full and 5 mm when empty. Any bladder wall irregularities should be noted. It is<br />
helpful to note the volume of urine in order to compare with the amount of residual urine after voiding.<br />
Residual urine may be indicative of accompanying bladder emptying disorder.<br />
95
[b] Ureters:<br />
Both vesicoureteral junctions are assessed for the presence of abnormalities like ureterocele or ectopia.<br />
Extent and form of dilatation of the ureters and presence of ureteral wall thickening are evaluated. The<br />
echogenicity of the ureteral content should be noted, too.<br />
[c.] Kidneys:<br />
The examination of the kidneys should be carried out form ventral and dorsal. A meticulous evaluation of the<br />
echogenicity of the kidneys with respect to the liver and spleen is necessary. Normally, the right and left<br />
kidneys are hyperechoic compared to the liver and spleen, respectively, except in newborns and infants in<br />
whom they can still be hyper- or isoechogenic. The presence and extent of the cortico-medullary<br />
differentiation is assessed. The measurement of the renal size i.e. renal length and /or volume is very<br />
important. A size increase above the norm for the height or weight of the patient or a volume difference of<br />
more than 30% between the two kidneys may indicate the involvement of the renal parenchyma. The<br />
pelvicalyceal system is assessed for the presence of dilatation, pelvic wall thickening and echogenic content.<br />
The thickness of the normal pelvic wall should not exceed 0.8 mm. Furthermore, a thorough color or power<br />
Doppler appraisal of the renal parenchyma may point out areas with decreased or absent perfusion due to<br />
edema and inflammation.<br />
Further diagnostic imaging studies for UTI are performed at the end of the antibiotic therapy for<br />
pyelonephritis or even later. The aims of these imaging studies are twofold, namely to find out if<br />
vesicoureteral reflux or renal scars are present. Reflux examination entails the use of one of the following<br />
methods: contrast-enhanced voiding urosonography (VUS), voiding cystourethrography (VCUG) or direct or<br />
indirect radionuclide cystography. The assessment for possible renal scars is carried out using DMSA scan.<br />
MALIGNANT ADRENAL MASSES<br />
Gabriel P. Krestin, M.D., Ph.D.<br />
Department of Radiology, Erasmus MC, University Medical Center Rotterdam<br />
PO Box 2040, Rotterdam, Netherlands 3000 CA<br />
e-mail: g.p.krestin@erasmusmc.nl<br />
Introduction<br />
Adrenal masses are seen at autopsy in 2-10% of all patients and metastases are found postmortem in the<br />
adrenal glands in up to 26% of patients with primary extra-adrenal malignancies. It is thus not surprising that<br />
adrenal mass lesions are quite common incidental findings during imaging of the abdomen. However, even<br />
in an oncologic setting, many adrenal lesions are benign, mostly non-hyperfunctioning adenomas, resulting<br />
in the need of a reliable method to distinguish them from malignant masses.<br />
Currently computed tomography (CT) and magnetic resonance imaging (MRI) are used in the evaluation of<br />
the adrenal glands. The role of ultrasound (US) in assessment of adrenal pathologies is limited. Although it<br />
can delineate most masses exceeding 2 cm, bowel gas may hamper depiction of the left adrenal gland and<br />
distinction between benign and malignant lesions is impossible in most cases. Radionuclide scanning can<br />
provide additional functional information in specific cases. Computed tomography is very sensitive in the<br />
detection of adrenal pathologies, but lacks tissue specificity except for uncomplicated cysts and most<br />
myelolipomas. Magnetic resonance imaging has been shown to be superior to CT in this respect.<br />
Imaging Strategies in Adrenal Masses<br />
Computed Tomography<br />
High resolution CT is currently the gold standard for the detection of adrenal pathology. Contiguous slices of<br />
10 mm thickness are adequate for routine scanning. Thinner sections are recommended for specific adrenal<br />
imaging using 3-5 mm contiguous or overlapping scans. Spiral CT may assess the glands in one single<br />
breath-hold. Spatial resolution may be improved if a small field of view is used. The raw scan data can be<br />
retained for a subsequent target reconstruction.<br />
96
Oral contrast should be used in all cases to identify the gastrointestinal tract. Initial scans should be<br />
performed without IV contrast medium to demonstrate calcifications or hemorrhage and to determine the<br />
plain attenuation values of the adrenal glands. If these scans are abnormal or equivocal, IV contrast may be<br />
used to define the contrast enhancement patterns of the lesion and to generate washout curves.<br />
Magnetic Resonance Imaging<br />
In most studies on MR imaging of the adrenal glands, axial T1-weighted and T2-weighted spin-echo<br />
sequences with 7-10 mm section thickness were used. The use of a T2-weighted fast spin-echo sequence<br />
instead of the conventional technique reduces acquisition time and thus motion artifacts resulting in better<br />
image quality. Alternatively to the T2-weighted spin-echo sequences, a fast gradient-echo sequence with<br />
relative T2-weighting (TR 60 ms/TE 30 ms/flip angle 15º) may be used. The technique has the advantage of<br />
shortened acquisition time. This allows for slice by slice imaging during suspended respiration resulting in<br />
improved image quality. A turbo gradient-echo sequence offers the possibility of imaging multiple slices<br />
within a breath-hold of 18-25 seconds using a TR of 100 - 150 ms (depending on patients’ ability to hold their<br />
breath), minimum TE (2 - 5 ms) and a flip angle 60 - 90°. Section thickness should range between 6 - 8 mm<br />
with a 20% gap.<br />
On these pulse sequences, the normal adrenal glands are iso- or hypointense compared to the liver. If fat<br />
suppression is applied, the glands become isointense to the liver on T1-weighted and hyperintense on T2-<br />
weighted images. Advantages of fat-saturation are reduced noise and sharper depiction of organ<br />
architecture, reduced respiratory motion induced artifacts, elimination of chemical shift artifacts and<br />
expanded gray scale to accentuate small differences in tissue contrast. Disadvantages include fewer<br />
sections per acquisition and possible inhomogeneity of fat suppression throughout the image.<br />
Adrenal adenomas and nodular hyperplasia contain large amounts of fat, whereas metastases and<br />
pheochromocytomas contain no or very little lipid. Thus chemical shift imaging with in-phase and opposed<br />
phase gradient echo images has been advocated to distinguish adenomas (fatty) from non-adenomatous<br />
(non-fatty) lesions. On a 1.5 Tesla MR system (64 MHz), lipid and water spins have a frequency difference<br />
of about 224 Hz. Thus, a phase cycling of water and lipid spins occurs with every 2.24 ms after the<br />
excitation pulse. At this interval, lipid and water spins are alternately in- and out-of-phase. The signal<br />
intensity of opposed phase images depends on the proportion of lipid and water content within the tissue.<br />
Compared to non-lipid containing tissue, fat-containing tissue will thus present low signal intensity on<br />
opposed phase images. Tsushima et al. propose FLASH (fast low-angle shot) images obtained breathheld<br />
with a TR of 100 ms and TE of 11 ms for the opposed phase images and a TE of 13 ms for the in-phase<br />
images with a flip angle of 20º. Mitchell et al. used a gradient recalled echo sequence (GRE) with 90º flipangle,<br />
TR = 59-142 ms/TE = 2.3-2.5 ms for the opposed phase images.<br />
Dynamic multiplanar fast gradient echo MR imaging with bolus injection during suspended respiration allows<br />
for high image quality as well as visualization of functional processes after administration of contrast material.<br />
It is reliable for demonstration and characterization of adrenal masses providing a statistically significant<br />
differentiation of adenomas, metastases, and pheochromocytomas, although some overlap is still seen<br />
between these pathologies. Dynamic MR imaging can be achieved by using a GRE sequence with a TR of<br />
30 ms, a TE of 15 ms and a flip angle of 70º. Orientation in the coronal section allows for simultaneous<br />
imaging of the adrenal glands, liver, and kidneys. Repeated imaging up to 15 minutes after intravenous<br />
administration of 0.1 mmol/kg body weight of a gadolinium compound should be performed.<br />
Presentation of Malignant Adrenal Lesions<br />
Adrenal Metastases<br />
Certain morphologic criteria are suggestive for a malignant adrenal lesion on CT or MRI, including diameter<br />
over 5 cm, irregular contours, invasion of neighboring structures and change in size on follow-up<br />
examinations. Adrenal metastases appear hypo- or isointense to liver on T1-weighted images and show a<br />
strong signal increase on T2-weighted images. Comparing relative lesion-to-fat signal intensities, malignant<br />
lesions usually present ratios of more than 2.0. Using these criteria, accuracies between 91% and 95% for<br />
distinction between adenoma and adrenal metastases were found.<br />
Following administration of contrast material, metastases show typically a rapid contrast-enhancement with a<br />
maximum signal increase > 150% and a persistent high signal intensity (>75%) after 10 min.<br />
97
On chemical shift opposed-phase images, metastases can be distinguished from the fat-containing<br />
adenomas by their higher signal intensities. Tsushima et al. calculated signal intensity indexes between inphase<br />
and opposed-phase images. In this study, using a cut-off value of 5%, a 100% accuracy in distinction<br />
of adenomas from non-adenomatous lesions was found.<br />
Metastases of renal cell carcinoma, hepatocellular carcinoma, and liposarcoma, however, may contain<br />
cytoplasmic lipid and thus also present with a loss of signal intensity on opposed-phase images.<br />
Adrenal Carcinoma<br />
Fifteen to fifty percent of adrenocortical carcinomas are hyperfunctioning with the majority of them causing<br />
Cushing's syndrome. They are usually larger than 6 cm in diameter and can invade adjacent organs and the<br />
inferior vena cava. Calcifications may be present. With MRI, relaxation times of carcinomas are not<br />
significantly different from those found in metastatic disease and distinction between these two entities can<br />
thus not be made. However, primary adrenocortical carcinomas are usually unilateral and often hormonally<br />
active. Due to its multiplanar imaging capabilities, MRI has been reported to be superior to CT in staging of<br />
disease allowing better identification of invasion into adjacent structures.<br />
Lymphoma<br />
Non-Hodgkin’s lymphoma may rarely involve the adrenal glands. Contiguous growth from regional affected<br />
lymph nodes into the adrenal glands is encountered more frequently, while isolated adrenal lymphoma<br />
occurs only in exceptional cases. Bilateral involvement is seen in half of the cases. At imaging the enlarged<br />
glands are indistinguishable from other malignant masses: The attenuation values at non-enhanced CT and<br />
signal intensities on T2-weighted MR images are usually elevated and wash-out of the contrast agent is slow.<br />
Suggested Readings<br />
1. Elsayes KM, Mukundan G, Narra VR, Lewis JS, Shirkhoda A, Farooki A, Brown JJ. Adrenal masses: MR imaging features with<br />
pathologic correlation. Radiographics 24:S73-S86, 2004<br />
2. Dunnick NR, Korobkin M, Francis I (1996) Adrenal radiology: distinguishing benign from malignant adrenal masses. AJR 167:861-<br />
867<br />
3. Korobkin M (2000) CT characterization of adrenal masses: the time has come. Radiology 217:629-632<br />
4. Korobkin M, Brodeur FJ, Francis IR, Quint LE, Dunnick NR, Londy F (1998) CT time-attenuation washout curves of adrenal adenomas<br />
and nonadenomas. AJR 170:747-752<br />
5. Lockhart ME, Smith JK, Kenney PJ. Imaging of adrenal masses. Eur J Radiology 41:95-112, 2002<br />
6. Maurea S, Mainolfi C, Bazzicalupo L, Panico MR, Imparato C, Alfano B, Ziviello M, Salvatore M (1999) Imaging of adrenal tumors<br />
using FDG PET: comparison of benign and malignant lesions. AJR 173:25-29<br />
7. Peppercorn PD, Reznek RH. State-of-the-art CT and MRI of the adrenal gland. Eur Radiol 7:822-836, 1997<br />
98
TECHNICAL PROTOCOLS FOR MALE AND FEMALE MRI OF THE<br />
PELVIS<br />
MAGNETIC RESONANCE EXAMINATIONS OF THE MALE PELVIS<br />
Ullrich G. Mueller-Lisse, M.D.<br />
Attending Radiologist, Associate Professor of Radiology, Dept. of Radiology,<br />
University of Munich, Ziemssenstrasse 1, 80336 Muenchen, Germany,<br />
e-mail: ullrich.mueller-lisse@med.uni-muenchen.de<br />
Ulrike L. Mueller-Lisse, M.D.<br />
Clinical Fellow, Dept. of Urology, University of Munich, Nussbaumstrasse 20<br />
80336 Muenchen, Germany<br />
Indications<br />
Scanners and Coils<br />
Sequences<br />
Learning Objectives<br />
Literature<br />
Indications<br />
Magnetic resonance (MR) examinations of the prostate and seminal vesicles primarily serve the purposes of<br />
staging prostate cancer prior to therapy and of recognizing and localizing prostate cancer prior to biopsy and<br />
after therapy. Other indications for MR examinations of the prostate, such as volumetric assessment of the<br />
prostate prior to therapy for benign prostatic hyperplasia (BPH) or guidance and follow-up of alternative<br />
therapies for prostatic disease, are rarely found outside of specialized centers.<br />
MR examinations of the urinary bladder are primarily performed for staging of invasive bladder tumors and<br />
for recognizing or ruling out other pelvic tumors that extend into the urinary bladder. Functional imaging of<br />
the pelvic organs and pelvic floor by means of MR imaging is performed in cases of incontinence and relies<br />
on repetitive imaging with high temporal resolution. Other indications, such as recognition or exclusion of<br />
pelvic malformations in children, are rarely found outside of specialized paediatric centers. Virtual MR<br />
cystoscopy is a new method under clinical investigation.<br />
Scanners and Coils<br />
MR examinations of the prostate and seminal vesicles and of the urinary bladder ought to be preformed on<br />
whole-body high-field MR scanners. Recent series of MR examinations of the male pelvis that underwent<br />
scientific evaluation were most frequently carried out at 1.5 T (e.g., Husband et al. 1989, Kim et al. 1994,<br />
Barentsz et al. 1996). Initially, the body coil was used for both transmission and signal reception. Current coil<br />
designs are based on multi-channel phased array technology with at least four independent coil elements.<br />
Complex integration of the respective signals received by each of the coils results in homogenous MR<br />
images with high signal-to-noise ratios. Recently, receiver coil systems with up to 32 independent channels<br />
were introduced that allow for either more detailed MR images, i.e., increased spatial resolution without loss<br />
of signal-to-noise, or for higher acquisition speed, particularly with so-called parallel imaging, i.e., the<br />
application of knowledge of respective surface coil positions to the determination of magnetic resonance<br />
signal origin as a means to decrease the number of phase encoding steps without losing spatial resolution in<br />
a given sequence.<br />
The application of endoluminal coils is of great advantage in MR examinations of the prostate and seminal<br />
vesicles, particularly when the endoluminal coil is integrated into a multi-channel phased array coil system<br />
(Hricak et al. 1994). Although butylscopolamine or glucagone can be used to decrease MR image<br />
degradation by bowel motion when respective contraindications are considered, it is usually sufficient to fill<br />
the inflatable balloon of the endorectal coil with 80-100 ccm of air once it has been placed in the emptied<br />
rectum. Digital rectal examination should precede application of the endorectal coil, to rule out lesions and<br />
narrowings in the rectum.<br />
99
Sequences<br />
Pelvic anatomy is best depicted in T2-weighted MR sequences. Full delineation of the urinary bladder and of<br />
the prostate and seminal vesicles requires acquisition of T2-weighted images in at least two different planes,<br />
better even in three planes (axial, coronal, and sagittal). Slice thickness should not exceed 5-6 mm for MRI of<br />
the urinary bladder, with interslice gaps not exceeding 1 mm. MR imaging of the prostate and seminal<br />
vesicles requires very detailed depiction, such that slice thickness should not exceed 3-4 mm, and interslice<br />
gap should be less than 0.6 mm. Axial images provide good overview of the urinary bladder and its<br />
respective relation to the rectum, uterus, adnexae, vagina, or seminal vesicles and prostate, as well as its<br />
separation from the iliac vessels and from the muscular and bony walls of the pelvis. Deviation from<br />
symmetry between the two halves of the pelvis provides valuable clues to extent of prevalent disease. Axial<br />
images with a field of view (FOV) with edges measuring up to 200 mm provide a good overview of the<br />
prostate and its relation to the rectum, seminal vesicles, urinary bladder, urogenital diaphragm, the iliac<br />
vessels, and the muscular and bony wall of the pelvis. Deviation from symmetry between the two halves of<br />
the pelvis hints at disease.<br />
T2-weighted spin-echo- (SE-) and turbo-SE- (TSE- or FSE-) MR images appear to delineate pathologic<br />
changes in the wall of the urinary bladder equally well (Husband et al. 1989, Kim et al. 1994, Barentsz et al.<br />
1996). Very fast, T2-weighted sequences, such as HASTE, SSFSE or True-FISP, have been available for<br />
several years. These sequences have been successfully applied in the upper abdomen, upper urinary tract,<br />
and retroperitoneum, with breathhold techniques decreasing motion artifact, and in functional MR imaging of<br />
the pelvic organs and pelvic floor (Lienemann et al. 1997, Pannu et al. 2003). However, for MR imaging of<br />
the urinary bladder, prostate, and seminal vesicles, equivalence of very fast sequences with SE and TSE<br />
sequences has not been sufficiently demonstrated for the diagnosis of malignant disease.<br />
T1-weighted, unenhanced SE- or FLASH- (spoiled GRE-) images with a slice thickness of 6-8 mm and an<br />
interslice gap of 2 mm or less extend from the urogenital diaphragm to the aortic bifurcation and help to<br />
recognize or rule out enlarged lymph nodes (particularly, along the obturator arteries, and the common,<br />
external and internal iliac arteries and in the presacral space), potentially metastatic bone lesions, tumor<br />
extending beyond the wall of the urinary bladder, and hemorrhage inside the prostate. Axial, T1-weighted SE<br />
images with a slice thickness of 3 mm increase spatial resolution in the prostate.<br />
Various studies have demonstrated that acquisition of rapid, T1-weighted MR images prior to, during, and<br />
after intravenous administration of interstitial, gadolinium-based contrast media (often referred to as dynamic<br />
contrast-enhanced MRI or DCE-MRI) at standard doses (e.g., 0.1 mmol of Gd-DTPA per kg of body weight)<br />
is advantageous for the recognition and staging of tumors of the urinary bladder (Neuerburg et al. 1989,<br />
Tachibana et al. 1991, Tanimoto et al. 1992, Kim et al. 1994, Barentsz et al. 1996). Single slice SE- or FSE<br />
sequences (Tachibana et al. 1991, Tanimoto et al. 1992), gradient echo sequences (FLASH or GRE,<br />
Neuerburg et al. 1989, Kim et al. 1994) as well as Turbo-FLASH sequences (Barentsz et al. 1996) have been<br />
applied to DCE-MRI of the urinary bladder. The imaging plane for DCE-MRI is adapted to the respective<br />
localization of the lesion in the urinary bladder, if the lesion was previously demonstrated in T2-weighted<br />
images (Mueller-Lisse et al. 1998). In the prostate, DCE-MRI with subsequent calculation of signal alteration<br />
characteristics, such as amplitude of contrast enhancement, or contrast exchange rates between the<br />
bloodstream and interstitial space, is under clinical investigation. In particular, correlation between contrast<br />
exchange rate and micro-vessel density in prostate tissue may provide new insight into biological tumor<br />
aggressiveness, since poorly differentiated prostate cancer frequently shows with increased micro-vessel<br />
density (Schlemmer et al. 2004). However, results have been demonstrated to depend on sequence<br />
selection (Kiessling et al. 2003).<br />
Organ-specific examinations include multi-dimensional MR spectroscopy (MRS) of the prostate. MRS is<br />
based either on SE-sequences (PRESS, Bottomley 1987, Ordridge et al. 1985) or on STEAM-sequences<br />
(Stimulated Echo Acquisition Mode, Frahm et al. 1987, Frahm et al. 1990) and analyzes the underlying<br />
frequencies of the MR signal. Shimming (minimization of full width at half maximum of the water signal by<br />
homogenization of the main magnetic field, B0) and suppression of signals from water and fat in the region of<br />
interest by means of selective inversion pulses and outside the region of interest by means of selective prepulses<br />
(outer volume suppression) gains access to signal contributions from metabolic products of lesser<br />
tissue concentration, such as citrate, choline, and creatine. As a specialized biochemical function of the<br />
prostate, citrate is accumulated rather than being entered into the citrate cycle of Krebs and broken down for<br />
energy metabolism. Development of prostate cancer is associated with loss of citrate accumulation and<br />
100
excretion. Free choline increases with increase of cell membrane turnover, such that it is more abundant in<br />
the presence of cancer. Creatine is part of the energy storage systems of mammalian cells (Kurhanewicz et<br />
al. 1995, Kurhanewicz et al. 1996, Costello et al. 1999, Heerschap et al. 1997, Scheidler et al. 1999, Mueller-<br />
Lisse et al. 2001a+b, Mueller-Lisse and Scherr 2003).<br />
Functional MR imaging of the urinary bladder and pelvic floor requires rapid, repetitive data acquisition by<br />
means of T1-weighted (FLASH, Turbo-FLASH, Gupta et al. 1992, Nolte-Ernsting et al. 1998) or T2-weighted<br />
(HASTE, True-FISP) sequences. Temporal resolution of 1 second or less is favorable (Lienemann et al.<br />
1997, Pannu et al. 2003). Virtual cystoscopy can be based on three-dimensional, T2-weighted TSE images<br />
(Lämmle et al. 2002).<br />
Learning Objectives<br />
- to get to know standard MR examination techniques and strategies in the diagnosis of diseases of the<br />
male pelvis by means of selected case studies<br />
- to get to know special MR examinations in the pelvis by means of selected case studies<br />
Literature<br />
Wittekind C, Mezer HJ, Bootz F (Hrsg.) UICC – International Union Against Cancer: TNM-Klassifikation maligner Tumoren (6. Aufl. 2002).<br />
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Barentsz JO, Lemmens JAM, Ruijs SHJ, Boskamp EB, Hendrikx AJM, Karthaus HFM, Kaanders JHAM, Rosenbusch G (1988) Carcinoma<br />
of the urinary bladder: MR imaging with a double surface coil. Am J Roentgenol 151:107--112<br />
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164:109--115<br />
Barentsz JO, Jager GJ, van Vierzen PBJ, Witjes JA, Strijk SP, Peters H, Karssemeijer N, Ruijs SHJ (1996) Staging urinary bladder cancer<br />
after transurethral biopsy: value of dynamic contrast-enhanced MR imaging. Radiology 201:1985--193<br />
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Kim B, Semelka RC, Ascher SM, Chalpin DB, Carroll PR, Hricak H (1994) Bladder tumor staging: comparison of contrast-enhanced CT, T1-<br />
and T2-weighted MR imaging, dynamic gadolinium-enhanced imaging, and late gadolinium-enhanced imaging. Radiology 193:239--245<br />
Lämmle M, Beer A, Settles M, Hannig C, Schwaibold H, Drews C (2002) Reliability of MR imaging-based virtual cystoscopy in the diagnosis<br />
of cancer of the urinary bladder. AJR Am J Roentgenol 178: 1483--1488<br />
Lienemann A, Anthuber C, Baron A, Kohz P, Reiser M (1997) Dynamic MR colpocystorectography assessing pelvic-floor descent. Eur<br />
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Mueller-Lisse GU, Heuck AF, Barentsz JO (1998) Bladder. In: Abdominal and Pelvic MRI, Heuck A, Reiser M (eds.), Medical Radiology –<br />
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Barcelona, Budapest, Hong Kong, London, Milan, Paris, Santa Clara, Singapore, Tokyo, 1998, 328 pp: 209--228<br />
Mueller-Lisse UL, Mueller-Lisse UG, Lienemann A, Schneede P, M.F. Reiser MF (2002) Feasibility of True-FISP MR voiding<br />
cysturethrography. Proceedings of the International Society for Magnetic Resonance in Medicine 10 th scientific meeting and exhibition,<br />
2002: 1901<br />
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gadolinium-enhanced dynamic MR imaging and CT. Radiology 185:741--747<br />
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Engelbrecht MR, Jager GJ, Laheij RJ, Verbeek AL, van Lier HJ, Barentsz JO (2002) Local staging of prostate cancer using magnetic<br />
rsonance imaging: a meta-analysis. Eur Radiol 12: 2294—2302<br />
Frahm J, Merboldt KD, Haenike W (1987) Localized proton spectroscopy using stimulated echos. J Magn Reson 72: 502--508<br />
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brain: water suppression, short echo times, and 1 ml resolution. J Magn Reson 90: 464--473<br />
Heerschap A, Jager GJ, van der Graaf M, Barentsz JO, Ruijs SH (1997) Proton MR spectroscopy of the normal human prostate with an<br />
endorectal coil and a double spin-echo pulse sequence. Magn Reson Med 37: 204--213<br />
Heuck A, Scheidler J, Sommer B, Graser A, Müller-Lisse UG, Maßmann J (2003) MR-Tomographie des Prostatakarzinoms. Radiologe 43:<br />
464—473<br />
Hricak H, White S, Vigneron D, Kurhanewicz J, Kosco A, Levin D, Weiss J, Narayan P, Carroll PR (1994) Carcinoma of the prostate gland:<br />
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McNeal J (1988) Normal histology of the prostate. Am J Surg Pathol 12: 619-633<br />
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Kurhanewicz J (2001a) Time-dependent effects of hormone-deprivation therapy on prostate metabolism as detected by combined magnetic<br />
resonance imaging and 3D magnetic resonance spectroscopic imaging. Magn Reson Med. 46: 49--57<br />
Mueller-Lisse UG, Vigneron DB, Hricak H, Swanson MG, Carroll PR, Bessette A, Scheidler J, Srivastava A, Males RG, Cha I, Kurhanewicz<br />
J (2001b) Localized prostate cancer: effect of hormone deprivation therapy measured by using combined three-dimensional 1H MR<br />
spectroscopy and MR imaging: clinicopathologic case-controlled study. Radiology 221: 380--390<br />
Müller-Lisse UG, Scherr M (2003) 1H-MR-Spektroskopie der Prostata: Ein Überblick. Radiologe 43: 481-488<br />
Müller-Lisse UL, Hofstetter A (2003) Urologische Diagnostik des Prostatakarzinoms. Radiologe 43: 432—440<br />
Nicolas V, Beese M, Keulers A, Bressel M, Kastendieck H, Huland H (1994) MR-Tomographie des Prostatakarzinoms – Vergleich<br />
konventionelle und endorektale MRT. RöFo – Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 161: 319--326<br />
Ordridge RJ, Bendall MR, Gordon RE, Conelly A (1985) Volume selection for in-vivo biological spectroscopy. In: Govil G, Khetrapal CL,<br />
Saran A (Hrsg.). Magnetic resonance in biology and medicine. Tata McGraw-Hill, New Dehli: 387--397<br />
Scheidler J, Hricak H, Vigneron DB, Yu KK, Sokolov DL, Huang RL, Zaloudek CJ, Nelson SJ, Carroll PR, Kurhanewicz J (1999) Prostate<br />
Cancer: localization with three-dimensional proton MR spectroscopic imaging – clinicopathologic study. Radiology 213: 473--480<br />
Schiebler ML, Tomaszewski JE, Bezzi M, Pollack HM, Kressel HY, Cohen EK, Altman HG, Gefter WB, Wein AJ, Axel L (1989) Prostatic<br />
carcinoma and benign prostatic hyperplasia: correlation of high-resolution MR and histopathologic findings. Radiology 172: 131-137<br />
Schlemmer HP, Merkle J, Grobholz R, Jaeger T, Michel MS, Werner A, Rabe J, van Kaick G (2004) Can pre-operative contrast-enhanced<br />
dynamic MR imaging for prostate cancer predict microvessel density in prostatectomy specimens? Eur Radiol 14: 309-317<br />
Wefer AE, Hricak H, Vigneron DB, Coakley FV, Lu Y, Wefer J, Mueller-Lisse U, Carroll PR, Kurhanewicz J (2000) Sextant localization of<br />
prostate cancer: comparison of sextant biopsy, magnetic resonance imaging and magnetic resonance spectroscopy with step section<br />
histology. J Urol 164: 400--404<br />
TECHNICAL PROTOCOLS FOR FEMALE MRI OF THE PELVIS<br />
PD, Dr. med, Karen Kinkel<br />
Clinique des Grangettes, Chêne-Bougeries, Geneva, Switzerland<br />
This workshop gives technical information to perform magnetic resonance (MR) imaging in the female pelvis.<br />
Imaging protocols are adapted to the clinical question and the pelvic organ. General technical consideration<br />
cover patient and coil positioning, pre-medication, sequences and contrast media. Case presentations helps<br />
understanding why performance of a female pelvis MR needs MD supervision due to different slice<br />
orientation and sequence adjustment according to findings during image acquisition.<br />
General technical recommendation include prior fasting, supine position, long IV line to allow performance of<br />
dynamic sequences, IM injection of peristaltic inhibitors, coil centering just below the umbilicus to cover mid<br />
symphysis pubis up to L5, anterior saturation bands placed on subcutaneous fat of abdominal wall. Slice<br />
orientation starts generally with sagittal T2-weighted images to allow subsequent parallel and perpendicular<br />
positioning of slices according to the axis of the endometrial stripe within the uterus corpus. The sequence<br />
protocol include at least two different orientations of T2-weighted Fast spin echo sequences with a minimum<br />
TR of 4000 msec, TE of 90 msec, FOV of 30cm, matrix 256x512, 2-4 nex, 4-5mm slices. One native T1-<br />
102
weighted Fast Spin Echo sequences with a TR of 600 msec is mandatory for assessing hemorrhage, an<br />
important diagnostic finding in patients with pelvic pain or large fibroids. Fat suppression is used<br />
subsequently whenever T1-hyperintense abnormalities are identified (call for MD to check after native T1<br />
(!!)). Main purpose of this sequence is the differentiation of blood (persistent white signal intensity in<br />
endometriomas or hemorrhagic cysts) from fat (decreased signal intensity in ovarian teratoma) [1]. Postcontrast<br />
enhanced T1-weighted sequences profit from fat suppression when questions concerning adnexal<br />
mass origin, bladder or rectal wall abnormalities are raised [2].<br />
IV Contrast injection is mandatory for uterine and ovarian cancer staging and characterization of adnexal<br />
masses [3-5]. Contrast media is helpful in patients with severe endometriosis to diagnose bladder or rectal<br />
endometriosis [6]. In patients with large pelvic masses of unknown origin, contrast injection helps to visualize<br />
the strongly enhanced normal myometrium. Enhancement degree of myometrial abnormalities helps to<br />
confirm necrotic leiomyomas (no enhancement), adenomyosis (little enhancement) and eventually sarcoma<br />
(hypervascular compared to myometrium). A dynamic mode of image acquisition every 1-2 minutes<br />
increases diagnostic confidence to diagnose myometrial invasion of endometrial cancer due to strong early<br />
enhancement of the normal myometrium at about 90 seconds and decreased enhancement within the<br />
invaded portion of the myometrium [7].<br />
Intra-rectal contrast medium is not necessary except in patients with anal insufficiency. Diagnosis of rectal<br />
endometriosis may require water enema in specific cases [6].<br />
Additional useful sequences include MR-urography (ureteral involvement or compression) [8], MRangiography<br />
(dilated ovarian veins), and dynamic pelvic floor MRI with or without proctography (to diagnose<br />
clinically questionable pelvic organ displacement, prolapse or enteroceles) performed during straining.<br />
References<br />
1. Yamashita Y, Torashima M, Hatanaka Y, Harada M, Sakamoto Y, Takahashi M, Miyazaki K, Okamura H. Value of phase-shift<br />
gradient-echo MR imaging in the differentiation of pelvic lesions with high signal intensity at T1-weighted imaging. Radiology 1994,<br />
191: 759-764.<br />
2. Bipat S, Glas AS, van der Velden J, Zwinderman AH, Bossuyt PM, Stoker J. Computed tomography and magnetic resonance imaging<br />
in staging of uterine cervical carcinoma: a systematic review. Gynecol Oncol 2003, 91: 59-66.<br />
3. Kinkel K, Kaji Y, Yu KK, Segal MR, Lu Y, Powell CB, Hricak H. Radiologic staging in patients with endometrial cancer: a metaanalysis.<br />
Radiology 1999, 212: 711-718.<br />
4. Forstner R, Hricak H, Occhipinti KA, Powell CB, Frankel SD, Stern JL. Ovarian cancer: staging with CT and MR imaging. Radiology<br />
1995, 197: 619-626.<br />
5. Kinkel K, Lu Y, Mehdizade A, Pelte M, Hricak H. Incremental value of a second imaging test to characterize a sonographically<br />
indeterminate ovarian mass: a meta-analysis and a Bayesian analysis. Radiology 2005, in press.<br />
6. Bazot M, Darai E, Hourani R, Thomassin I, Cortez A, Uzan S, Buy JN. Deep Pelvic Endometriosis: MR Imaging for Diagnosis and<br />
Prediction of Extension of Disease. Radiology 2004, 232: 379-389 Epub 2004 Jun 2017.<br />
7. Yamashita Y, Harada M, Sawada T, Takahashi M, Miyazaki K, Okamura H. Normal uterus and FIGO stage I endometrial carcinoma:<br />
dynamic gadolinium-enhanced MR imaging. Radiology 1993, 186: 495-501.<br />
8. Balleyguier C, Roupret M, NGuyen T, Kinkel K, Helenon O, Chapron C. Ureteral endometriosis: The role of Magnetic Resonance<br />
Imaging. J Am Assoc Gynecol Laparosc 2004, 4: 530-536.<br />
103
CONTRAST MEDIA GUIDELINES<br />
EFFECTS OF IODINATED CONTRAST MEDIA ON BLOOD AND<br />
ENDOTHELIUM<br />
P. Aspelin, MD, F. Stacul, MD, A.J. van der Molen, MD, T. Almén, MD, M.F. Bellini, MD, J.Å. Jakobsen,<br />
MD, R. Oyen, MD, J.A.W. Webb, MD, H.S. Thomsen, MD, S.K. Morcos, MD, and the members of contrast<br />
media safety committee of European Society of Urogenital Radiology (ESUR)<br />
ESUR statement on effects of iodinated contrast media on blood and endothelium<br />
The clinically important adverse effect of iodinated contrast media on blood and endothelium is thrombosis. It<br />
is recognized that:<br />
• All contrast media have anticoagulant properties, especially ionic agents.<br />
• High osmolar ionic contrast media may induce thrombosis due to endothelial damage, particularly in<br />
phlebographic procedures.<br />
• Drugs and interventional devices that decrease the risk of thromboembolic complications during<br />
interventional procedures minimize the importance of the effects of contrast media.<br />
Guidelines<br />
• Meticulous angiographic technique is mandatory and is the most important factor in reducing<br />
thromboembolic complications.<br />
• Low- or iso-osmolar contrast media should be used for diagnostic and interventional angiographic<br />
procedures including phlebography.<br />
ABSTRACT<br />
Purpose<br />
To assess the effects of iodinated contrast media on blood components and endothelium based on<br />
experimental and clinical studies and to produce clinical relevance guidelines for reducing thrombotic and<br />
hematologic complications following the intravascular use of contrast media.<br />
Material and Methods<br />
A report has been drafted after review of the literature and discussions among the members of the Contrast<br />
Media Safety Committee of the European Society of Urogenital Radiology. The final report was produced<br />
following discussion at the 12 th European Symposium on Urogenital Radiology in Ljubljana, Slovenia (2005).<br />
Results and Conclusion<br />
Experimental data indicate that all iodinated contrast media possess an anticoagulant effect and that this<br />
effect is greater with ionic contrast media. Several of the in-vitro and experimental in-vivo studies on<br />
hematologic effects of contrast media have not been confirmed by clinical studies. Low- or iso-osmolar<br />
contrast media should be used for diagnostic and interventional angiographic procedures including<br />
phlebography. Meticulous angiographic technique is the most important factor for reducing the thrombotic<br />
complications associated with angiographic procedures. Drugs and interventional devices that decrease the<br />
risk of thromboembolic complications during interventional procedures minimize the importance of the effects<br />
of contrast media.<br />
Key-Words: Iodinated contrast media, coagulation, endothelium, blood cells, thrombosis.<br />
Introduction<br />
Iodinated contrast media are widely used either to visualize blood vessels (angiography) or to enhance the<br />
density of the parenchyma of different organs. In both instances they are administered intravascularly and<br />
ideally their effects on blood and endothelium should be minimal. However, all contrast media have some<br />
104
effects on the endothelium, blood and its constituents. There is a vast literature on these effects both in vitro<br />
and in vivo. The Contrast Media Safety Committee of the European Society of Urogenital Radiology (ESUR)<br />
decided to review the literature and based on this review to draw up guidelines.<br />
Iodinated contrast media may be either ionic or nonionic and they all produce various effects on blood<br />
components. These effects are thought to be caused by the chemical nature of contrast media, their<br />
electrical charge, and by the viscosity and the osmolality of the solution in which they are given although<br />
contribution by pharmaceutical excipients and Ph of the contrast agent solution cannot be ruled out. Different<br />
contrast media have varying effects on the many components of the blood. The present paper is not intended<br />
to be a complete review of all the available data, but to summarize the effects from a clinical point of view in<br />
order to decide whether there are important differences between the types of iodinated contrast media<br />
currently available for clinical use.<br />
The hematologic effects of iodinated contrast media have been divided into the following categories: red<br />
blood cells, white blood cells, endothelium, platelets, coagulation and fibrinolysis.<br />
Red Blood Cells<br />
The effect of contrast media on red blood cells can be divided into the effects on morphology, aggregation<br />
and rheology (flow properties of the blood). When iodinated contrast media come into contact with red blood<br />
cells while they are only minimally diluted, the normal discoid shape of the red blood cells changes [1, 2].<br />
Two changes caused by extraction of water may occur: either shrinkage of the red blood cells producing a<br />
dessicocyte or changes in shape called echinocyte or stomatocyte deformation.<br />
Red blood cell morphology<br />
Dessicocyte formation is an in vitro effect of dehydration of the red blood cell in a fraction of RBC and has<br />
been observed when exposed to high concentrated contrast media and is proportional to the osmolality of<br />
the contrast media to which it is exposed [1].<br />
Echinocyte formation in vitro is dependent on the chemotoxicity (including electrical charge, pH or salt<br />
concentration) [3] and not the osmolality of the contrast agent. All contrast media including the iso-osmolar<br />
dimers may induce some degree of echinocyte formation and stomatocyte deformation is seen more<br />
common with dimers [4, 5].<br />
Red blood cell aggregation<br />
Contrast media in vitro cause disaggregation of red blood cell rouleaux formation and not aggregation as<br />
sometimes is believed [5]. The reason for the misunderstanding could be that contrast media make red cells<br />
more rigid causing precapillary stasis which can be mistaken for increased red blood cell aggregation [6, 7].<br />
Blood rheology<br />
The combined effect of the dessicocytes and echinocytes is reduced plasticity of the red blood cells [6, 7, 8].<br />
Plasticity is essential for the smooth flow of red blood cells through small capillaries and when it is lost there<br />
is a decrease in blood flow especially after intraarterial injections [9-12]. Pure echinocyte and stomatocyte<br />
formation without any dehydration of red blood cells produces only minor rheological change [1, 2]. However,<br />
the overall in vivo effect is a mixture of the effect of contrast media on red blood cell morphology, rigidity,<br />
viscosity and vascular tone and is also dependent on external parameters, e.g. shear stress. Contrast media<br />
can induce both vasoconstriction and vasodilatation in different organs [13-16]. In the pulmonary circulation<br />
contrast media can induce red cell rigidity and pulmonary arterial vasoconstriction leading to an increase in<br />
pulmonary vascular resistance [12-15]. In the kidney contrast media can reduce the blood flow in the vasa<br />
recta in the medulla [16]. It is not clear whether this effect is mainly caused by stasis due to vasoconstriction<br />
or by increased red blood cell aggregation in vivo. The morphological red cell changes may also affect the<br />
capacity for oxygen delivery and pH-buffering [17]. However these effects have not been proven to be of<br />
importance in clinical studies [18].<br />
The overall effect of contrast media on red blood cells has not been shown to be of clinical importance.<br />
White Blood Cells<br />
The function of the white blood cells is mainly host defense, but their interactions with the endothelial cells<br />
and platelets are also important. White blood cells must be able to adhere to the endothelium and migrate<br />
through the vessel wall in order to phagocytize and inactivate toxic products. This involves adherence,<br />
chemotaxis, degranulation and phagocytosis. In vitro studies have shown that all these processes are<br />
affected by contrast media.<br />
105
Phagocytosis<br />
Contrast media reduce the ability of white blood cells to exhibit phagocytosis [19-21]. This effect is studied<br />
and observed only with ionic high osmolar contrast media. The clinical importance of these in-vitro<br />
observations is not known.<br />
Chemotaxis, Granulocyte adherence and Inflammation<br />
Contrast media have been shown in vitro to inhibit the chemotoxic response of white blood cells. In vivo<br />
studies have not shown this finding to be significant [22]. All contrast media decrease the adherence property<br />
of white blood cells [23-26]. Contrast media may interfere with the inflammatory response of white blood cells<br />
in the body [27-29].<br />
There are no clinical data to suggest that any of these interactions of contrast media and white blood cells<br />
are of clinical importance.<br />
Endothelium<br />
Endothelial cells contribute to the regulation of many aspects of vascular homeostasis, including coagulation,<br />
fibrinolysis and platelet function. In addition they are important modulators of vascular tone, primarily by the<br />
regulated secretion and rapid clearance of powerful vasoactive mediators such as prostacyclin, nitric oxide,<br />
endothelin and adenosine. The endothelium also controls solute permeability and leukocyte movement<br />
during the generation of inflammatory and immune responses [, 30].<br />
Endothelial cells are exposed transiently to high concentrations of contrast media following intravascular<br />
administration. The endothelial effects of contrast media may contribute to the hemodynamic disturbances,<br />
thrombosis and pulmonary edema associated with the intravascular use of these agents.<br />
Modulation of the production of endothelial vasoactive substances plays an important role in mediating the<br />
hemodynamic effects of contrast media particularly in the kidney [31]. Contrast media can increase the<br />
release and expression of the potent vasoconstrictor peptide endothelin by the endothelial cells [32]. In<br />
addition, contrast media may decrease the endothelial production of nitric oxide by reducing the activity of<br />
the enzyme nitric oxide synthase which is responsible for the endogenous synthesis of this vasodilator [33,<br />
34]. How contrast media increase the release of endothelin or reduce the production of nitric oxide is not<br />
fully understood.<br />
Contrast media, particularly high osmolality ionic agents, have cytostatic and cytotoxic effects on endothelial<br />
cells which may precipitate thrombosis [35-41]. In addition, contrast media can induce apoptosis<br />
(programmed cell death) of endothelial cells [42]. An increase in the frequency of apoptosis in the<br />
endothelium may alter vascular homeostasis including coagulant and thrombotic properties, permeability and<br />
tone of the blood vessel wall as well as vessel growth and angiogenesis [42].<br />
The biocompatibility of contrast media is influenced both by osmolality and chemical structure, particularly<br />
the presence of carboxyl groups in the molecules of the ionic agents. In the nonionic media the absence of<br />
carboxyl groups and the presence of many hydroxyl groups which increase hydrophilicity markedly improve<br />
biocompatibility and significantly reduce cytotoxicity [60-63]. Ionic contrast media, in particular high osmolar<br />
agents, have greater effects on enzymes, higher affinity to proteins and lipids in comparison to nonionic<br />
media and can induce injury to cell membranes and interfere with cell metabolism [43-44]. In addition,<br />
contrast media can penetrate endothelial cells forming dense granules on the luminal surface and pinocytotic<br />
vesicles [45].<br />
Ionic contrast media may increase vascular endothelial permeability leading to pulmonary edema [46-51].<br />
Subclinical pulmonary edema without obvious signs or symptoms of respiratory distress is thought to be<br />
common after intravascular use of contrast media but its true incidence is difficult to establish [46].<br />
Pulmonary edema produced by contrast media could also be responsible for the increase in the pulmonary<br />
vascular resistance (PVR) caused by these agents [46]. Experimental studies have shown that ioxaglate<br />
induced the largest increase in PVR of the isolated rat lung preparation and more marked pulmonary edema<br />
compared to other classes of contrast media [47-51]. However, these experimental observations have not<br />
been confirmed in larger clinical studies [52].<br />
The endothelial effect of high osmolar ionic contrast media is of clinical importance in phlebography because<br />
of the increased frequency of thrombosis after the procedure.<br />
Platelets<br />
Briefly, platelets adhere to exposed collagen, von Willebrand factor and fibrinogen at the site of arterial injury<br />
(adhesion step). Adherent platelets are then activated by mediators such as thrombin, collagen, ADP,<br />
serotonin, etc. (activation step). Activated platelets degranulate and secrete chemotaxins, clotting factors and<br />
106
vasoconstrictors, thereby promoting thrombin generation, vasospasm and additional platelet accumulation<br />
(aggregation step) (53) (54). Therefore, the interaction of contrast media with platelets I assessed, each step<br />
of platelet physiology should be evaluated separately.<br />
Experimental effects<br />
Platelet adhesion: Grabowski et al. (55) showed that in vitro platelet adhesion/aggregation was inhibited in<br />
the order diatrizoate > ioxaglate > iohexol > saline. However, these effects rapidly diminished because of<br />
hemodilution. In a baboon study (56), contrast media were found to inhibit platelet deposition on stents in the<br />
order ioxaglate > iohexol = iodixanol > saline.Thus, all contrast media inhibit platelet adhesion, with ionic<br />
agents being more potent than nonionics.<br />
Platelet activation by thrombin: In vitro platelet activation by thrombin was inhibited by low osmolar ionic<br />
contrast media whereas nonionic monomeric and dimeric contrast media did not affect it (57).<br />
Direct platelet activation: Direct activation of platelets (i.e. degranulation and release of the procoagulant<br />
content of dense bodies and α-granules) was induced in vitro by nonionic monomeric contrast media. Lesser<br />
activation was caused by high-osmolar ionic contrast media and there was no activation by low-osmolar ionic<br />
and nonionic dimeric contrast media [3-58]. Chronos et al [3] showed that blood from patients anticoagulated<br />
with heparin and pretreated with aspirin in preparation for percutaneous coronary angioplasty (PTCA)<br />
showed the same pattern of nonionic monomeric contrast medium-induced platelet activation as normal<br />
subjects.<br />
Platelet aggregation: An inhibitory effect of contrast media on platelet aggregation was first described by Zir<br />
et al. in 1974 [59] and has been widely investigated since. Ionic contrast media, both high- or low-osmolar,<br />
inhibit in vitro platelet aggregation (induced by mediators such as thrombin, ADP or collagen) more than<br />
nonionic agents (monomeric or dimeric) [60-61]. Potentiation of the anti-thrombotic effects of clopidogrel, an<br />
anti-aggregant drug, has been found in rats with an ionic low osmolar contrast medium but not with a<br />
nonionic monomer [62].<br />
Clinical pharmacology studies<br />
Clinical pharmacology studies comparing the different categories of contrast media, however, led to more<br />
equivocal conclusions than in vitro or animal studies.<br />
In patients, no significant platelet activation (P-selectin expression) was found following left ventriculography<br />
or coronary angiography with iohexol [63]. Similarly, Arora et al. [64] and Brzosko et al [65] did not find a<br />
significant difference between ionic and nonionic contrast media when platelet degranulation markers were<br />
measured in peripheral venous samples. Polanowska et al. [66] reported an increase in the venous level of<br />
β-thromboglobulin following arteriography with a high osmolar contrast agent. Conversely, in another study<br />
[67], following cardiac catheterization, no platelet activation was found with ioxaglate whereas serotonin<br />
release was detected following injection of a nonionic monomer. It is worth noting that most of these studies<br />
(except Albanese et al.) evaluated peripheral venous and not local blood samples and that arterial<br />
catherization itself may activate platelets.<br />
With respect to platelet aggregation, most clinical pharmacology studies have shown a higher antiaggregatory<br />
effect for ionic agents than nonionic monomers, as recently confirmed by Dalby et al.[68, 61].<br />
However, one study did not reveal difference between these categories of contrast media [69].<br />
The clinical impact of these in vitro and experimental in vivo changes is debatable and is discussed in the<br />
section on coagulation.<br />
In summary, there are no clinical data to suggest that the effect of nonionic contrast media on platelets<br />
induces increased coagulation. The mechanisms responsible for the effects of contrast media on platelets<br />
are still unclear and clinically significant effects have not been shown.<br />
Coagulation<br />
In vitro effects of contrast media<br />
All contrast media inhibit blood coagulation but to different extents. Prothrombin time, reptilase time,<br />
activated partial thromboplastin time and recalcification clotting time are significantly increased in proportion<br />
to the dose of the contrast media [61]. Comparison of assays of fibropeptide A and thrombin-antithrombin<br />
complex between ionic agents (both monomeric and dimeric) and nonionic monomers showed that<br />
coagulation times were shorter for nonionic monomers, but were always longer than in the controls [52, 70-<br />
75].<br />
107
The ionic dimer ioxaglate shows similar anticoagulant activity to the ionic monomers [61]. In one study the<br />
nonionic dimer iodixanol was significantly less anticoagulant than the nonionic monomer iohexol [58] while in<br />
another study it was reported that iodixanol affects the bleeding time similarly to nonionic monomers [76].<br />
However, the precise mechanisms responsible for this inhibition are still unclear. It has been suggested that<br />
the main factors are inhibition of activation of factor X, which leads to the formation of thrombin from<br />
prothrombin [61, 77, 78] and inhibition of fibrin polymerization [69, 77, 79, 80]. Al Dieri et al [81, 82] showed<br />
that ioxaglate blocks feedback activation of factors V and VIII, significantly inhibits platelet dependent<br />
thrombin generation and boosts the effect of abciximab, whereas iodixanol does not. Interference with the<br />
assembly of fibrin monomers by contrast media results in poor fibrin stabilization of clots [3, 71].<br />
Therefore, ionic monomers and dimer have similar anticoagulant activity in vitro which is more pronounced<br />
than that of nonionic monomers and dimers. Nonionic monomers probably have more anticoagulant effect<br />
than nonionic dimers.<br />
Clinical trials<br />
Clinical data are less easy to evaluate because of patient related and procedure related variability (state of<br />
the haemostatic system, condition of the vessel wall, use of guidewires, catheters, balloons, stents). Because<br />
of the rapid clearance of contrast media, their anticoagulant effect is local rather than systemic and their<br />
effect may be not significant if measured in distant peripheral blood vessels.<br />
Following the in vitro observation by Robertson [83] of more frequent clot formation in blood contaminated<br />
syringes with nonionic monomers than with ionic agents, a few case reports of thrombotic complications in<br />
diagnostic angiography with nonionic monomers were published [84-86]. However, trials have shown no<br />
clinical evidence of significant differences in thrombotic complications when ionic agents are compared to<br />
nonionic monomers for coronary angiography [87, 88].<br />
Randomized trials comparing ioxaglate to nonionic monomers during PTCA have produced conflicting results<br />
[89-95]. In the two studies with the largest number of patients, one showed no significant difference between<br />
ioxaglate and iomeprol in the incidence of sudden vessel occlusion [93] while the other showed a trend<br />
toward less thromboembolic complications with ioxaglate compared to ioversol [94]. Scheller et al [96]<br />
reported that patients undergoing stent placement had fewer acute and subacute stent occlusions when<br />
imaged using ioxaglate (versus multiple nonionic agents). However, Danzi et al [95] recently reported that<br />
nonionic monomers (iopamidol and iopromide) did not adversely affect stent patency when compared to<br />
ioxaglate. The considerable periprocedural use of antiplatelet agents may explain their results. A metaanalysis<br />
comparing nonionic monomers to ioxaglate showed a significant reduction of coronary vessel abrupt<br />
occlusions with ioxaglate [97]. Iodixanol was compared to ioxaglate in three trials. In one, no significant<br />
differences with regard to Major Adverse Cardiac Events (MACE) were detected [98]. In a second, I an a<br />
high-risk patient group less abrupt vessel occlusions (p = 0.05) were found with iodixanol [99]. This<br />
difference was more significant in patients that did not receive GpIIb/IIIa blockers. In the third, no significant<br />
differences between the two media were found and there was no clear advantage with the use of an ionic<br />
contrast agent in a large population of patients undergoing percutaneous coronary intervention for both<br />
stable and unstable coronary artery disease [100].<br />
Contrast media interactions with angiographic devices<br />
Interactions of contrast media with angiographic devices have been investigated both in vitro and in vivo. The<br />
syringe material greatly influenced the possibility of clot formation in syringes containing contrast media and<br />
blood. Glass was a more powerful activator of coagulation than plastic and among the plastic syringes, those<br />
made of styrene acrylonitrile activated coagulation more than those made of polypropylene. Furthermore<br />
clots formed only in situations where there was very poor angiographic technique [79].<br />
Teflon coated catheters and guidewires are more thrombogenic than polyurethane materials and much more<br />
than polyethylene materials [80]. Idée and Corot [78] comprehensive reviewed the many factors influencing<br />
clotting in catheters including the length of the procedure, blood/catheter contact time, volume of blood in the<br />
catheter, size and type of the catheter, type of contrast material and degree of blood/contrast medium<br />
mixture in the catheter. Some of these factors are difficult to control or standardize in clinical studies.<br />
Therefore catheter and guidewire materials probably play a significant role in clinical studies of contrast<br />
media and coagulation. The use of equipment with technically improved surfaces will probably largely<br />
overcome this problem.<br />
108
Fibrinolysis<br />
Contrast media impede fibrinolysis and delay the onset of lysis by recombinant tissue-type plasminogen<br />
activator (rt-PA), urokinase and streptokinase [101]. This effect is reduced by increasing the concentration of<br />
the lysis agent. Contrast media cause fibrin to form in long/thin fibrils, which have a lower mass/length ratio<br />
and are more resistant to fibrinolysis [102-103]. In vitro studies have shown that diatrizoate and iohexol delay<br />
the onset of lysis induced by all lysis agents. However, ioxaglate delayed the onset of lysis by rt-PA and<br />
urokinase but not by streptokinase [101]. Another in vitro study showed that thrombi formed with iodixanol<br />
and iohexol are larger and more resistant to thrombolysis when compared to thrombi formed with ioxaglate<br />
[104]. In vivo studies in dogs showed that alteplase-induced thrombolysis could be delayed by iohexol and<br />
amidotrizoate whereas ioxaglate had no significant effects [105]. In a small group of patients undergoing<br />
pulmonary angiography iohexol significantly increased plasma levels of PAI-1, an inhibitor of t-PA and<br />
urokinase, while ioxaglate did not [106]. Other effects on fibrinolysis caused by interactions of contrast media<br />
with concomitantly given drugs are described in more detail in another paper from the ESUR Contrast Media<br />
Safety Committee [107].<br />
Summary<br />
All contrast agents may alter the morphology and function of red blood cells. However, the overall effect of<br />
contrast media on red cells has not been shown to be of clinical importance. Similarly the effect on white<br />
blood cells has not been shown to be clinically important.<br />
In vitro studies have shown that nonionic monomers cause more activation of platelets than ionic contrast<br />
media. Iso-osmolar dimeric contrast media have not been shown to activate platelet function. Clinical studies<br />
have not confirmed these in-vitro observations.<br />
Contrast media have cytostatic, cytotoxic and apoptotic effects on endothelial cells. These effects are more<br />
evident with ionic contrast media, in particular high osmolar agents, than with nonionic media. Contrast<br />
media induced endothelial injury may play a role in the pathophysiology of the effects of contrast media.<br />
These include hemodynamic effects, thrombosis and contrast media-induced pulmonary edema.<br />
The risk of thrombosis induced by contrast media relates to the combined effect on platelets, endothelial cells<br />
and coagulation factors. In clinical practice, high osmolar contrast media can induce thrombosis after<br />
intravenous injection mainly because of endothelial injury produced by the high osmolality. This effect is less<br />
with nonionic low-osmolar and iso-osmolar contrast media.<br />
All contrast media have anticoagulant properties, and ionic media are more anticoagulant than nonionic<br />
compounds. Acute and subacute thrombus formation remains a topic of debate including the use of lowosmolar<br />
ionic contrast media in preference to low-osmolar nonionic contrast media in coronary interventions.<br />
However, the general consensus is that good angiographic technique is the most important factor in reducing<br />
thrombotic complications. Drugs and interventional devices that decrease the risk of thromboembolic<br />
complications during interventional procedures minimize the importance of the effects of contrast media<br />
[108].<br />
References<br />
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70. Corot C, Perrin JM, Belleville J, Amiel M, Eloy R (1989) Effect of iodinated contrast media on blood clotting. Invest Radiol 24: 390-393.<br />
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75. Rasuli P, McLeish WA, Hammond DI (1989) Anticoagulant effects of contrast materials: in vitro study of iohexol, ioxaglate and<br />
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77. Fay WP, Parker AC (1998) Effects of radiographic contrast agents on thrombin formation and activity. Thromb Haemost 80:266-272.<br />
78. Idée J-M, Corot C (1999) Thrombotic risk associated with use of iodinated contrast media in interventional cardiology: pathophysiology<br />
and clinical aspects. Fundam Clin Pharmacol 13: 613-623.<br />
79. Dawson P, Hawitt P, Mackle IJ, Machin SJ, Amin S, Bradshaw A (1986) Contrast, coagulation and fibrinolysis. Invest Radiol 21: 248-<br />
252.<br />
80. Dawson P (1999) Contrast media interactions with endothelium and the blood. In: Dawson P, Cosgrove DO, Grainger RG (Eds)<br />
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82. Al Dieri R, de Muinck E, Hemker C, Beguin S (2001) An ionic contrast agent inhibits platelet-dependent thrombin generation and boots<br />
the effect of abciximab. Thromb Haemost 85:944-945.<br />
83. Robertson HJF (1987) Blood clot formation in angiographic syringes containing nonionic contrast media. Radiology 163: 621-622.<br />
84. Bashore TM, Davidson CK, Mark DB (1988) Iopamidol use in the cardiac catheterization laboratory: a retrospective analysis of 3313<br />
patients. Cardiology 5: 60-100.<br />
85. Grollman JH Jr, Liu CK, Astone RA, Lurie MD (1988) Thromboembolic complications in coronary angiography associated with the use<br />
of nonionic contrast medium. Cathet Cardiovasc Diagn 14: 159-164.<br />
86. Millet PJ, Sestier F (1989) Thromboembolic complications with nonionic contrast media. Cathet Cardiovasc Diagn 17: 192.<br />
87. Davidson CJ, Mark DB, Pieper KS et al (1990) Thrombotic and cardiovascular complications related to nonionic contrast media during<br />
cardiac catheterization: analysis of 8517 patients. Am J Cardiol 65: 1481-1484.<br />
88. Schrader R (1998) Thrombogenic potential of nonionic contrast media, fact or fiction?<br />
Eur J Radiol 23 (suppl 1): S10-S13.<br />
89. Piessens JH, Stammen F, Vrolix MC et al (1993) Effects of an ionic versus a nonionic low osmolar contrast agent on the thrombotic<br />
complications of coronary angioplasty. Cathet Cardiovasc Diagn 28: 99-105.<br />
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90. Grines CL, Schreiber TL, Savas V et al (1996) A randomized trial of low osmolar ionic versus nonionic contrast media in patients with<br />
myocardial infarction or unstable angina undergoing percutaneous transluminal coronary angioplasty. J Am Coll Cardiol 27:1381-1386.<br />
91. Esplugas E, Cequier A, Jara F et al (1991) Risk of thrombosis during coronary angioplasty with low osmolality contrast media. Am J<br />
Cardiol 68: 1020-1024.<br />
92. Malekianpour M, Bonan R, Lespérance J, Gosselin G, Hudon G, Doucet S (1998) Comparison of ionic and nonionic low osmolar<br />
contrast media in relation to thrombotic complications of angioplasty in patients with unstable angina. Am Heart J 135: 1067-1075<br />
93. Schrader R, Esch I, Ensslen R et al (1999) A randomized trial comparing the impact of a nonionic (iomeprol) versus an ionic<br />
(ioxaglate) low osmolar contrast medium on abrupt vessel closure and ischaemic complications after coronary angioplasty. J Am Coll<br />
Cardiol 33: 395-402.<br />
94. Fleisch M, Mulhauser B, Garachemani A et al (1999) Impact of ionic (ioxaglate) and nonionic (ioversol) contrast media on PTCArelated<br />
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95. Danzi GB, Capuano C, Sesana M, Predolini S, Baglini R (2003) Nonionic low-osmolar contrast media have no impact on major<br />
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477-482.<br />
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97. Cucherat M, Leizorovicz A (1999) Effects of nonionic contrast media on abrupt vessel closure and ischaemic complications after<br />
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Trial Investigators. Circulation 101: 131-136.<br />
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100. Sutton AGC, Ashton VJ, Campbell PG, Price DJA, Hall JA, de Belder MA (2002) A randomized prospective trial of ioxaglate 320<br />
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101. Dehmer GJ, Gresalfi N, Daly D, Oberhardt B, Tate DA (1995) Impairment of fibrinolysis by streptokinase, urokinase and recombinant<br />
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Circ Res 68: 881-887.<br />
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107. Morcos SK, Thomsen HS, Exley CM, Members of Contrast Media Safety Committee of European Society of Urogenital Radiology<br />
(ESUR) (2005) Contrast Media: Interaction with other drugs and clinical tests. Eur Radiol 15: in press.<br />
108. Aguirre FV, Simoons ML, Ferguson JJ et al (1997) Impact of contrast media on clinical outcomes following percutaneous coronary<br />
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USE OF CONTRAST MEDIA IN THE EMERGENCY DEPARTMENT<br />
James H. Ellis, M.D.<br />
University of Michigan, USA<br />
Objectives<br />
The intravascular administration of radiographic iodinated contrast media (RICM) provides great benefit to<br />
patients in the performance of diagnostic and interventional procedures, and its use is generally<br />
straightforward and without complication. Some situations, however, are more problematic: the patient at<br />
higher risk for an acute reaction, the patient taking metformin, and the patient who is pregnant or breastfeeding.<br />
In the Emergency Department, the press of time constraints adds an additional dimension to the<br />
situation. Providing assistance in assessing and managing these patients is the objective.<br />
Avoiding the Use of Intravascular Contrast Material<br />
In many clinical situations, the use of intravascular RICM is not needed, or in some cases, may potentially<br />
interfere with interpretation. Perhaps the best example is CT of the brain for intracerebral or subarachnoid<br />
hemorrhage. Because intracranial hemorrhage almost always has higher attenuation than normal brain<br />
tissue, the blood itself provides its own contrast with normal structures. RICM, by enhancing both normal and<br />
abnormal tissues, could obscure acute or subacute hemorrhage. The detection by CT of a ruptured<br />
abdominal aortic aneurysm is another test where intravascular RICM is not needed for the basic diagnosis.<br />
Although many institutions use intravenous contrast enhancement for CT of the appendix in suspected<br />
112
appendicitis, CT maintains high accuracy for appendicitis even in the absence of IV contrast (and in some<br />
studies, the additional absence of oral and rectal contrast) in both adults and children [1-3]. The use of<br />
noncontrast helical CT for acute urinary tract colic has essentially replaced the excretory urogram wherever<br />
CT is available for this indication [4] although outcomes studies are few [5].<br />
In other situations, if there is any question about the patient’s ability to tolerate RICM, alternate tests may be<br />
substituted for those that might ordinarily involve the use of RICM. Many causes of abdominal pain can be<br />
detected on noncontrast CT even though contrast-enhanced CT may provide better images or additional<br />
information. For example, noncontrast CT can usually detect any extrapancreatic spread or complications of<br />
pancreatitis, though it may not be useful to detect pancreatic necrosis [6]. Ultrasound is widely used as a less<br />
expensive alternative to CT, but is of particular value when the patient has contraindications to contrast<br />
material. Magnetic resonance imaging is superior to CT for evaluation of most pathologic processes of the<br />
central nervous system. MR of the abdomen can diagnose many acute conditions. In most patients with<br />
contraindications to RICM, gadolinium contrast agents for MR have a tolerable safety profile.<br />
However, noncontrast CT, ultrasound, and MR are limited in evaluation of the severe trauma patient,<br />
particularly for traumatic injuries to the thoracic and abdominal internal organs. In these and other emergency<br />
cases, it may be preferable to perform a study using RICM. In these circumstances, it is important to deal<br />
expediently with conditions in which RICM poses a higher risk to the patient than to the normal population.<br />
The Patient at Higher Risk for an Acute Allergic-Like Reaction<br />
Adverse reactions to RICM are encountered in as many as 3.1% of patients receiving intravenous injections<br />
of low osmolality nonionic contrast media (LOCM) and 12.7% of patients receiving intravenous injections of<br />
high osmolality ionic contrast media (HOCM) [7]. Fortunately, the majority of these reactions are mild and<br />
clinically insignificant. Severe and very severe reactions (the latter requiring hospitalization) have been noted<br />
much less frequently, in only 0.04% and 0.004% of patients receiving intravenous injections of LOCM and<br />
0.22% and 0.04% of patients receiving intravenous injections of HOCM, respectively [7]. The vast majority of<br />
patients who have severe, even potentially life-threatening, reactions respond to rapid and aggressive<br />
treatment [8]. Fatal reactions to both types of contrast media are exceedingly rare, having been encountered<br />
in as few as 1:170,000 patients injected with either agent [7].<br />
Adverse reactions can be broadly classified as idiosyncratic or nonidiosyncratic [8]. Idiosyncratic reactions<br />
have manifestations identical to those seen with true allergic reactions. Nonidiosyncratic reactions have<br />
manifestations that do not resemble allergic reactions, but instead are believed to reflect physiologic effects<br />
of contrast media or direct toxicity of contrast media on a variety of organ systems.<br />
Idiosyncratic reactions most often begin within 20 minutes of contrast media injection [8]. Their occurrence is<br />
not related to the administered dose of contrast material. Although the manifestations of idiosyncratic<br />
reactions are identical to those seen in patients having true anaphylactic reactions, reactions to contrast<br />
material are not true allergic reactions in the vast majority of patients [9, 10]. Hence idiosyncratic reactions to<br />
radiographic contrast material have been termed anaphylactoid or allergic-like rather than anaphylactic or<br />
allergic reactions.<br />
Certain groups of patients are more likely to have idiosyncratic reactions to RICM. Patients with a history of<br />
prior contrast reaction have about four times the risk of an adverse reaction, and patients with a history of<br />
allergies or asthma have about two to three times the risk of an adverse reaction, compared to patients who<br />
do not have these histories [7]. Shellfish allergy is not a “special” allergy with respect to contrast media<br />
injection, but should be managed in the same way as other non-contrast allergies (e.g., peanut, bee sting, or<br />
penicillin allergies) [11].<br />
To reduce the risk of a contrast reaction in these high-risk patients, premedication with steroids and H1<br />
antihistamines is recommended, along with the use of LOCM. Other drugs such as H2 antihistamines and<br />
ephedrine can be added to the regimen, but are not widely used [8, 12]. If the patient has had a prior severe<br />
reaction to a specific contrast agent, switching to another brand of LOCM or iso-osmolality contrast agent<br />
makes common sense but has not been scientifically tested.<br />
113
Various premedication protocols have been proposed for high-risk patients. Ours (with the drug schedule<br />
adapted from [13, 14]) is:<br />
Premedication: To reduce the risk of anaphylactoid reactions to radiographic contrast media.<br />
Generally recommended for patients who have a history of:<br />
Previous allergic-like reaction to contrast media<br />
Other true allergies, particularly if multiple and/or severe<br />
True asthma, particularly with frequent or severe attacks, or currently or recently symptomatic<br />
Oral / Elective:<br />
Prednisone 50 mg PO 13, 7, and 1 hour prior<br />
and<br />
Diphenhydramine (Benadryl) 50 mg PO (or IM) 1 hour prior to exam<br />
(Patients should not drive after diphenhydramine.)<br />
Intravenous / Urgent:<br />
Hydrocortisone (Solu-Cortef) 200 mg IV stat and q 4 hour until exam complete<br />
and<br />
Diphenhydramine (Benadryl) 50 mg IV 1 hour before procedure if time permits<br />
Thus one can shorten the preparation time to about 4 hours in the urgent Emergency Department situation. If<br />
the patient has emergent need for RICM, the risk-benefit ratio must be considered. Intravenous<br />
hydrocortisone and diphenhydramine can be (and in the emergent situation, frequently are) given<br />
immediately before RICM in high-risk patients. This is a low-risk intervention but its effectiveness is unknown.<br />
The Patient at Risk for Nephrotoxicity<br />
Nephrotoxicity is covered in greater detail in another presentation. With respect to the Emergency<br />
Department, however, it is worthwhile knowing if any of the typical actions taken to reduce the risk of<br />
nephrotoxicity can be administered more speedily than usual. Although the usefulness of acetylcysteine in<br />
the reduction of nephrotoxicity risk is debatable [15, 16], it can be given intravenously to reduce the time from<br />
the start of premedication to the time the RICM can be administered. Studies using oral acetylcysteine<br />
typically start premedication the day before the examination [15, 16]. In one study [17], oral administration<br />
beginning one hour prior to RICM was not effective. However, in a study [18] using intravenous saline as the<br />
control, contrast-induced nephrotoxicity was reduced by administering acetylcysteine intravenously beginning<br />
30 minutes before the administration of RICM.<br />
The choice of RICM may also affect the risk of nephrotoxicity, and presents no delay in obtaining a contrastenhanced<br />
study. Low-osmolality contrast material has a lower incidence of contrast-induced nephrotoxicity<br />
compared to high osmolality contrast material [19, 20]. Iso-osmolality contrast material may reduce the risk<br />
even further, in high-risk patients [21, 22].<br />
The Patient Taking Metformin<br />
Metformin (generic, or alone or in combination in trade name drugs Glucophage, Glucovance, Avandamet,<br />
Metaglip, and others), is an oral antihyperglycemic medication that is being prescribed with increased<br />
frequency. Although metformin itself is not nephrotoxic, patients who are taking this drug and who happen to<br />
develop renal failure (as a result of a contrast material injection or other renal insult) may rarely develop lactic<br />
acidosis, which can be fatal [23-25]. The USA FDA drug package insert for metformin states that this agent<br />
should be discontinued at the time that a contrast enhanced study is performed and should not be restarted<br />
until the patient's renal function is documented to be normal a minimum of 48 hours after that study [26].<br />
Some referring physicians may want their patients to have alternate glucose control over this time.<br />
Some European authors [27, 28] have asserted that, if a patient undergoing a contrast examination has<br />
normal renal function, metformin can be continued. This argument is based on literature reviews that show<br />
that almost every case of metformin-related lactic acidosis occurred in patients with pre-existing renal<br />
disease or other contraindication to metformin. However, the European Society of Urogenital Radiology<br />
114
(ESUR) [29] recommends temporarily withholding metformin after RICM, in a manner similar to the FDA<br />
directive.<br />
The Pregnant Patient<br />
Iodinated contrast media crosses the placenta. In general, intravenous contrast material should be avoided,<br />
when possible, in pregnant women so as to eliminate any theoretical adverse effects on the fetus [30].<br />
However, if contrast media administration is required, it can probably be safely injected (at least in the third<br />
trimester) [31]. A guideline from the ESUR is available on the Society web site.<br />
The Patient who is Breast Feeding<br />
A number of studies have shown that the amount of contrast material excreted in breast milk is minimal. In<br />
one study, it was determined that the amount of nonionic iohexol-350 ingested by a breast-fed baby within 24<br />
hours of maternal contrast media injection (at a volume of 1 ml/kg) would equal only 0.2% of the allowed<br />
pediatric dose for that infant [32]. Excretion of the MRI contrast agent gadopentetate dimeglumine is even<br />
lower [33]. These studies indicate that there is no definite reason for a lactating mother to stop breast feeding<br />
after a contrast media injection. Nonetheless, as an extra precaution, some researchers (and the USA FDA<br />
package inserts) recommend that infants be fed formula and that the mother use a breast pump for 24 hours<br />
following maternal contrast administration [33]. The American College of Radiology suggests that the mother<br />
be informed about the safety of continuing to breast feed but be allowed to make her own choice [30]. A<br />
guideline from the ESUR is available on the Society web site.<br />
Conclusion<br />
RICM is a valuable adjunct to diagnostic imaging. In most cases, it can be given in the emergent situation<br />
without adverse events. Other situations present cautions or higher risks, but these can be managed<br />
effectively with generally simple interventions.<br />
References<br />
1. Lane MJ, Liu DM, Huynh MD, Jeffrey RB Jr, Mindelzun RE, Katz DS. Suspected acute appendicitis: nonenhanced helical CT in 300<br />
consecutive patients. Radiology 1999; 213:341-346<br />
2. Mullins ME, Kircher MF, Ryan DP, Doody D, Mullins TC, Rhea JT, Novelline RA. Evaluation of suspected appendicitis in children<br />
using limited helical CT and colonic contrast material. AJR 2001; 176:37-41<br />
3. Hoecker CC, Billman GF. The utility of unenhanced computed tomography in appendicitis in children. J Emerg Med 2005; 28:415-421<br />
4. Chen MYM, Zagoria RJ. Can noncontrast helical computed tomography replace intravenous urography for evaluation of patients with<br />
acute urinary tract colic? J Emerg Med 1999; 17:299-303<br />
5. Mendelson RM, Arnold-Reed DE, Kuan M, Wedderburn AW, Anderson JE, Sweetman G, Bulsara MK, Mander J. Renal colic: a<br />
prospective evaluation of non-enhanced spiral CT versus intravenous pyelography. Australas Radiol 2003; 47:22-28<br />
6. Paulson EK, Vitellas KM, Keogan MT, Low VH, Nelson RC. Acute pancreatitis complicated by gland necrosis: spectrum of findings on<br />
contrast-enhanced CT. AJR 1999; 172:609-613<br />
7. Katayama H, Yamaguchi K, Kozuka T, et al. Adverse reactions to ionic and nonionic contrast media. A report from the Japanese<br />
Committee on the Safety of Contrast Media. Radiology 1990; 175:621-628<br />
8. Cohan RH, Leder RA, Ellis JH. Treatment of adverse reactions to radiographic contrast media in adults. Radiol Clin NA 1996;<br />
34:1055-1076<br />
9. Carr DH, Walker AC. Contrast media reactions: experimental evidence against the allergy theory. Br J Radiol 1984; 57:469-473<br />
10. Shehadi WH. Contrast media adverse reactions: occurrence, recurrence, and distribution patterns. Radiology 1982; 143:11-17<br />
11. Coakley FV, Panicek DM. Iodine allergy: an oyster without a pearl? AJR 1997; 169:951-952<br />
12. Marshall GD Jr., Lieberman PL. Comparison of three pretreatment protocols to prevent anaphylactoid reactions to radiocontrast<br />
media. Ann Allergy 1991; 67:70-74<br />
13. Greenberger PA, Halwig JM, Patterson R, Wallemark CB. Emergency administration of radiocontrast media in high-risk patients. J<br />
Allergy Clin Immunol 1986; 77:630-634<br />
14. Greenberger PA, Patterson R. The prevention of immediate generalized reactions to radiocontrast media in high-risk patients. J<br />
Allergy Clin Immunol 1991; 87:867-872<br />
15. Fishbane S, Durham JH, Marzo K, Rudnick M. N-Acetylcysteine in the prevention of radiocontrast-induced nephropathy. J Am Soc<br />
Nephrol 2004; 15:251-260<br />
16. Morcos SK. Prevention of contrast media nephrotoxicity – the story so far. Clin Radiol 2004; 59:381-389<br />
17. Durham JD, Caputo C, Dokko J, Zaharakis T, Pahlavan M, Keltz J, Dutka P, Marzo K, Maesaka JK, Fishbane S. A randomized<br />
controlled trial of N-acetylcysteine to prevent contrast nephropathy in cardiac angiography. Kidney Int 2002; 62:2202–2207<br />
18. Baker CS, Wragg A, Kumar S, De Palma R, Baker LRI, Knight CJ. A rapid protocol for the prevention of contrast-induced renal<br />
dysfunction: The RAPPID study. J Am Coll Cardiol 2003; 41:2114–2118<br />
19. Rudnick MR, Goldfarb S, Wexler L, et al. Nephrotoxicity of ionic and nonionic contrast media in 1196 patients: a randomized trial.<br />
Kidney Int 1995; 47:254-261<br />
115
20. Barrett BJ, Carlisle EJ. Metaanalysis of the relative nephrotoxicity of high- and low-osmolality iodinated contrast media. Radiology<br />
1993; 188:171-178<br />
21. Chalmers N, Jackson RW. Comparison of iodixanol and iohexol in renal impairment. Br J Radiol 1999; 72:701-703<br />
22. Aspelin P, Aubry P, Fransson SG, Strasser R, Willenbrock R, Berg KJ. Nephrotoxic effects in high-risk patients undergoing<br />
angiography. N Engl J Med 2003; 348:491-499<br />
23. Assan R, Heuclin C, Ganeval D, George J, Girard JR. Metformin-induced lactic acidosis in the presence of acute renal failure.<br />
Diabetologia 1977; 13:211<br />
24. Bailey CJ, Turner RC. Metformin. N Engl J Med 1996; 334:574-579<br />
25. Dachman AH . New contraindication to intravascular iodinated contrast material. Radiology 1995; 197:545<br />
26. Rasuli P, French GJ, Hammond DI. Metformin hydrochloride all right before, but not after, contrast medium administration. Radiology<br />
1998; 209:586-587<br />
27. Nawaz S, Cleveland T, Gaines PA, Chan P. Clinical risk associated with contrast angiography in metformin treated patients: a clinical<br />
review. Clin Radiol 1998; 53:342-344<br />
28. McCartney MM, Gilbert FJ, Murchison LE, Pearson D, McHardy K, Murray AD. Metformin and contrast media – a dangerous<br />
combination? Clin Radiol 1999; 54:29-33<br />
29. Thomsen HS, Morcos SK, ESUR Contrast Media Safety Committee. Contrast media and metformin: guidelines to diminish the risk of<br />
lactic acidosis in non-insulin-dependent diabetics after administration of contrast media. Eur Radiol 1999; 9:738-740<br />
30. American College of Radiology Committee on Drugs and Contrast Media. Manual on Contrast Media, 5 th ed., Reston VA, 2004<br />
31. Bona G, Zaffaroni M, Defilippi C, Gallina MR, and Mostert M. Effects of iopamidol on neonatal thyroid function. Eur J Radiol 1992;<br />
14:22-25<br />
32. Nielson ST, Matheson JN, Skinnemoen K, Andrew E, Hafsahl G. Excretion of iohexol in human breast milk. Acta Radiologica 1987;<br />
28:523-526<br />
33. Schmiedl U, Maravilla KR, Gerlach R, Dowling CA. Excretion of gadopentetate dimeglumine in human breast milk. AJR 1990;<br />
154:1305-1306<br />
ESUR GUIDELINES ON CONTRAST MEDIUM INDUCED NEPHROPATHY<br />
Henrik S. Thomsen<br />
Copenhagen University Hospital, DK<br />
The term contrast medium induced nephropathy is widely used to refer to the reduction in renal function<br />
induced by contrast media. It implies impairment in renal function (an increase in serum creatinine by more<br />
than 25% or 44µmol/L (0.5 mg/dL)) occurred within 3 days following the intravascular administration of<br />
contrast media and the absence of alternative etiology. Most authors use that definition which was endorsed<br />
by ESUR in 1999 [1].<br />
Contrast medium induced nephropathy is considered an important cause of hospital acquired renal failure [2,<br />
3]. This is not surprising, since diagnostic and interventional procedures requiring the use of contrast media<br />
are performed with increasing frequency. In addition, the patient population subjected to these procedures is<br />
progressively older with more co-morbid conditions [4]. Prevention of this condition is important to avoid the<br />
substantial morbidity and even mortality that can be sometime associated with contrast medium induced<br />
nephrotoxicity. Even a small decrease in renal function may greatly exacerbate morbidity that is caused by<br />
coexisting conditions [5, 6]. Sepsis, bleeding, coma, and respiratory failure are frequently observed in<br />
patients with acute renal failure.<br />
The patients at highest risk for developing contrast induced acute renal failure are those with pre-existing<br />
renal impairment (> 132 µmol/L (1.5 mg/dL)) particularly when the reduction in renal function is secondary to<br />
diabetic nephropathy [1, 7]. Diabetes mellitus per se without renal impairment is not a risk factor [7]. The<br />
degree of renal insufficiency present before the administration of contrast media determines to a great extent<br />
the severity of contrast media nephrotoxicity. Large doses of contrast media and multiple injections within 72<br />
hours increase the risk of developing contrast medium induced nephropathy. The route of administration is<br />
also important and contrast media are less nephrotoxic when administered intravenously than when given<br />
intra arterially in the renal arteries or in the aorta proximal to the origin of the renal blood vessels [1].<br />
Determination of serum creatinine<br />
Serum creatinine is often used to determine the renal function and to identify high risk patients in spite of the<br />
limitations of this measurement. However, serum creatinine is not an ideal marker of renal function. The<br />
serum creatinine level depends on muscle mass and is not usually raised until the glomerular filtration rate<br />
has fallen by at least 50%. Endogenous serum creatinine clearance as a measure of glomerular filtration rate<br />
is also inaccurate especially when renal function is low because of a compensatory increase in tubular<br />
116
secretion which limits its validity as a glomerular filtration marker. Radionuclide techniques are preferable [8]<br />
but each of these tests is labor-intensive and impossible to perform in all patients undergoing contrast<br />
enhanced imaging. Alternatively, renal function can be estimated by using specially derived predictive<br />
equations. The most accurate results are obtained with the Cockroft-Gault equation whereas the most<br />
precise formula is the Modification of Diet in Renal Disease (MDRD) study equation [9]. Unfortunately, the<br />
predictive capabilities of these formulae are suboptimal for ideal patient care [9]. However, these methods<br />
are far superior for assessing renal function compared to a simple serum creatinine measurement. Another<br />
alternative is to use cut-off values for serum creatinine as an indicator of several levels of renal impairment.<br />
However, the use of cut-off levels (especially the low levels) will include several patients with normal renal<br />
function and use of the cut-off high levels will exclude patients with renal impairment [10]. Despite the<br />
inaccuracies of serum creatinine measurements it is an adequate measure for identifying those patients at<br />
risk for contrast medium nephropathy as patients with normal serum creatinine (< 132 µmol/L (1.5 mg/dL))<br />
has almost no risk [7].<br />
A questionnaire designed to elicit a history of renal disorders as well as additional risk factors for contrast<br />
media induced nephropathy may identify patients with normal serum creatinine in whom blood testing would<br />
be unnecessary [11]. However, a questionnaire does not completely exclude the presence of renal<br />
insufficiency, but it is practical and cost-efficient. As a matter of fact several patients referred from hospital<br />
departments have had their serum creatinine determined for other reasons within the last year and one can<br />
glance at these figures.<br />
To avoid contrast medium induced nephrotoxicity<br />
Several measures have been recommended to reduce the incidence of contrast medium induced<br />
nephropathy [12,13]. They include volume expansion, hydration with intravenous administration of normal<br />
saline solution (NaCl 0.9%) or half strength saline solution (NaCl 0.45%), infusion of sodium bicarbonate in<br />
stead of normal saline, infusion of mannitol, pharmacological manipulation (administration of atrial natriuretic<br />
peptide, loop diuretics, calcium antagonists, theophylline, dopamine, dopamine-1 receptor antagonist<br />
fenoldopam, acetylcysteine), use of low-osmolar non-ionic contrast media instead of high-osmolar ionic<br />
contrast media, use of isoosmolar contrast media instead of low-osmolar contrast media, gadolinium based<br />
contrast media instead of iodine based contrast media for radiography and CT, hemodialysis rapidly after<br />
contrast administration, hemofiltration during and after contrast administration, an injection of small volume of<br />
contrast medium, and avoiding short intervals (less than 48 hours) between procedures requiring<br />
intravascular administration of contrast media.<br />
Of all the above mentioned measures, extracellular volume expansion and use of low osmolar contrast<br />
media have been found systematically to be consistently effective [1, 14-17]. Volume expansion can be<br />
achieved with the intravenous injection of at least 100 ml/hr of 0.9% saline solution starting 4 hours before<br />
contrast administration and continuing for 24 hours afterwards [1]. In areas with hot climate more fluid should<br />
be given. This regime is suitable for patients who are not in congestive heart failure and are not allowed to<br />
drink or eat before undergoing an interventional or surgical procedure. If there is no contraindication to oral<br />
administration, free fluid intake should be encouraged. At least 500 ml of water or soft drinks before and<br />
2500 ml for 24 hours after the procedure is recommended by ESUR. Recently, it has been suggested that<br />
sodium bicarbonate offers a better protection than normal saline [18], but the experience is still limited.<br />
Concurrent administration of nephrotoxic drugs such as gentamicin and non-steroid anti-inflammatory drugs<br />
should also be avoided. Mannitol and furosemide enhances the risk if nephrotoxicity [14].<br />
Over the years various regimes of pharmacologic manipulation have been suggested in order to reduce the<br />
frequency of contrast medium induced nephropathy. The regimes have included 1) calcium channel blockers,<br />
which prevent the influx of calcium ions through voltage-operated channels and hereby cause a vasorelaxant<br />
effect in all vascular beds including the kidney, 2) selective dopamine-1 receptor agonist (fenoldopam) which,<br />
in contrast to dopamine, increases both cortical and medullary blood flow, 3) endothelin antagonists, which<br />
play an important role in renal vasculature, 4) non-selective adenosine receptor antagonist theophylline,<br />
which also cause vascular dilatation and 5) acetylcysteine, which is an antioxidant and scavenger of oxygen<br />
free radicals. Administration of these drugs has been shown both to be effective in preventing contrast<br />
medium induced nephropathy in some studies and to be without any effect in others. Even the result of<br />
several metaanalyses has been conflicting. Therefore, the ESUR does not for the time being recommend any<br />
pharmacological manipulation for routine use in prevention of contrast medium induced nephropathy.<br />
The ESUR recommends that non ionic media are used in patients at risk of developing contrast medium<br />
induced nephropathy. At this moment it is unclear whether there is a different in nephrotoxic potential<br />
117
etween low osmolar non ionic monomeric and iso-osmolar non ionic dimeric contrast media. Various<br />
studies have reported conflicting results. However, it is clear that all contrast media can cause nephropathy<br />
in patients with risk factors.<br />
Dialysis and contrast media administration<br />
Dialysis has been used in the prevention of contrast medium induced nephropathy. Hemodialysis and<br />
peritoneal dialysis safely remove both iodinated and gadolinium based contrast media from the body [19].<br />
The effectiveness of hemodialysis depends on many factors including blood and dialysate flow rate,<br />
permeability of dialysis membrane, duration of hemodialysis and molecular size, protein binding,<br />
hydrophilicity and electrical charge of the contrast medium. Generally several hemodialysis sessions are<br />
needed to removal all contrast medium, whereas it takes 3 weeks for continuous ambulatory dialysis to<br />
remove the agent completely. The ESUR concluded that there is no need to schedule the dialysis in relation<br />
to the time of the injection of a contrast medium or the injection of the contrast agent is scheduled in relation<br />
to the dialysis program.<br />
Hemodialysis does not protect poorly functioning kidneys against contrast medium induced nephropathy [20-<br />
23]. In addition, hemodialysis may cause deterioration of renal function through activation of inflammatory<br />
reactions with the release of vasoactive substances that may induce acute hypotension.<br />
Hemofiltration which is a continuous form of renal replacement therapy requires the intravenous infusion of<br />
large volume of isotonic replacement fluid (1000 ml/h). This is exactly matched with rate of ultrafiltrate<br />
production, so that no net fluid loss or overload occurs. A single study has shown that in patients with chronic<br />
renal failure who are undergoing coronary interventions, hemofiltration given in intensive care unit (ICU)<br />
setting appears to be effective in reducing the incidence of contrast medium induced nephropathy as well as<br />
reduces the rate of in-hospital mobidity and mortality [24]. However, the procedure is very costly and requires<br />
intensive treatment setting. Further studies are strongly warranted before this costly method can be<br />
recommended for routine use.<br />
Use of gadolinium–based contrast media for radiographic examinations<br />
Gadolinium based contrast agents are believed to be safe and not nephrotoxic in the standard MRI doses up<br />
to 0.3 mmol/kg body weight. Therefore it has been suggested that gadolinium-based contrast media could be<br />
used in place of iodinated agents for radiological examinations in patients with significant renal impairment<br />
[25]. However, the dose requirement for a satisfactory diagnostic study differs between MRI and radiography<br />
because different properties of the gadolinium are being used in the two techniques. The commonly used<br />
dose for body CT is 150 ml of a 300 mg I/ml (2.38 mmol I/ml) solution. The standard dose for contrastenhanced<br />
MRI is 0.2 ml/kg body weight of a 0.5 mmol/ml gadolinium-based contrast agent. For body CT, a<br />
patient weighing 70 kg would receive 120 mmol of the iodinated agent molecule and 360 mmol of iodine. For<br />
MRI, this same 70 kg patient would receive 7 mmol of the gadolinium based agent molecule and 7 mmol of<br />
gadolinium [25]. Thus, the number of iodinated contrast agent molecules administered would be almost 17<br />
times that of gadolinium containing molecules, and the number of iodine atoms administered is 51 times that<br />
of gadolinium.<br />
In 3.5% of 195 patients with abnormal pre-examination creatinine clearance levels, acute renal failure<br />
(anuria) developed after gadolinium-based contrast medium administration; for MR-angiography the<br />
incidence was 1.9% and for digital subtraction angiography it was 9.5% [26]. Dialysis was required in 3 of the<br />
7 patients who developed acute renal failure. The doses of gadolinium-DTPA ranged from 0.31 to 0.41<br />
mmol/kg for MR angiography and 0.27 to 0.42 mmol/kg for digital subtraction angiography. Several other<br />
reports have shown the nephrotoxic potential of gadolinium based contrast media [27-31]. An experimental<br />
study in pigs has indicated the gadolinium based contrast media are more nephrotoxic than iodinated<br />
contrast media [31]. Thus, the use of gadolinium based contrast media for radiographic examinations cannot<br />
be recommended to avoid nephrotoxicity in patients with renal impairment [25].<br />
Administration of contrast media to diabetics taking metformin<br />
The use of contrast media in patients receiving metformin should be done with care. Contrast media can<br />
induce a reduction in renal function leading to retention of metformin that may induce lactic acidosis, since<br />
there is a very rapid onset of renal injury after administration of contrast medium [32]. However, there is no<br />
conclusive evidence indicating that the intravascular use of contrast media precipitates the development of<br />
metformin induced lactic acidosis in patients with normal serum creatinine (
function before injection of contrast media. Serum creatinine should always be monitored to check that it is<br />
within normal range before administration of metformin is resumed.<br />
Conclusion<br />
Measurement of S-creatinine must always be measured no longer 7 days before administration of iodinated<br />
contrast in patients with 1) renal disease, 2) renal surgery, 3) proteinuria, 4) diabetes mellitus, 5)<br />
hypertension, 6) gout and 7) recent intake of nephrotoxic drugs. The answers should be provided to the<br />
department of radiology with the imaging request. In emergency situation serum-creatinine should always be<br />
measured if the delay of the examination does not do any harm to the patient.<br />
In case of increased serum-creatinine levels one should not 1) give high osmolar contrast media, 2)<br />
administer large doses of contrast media, 3) administer mannitol and diuretics, particularly loop-diuretics and<br />
4) perform multiple studies with contrast media within a short period of time and 5) continue metformin<br />
administration 48 hours prior to contrast administration. It is of importance that one 1) makes sure that the<br />
patient is well hydrated [give at least 100 ml (oral (e.g. soft drinks) or intravenous (normal saline) depending<br />
on the clinical situation) per hour starting at least 4 hours before to 24 hours after contrast administration – in<br />
warm areas increase the fluid volume], 2) uses low- or iso-osmolar contrast media, 3) stops administration of<br />
nephrotoxic drugs for at least 24 hours, and 4) considers alternative imaging techniques, which do not<br />
require the administration of intravascular radiographic contrast media. There is no need to do hemodialysis<br />
right after the contrast medium injection as it does not reduce the risk of contrast medium induced<br />
nephropathy. For radiographic examinations gadolinium based contrast media cannot be recommended to<br />
avoid nephrotoxicity. Metformin should be stopped and the contrast study should be delayed for 48 hrs.<br />
Metformin should only be restarted 48 hrs later after the examination if serum creatinine is normal.<br />
References<br />
1. Morcos SK, Thomsen HS, Webb JAW and members of contrast media safety committee of the European Society of Urogenital<br />
Radiology (ESUR) Contrast media induced nephrotoxicity: A consensus report. Eur Radiol 1999; 9: 1602-1613.<br />
2. Hou SH, Bushinsky DA, Wish JB et al. Hospital acquired renal insufficiency: A prospective study. Am J Med 1983; 74: 243-248.<br />
3. Nash K, Hafeez A, Hou S. Hospital-acquired renal insufficiency. Am J Kidney Dis 2002; 39: 930-936.<br />
4. Solomon R. Contrast medium-induced acute renal failure. Kidney Int 1998; 53: 230-242.<br />
5. Gruberg L, Mintz GS, Mehran R et al. The prognostic implications of further renal function deterioration with 48 h of interventional<br />
coronary procedures in patients with pre-existent chronic renal insufficiency. J Am Coll Cardiol 2000; 36: 1542-1548.<br />
6. McCullough PA, Wolyn R, Rocher LL et al. Acute renal failure after coronary intervention: incidence, risk factors and relationship to<br />
mortality. Am J Med 1997; 103: 368-375.<br />
7. Rudnik MR, Goldfarb S, Wexler L et al. Nephrotoxicity of ionic and nonionic contrast media in 1196 patients: a randomized trial.<br />
Kidney Int 1995; 47: 254-261.<br />
8. Blaufox MD, Aurell M, Bubeck B et al. Report of the Radionuclide in Nephrourology Committee on renal clearance. J Nucl Med 1996;<br />
37: 1883-1890.<br />
9. Bostrom AG, Kronenberg F, Ritz E. Predictive performance of renal function equations for patients with chronic kidney disease and<br />
normal serum creatinine levels. J Am Soc Nephrol 2002; 13: 2140-2144.<br />
10. Couchoud C, Pozet N, Labeeuw M, Pouteil-Noble C. Screening early renal failure: Cut-off values for serum creatinine as an indicator<br />
of renal impairment. Kidney Int 1999; 55: 1878-1884.<br />
11. Thomsen HS, Morcos SK, Members of Contrast Media Safety Committee of European Society of Urogenital Radiology (ESUR). In<br />
which patients should serum-creatinine be measured before contrast medium administration? Eur Radiol 2005; 15; 749-754.<br />
12. Thomsen HS. Contrast nephropathy. In: Thomsen HS, Muller RN, Mattrey RF (eds) Trends in contrast media. 1999, Berlin, Springer<br />
Verlag, 103-116.<br />
13. Morcos SK (2004) Prevention of contrast media nephrotoxicity – the story so far. 2004; 59: 381-389.<br />
14. Solomon R, Werner C, Mann D, D’Elia J, Silva P. Effects of saline, mannitol and furosemide on acute decreases in renal function<br />
induced by radiocontrast agents. N Engl J Med 1994; 331: 1416-1420.<br />
15. Allaqaband S, Tumuluri R, Malik AM et al. Prospective randomized study of N-aceyltylcysteine, fenoldopam and saline for prevention<br />
of radiocontrast-induced nephropathy. Catheter Cardiovasc Intervent 2002; 57: 279-283.<br />
16. Mueller C, Burkle G, Buerkle HJ et al. Prevention of contrast media-associated nephropathy. Randomized comparison of 2 hydration<br />
regimens in 1620 patients undergoing coronary angioplasty. Arch Intern Med 2002; 162: 329-336.<br />
17. Trivedi HS, Moore H, Nasr S et al. A randomized prospective trial to assess the role of saline hydration on the development of contrast<br />
nephrotoxicity. Nephron Clin Pract 2003; 93: c29-c34.<br />
18. Merten GJ, Burgess WP, Gray LV et al. Prevention of contrast-induced nephropathy with sodium bicarbonate. A randomized<br />
controlled trial. JAMA 2004; 291: 2328-2334.<br />
19. Morcos SK, Thomsen HS, Webb JAW, members of the Contrast Media Safety Committee of European Society of Urogenital<br />
Radiology (ESUR). Dialysis and contrast media. Eur Radiol 2002; 12: 3026-3030.<br />
20. Dehnarts T, Keller E, Gondolf K et al. Effect of haemodialysis after contrast medium administration in patients with renal insufficiency.<br />
Nephrol Dial Transplant 1998; 13: 358-362.<br />
21. Vogt B, Ferrari P, Schonholzer C et al. Pre-emptive haemodialysis after radiocontrast media in patients with renal insufficiency is<br />
potentially harmful. Am J Med 2001; 111: 692-698.<br />
22. Frank H, Werner D, Lorusso V et al. Simultaneous hemodialysis during coronary angiography fails to prevent radiocontrast-induced<br />
nephropathy in chronic renal failure. Clin Nephrol 2003; 60: 176-182.<br />
119
23. Huber W, Jeschke B, Kreymann B et al. Haemodialysis of the prevention of contrast-induced nephropathy. Outcome of 31 patients<br />
with severely impaired renal function, comparison with patients at similar risk and review. Invest Radiol 2002; 37: 471-481.<br />
24. Marenzi G, Marana I, Lauri G et al. The prevention of radiocontrast-agent-induced nephropathy by hemofiltration. N Engl J Med 2003;<br />
349: 1333-1340.<br />
25. Thomsen HS, Almén T, Morcos SK, members of Contrast Media Safety Committee of European Society of Urogenital Radiology<br />
(ESUR). Gadolinium-containing contrast media for radiographic examinations: a position paper. Eur Radiol 2002; 12: 2600-2605.<br />
26. Sam II AD, Morasch MD, Collins J, et al Safety of gadolinium contrast angiography in patients with chronic renal insufficiency. J Vasc<br />
Surg 2003; 38: 313-318.<br />
27. Spinosa DJ, Angle JF, Hagspiel KD et al. Lower extremity arteriography with use of iodinated contrast material or gadodiamide to<br />
supplement CO 2 angiography in patients with renal insufficiency. J Vasc Interv Radiol 2000; 11: 35-43.<br />
28. Gemmete JJ, Forauer AR, Kazanjian S et al. Safety of large volume gadolinium angiography. (<strong>abstract</strong>) J Vasc Interv Radiol 2001; 12<br />
(part 2): S 28.<br />
29. Schenker MP, Solomon JA, Roberts DA. Gadolinium arteriography complicated by acute pancreatitis and acute renal failure. (letter) J<br />
Vasc Interv Radiol 2001, 12: 393.<br />
30. Terzi C, Sokmen S. Acute pancreatitis induced by magnetic-resonance-imaging contrast agent. Lancet 1999; 354: 1789-1790.<br />
31. Elmståhl B, Nyman U, Leander P et al. Gadolinium contrast media are more nephrotoxic than a low osmolar iodine medium employing<br />
doses with equal X-ray attenuation in renal arteriography: An experimental study in pigs. Acta Radiol 2004; 11: 1219-1228.<br />
32. Thomsen HS, Morcos SK and members of contrast media safety committee of the European Society of Urogenital Radiology (ESUR)<br />
Contrast media and metformin. Guidelines to diminish the risk of lactic acidosis in non-insulin dependent diabetics after administration<br />
of contrast media. Eur Radiol 1999; 9: 738-740.<br />
120
ABSTRACTS<br />
MEMBERS’ SESSION<br />
MS1<br />
In-vivo magnetic resonance imaging of magnetically labeled stem cells in kidneys after selective<br />
intraarterial injection: initial results<br />
Harald Ittrich 1, Friedrich Thaiss 2, Claudia Lange 3, Hannes Dahnke 4, Gerhard Adam 1, Claus Nolte-Ernsting 1<br />
1 Department of Diagnostic and Interventional Radiology, 2 Department of Internal Medicine, Division of Nephrology and<br />
Osteology, 3 Department of Haematology/Oncology, Bone Marrow Transplantation, University Hospital Hamburg-Eppendorf<br />
Martinistr. 52, DE-20246 Hamburg, Germany, 4 Philips Research Laboratories – Hamburg Division Technical Systems<br />
Roentgenstr. 24-26, DE-22335 Hamburg, Germany<br />
OBJECTIVES: To evaluate MRI for in-vivo tracking of selectively intraarterial injected iron oxide-labeled mesenchymal stem cells<br />
(rMSCs) in a rat model of glomerulonephritis.<br />
MATERIAL AND METHODS: 10^6 magnetically labeled rMSC were injected in the left renal artery in rats four days after the<br />
induction of an anti-Thy1 antibody-induced glomerulonephritis (control group: no rMSC injection). In-vivo MR Imaging and MR<br />
Relaxometry were performed repetetivly up to day 22 using a clinical whole body 3T scanner. MRI data were correlated with kidney<br />
histology. Statistical analyses of signal intensity (SI) changes and T2* relaxation-time in both groups were performed.<br />
RESULTS: Significant SI decrease and shortening of T2* (96.8-58%, 3.3–20.8ms, day 0-22)) was observed in the cortex and the<br />
outer medulla of left kidneys in rMSC group up to 3 weeks after rMSC administration (control: 1.6±3.7%, 42.7±2.6ms, p
In 7 adult New Zealand White rabbits focal RPDs were determined by polyvinyl alcohol embolizing particles (150 - 250 ìm in<br />
diameter) injected in abdominal aorta. Other 3 not-embolized rabbits were considered controls. Both kidneys were insonated at<br />
baseline, and contrast-enhanced US at low transmit power (mechanical index: 0.09 - 0.12) by one sonologist who assessed on-site<br />
RPDs dimensions and conspicuity (visual score 0 - 4). Digital cine-clips were reviewed off-site by two blinded independent readers<br />
who assigned a confidence level (grade 1 - 5) in RPD diagnosis.<br />
RESULTS: RPDs appeared as focal areas of absent or diminished vascularity (diameter of the smallest identified RPD = 6 mm;<br />
median visual conspicuity score = 4) corresponding closely to renal infarctions or ischemic areas showed at macroscopic/histologic<br />
analysis. Diagnostic confidence in RPDs improved significantly (P < 0.05) at contrast-enhanced US (area under Receiver Operating<br />
Characteristic curve: 0.615 vs 0.972 -reader 1-; 0.720 vs 0.953 -reader 2-).<br />
CONCLUSION: Contrast-enhanced US at low transmit power insonation was feasible in focal RPDs diagnosed in an animal model.<br />
MS5<br />
Doppler ultrasonography of arterial stenosis in renal transplanted patients<br />
Gaute Hagen 1,4, Jonas Wadström 2, Anders Magnusson1; 1Department of Radiology, 2Department of Transplantation Surgery,<br />
Uppsala University Hospital, SE-751 85 Uppsala, Sweden, 4 Department of Radiology, Sykehuset Östfold Moss, N-1535 Moss,<br />
Norway<br />
PURPOSE: To evaluate the accuracy of Doppler ultrasonography in the diagnosis of transplant renal artery stenosis (TRAS) or iliac<br />
artery stenosis.<br />
MATERIALS AND METHODS: Three-dimensional rotational angiography (3D-RA) was carried out on 55 consecutive renal<br />
transplanted patients with suspicion of TRAS or<br />
iliac artery stenosis. The suspicion was based on Doppler ultrasonography findings, increasing serum creatinine, hypertonia, and/or<br />
biopsy findings indicating ischemia. The stenoses were defined by the angiographic location and when possible verified with<br />
pressure measurement. Prior to the 3D-RA the patients were examined with Doppler ultrasonography. A significant stenosis was<br />
suspected when the peak systolic velocity (PSV) was 2.5 m/s or more at a Doppler angle of 60° or less.<br />
RESULTS: Doppler ultrasonography suspected stenosis in 42/55 (76%) patients; 35 with TRAS, 5 with iliac artery stenosis and 2<br />
with both. There were no false-negative Doppler ultrasonographies, but 14 false-positive examinations, all TRAS. The sensitivity of<br />
Doppler ultrasonography was 100%, the specificity was 48%, and the PPV was 67%.<br />
CONCLUSION: Doppler ultrasonography is an important initial method for the evaluation of arterial stenosis in renal transplanted<br />
patients, but an angiographic confirmation is still required.<br />
MS6<br />
Catheter-based optical coherence tomography of the porcine ureter ex vivo: morphometric comparison with histology<br />
U.L. Mueller-Lisse, O. A. Meissner, M. Bauer, M. Jaeger, F. Roggel, G. Babaryka, M. Reiser, U.G. Mueller-Lisse;<br />
Klinik und Poliklinik für Urologie, Institut für Pathologie und Institut für Klinische Radiologie der Ludwig-Maximilians-Universität,<br />
München<br />
PURPOSE: Based on near-infrared light (1350 nm), which is emitted from a catheter-mounted optical fiber, intraluminal optical<br />
coherence tomography (OCT) provides cross-sectional images of vessels and hollow organs, with a lateral resolution of 4-20 ľm.<br />
We compared width estimates of different ureteral wall layers in OCT images with histologic sections of porcine ureters ex vivo.<br />
MATERIALS AND METHODS: The OCT probe (diameter, 0.014 inch, LightLab Inc., Westford, MA) was introduced into each of 6<br />
porcine ureter specimens ex vivo. Ureters were dilated with normal saline solution to approximately 4 mm. Single-slice crosssectional<br />
OCT images and H&E-stained histologic sections were obtained at marked positions. Two independent observers (O1,<br />
O2) each determined width of ureteral wall layers (urothelium, lamina propria, muscle layer) by means of OCT software and light<br />
microscopy, respectively. At least 10 different positions per specimen were evaluated.<br />
RESULTS: OCT distinguished ureteral wall layers in all specimens. Means +/- standard deviations of measurements (in ľm) by<br />
O1/O2 for OCT vs. histology were 70+/-10/80+/-10 vs. 50+/-10/70+/-10 for urothelium, 160+/-30/170+/-30 vs. 120+/-30/120+/-20 for<br />
lamina propria, and 310+/-90/540+/-120 vs. 220+/-30/310+/-110 for muscle layer, respectively.<br />
CONCLUSION: Intraluminal OCT demonstrates different ureteral wall layers with width estimates very similar to width estimates in<br />
histologic sections. Overestimation by OCT may be due to higher spatial resolution of light microscopy and tissue shrinkage in<br />
histologic sections.<br />
MS7<br />
Assessment of diagnostic confidence in renal malignancies diagnosed at contrast-enhanced US<br />
Emilio Quaia, Alessandro Palumbo, Stefania Rossi, Maria Cova / Department of Radiology - Cattinara Hospital,<br />
University of Trieste (Italy)<br />
PURPOSE: To assess diagnostic confidence in renal malignancies diagnosed at contrast-enhanced US.<br />
MATERIALS AND METHODS: A series of solid (46 renal cell carcinomas -RCCs-, 5 renal metastases, 4 embryonal matanephric<br />
adenomas -EMAs-, 14 angiomyolipomas -AMLs- and 1 oncocytoma) or cystic (15 cystic RCCs, 2 multilocular cystic nephromas, 2<br />
inflammatory and 4 haemorragic cysts) renal tumours < 4 cm, in 93 consecutive patients (55 male and 38 female, age 65 +/- 15<br />
years), were scanned after microbubble injection. Two independent blinded readers not involved in scanning retrospectively<br />
expressed a malignant or benign diagnosis according to standard criteria. Histology (n=75) or multimodality imaging modalities<br />
(n=18 tumours) were reference procedures.<br />
RESULTS: Solid tumours revealed diffuse homogeneous (17 RCCs, oncocytoma and 4 AMLs) or heterogeneous (29 RCCs and<br />
EMAs), dotted (10 AMLs) or absent (metastases) enhancement. Cystic RCCs revealed peripheral rim-like (n=3), nodular (n=3) or<br />
diffuse nodular and septal (n=9) enhancement, while benign cystic renal tumours revealed peripheral rim-like (multilocular cystic<br />
nephromas and inflammatory cysts) or absent (haemorragic cysts) enhancement. Diagnostic confidence in malignancy diagnosis<br />
improved significantly (P
CONTENT: The purpose of our study was to evaluate the different variables at dynamic MRI before and after kidney drainage in<br />
cases of acute upper urinary tract obstruction.<br />
M.M: Thirty patients with acute upper urinary tract obstruction; 5 bilateral and 25 solitary functioning kidneys (17 left & 8 right). Their<br />
age range 26-74 yrs, the mean age 53 + 12 yrs. Dynamic study for the kidney using gradient echo T1, we assessed the kidney<br />
size, parenchymal SI, corticomedullary differentiation, cortico-medullary crossing time & time to peak. All these variables were<br />
evaluated before & after kidney drainage.<br />
RESULTS: Among the 35 units, there was no significant change in kidney size, the parenchymal SI was increased in 30 units, in 3<br />
units there was a drop & no change in 2 (r=.29). There was good CMD in 31 units & two of the remaining 4 showed improvement<br />
after drainage. There was CM crossing in 28 with improved curves after drainage while in the remaining 7 there was crossing in 4<br />
after drainage. The CM crossing time was 163.6 + 70.4 sec. before drainage & 138 + 57.5 sec after drainage (r = .627). The TP for<br />
each unit was 71.6 + 118 sec before & 67 + 79 sec after (r = .76).<br />
CONCLUSION: Dynamic MRI could be used as an on-invasive technique in diagnosis of acute upper urinary tract obstruction.<br />
MS9<br />
Delineation of upper urinary tract segments at low-dose multidetector CT urography: retrospective comparison with a<br />
standard protocol<br />
Mueller-Lisse UG, Meindl T, Coppenrath E, Mueller-Lisse UL, Degenhardt C, Khalil R, Reiser MF<br />
Depts. of Radiology and Urology, University of Munich, Germany<br />
PURPOSE: CT urography (CTU), as an add-on to contrast-enhanced CT of the abdomen and pelvis, may replace excretory<br />
urography in patients with pelvic tumors. However, radiation exposure is a concern. We retrospectively compared upper urinary<br />
tract (UUT) delineation in low-dose and standard CTU.<br />
MATERIALS AND METHODS: CTU (1-2 phases) was obtained with 120 KV, 4x2.5 mm collimation, and pitch 0.875 after i.v.<br />
injection of 120 ml of non-ionic contrast media with 300 mg of iodine/ml with standard (14 patients, n=116 UUT segments, average<br />
175.6 mAs/slice, average delay 16.8 minutes) or low-dose (26 patients, n=344 UUT segments, 29 mAs/slice, average delay 19.6<br />
minutes) protocols. UUT segments included intrarenal collecting system (IRCS), upper, middle, and lower ureter (UU,MU,LU). Two<br />
independent readers (R1,R2) graded UUT segment delineation as 1-absent, 2-partial, 3-complete (noisy margins), 4-complete and<br />
clear. Chi square (X2) statistics were calculated for grades 1-2 vs. 3-4 (delineates course of UUT, may locate obstruction/dilation)<br />
and 1-3 vs. 4 (may locate intraluminal lesions).<br />
RESULTS: Delineation of UUT was equally good for all segments in standard and low-dose CTU (R1, X2=0.0036-1.74, p>0.15; R2,<br />
X2=0.074-1.308, p>0.2 ). IRCS, UU, and MU were as oftenly clearly delineated in standard as in low-dose CTU (R1, X2=0.074-<br />
1.013, p>0.25; R2, X2=0.919-2.159, p>0.1). However, LU was more oftenly clearly delineated in standard CTU (R1, 18/24<br />
standard, 38/69 low-dose, X2=2.178, p>0.1; R2 18/24 standard, 21/69 low-dose, X2=12.75, p
AMLs were interpreted as renal cancers, four renal carcinomas were interpreted as AMLs, 1 MLCN was misinterpreted as cyst, and<br />
seven renal cancers were interpreted as “most probably” or definitely renal cyst, including the largest observed renal cancer that<br />
had 9 cm in diameter and was cleary hypervascular on color and power Doppler. In patients with wrong initial diagnosis<br />
examination was performed most commonly by general practitioners (20), but also by nephrologists (4), urologists (4),<br />
gastroenterologists (3), abdominal surgeons (2), and radiologists (2). The diagnosis was delayed up to one year.<br />
CONCLUSION: Non-visualization or erroneous characterization of solid renal lesions on US is very common, particularly when<br />
examinations are performed by insufficiently trained physicians and non-radiologists. Good education in US and experience are<br />
essential for proper visualization and characterization of renal tumors.<br />
MS12<br />
Diagnosis of upper tract transitional cell carcinoma (TCC) with a single phase multidetector CT urography<br />
F.Cornud, M.Bienvenu, H.Guerini, X. Poittevin, A.ChevrotT<br />
PURPOSE: to describe upper tract TCC features on a single phase MDCTU with split bolus injection and hyperdiuresis.<br />
MATERIALS AND METHODS: 29 patients (mean age: 69, range 56-88, 23 men) with a histologically proven TCC were reviewed. A<br />
3 phase protocol with hyperdiuresis (furosemide 20mg) was used in all patients (unenhanced, corticomedullary and combined<br />
nephrographic-excretory phase after reinjection of 50 ml of contrast medium). Ability of the third phase to detect the tumor and<br />
assess pT stage was investigated.<br />
RESULTS: 17 lesions were located in the pelvicaliceal system and 12 in the ureter. Lesions presented as a non obstructive filling<br />
defect in 12 cases, an obstructive mass in 7 cases and with an infiltrative pattern in 10 cases. On the combined nephrographicexcretory<br />
phase, all tumors could be detected. Tumor size was overestimated in one case due to the presence of a clot abutting the<br />
tumor.<br />
Tumor enhancement was obvious in all obstructive masses and in 9/10 infiltrative tumors.<br />
CONCLUSION: Upper tract TCC’s can be accurately detected on a single phase MDCTU with split bolus injection and induction of<br />
a hyperdiuresis. The value of a one phase MDCTU should be assessed to reduce irradiation when investigating the urinary tract<br />
with MDCTU.<br />
MS13<br />
Does a limited CT Urography (CTU) offer important additional information in patients with haematuria who had normal<br />
IVU, Ultrasound and Flexible Cystoscopy?<br />
H S Ganesh, F Salim, S K Moecos; Department of Diagnostic Imaging,Central Sheffield Teaching Hospitals NHS Foundation Trust,<br />
Herries Road, Sheffield, S5 7AU,UK<br />
OBJECTIVE: Evaluating the impact of of CTU in patients with haematuria and normal IVU, ultrasound and flexible cystoscopy.<br />
PATIENTS AND METHODS: A total of 34 patients (23males, 11 females, mean age 58.6, range 29-87 years) with negative<br />
investigations for haematuria underwent CTU using a multislice CT scanner (4 slice). A precontrast scan of the kidneys was<br />
performed followed by a scan of the whole abdomen 5 minutes after intravenous injection of 50 mls of non ionic contrast medium<br />
(300mg iodine/ml) and 10 mg of furosemide. The scanning parameters were 2.5mmx4 collimation, 120kVP, 80mAs. Contiguous<br />
axial images(5mm slice thickness), coronal images (3mm slice thickness using MIP) and a thick coronal slab (80mm slice thickness<br />
using MIP) were obtained. The scans were assessed independently by two uroradiologists.<br />
RESULTS: Twenty scans (58%) were reported as normal and 14 (42%) abnormal [small renal calculi in 8 patients(23%), simple<br />
cysts(4 patients), high density cyst(1 patient)and previous partial nephrectomy(1 patient)]. Good agreement was observed between<br />
the two radiologists (K>0.65). The diagnostic quality of the examinations were rated as either excellent or very good except in three<br />
examinations which reported as satisfactory by one uroradiologist.<br />
CONCLUSION: Small renal calculi not detected by standard imaging techniques were the only important abnormality detected in<br />
this group of patients.<br />
MS14<br />
Ferumoxtran-10 enhanced MR imaging in detection of metastases out of the surgical view in prostate cancer<br />
R.A.M. Heesakkers, J.A. Witjes, C.A. Hulsbergen- van de Kaa, J.O. Barentsz; Radboud University Nijmegen medical centre<br />
PURPOSE: To evaluate the diagnostic value of Ferumoxtran-10 enhanced MR imaging in the detection of lymph node metastases<br />
out of the surgical view in patients with prostate cancer.<br />
MATERIAL AND METHODS: 150 consecutive patients with prostate cancer were enrolled in this study. At 1.5T, T1 and T2*<br />
weighted MR images of the obturator area were obtained, 24 hours after Ferumoxtran-10 administration. The MR examinations<br />
were evaluated by one experienced reader.<br />
Lymph node metastases were confirmed by lymph node dissection, follow-up scan or CT-guided lymph node biopsy.<br />
RESULTS: Thirty-one out of 150 patients had positive lymph nodes confirmed by histopathology. Of these 31 patients, 16 patients<br />
had positive lymph nodes only outside, 8 in and outside, and 6 inside the surgical view (e.g. obturator area), respectively. Twentyfive<br />
out of 31 were detected using USPIO enhanced MR imaging (X out of X outside the surgical view).<br />
CONCLUSION: Ferumoxtran-10 enhanced MR imaging may be used to guide the urologist in selective dissecting of positive lymph<br />
nodes.<br />
MS15<br />
IMRT boost planning on dominant intraprostatic lesion by means of gold marker-based 3D fusion of CT, 1H spectroscopic<br />
and dynamic contrast-enhanced MR imaging.<br />
Jurgen J Futterer, Emile N.J.Th van Lin, Stijn W.T.P.J., Heijmink, Lisette P. van der Vight, Aswin L. Hoffmann, Peter van<br />
Kollenburg, Henkjan J. Huisman, J. Alfred Witjes, Jan Willem Leer, Andries G. Visser, Jelle O. Barentsz;<br />
Dept of radiology, urology and radiotherapy, university medical Center nijmegen, The Netherlands<br />
PURPOSE: To demonstrate the feasibility of the fusion of functional MR imaging techniques with CT using gold markers as<br />
fiducials, to define biological target volume for high-dose dominant intraprostatic lesion (DIL) boosting with intensity modulated<br />
radiotherapy (IMRT).<br />
MATERIAL AND METHODS: Seven patients with biopsy-proven, localized prostate cancer enrolled in this study. Four fine gold<br />
markers were inserted via trans-rectal ultrasound. Patients underwent both CT and MR imaging on the same day. The planning CT<br />
scan was obtained at 3-mm slice thickness using an endorectal balloon. Endorectal MR imaging was performed obtaining T2-<br />
124
weigthed, spectroscopic and dynamic contrast-enhanced MR imaging. CT and MR imaging sets were aligned by registration of the<br />
gold markers. The functional MR data were fused with the CT data. An experienced radiologist and radiotherapist evaluated all<br />
data.<br />
RESULTS: In all seven patients a DIL could be determined with combined functional imaging techniques. The DIL volumes ranged<br />
between 1.1-8.5 cc. IMRT treatment planning could be performed in all patients. The dose distribution of the inner rectal wall<br />
circumference for the IMRT plans<br />
clearly showed an improved pattern of dose exposure to the rectal wall mucosa.<br />
CONCLUSION: Functional MR imaging can be used to accurately define the DIL for boosting with IMRT.<br />
MS16<br />
The additive effect of contrast agent administration in transrectal ultrasound staging of prostate cancer<br />
1Stijn W.T.P.J. Heijmink1, 2 Hilco van Moerkerk, 1 Jurgen J. Fütterer; 3 Christina A. Hulsbergen-van de Kaa, 2 Ben C. Knipscheer,<br />
2 J. Alfred Witjes, 1 Johan G. Blickman, 1 Jelle O. Barentsz; Department of Radiology 1, Department of Urology 2, Department of<br />
Pathology 3, Radboud University Nijmegen Medical Centre<br />
URPOSE: To assess the value of contrast-enhanced over non-enhanced transrectal ultrasound (TRUS) staging of prostate cancer<br />
(PC).<br />
MATERIALS AND METHODS: From February 2004 to February 2005, 50 consecutive patients with biopsy-proven and clinically<br />
localized PC underwent TRUS prior to radical prostatectomy. Axial imaging of the whole prostate was performed using gray-scale,<br />
colour and power Doppler imaging. Subsequently, during a slow (1ml/min) intravenous infusion of Sonovue® another set of power<br />
Doppler images was obtained.<br />
Prospectively, two readers (one with one year of TRUS experience and one without prior experience) independently reviewed all<br />
imaging and determined the disease stage as stage T2 or T3 disease on a 5-point probability scale for each set of imaging. Wholemount<br />
section histopathology was the standard of reference.<br />
RESULTS: For the experienced reader staging sensitivity and specificity at gray-scale imaging were 25% (3/12) and 95% (36/38),<br />
respectively. Contrast-enhanced power Doppler imaging increased sensitivity to 58% (7/12) with a specificity of 79% (30/38).<br />
Contrast-enhanced power Doppler had significantly higher sensitivity than non-enhanced Doppler (p
SI changes in a ROI enclosing the whole prostate were fitted to a gamma-variate curve. Changes of enhancement peak, time-topeak<br />
(TP), sharpness-of-the-bolus transit, and area-under-the-curve (AUC) were considered for further analysis.<br />
RESULTS: After tadalafil administration the enhancement peak and AUC increased significantly (p= 1.3x density of peripheral zone)<br />
differentiated central gland and peripheral zone in 51 prostates (61%).<br />
CONCLUSIONS: pvMDCT is capable of distinguishing central gland and peripheral zone of normal prostates. Comparison of<br />
respective CT densities is superior to visual analysis of pvMDCT images. However, results imply that pvMDCT would contribute to<br />
prostate cancer localization by means of PET-CT only in a subset of patients.<br />
MS20<br />
The Urethral Support System as Defined By Phased-Array MRI with Cadaveric Dissection and Histological Correlation in<br />
Nulliparous Female<br />
Rania F. El Sayed*, Medhat Morsi **Sahar El Mashed *, Mohamed S. Abd El Azim ***.<br />
Departments of Radiology *, Anatomy **. Urology ***, Faculty of Medicine, Kaser El Ainy Hospitals, Cairo University, Egypt.<br />
PURPOSE: To determine which element of the female urethral support structures is found on anatomic dissection and could be<br />
visualized on MRI performed without an endovaginal coil, plus histological analysis of each structure.<br />
MATERIALS AND METHODS: Volunteer study included 17 healthy nulliparous volunteers. MRI was done using 1.5-T (Gyroscan<br />
Philips). T2WI TSE were acquired in the axial, sagittal, and coronal planes with a slice thickness 5mm and slice gap 0.7 mm,<br />
TR/TE 5000/132, Field of view 240-260.<br />
Cadaveric Study: Dissection of 6 cadavers was done in an experimental way to explore the periurethral supporting structures. The<br />
ligaments were labeled by a marker for their identification, digital images were taken, and MR imaging was performed. Then<br />
comparison between the dissected specimen, their MRI images and the MRI of the control subjects was done. Histological study:<br />
Microscopic analysis was performed by an experienced pathologist.<br />
RESULTS: Guided by the marker placed on the different urethral supporting ligaments in the cadavers, we identified different<br />
orientation of two of the urethral supporting ligaments (pubourethral, uretheropelvic), to our knowledge those orientations haven’t<br />
been described previously. Applying the grid system on the MR images of the control group , the most fixed ligaments that could<br />
be visualized were the periurethral ligament, followed by the uretheropelvic ligament.<br />
CONCLUSION: Our MRI findings suggest that MRI yielded detailed information on the urethral support system.<br />
SCIENTIFIC SESSIONS<br />
SS1<br />
Multi-detector row CT urography in the investigation of painless hematuria<br />
A. Ch. Tsili1, C. Tsampoulas1, O. Katsios1, D. Giannakis2, P. Tzoumis2, D. Dristiliaris3, N. Sofikitis2, S. C. Efremidis1.<br />
1Department of Clinical Radiology 2Department of Urology 3Department of Medical Physics University Hospital of Ioannina,<br />
GREECE<br />
PURPOSE: To assess the role of multi-detector row CT (MDCT) urography, with a 16-row CT scanner in the evaluation of patients<br />
presenting with painless hematuria.<br />
MATERIALS AND METHODS: The study included seventy-five patients referred for painless hematuria. Examinations were<br />
performed on a 16-row CT scanner and a three-phase protocol was used. Unenhanced images were obtained with a detector<br />
configuration of 16 C 1.5 mm and pitch of 1.2. After intravenous administration of iodinated contrast material and 250 ml of saline<br />
solution nephrographic-phase and excretory-phase images were obtained, with collimation thickness of 16 X 0.75 mm and pitch of<br />
1.2. Axial and coronal reformatted images were evaluated. Three- dimensional reformations of the excretory-phase data was<br />
performed using the volume-rendering technique. The standard of reference included clinical and imaging follow- up, cystoscopic<br />
and/or ureteroscopic findings, surgical and histologic findings.<br />
RESULTS: MDCT urography demonstrated a sensitivity of 96%, a specificity of 89%, a positive predictive value of 96% and a<br />
negative predictive value of 89% in the identification of the cause of hematuria, when compared to the methods used as reference.<br />
CONCLUSION: A hematuria CT protocol based on 16-slice multidetector technology is highly accurate in detecting and excluding<br />
significant causes for painless hematuria.<br />
SS2<br />
Multiphase Multidetector-Row CT (MDCT) of Transitional Cell Carcinoma of the Renal Pelvis and the Ureter: Improved<br />
Detection, Diagnosis and Staging<br />
126
Gerald A. Fritz, Helmut Schoellnast, Hannes A. Deutschmann, Martin Wehrschuetz, Manfred Tillich Department of Radiology Univ.<br />
Hospital Graz, Austria<br />
PURPOSE: To evaluate the potential of multiphase multidetector CT (MDCT) in detection, diagnosis and staging of transitional cell<br />
carcinomas (TCC) of the upper urinary tract.<br />
MATERIALS AND METHODS: We performed a retrospective chart review of 36 consecutive patients with suspect urothelial lesions<br />
of the upper urinary tract. In all patients the urinary tract was examined using MDCT performing unenhanced and contrast<br />
enhanced scans during the cortical nephrographic, tubular nephrographic and pyelographic phase. The attenuation of the lesions<br />
was documented in Hounsfield units (HU). Tumor staging was performed according to TNM-classification. MDCT and<br />
histopathological findings were correlated.<br />
RESULTS: Histopathological examination revealed 33 TCC (13 renal, 20 ureteral) and 3 patients with inflammatory changes. All<br />
TCC were visible on cortical nephrographic and tubular nephrographic phase scans. TCC showed a mean attenuation of 77.8 ±18.5<br />
HU and 77.3 ±16.4 HU in these phases (p > 0.05), inflammatory changes of 67.4 ±8.4 HU and 112.5 ±13.2 HU (p = 0.05). There<br />
was a significant difference in mean attenuation between between neoplastic and inflammatory changes in the tubular<br />
nephrographic phase (p = 0.002). A differentiation between organ confined stages (0 - II) was not possible with MDCT. CT correctly<br />
diagnosed a TCC confined to the organ (stage 0a– II) in 22 / 23 cases. A stage III and IV was correctly diagnosed in 6 / 10 patients.<br />
Overall, CT was accurate in predicting pathologic TNM stage in 28 / 33 patients (84.8 %).<br />
CONCLUSION: MDCT with its high spatial resolution is an accurate tool for diagnosis and staging of TCC. Significant higher<br />
attenuation of inflammatory changes in tubular nephrographic phase was seen.<br />
SS3<br />
Patients at high risk of upper tract urothelial cancer: evaluation of hydronephrosis using high-resolution magnetic<br />
resonance urography<br />
Rohit Chahal, Kathryn Taylor, Ian Eardley, Stuart N Lloyd, John A Spencer, St James's University Hospital, Leeds LS9 7TF, UK<br />
PURPOSE: To assess the potential of magnetic resonance urography (MRU) in the evaluation of hydronephrosis not explained by<br />
standard investigation in patients at high risk of upper tract urothelial cancer.<br />
MATERIALS AND METHOD: 23 consecutive patients in a specialist urological unit with unexplained hydronephrosis prospectively<br />
underwent MRU which comprised overview heavily T2-weighted MR urographic images followed by focussed high-resolution TSE<br />
T2-weighted sequences obtained in an axial and coronal oblique plane through the level of urinary obstruction. All were at high risk<br />
of urothelial cancer and had either contraindications to or problems with standard investigations including poor contrast excretion<br />
due to obstruction or renal failure, failed ureteric cannulation or contrast allergy.<br />
RESULTS: In 23 patients, 8 ureteric TCCs and 5 renal pelvic TCCs (two bilateral) were diagnosed by MR and confirmed<br />
histologically. In a further 5 patients benign causes for the hydronephrosis were found. No intrinsic or extrinsic pathology was<br />
demonstrable in 5 patients whose imaging findings were stable over one year of follow up.<br />
CONCLUSION: MRU is a valuable non-invasive investigation in this group of patients where routine investigation had failed to<br />
provide clinically important information. Focussed high- resolution T2-weighted images were reliable in the diagnosis of ureteric and<br />
renal pelvic TCCs and were valuable in excluding these and other mass lesions as the cause of hydronephrosis.<br />
SS4<br />
Pheochromocytoma: a retrospective review of 27 cases with their histopathologic correlation<br />
Dogra VS, Bhatt S, Novak R, Martin C, MacLennan G Case Western Reserve University Cleveland, OH USA<br />
PURPOSE: To assess cross – sectional imaging features of pheochromocytoma with histopathologic correlation and clinical<br />
presentation.<br />
MATERIAL AND METHODS: A retrospective review of a pathological data base from 1995 to 2005 was performed. In total, 27<br />
cases of histopathologically confirmed cases of pheochromocytoma were identified in 11 females and 16 males, age range (7- 73;<br />
mean 41.8±23 yrs). Of these 27 cases, 21 had imaging studies performed in our institution. Imaging appearances of these cases<br />
were compared with their histopathologic features, and co-related with their clinical presentations and their laboratory test values.<br />
All the 27 cases underwent surgical excision of the pheochromocytoma; prior biopsy was performed only in one patient. Because of<br />
the small number of patients and the non-normal distribution of vanillylmandelic acid (VMA) values, the Mann-Whitney U test was<br />
used to test differences between groups.<br />
RESULTS: Following observations were made in this retrospective study of 27 surgically confirmed cases of pheochromocytoma:<br />
Unilateral Rt- 15 Lt-7 Bilateral 1 Extra-adrenal 3 Associated with hereditary syndromes 3 Malignant 3 Recurrent<br />
Pheochromocytoma 2 Children ( < 18 years) 6 In one case, side could not be determined. 6 of 27 patients = 22% were below the<br />
age of 18 years. Average size of the lesion in adrenal pheochromocytomas (19/21) was 5.6cm. ( Including one bilateral). Average<br />
size of the lesion in extra adrenal pheochromocytomas (3/21) was 2.46 cm. Malignant nature of pheochromocytoma was<br />
established in patients with metastasis and was seen in 3/27 cases = 11%. 9/21 patients underwent MRI , 9/21 had CT , 4/21 had<br />
Ultrasound and 5/21 had Radionuclide study. MRI features of low and high signal intensities on both T1 and T2 weighted images,<br />
was the commonest feature due to presence of both hemorrhage and necrosis, observed in 7/9 MRI studies Ultrasound was not<br />
helpful in making a diagnosis of pheochromocytoma, but an adrenal mass was detected on ultrasound in 4 of the above cases, and<br />
showed a solid appearing mass lesion in 3 cases, and central cystic change in 1 case, with increased peripheral vascularity in 2<br />
cases. Increased uptake of I-131 or I-123 MIBG was observed in all 5 cases in which MIBG study was performed. Clinical<br />
presentation and laboratory values of VMA of all these patients were retrospectively studied and correlated with their imaging<br />
findings and their attributes. VMA range was observed to be (5.1-76.8 mg/24hr.) [Normal VMA levels - < 6.8mg/24 hrs]. Average<br />
VMA value was 22.8±19.4 mg/24 hr. Average VMA in malignant pheochromocytomas (3/21) was observed to be 48.2<br />
mg/24hr.Average VMA in non-malignant pheochromocytomas (13/21) was observed to be 20.11 mg/24hr. (In 5/21 cases, VMA<br />
could not be measured due to inappropriate collection of urine sample).VMA values were not found to be different between adrenal<br />
and extra-adrenal pheochromocytomas (U= 29.0, p = 0.58). In this group of patients, 15/21 presented with hypertension and 6/21<br />
did not, when hypertension is defined as 160/90 mm/Hg. There was no difference in VMA values between hypertensive and nonhypertensive<br />
individuals in this study (U=27.0, p=0.46).<br />
CONCLUSION Low and high signal intensities on both T1 and T2 weighted images is commonest MR finding. Pheochromocytomas<br />
had a much higher unilateral occurrence (right > left), than bilateral occurrence. Extra-adrenal pheochromocytomas were smaller in<br />
size than adrenal pheochromocytomas.<br />
127
SS5<br />
Evaluation of focal renal lesions with contrast enhanced ultrasonography (CEUS) using a new microbubble contrast agent<br />
(SonoVue®)<br />
Pallwein L.1, Frauscher F.1, Neururer R.2, Georg B.2, Klauser A.2 , Gradl H1, Schurich M1.; 1Radiology II, Innsbruck, Austria,<br />
2Urology, Innsbruck, Austria<br />
PURPOSE: To assess the value of contrast enhanced ultrasonography (CEUS) with a new microbubble contrast agent<br />
(SonoVue®; Bracco) in differential diagnosis and delineation of focal renal lesions<br />
MATERIALS AND METHODS: 23 focal renal lesions were examined prospectively with CEUS using SonoVue® (Bracco, Italy)<br />
performing bolus injection (2.5 ml) and an Acuson Sequoia, Mountain View, CA (4Hz, low MI =0.3; pulse- inversion imaging).<br />
Diagnosis was based on CT and/or Histology (renal cell carcinoma (RCC) n=11; transitional cell cancer (TCC) n=2, angiosarcoma<br />
n=1; cystic lesion Bosniak II-IV n=5; hypertrophic columna n=1; regenerating nodule n=3)<br />
RESULTS: RCCs showed a high contrast agent uptake during arterial phase and a contrast agent "wash out" during venous phase.<br />
TCCs demonstrated a low, increasing enhancement during arterial and venous phase. Benign lesions (hypertrophic columna and<br />
regenerating nodule) showed contrast enhancement equal to the renal cortex and no wash out. Bosniak II cystic lesions had no<br />
contrast agent uptake. These enhancement patterns were associated with the either benign or malign nature of the lesion (p=0.02;<br />
Chi Quadrat test).<br />
CONCLUSION: CEUS with SonoVue® improves lesion delineation and lesion detection rate of small renal masses. The<br />
enhancement pattern of a lesion yielded important information for the differential diagnosis between benign and malign focal renal<br />
lesions.<br />
SS6<br />
Multi-detector row CT cystoscopy in the assessment of urinary bladder tumors<br />
A. Ch. Tsili1, C. Tsampoulas1, O. Katsios1, P. Champilomatis2, P. Tzoumis2, N. Chatziparaskevas1, N. Sofikitis2, S. C.<br />
Efremidis1; 1Department of Clinical Radiology, 2Department of Urology, University Hospital of Ioannina, GREECE.<br />
PURPOSE: To assess the role of multi-detector row CT (MDCT) cystoscopy, with a 16-row scanner in the detection of urinary<br />
bladder tumors.<br />
MATERIALS AND METHODS: The study included thirty-eight patients with urinary bladder tumors diagnosed on conventional<br />
cystoscopy. The patients were examined after distention of the urinary bladder with room air. We used a detector configuration of<br />
16 X 0.75 and a pitch of 1.2. Virtual images were created using volume-rendered algorithms. The lesions were studied on<br />
transverse tomographic slices, on multiplanar reformations and on virtual images, using conventional cystoscopy as the gold<br />
standard.<br />
RESULTS: MDCT cystoscopy depicted 52 lesions in 28 patients. Forty-eight lesions revealed on CT cystoscopy were true-positive<br />
findings and four were false-positive. We had one false-negative case, in a patient with a tumor involving the prostatic urethra. On<br />
CT cystoscopy 19 lesions smaller than 0.5 cm were identified. The sensitivity, specificity, positive predictive value and negative<br />
predictive value of MDCT cystoscopy for the detection of the urinary bladder tumors were 98 %, 69 %, 92 % and 90 %,<br />
respectively.<br />
CONCLUSION: MDCT cystoscopy is an effective diagnostic modality in the evaluation of urinary bladder neoplasms, capable in<br />
identifying lesions smaller than 0.5 cm.<br />
SS7<br />
Preoperative MSCT imaging of venous spread of renal cell carcinoma (RCC)<br />
Stern-Padovan R, Perkov D, Smiljanic R, Oberman B, Lusic M, Marinic J.<br />
Clinical Institute of Diagnostic and Interventional Radiology, Clinical Hospital Center Zagreb, University of Zagreb, School of<br />
Medicine, Zagreb, Croatia<br />
PURPOSE: To assess MSCT in the preoperative evaluation of RCC, with special consideration of the presence and extent of a<br />
thrombus in inferior vena cava (IVC), hepatic veins and right atrium.<br />
MATERIALS AND METHODS: Multiphase MSCT examinations performed during 3-year period in patients with RCC and the tumor<br />
spread into the renal vein and IVC (Robson IIIa; TNM T3b/T3c) were retrospectively analyzed.<br />
RESULTS: MSCT has shown to be highly accurate in the diagnosis of spread of RCC into the IVC, hepatic veins and right atrium.<br />
Venous extension is optimally shown during the corticomedullary phase of enhancement, with a combination of axial images and<br />
coronal, sagittal and/or multiplanar reconstruction. The most specific sign of venous extension is the presence of a low-attenuation<br />
filling defect within the vein. The level of venous involvment, the distal and proximal extension of the thrombus and infiltration of the<br />
venous wall, including IVC, hepatic veins and right atrium, dictates the surgical approach.<br />
CONCLUSION: An accurate preoperative evaluation of involvement of IVC, hepatic veins and right atrium in patients with RCC is<br />
crucial. MSCT is presently the best technique for diagnosing the RCC and the tumor spread into the IVC, hepatic veins and right<br />
atrium, as well as for planing the surgical procedure.<br />
SS8<br />
Evaluation of Varicocele Incidence of Paraplegic Patients by Colour Doppler Ultrasonography<br />
Alparslan UNSAL*, Bilge YILMAZ**, Ahmet T. TURGUT***, Can Z. KARAMAN*, Ridvan ALACA**<br />
* Adnan Menderes University Faculty of Medicine Department of Radiology, AYDIN<br />
** Turkish Armed Forced Rehabilitation & Care Center Department of Physical Medicine and Rehabilitation, ANKARA<br />
*** S.B. Ankara Training & Research Hospital Department of Radiology, ANKARA<br />
PURPOSE: To evaluate the varicocele incidence of patients with spinal cord injury by color Doppler ultrasonography.<br />
MATERIALS AND METHODS: Sixty patients {48 patients with upper motor neuron injury (U-MNI) & 12 patients with lower-MNI}<br />
with traumatic spinal cord injury and age matched 48 healthy volunteers were enrolled in this prospective study. Testis volumes and<br />
varicocele grades were determined. Presence of varicocele was also classified according to clinical significance.<br />
RESULTS: Testis volumes of U-MNI sub-group (14.81 ą 4.74 ml) were significantly smaller than in the control group (18.20 ą 4.52<br />
ml, p=0.000) and L-MNI sub-group (17.88 ± 3.23 ml, p=0.008). No left-sided clinical varicocele was found in L-MNI sub-group (0/12,<br />
0%), whereas there were 14 patients in the control group (14/48, 29%) and 7 patients in the U-MNI sub-group (7/47, 15%), and the<br />
difference was statistically significant (p=0.000, p=0.007, respectively).<br />
128
CONCLUSION: Clinical varicocele incidence of U-MNI patients, who have spastic paralysis of abdominal muscles, is similar to the<br />
control group. This finding inspires that intra-abdominal pressure via normal to increased abdominal muscle tonus may have a role<br />
in the varicocele etiology, besides the classical factors. Absence of clinical varicocele in L-MNI patients, who have flaccid paralysis<br />
of the same muscle groups, supports this observation.<br />
SS9<br />
Resistivity and Pulsatility Index Alteration in Subcapsular Branches of Testicular Artery: Indicator of Impaired Testicular<br />
Microcirculation in Clinical Varicocele?<br />
Alparslan UNSAL*, Ahmet T. TURGUT**, Fusun TASKIN*, Can Z. KARAMAN*<br />
* Adnan Menderes University Faculty of Medicine Department of Radiology, AYDIN<br />
** S.B. Ankara Training & Research Hospital Department of Radiology, ANKARA<br />
PURPOSE: To compare the testicular artery spectral Doppler parameters of the subclinical and clinical varicocele cases.<br />
MATERIALS AND METHODS: One hundred and seven volunteers were enrolled in this prospective study. Testis volumes and<br />
varicocele grades according to clinical significance were determined. Spectral Doppler analyses of testicular arteries {peaksystolic/end-diastolic<br />
velocity, resistivity/pulsatility index (RI/PI)} were obtained from subcapsular and central branches.<br />
RESULTS: Average testis volumes of subclinical (n=86, 16.41 ± 4.99 ml) and clinical varicocele (n=21, 16.26 ± 4.19 ml) groups<br />
were comparable (p=0.892). No statistically significant difference was found between the Doppler parameters obtained from the<br />
central branches. On the other hand; average RI (0.68 ± 0.04) and PI (1.20 ± 0.16) values of subcapsular branches of left-sided<br />
clinical varicocele cases were significantly greater than the subclinical cases {0.64 ± 0.06 (p=0.006) and 1.07 ± 0.18 (p=0.004),<br />
respectively}.<br />
CONCLUSION: Increased resistivity and pulsatility indices of subcapsular testicular arterial branches on spectral Doppler<br />
examination can be an indicator of impaired testicular microcirculation among the patients with clinical varicocele. Further studies<br />
aimed to estimate cut-off values for these indices and to elucidate any effect on fertility by means of correlations with the sperm<br />
parameters are needed.<br />
SS10<br />
The reliability of ultrasonography in the evaluation of acute scrotal pain<br />
Lyssiotis Ph.*, Constantinidis F.*, Alivisatos G.**, Anastopoulos I*, Liakouras Ch.**, Tsines G.*, Tavernaraki K.*, Malahias G.*<br />
*Radiology and U/S department; **2nd Urology Department, Athens Medical School, Sismanoglion General Hospital, Athens,<br />
Greece<br />
PURPOSE: The aim of this work is the investigation of the reliability of U/S examination in the evaluation of patients with acute<br />
scrotal pain, a condition that often requires immediate surgical treatment in order to avoid irreversible testicular damage.<br />
MATERIALS AND METHODS: The study includes 126 individuals (18-74 years old) admitted to the Urologic Outpatient Department<br />
claiming painful scrotal swelling associated with other local or general symptoms. All the above mentioned persons underwent a<br />
gray-scale and colour Doppler U/S examination for the estimation of the scrotal and adjacent tissues' ecomorphology and<br />
vascularity.<br />
RESULTS: The U/S examination yielded normal findings in 88 cases (70%) and pathologic in 38 cases (30%) including:<br />
Torsion (2 cases), Testicular trauma (1 case), Inflammatory desease (35 cases)<br />
CONCLUSION: Ultrasonography is a simple, cost-effective, harmless and non-invasive reliable method for the evaluation of the<br />
acute scrotum. Other diagnostic imaging methods should be considered only when the sonographic findings are in contrast with the<br />
clinical examinations' results.<br />
SS11<br />
Chronic constipation is a significant factor for the etiopathogenesis of varicocele<br />
Ahmet Tuncay Turgut*, Eriz Ozden**, Pinar Kosar*, Ugur Kosar*, Basak Cakal***Ayhan Karabulut****.<br />
*Department of Radiology, Ankara Research and Training Hospital, The Ministry of Health, Ankara, Turkey<br />
**Department of Urology, University of Ankara, School of Medicine, Ankara, Turkey<br />
***Department of Gastroenterology, Yuksek Ihtisas Hospital, The Ministry of Health, Ankara, Turkey<br />
****Department of Urology, Ankara Research and Training Hospital, The Ministry of Health, Ankara, Turkey<br />
PURPOSE: To determine the role of chronic constipation for the etiopathogenesis of varicocele.<br />
MATERIALS AND METHODS: Group 1 included 25 male patients with chronic constipation with mean duration of 17.0±20.3<br />
(range, 3-96) months whereas group 2 included 26 males without any complaint associated with constipation. All subjects were<br />
examined clinically and by scrotal US. For the plexus panpiriformis (PP) veins mean diameter exceeding 2 mm and reflux with a<br />
duration of more than 1 second were accepted suggestive for varicocele.<br />
RESULTS: Left sided varicocele was detected in 52%(13/25) of subjects in group 1, and 19%(5/26) of subjects in group 2(p=0.02).<br />
Mean diameter of PP veins on the left side was 2.6±1.0 (range 1.2-4.2) mm in group 1 and 1.7±0.5 (range 1.1-3.0) mm in group 2<br />
(p
(95 KUUs) with Direct Radionuclide Cystography (DRNC) at the same session.For the statistical analysis we used Mc Nemar’s, k-<br />
coefficient and T-student’s tests.<br />
RESULTS: VUS, VCUG and DRNC detected reflux in 149/393 (38%), 57/298(19%)and 26/95 KUUs (27%)<br />
respectively.Concordance in findings regarding the presence of reflux between VUS and VCUG was found in<br />
251/298KUUs(84%)and between VUS and DRNC in 69/95KUUs (72%). Thirty-eight out of the total 97 refluxing KUUs (40%)were<br />
depicted only by VUS when compared to VCUG.Reflux was detected only by VCUG in 7KUUs. Besides, VUS only disclosed reflux<br />
in 24 out of the totally of 43 refluxing KUUs(55%)and missed no refluxing KUU compared to DRNC. The difference in the detection<br />
rate of reflux was very significant.<br />
SS13<br />
Voiding Urosonography combined with Fluoroscopic Voiding Cystourethrography in the diagnosis of reflux: Does the<br />
order matter?<br />
A. Anthopoulou, F. Papadopoulou, J. Tzovara, E. Siomou, E. Arkoumani, F. Katzioti, S. Efremidis/ Ioannina, Greece<br />
PURPOSE: Diagnostic imaging of reflux encompasses fluoroscopic-voiding-cystourethrography (VCUG) and contrast-enhancedvoiding-urosonography-harmonic-imaging<br />
(CE VUS HI). Many studies show a higher sensitivity of VUS over VCUG due to VUS<br />
usually proceeding VCUG when performed at the same session. The purpose of our study is to assess if the order of the<br />
examination affects the detection of reflux.<br />
MATERIALS AND METHODS: Two-hundred-and two children with 402 kidney-ureter-units (KUU) were studied for possible reflux.<br />
In all children, VUS with 1-2ml of 2 nd generation contrast-agent (SonoVue) and VCUG with the standard technique were performed.<br />
In group-A (108 children, 214 KUU) VCUG proceeded VUS, while in group-B (94 children, 188 KUU) the sequence was reversed.<br />
For statistical analysis we used McNemar’s, k-oefficient and T-student’s tests.<br />
RESULTS: In group-A VUS and VCUG revealed reflux in 65 (30,4%) and 41(19,2%) KUUs respectively. In group-B VUS and<br />
VCUG depicted 75 (39,9%) and 43 (22,8%) refluxing KUUs respectively. Concordance of findings regarding the presence of reflux<br />
between VUS and VCUG was found in group-A in 179/214(83,6%) KUUs and in group-B in 154/188 (81,9%) KUUs (p=0.48). In<br />
group-A VUS depicted 29/70 (41,4%) more refluxing KUUs and missed 5/70 (0,07%) compared to VCUG. In group-B VUS<br />
disclosed VUR in 33/76(43,4%) more KUUs and missed 1/76 (0,01) refluxing KUUs. No significant difference was found between<br />
group-A and B in the detection of reflux by the two modalities.<br />
CONCLUSION: The order of the examination does not influence the detection of reflux by VUS and VCUG.<br />
SS14<br />
Effect of premicturitional bladder volume on accuracy of postvoid residual urine volume measurements; Bladder fullness<br />
rate is of great importance for preventing false positive residue diagnosis<br />
Eriz Özden, Ahmet Tuncay Turgut*, Çađatay Göđüţ, Uđur Koţar*, Sümer Baltacý<br />
Departmeny of Urology, University of Ankara, School of Medicine, Ankara, Turkey<br />
*Department of Radiology, Ankara Research and Training Hospital, The Ministry of Health, Ankara, Turkey<br />
PURPOSE: To evaluate the effect of premicturitional bladder volume (V1) on postvoid residual urine (V2) measurement and assess<br />
the ideal V1 for an accurate V2 determination.<br />
MATERIALS AND METHODS: 25 healthy young men without any urinary symptoms comprised the study group. Measurements by<br />
transabdominal ultrasonography (TAUS) for V1 and V2 were performed for each subject on three different phases –each preceded<br />
by oral intake of 1000cc of water- which were accompanied by the “mild”, “moderate” and “urgent” sensations of micturation,<br />
respectively.<br />
RESULTS: Mean V1 and V2 during first, second and third phases were 117.7±70.3(SD)cc and 1±1.3cc, 356.2±112.3 and 11.5±12<br />
cc, 639.6±171.8 and 58.8 ± 35.2 cc respectively. By accepting 50 cc as a cut-off value for a pathological V2, 15(60%) of healthy<br />
men were noticed to have V2 in the third phase exceeding this value, whereas the same rate was calculated as 0% for either of the<br />
first two phases. No patient with V1 under 540 cc had V2 above 50 cc.<br />
CONCLUSION: V2 measurements with an uncomfortably full bladder cause high pathologic residue values even in healthy men.<br />
We strongly advise to perform V1 measurement of bladder by TAUS and not to measure V2 if V1 is above 540 cc.<br />
SS15<br />
SS16<br />
From IVU to Unenhanced CT: Modernising the Imaging of Acute Renal Colic<br />
Arvind Pallan, J. Graham Young, Paul Crowe, Rajesh Patel, Linda Freeman, Sean Morris Birmingham Heartlands Hospital<br />
Bordesley Green East, Birmingham B9 5SS<br />
PURPOSE: Uncontrasted CT is the most sensitive investigation for detecting calculi in patients presenting with suspected renal<br />
colic. Its introduction in the UK has been hampered by perceived limitations in CT capacity and concerns regarding radiation dose.<br />
We received funding from the NHS Modernisation Agency through Action on Urology to introduce CT for patients with suspected<br />
renal colic in our Trust.<br />
MATERIALS AND METHODS: Activity over a 12 month period after introduction of CT has been compared with 60 consecutive<br />
patients undergoing IVU for suspected renal colic in 2002. Patients presenting between 09:00 and 17:00 underwent immediate CT.<br />
Patients presenting outside these hours were admitted and investigated the following day. 423 patients underwent CT under this<br />
protocol.<br />
RESULTS: Stones were identified as the cause of pain in 223 (53%) and other significant pathology in 38 (9%). No abnormality was<br />
found in 163 (39%). 109 patients were discharged from A&E after the CT. Bed occupancy was 2.06 days/patient, compared to 2.82<br />
days/patient in the IVU group.<br />
CONCLUSION: Uncontasted CT is an accurate and economic investigation in acute renal colic. Our protocol has been adopted by<br />
the Trust and will continue when Modernisation Agency funding ceases.<br />
Emergency non traumatic urogenital imaging. What happens when CT is not available?<br />
Demosthenes D Cokkinos, Elissavet Protopapa, Nikolaos Sakaridis, Ioanna Papaconstantinou, Styliani Giannou/Athens<br />
Hippocration Hospital, Radiology Department<br />
PURPOSE: Non contrast low dose CT is considered the standard imaging modality for non traumatic urogenital emergency<br />
evaluation. When CT is not available, KUB films, ultrasound (US) and intravenous urography (IVU) are still being used. We assess<br />
their efficacy in this clinical setting.<br />
130
MATERIALS AND METHODS: 846 patients (453 male, 393 female, median age 44.6) were studied. 397 presented with acute renal<br />
colic, 73 with scrotal pain, 130 with hematuria, 15 with pyelonephritis related symptoms, 168 with pelvic pain and 60 with urine<br />
retention. They were examined with one or more imaging methods (KUB, US, IVU).<br />
RESULTS: 750 patients underwent KUB, 846 US and 152 IVU. 509, 454 and 86 had negative KUB, US and IVU respectively.<br />
Urolithiasis was imaged in 115 with KUB and in 72 with US. In 29 IVU confirmed renal colic. US diagnosed 1 scrotal torsion and 14<br />
urine retention cases due to prostatic hyperplasia. IVU confirmed pyelonephritis in 10. Altogether a diagnosis was made in 670/846<br />
cases (79.2%). CT was needed in 28/846 (3.3%).<br />
CONCLUSION:In most cases KUB, US and IVU were adequate for a definite diagnosis. Only in 3.3 % there was need for CT.<br />
These modalities are still valuable for non traumatic urogenital emergencies evaluation.<br />
SS17<br />
Renal Injuries - Diagnostic Evaluation by Sonography<br />
Dubravka Vidmar Institute of Radiology, University Medical Centre, 1525 Ljubljana, Slovenia<br />
PURPOSE: Renal injury is present in 8-10% of all patients with blunt abdominal trauma. More severe renal injuries are<br />
accompanied by macrohaematuria, but may also be associated with no haematuria at all. Sonography is the initial diagnostic<br />
modality used in our institution to categorize injury in order to predict conservative or surgical treatment.<br />
PATIENTS AND METHODS: Between March 2004 and March 2005 we diagnosed renal injuries in seven patients with blunt<br />
abdominal trauma and one with penetrating wound (mean age 21.5 years). The mechanism was traffic accident in one, sport in<br />
four, hit in two patients, gun shot in one. All patients had sonography in the Emergency Unit immediately after arrival. US<br />
examinations were performed on Toshiba Power Vision 6000 with 3- 6 Mhz convex transducer with colour Doppler.<br />
RESULTS: We diagnosed severe rupture in two patients, who were operated. The others had less severe injuries (superficial<br />
lacerations with intraparenchimal and/or perirenal and subcapsular haematoma) and were treated conservatively. Sonography was<br />
the only examination in six patients, while three had further examinations (two CT, one CT angiography, excretory urography),<br />
which completely corresponded to US results.<br />
CONCLUSION: An experienced examiner can describe renal injury sufficiently enough for decision about treatment. More invasive<br />
diagnostic tools rarely give additional information.<br />
SS18<br />
SS19<br />
CT imaging of iatrogenic urinary lesions after urologic, gynecologic, and obstetric procedures<br />
Hrabak M, Stern-Padovan R, Smiljanic R, Perkov D, Lusic M.<br />
Clinical Institute of Diagnostic and Interventional Radiology, Clinical Hospital Center Zagreb, University of Zagreb, School of<br />
Medicine, Zagreb, Croatia<br />
PURPOSE: Iatrogenic trauma is the leading cause of urinary lesions, which are usually clinically silent, and therefore associated<br />
with delay in diagnosis and significant morbidity. The aim of the study was to evaluate the role of MSCT imaging in early detection<br />
of iatrogenic urinary tract lesions.<br />
MATERIALS AND METHODS: CT examinations performed using different protocols during 3-year period in patients with suspect<br />
urinary tract lesion after urologic, gynecologic, or obstetric procedure, were retrospectively analyzed.<br />
RESULTS: Urinary tract lesions were found after kidney transplantation and autotransplantation, nephrectomy, cystectomy,<br />
prostatectomy, hysterectomy, caesarian section, ESWL, percutaneous nephrostomy, and penectomy. In most patients pathologic<br />
fluid collections, including urinomas, hematomas, seromas, and abscesses, were evidenced. Multiple urogenital trauma, with urine<br />
extralumination due to ureteral, urinary bladder and vaginal lesions, was found after caesarian section. Ureteral strictures were late<br />
complications after renal procedures, hysterectomy or cystectomy. Vesicointestinal fistula was detected after transurethral<br />
prostatectomy, and vesicovaginal fistula after hysterectomy with pelvic irradiation.<br />
CONCLUSION: Iatrogenic urinary tract damage should be suspected if ultrasonography reveals free or localized fluid collection. CT<br />
angiography and/or CT urography are primary modalities for assessment of suspect urinary tract lesions, because they enable fast<br />
and accurate diagnosis before interventional or surgical treatment.<br />
Retrospective analysis of ureteral distension as function of delay time after i.v. contrast-media injection followed by i.v.<br />
saline infusion in CT-Urography<br />
T Meindl, E Coppenrath, C Degenhardt, UL Müller-Lisse, M Reiser, UG Müller-Lisse, Institute for Clinical Radiology, University<br />
Munich, Germany<br />
PURPOSE: To evaluate the effect of delay time on distension of the upper urinary tract (UUT) in CT-urography (CTU).<br />
MATERIAL AND METHODS: During a 7-months period, 54 patients (mean age, 60 years, mean serum creatine, 0,94mg/dL)<br />
underwent multi-detector-CT of the UUT (4x2.5mm, 120kV, 30-50mAs/slice) after i.v. contrast media injection followed by infusion<br />
of 250mL saline. UUT was divided into four segments, intrarenal-collecting system (IRCS), proximal, middle and distal ureter. Two<br />
independent readers rated distension of UUT segments, score 1, no contrast filling, 2, distension less than 3mm or 3, distension<br />
more than 3mm. UUTs were divided regarding delay time groups in steps of 5 minutes, 5-10, 11-15, 16-20, 21-25, 26-30 minutes.<br />
Delay time groups were compared by means of Chi-square testing.<br />
RESULTS: In total, 664 UUT segments were analysed. For the IRCS and proximal ureter significantly better distension was found<br />
for delay times between 5-10 and 11-15 minutes when compared with longer delay times (3.7
PURPOSE: To evaluate the role of diuretic,Gd -enhanced excretory MRUin assessment of the non-dilated urinary tracts in<br />
comparison to EU.<br />
MATERIALS AND METHODS: 100 patients with urologic symptoms and non-dilated upper urinary tract. They were examined at<br />
1.5T using T1 weighted,3D,fast spoiled gradient echo(FSPGR) after intravenous injection of 5-10mg. furosemide and, 30-60<br />
second later,0.1mmol\KgmBW of Gd-DTPA. Coronal MIP and source images were compared to EU with regard to morphologic<br />
accuracy, anatomic variability, filling defects and tumor visibility.<br />
RESULTS: MRU was superior to EU in identification of renal fusion in crossed ectopic and horse-shoe kidneys and PCS<br />
configuration in malrotated kidneys. For urolithasis MRU identify urinary stones in 75% of patients and EU in 91.7%. MRU was<br />
superior in identification the exact location and nature of the renal and bladder masses. MRU revealed a distinct superiority in the<br />
visualization of the renal parenchyma 156\200(78%) renal units. An equivalent information in 115\200(57.5%) of calyces,<br />
120\200(60%) of pelves and 107\200(53.5%) of ureters<br />
CONCLUSION: MRU provides an excellent anatomical information about non-dilated urinary tracts and parenchyma, without<br />
repeated exposure to ionizing radiation and iodinated contrast media particularly in patients with congenital anomalies. Single plain<br />
x-ray film should be included for better detection of urinary calcification. MRU if performed in conjunction with standard MRI<br />
sequences avoids multiple separate diagnostic procedures.<br />
SS21<br />
Computed tomography angiography of haemodialysis arteriovenous fistulae: Impact of 3D image reconstructions in<br />
complicated clinical cases<br />